摘要：The home health care sector is a critical element in a pandemic influenza emergency response. Roughly 85% of the 1.5 million workers delivering in-home care to 7.6 million clients are low-wage paraprofessionals, mostly women, and disproportionately members of racial and ethnic minorities. Home health care workers' ability and willingness to respond during a pandemic depends on appropriate communication, training, and adequate protections, including influenza vaccination and respiratory protection. Preparedness planning should also include support for child care and transportation and help home health care workers protect their income and access to health care. We summarize findings from a national stakeholder meeting, which highlighted the need to integrate home health care employers, workers, community advocates, and labor unions into the planning process. THE HOME HEALTH CARE SEC tor is recognized as a critical element in the response to an influenza pandemic. 1 On a typical day in the United States, the number of patients cared for at home is nearly 3 times the number hospitalized. 1 The home health care workforce comprises some skilled nursing and other professionals and far more paraprofessionals, who provide personal assistance with tasks such as bathing, toileting, cooking, and housekeeping. An important aspect of care is the provision of comfort and companionship to individuals who may be isolated, disoriented, disabled, or aged. 2 The paraprofessional workforce may be at high risk for exposure and infection during a pandemic event. This risk may arise not only from work-related exposures but also from the crowded living conditions and inadequate access to health care that are common among low-income workers. 3 When formal or informal caregivers are unable to provide services during a disaster, care-dependent community members may be left without assistance. Emergency response and public health planners can provide informed guidance to home health care workers and employers by understanding the needs of this important worker population. The elderly and the disabled populations are growing 1 ; estimates project that the number of elderly with activity limitations will reach 28 million by 2030, up from 12 million in 1994. 4 Simultaneously, there has been a shift away from institutional care (such as nursing homes) and toward community-based long-term care through the expanded availability of in-home supportive services. This trend is driven by individuals' preference to stay in their own homes, the perception that the quality of care at home may be better than that provided by institutions, and the cost savings realized by home health care. 5 , 6 Recognizing the growing importance of in-home care, the Agency for Healthcare Research and Quality convened an expert meeting in July 2007 to address the key issues associated with provision of home health care services during a pandemic. A July 2008 report, developed by the agency and the Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, summarized the findings and identified issues to improve preparedness planning. 1 To provide a more focused examination of the issues specific to protecting the paraprofessional workforce, the National Institute for Occupational Safety and Health convened a stakeholder meeting in June 2008 (see the box on the next page). In preparation for the meeting, we drew from our previous research on emergency preparedness and home health care worker health needs to delineate 5 broad policy areas for stakeholders to comment on ( Table 1 ). Here we summarize the findings and advice expressed by the stakeholders at that meeting. Home Health Care Worker Preparedness and Pandemic Influenza: June 10, 2008 Federal government agencies with roles in funding, regulating, or researching home care services or protecting home care workers and clients Agency for Healthcare Research and Quality Center for Medicaid and Medicare Services Centers for Disease Control and Prevention, Office of Minority Health and Health Disparities and National Institute for Occupational Safety and Health Occupational Safety and Health Administration Assistant Secretary for Preparedness and Response, Department of Health and Human Services State and local government agencies responsible for preparedness planning for the elderly and persons with disabilities Public Health Emergency Preparedness and Response, Montgomery County, MD Emergency Preparedness Policy, Maryland State Department of Disabilities Home health care employer representatives National Association for Home Care and Hospice HCR Manor Care - Heartland Home Health and Hospice California Association of Public Authorities for In-Home Supportive Services Home health care labor unions and worker advocacy groups Service Employees International Union, Education and Support Fund 1199 Service Employees International Union, Training and Education Fund Direct Care Alliance Academic researchers Center for Public Health Preparedness, Mailman School of Public Health, Columbia University Division of Environmental and Occupational Health Sciences, School of Public Health, University of Illinois at Chicago Work and Health Research Center, School of Nursing, University of Maryland Open in a separate window TABLE 1 Home Health Care Worker Preparedness and Pandemic Influenza: Discussion Topics at Stakeholder Meeting, June 10, 2008 Questions to Stakeholders Role of home health care workers If home health care workers provide the only support for low-income clients who are frail or disabled, are they considered essential personnel? What are the expectations by public health and other community preparedness agencies for the role of home health care workers in increasing surge capacity during a pandemic? Ability and willingness to respond What is the degree of ability and willingness of home health care workers to report for duty under different disaster scenarios? What structural interventions are needed to support workers' ability, especially with some of the constraints related to agency size and type? Communication and training What elements are needed to effectively communicate and demonstrate that emergency preparedness plans include provisions for protecting worker safety? Will home health care workers know how to protect themselves in the event they are assigned to take care of a patient with influenza? What channels and formats can be used to ensure that home health care workers, especially workers with low English proficiency, get accurate, clear information? Vaccination and respiratory protection What specific barriers exist to developing and implementing a policy for vaccination (either seasonal or during a pandemic) among home health care workers? Will use of respiratory protection be recommended for home health care workers, and, if so, what provisions for fit testing will be made and how should they be supported? Economic, legal and ethical issues If home health care workers are mobilized as part of the staffing plan to meet surge capacity, how can we ensure that they will be paid in a timely manner? How will issues such as child care and transportation be arranged? What kinds of legal protections are available, especially if workers are providing services outside of their normal job duties? Can home health care workers file for workers compensation if they contract flu while taking care of a client? Open in a separate window Note . Discussion issues were formulated by the authors from their previous research into emergency preparedness and home health care worker health needs.
