The professional agency-based model of care in which home care agencies assign, train and supervise workers is assumed to be a safer model of care for disabled clients than those in which clients hire and direct workers, who may be family members. Worker abuse and neglect was found to be no more common in client-directed models of care, suggesting that factors other than professional monitoring help to minimize abuse and neglect by workers.

Background: There are two distinct models of organizing and delivering home-based services: the professional agency-based model (PAM) in which home care agencies hire, train and assign providers as well as co-ordinate services, and the consumer-directed model (CDM) in which clients retain all responsibilities for recruiting, hiring, training, and supervising the worker. A prevailing assumption is that PAM involves increased safety for clients since workers are professionally trained and monitored. Further, the use of public funds to hire family members as paid providers by some CDM clients has raised concerns regarding cost, service quality, and quality assessment. The study reported here examined variations in abuse and neglect of clients by workers associated with differences in home-based service models and the type of relationship between clients and providers.

Method: A sample of 1,095 low-income, primarily Medicaid funded home care recipients in California, who either received care from a professional agency or who hired their own care worker were interviewed by telephone between October 1996 and March 1997. Research questions were designed to elicit information regarding 1) the relationship between service model (PAM or CDM) and abuse-related behaviour by workers; 2) differences in outcomes of care provided by family and non-family providers; and 3) the relevance of client demographics, case mix and service resources to clients' risks of physical and psychological abuse and neglect, and to their sense of security.

Findings: In comparison to PAM clients, CDM clients were more ethnically and racially diverse, required more paramedical help and assistance with activities of daily living, and were more likely to have known their worker before the service relationship. They were less likely to experience in-home providers, worker turnover and client-worker language difficulties. Nearly half of the CDM clients hired relatives. Comparisons between the models indicated that while the majority of PAM and CDM clients seldom or never experienced neglect, twice as many PAM clients reported neglect. Similarly, although the absolute numbers were small, PAM clients were more likely to report theft and less likely than CDM clients to report that providers had yelled at them. Clients who were Asian, who received less paramedical help, who had fewer providers in the past year, and who reported more confidence with back-up help by family and friends indicated less physical and psychological risk of neglect and abuse. Clients who felt more secure with their providers were more likely to be white than Hispanic or Asian, live alone, require less paramedical help, be previously acquainted with their provider, and feel that they received too few service hours.

Conclusion: Clients in consumer-directed models appear to be at no higher risk of being abused or neglected by workers than agency clients. This suggests that factors other than professional monitoring help to minimize abuse and neglect. Clients reporting little or no abusive provider behaviour had less complex needs, less paramedical dependence, a stable provider relationship, and more confidence regarding supportive assistance by family and friends. Those who felt a greater sense of security faced fewer barriers to client-worker compatibility and lived alone, which may indicate more resourcefulness and independence.

Reference: Matthias, R.E., and Benjamin, A.E. Abuse and neglect of clients in agency-based and consumer-directed home care. Health & Social Work, 2003, 28(3), 174-184.

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