For many senior citizens and the chronically sick, moving from nursing-home to in-home care is a preferable option when available. After all, we'd much rather be in a familiar, comfortable environment than in what can seem an impersonal medical facility. For this reason the shift to in-home care is quite understandable. Sadly, however, the opportunities for elder abuse and neglect also multiply in a home setting, as a recent article in The Atlantic makes evident. This comes down to one pivotal reason: a systemic lack of oversight to ensure patient safety and caregiver responsibility.
In California, in-home medical care for lower-income elderly and disabled patients is funded to the tune of $7.3 billion taxpayer dollars through the In-Home Supportive Services program (IHSS), which currently serves 490,000 clients. The caseload is twice what it was in 2001, and caseworkers are overloaded - in Riverside County, for example, a state employee will have around 500 clients each. Even halving that figure to 250 clients, the average for Los Angeles case workers, is still far too great to permit proper oversight.
With an inability to conduct thorough check-ups with clients, there inevitably grows the potential for incidents of abuse and neglect of patients. Let's add to this several other additional contributing factors:
- Caregiver training - instruction in skills necessary for this tough job - is "minimal and mostly optional." Training in how to perform CPR, first aid, or other techniques isn't mandatory, despite the fact that some caregivers are forced by circumstances to effectively act as nursing aides. In such cases California requires additional training and doctor authorization, but "only one in nine" receives it, according to state officials.
- Most of the caregivers are related to patients, at a figure of 73 percent. It's important to note here that the great majority of elder abuse is carried out by relatives of the victim, a pattern that seems to continue in incidents reported to the IHSS.
- Screening for caregivers is insufficient. Background checks to bar those convicted of elder or child abuse are required under state law, but felons convicted of crimes like robbery, rape and assault can all work in the IHSS program with a waiver. Caregivers who might themselves have problems with drug addiction, for example, can hardly be expected to look after a patient's well-being.
- Incidences of abuse are severely underreported. Just one case is enough to show there's a massive problem in reporting by caseworkers. In 2012-2013, not one critical incident was reported among 235,000 clients in Los Angeles, Orange, and San Diego counties, while Sacramento to its credit reported 1,688 incidents during the same period.
California's IHSS in-home care program could work well with the right institutional safeguards in place. But in order to improve the situation and prevent further negligence and abuse, we must up the accountability of all sides - both for the state and caregivers.