This article was downloaded by: [York University Libraries]On: 07 November 2014, At: 07:20Publisher: RoutledgeInforma Ltd Registered in England and Wales Registered Number:1072954 Registered office: Mortimer House, 37-41 Mortimer Street,London W1T 3JH, UK

Journal of GerontologicalSocial WorkPublication details, including instructions forauthors and subscription information:http://www.tandfonline.com/loi/wger20

Homecare for the FrailElderly:Susan Rosenfeld Friedman MSW a & Lenard W.Kaye MSW ba Planning Associate, New York CityDepartment for the Aging, New York, NY,10007b doctoral candidate, Columbia UniversitySchool of Social WorkPublished online: 08 Sep 2010.

To cite this article: Susan Rosenfeld Friedman MSW & Lenard W. Kaye MSW(1980) Homecare for the Frail Elderly:, Journal of Gerontological Social Work,2:2, 109-123, DOI: 10.1300/J083V02N02_04

To link to this article: http://dx.doi.org/10.1300/J083V02N02_04

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HOMECARE FOR THE FRAIL ELDERLY: Implications for an Interactional Relationship

Susan Rosenfeld Friedman, MSW Lenard W . Kaye, MSW

ABSTRACT. Based upon thejindingsofa monitoringstudy ojelderly, publiclyfunded homecore recipienrs, rhispaper seeks l o define homecoreas an interactional sys- tem in which all members oJthe relationship affect the viability of the homecoreplan. Out ofthis moniroring experience, sourcesojstressin the homecarerelarionshipderiving Jrom the Junction- inx oJthe homecare bureaucracy, and rhepersonali?vstructuresandroleperceprionsoJtheprime actors, areidentiJied.

In a society in which significant advances in modern medicine have resulted not only in prolonging life, but also in many in- stances in prolonging years of disability, serious consideration must be given to the development of alternative modalities of care.

Increasingly, community based in-home services have been identi- fied as a vital component of any continuum of care planning for the elderly. A logical outgrowth of this developing interest in homecare services should be a concomitant concern with the quality of care they provide.

A growing literature has emerged in recent years with touches upon a broad range of hornecare related issues. A number of key areas of con- cern can be briefly identified here:

( I ) The fragmentation and lack of coordination found within pre-

Mrs. Friedman was formerly the Assistant Coordinator for Aging Ser- vices of the Communiry Service Society of New York. She presently isa Planning Associate with the New York City Department for the Aging, 250 Broadway, New York, NY 10007. Mr. Kaye was formerly the Outreach Supervisor of the Older Persons Service of the Community Service Society of New York. He is presently a doctoral candidate at the Columbia University School o f Social Work.

JournnlotCcranlolo~inlSocialWork. Vol. 2UI. Wintcr 1919 0 1980 by Thc Havonh P m . All righlrmcwed. 109

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I10 JOURNAL OFGERONTOLOGICAL SOCIAL WORK

sent homecare policy and funding patterns, as well as a bias toward short-term acute care, have been frequently identified by observers of the American homecare system.''2"

(2) A number of recent empirical evaluations have reported a favor- able correlation between the provision of homecare services to the frail elderly and the deterrence of institutionalization.'.' However, the cost- effectiveness of homecare vis-a-vis institutionalization has been the subject ofconsiderable controver~y.".'.'.~

(3) The extent of training and supervision necessary for homecare workers serving the frail elderly has also been'widely debated, particu- larly with regard to defining the typeof professional most suited toper-

1r1.1 1.12 form these functions. A lack of agreement is also evident in the conceptualization of the case management/supervisory process." par- ticularly with regard to the respective roles of the supervisor/case manager and the homecare worker. Interdisciplinary teams have been stressed as important to the effective delivery of home-based services, but in most cases, a secondary status is assigned the homecare worker.

(4) To address these issues, a research methodology continues to de- velop which seeks to assess both individual functional incapacity vis-a-

IJJ ! 16.1- I F vis homecare, as well as to estimate broad community needs. Despite the breadth and scopeof issues raised in the literature, a review of the available knowledge base in this field reveals a striking lack of emphasis upon the significance of the relationship between the elderly recipients of homecare services and the homecare workers who provide this service. The role of this relationship in the maintenance of the homecare plan, and the identification of internal and external stresses upon that relationship, merit closer examination.'"

Based upon the findings of a monitoring study of elderly, publically funded homecare recipients, this paper seeks to define homecare as an interactional system in which all members of the relationshipaffect the viability of the homecare plan. Out of this monitoring experience. sources of stress in the homecare relationship, deriving from the Func- tioning of the homecare bureaucracy, and the personality structures and role perceptions of the prime actors, are identified.

CSS HOMECARE MONITORING PROJECT

In order to obtain a more precise pictureof the prob- lem areas affecting the maintenance of the homecare plan, the Corn- munity Service Society of New York, a non-sectarian social agency,

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Susan Rosenfeld Friedman and Lenard W. Kaye 11 1

undertook in 1977 a monitoring study o f a sample of elderly clients receiving publicly-funded (Title XIX) homecaresupport s e r ~ i c e s . ' ~

The sample group (N =48) of homecare cases monitored was drawn from a general pool of intake applications. Monitoring was initiated at the point of access to theentitlement and continued for a period of two to seven months. Included in the appraisal process was a preliminary inlalie assessment which measured the primary disabilities and home- care service needs of the client, and which assessed personality factors expected t o impact on the homecare relationship. The preliminary a's- essment was followed by structured interviews with theclient and/or a member of his natural support system on a minimum of a bi-weekly basis.

Demographically, clients ranged in age from 65 to 95 years, with over half being over 80, and SSI recipients o r eligible for Medicaid ben- efits. The majority lived in low-cost housing (65% at o r below $160per month), and represented a largely isolated group, with 67070 living alone and almost one-half (46010) having no friends o r relatives from whom they could expect to receive care and assistance. In general, the samplegroup represented a g r o u p o f elderly people who were no longer autonomous, with 74% being unable to carry out personal care f'unc- [ions, and requiring help with a range of activities of daily living in or- d e r t o remain in their homes.

From monitoring theexperiences of the48 elderly studies in this pro- ject, three main areas of stress in the homecare relationship were iden- tified: that which derived from the orgainzational system which pro- vides the service: that which developed out of a constellation o f factors from which theclients'and workers' personalities werecomposed; and that which grew ou t o f a clash between role perceptions and expecta- tions o f the various members of the homecare relationship.

T H E ORGANIZATIONAL SYSTEM

Publicly-funded homecare thrusts the functionally impaired individual into a bureaucratic structure, and makes his ability to remain in the community dependent, in part, upon the effective functioning of that bureaucracy.

General systems theory provides a helpful framework with.in which the interactional nature of the homecare system can be understood." A major tenet of this theory is that the individual and the subsystems which constitute his environment c a n n o t . be dichotomized. The

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primary characteristic o f any system is that all parts are in transaction, so that whatever affects one part of the system affects all parts to some degree. Throughout the monitoring of the homecare cases in this study, it appeared that the worker-client subsystem was often irnpact- ed upon in a negative way by the functioning o f the larger system.

A range of bureaucratic problems was identified in this study, which included lengthy delays in access t o services, gaps in service delivery, delay in payment t o workers, lack o f quality controls, and inaccessibil- ity to supervisory-case management personnel. All o f these problems derive from functions which the individual homecare relationship must depend upon the larger system to provide.

T h e following vignette describes the way in which this bureaucratic malfunctioning not only affects theinterpersonal relationship between client and workers, but also the quality of care provided theclient:

In the case of Mrs. A,, a diabetic who suffered from a. heart condition, over eight weeks had passed before her homecare worker had received any of her salary from the city's payment center. During that time. rensions escalated between the client and frustrated worker who regularly threatened to quit, and who did in fact become less willing to independently perform her regular tasks. Mrs. A., a rather unasser!ive woman. was fearful of antagonizing the worker, and therefore avoided making any specific re- quests of her, which included a special bathing regimen for her feet. As a re- sult, Mrs. A. developed an ulcerativecondition that required temporary hos- pitalization.

At the time of this study, 46% of the clients receiving services through the New York City Division of Home Attendant Services re- ported delays in the payment of their workers of up to 10 weeks. In 70% of these cases, such delays resulted in interpersonal problems in otherwise unproblematic relationships, or exacerbated already prob- lematic relationships. It should be noted that a number of workers continued t o work out of concern for the clients' well-being, even when they were forced to borrow money to meet the needs of their families. However, such stresses upon the worker's family system ultimately re- turned t o haunt these already beleaguered homecare relationships.

A second area of stress for both client and worker which derived from the structure of the larger system was that which resulted from gaps in service delivery. The provision of replacements when the worker is unable t o attend the client is a function that the individual homecare relationship cannot provide itself, yet in the sample group ,

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Susan Rosenfeld Friedman and Lenard W. Kaye 113

studied, of the 75% of clients who made at least one request for a re- placement, 83% were unmet. Furthermore, acquisition of replace- ments did not occur any more expeditiously for the more severely dis- abled of the group. In several cases, delays in replacements resulted in extended hospitalization for some clients and discharge without the appropriatelevel care for others. The process of recertification, that is, reassessment of client need, which in the system studied must be car- ried out every six months, also resulted in gaps in services o r the de- livery of the inappropriate level o f services in 19% of the cases m0n.i- tored.

Such problems are exacerbated when no viable mechanisms exist within a system for clients and workers to signal for assistance. In 35% of the cases monitored, clients and/or workers were unsuccessful in their attempts to reach the provider agency to report such problems. Failure on the part of the-larger system to be responsive to such needs and to guarantee continuous service results in an inappropriate level of client dependency upon the health, reliability, and devotion of the in- dividual worker. This has particularly serious implications for both cli- ent and workers in cases where no viable informal supports exist to whom theclient can turn for help.

Thus far, discussion hasonly focused on the impact of the larzer sys- tem upon the worker-client subsystem; however, as all members of a system are in transaction, i t would seem logical that the stresses which are felt by the worker and client relationship will, in turn, affect the provider agency. Documentation from the cases monitored appears to bear out this logic.

The publicly-funded hornecare system studied cieates an atypical employer-employee relationship, in that the client does not pay the worker directly, and therefore, much of his control as employer is di- minished. As no regular supervision was provided by the provider agencies to ensure worker accountability, it was not surprising to find that 55% of the clients monitored reported that their workers provided less than the specified number o f hours o f service; and in 16% of this group, this occurred over 25% of the time. A system lacking ongoing supports is not one that reinforces worker motivation to provide a quality service.

The problems connected with recertification and worker replace- ment, described earlier, extracted both a human as well as a financial cost. Two clients who required replacements o f their workers in order to be discharged from a temporary hospitalization were forced to re-

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main hospitalized eight days and eleven days longer, respective1y;than required, at a cost to Medicaid of over $250 a day. In another case, a client who had recuperated from a wrist fracture received over two months of significantly greater number of care than was required, be- cause of thesystem's failure to recertify her into a lower level of care.

Perhaps most costly of all in both emotional and financial terms were the cases of two clients who became so discouraged and anxious regarding breaks in services and the lack of responsiveness of the homecare system, that they chose to be institutionalized (at a greater cost to the Medicaid system). Thus, the inefficiency of the bureaucracy not only affected the individual clients and workers, but also the tax- payers who finance the system.

INTERNAL STRESS

By placing a homecare worker in an older person's home without any provisions for case supervision, several implicit as- sumptions are made by the provider agency. First, it is assumed that the older person will quickly adapt to the ongoing presence of another per- son in their home; second, that the personal habits and attitudes of each member of the relationship can be accepted by the other; and third, that the client, the client's fam.ily, and the worker are able on their own to agree upon the tasks that need to be done, involving both the priorities and the way in which tasks are carried out. The finding that 62% of the clients monitored in this study experienced problems in all or in combinations of these areas, and that for 80% of the group problems continued far more than 25% of the time they received ser- vices, speaks to the need for careful review of the management of homecare cases.

A variety of forces are called into play with the initiation of a home- care relationship. As suggested earlier, the client-worker subsystem is in continuous transaction, receiving both input and feedback from a variety of other existing systems, of which the agency providing horne- care is one part. Additionally, each member of the homecare relation- ship brings with him a personality structure, a history, standards, atti- tudes, and set of expectations which color his perception of the world around him. These determine both the quality of his capacity for rela- tionships with others, as well as his ability to cope with new demands on his functioning and changes in his normal patternsof life.

Much has been written regarding the meaning and impact of institu-

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Susan Rosenfeld Friedman and Lenard W. Kaye 115

tionalization and an institutional life style for the elderly; that home- care can represent for the frail older person a change in life style has not been well explored. Homecare requires that the older person accept the caring situation and some concomitant level o f dependency. It involves frequent and often intimate association with another individual who, until recently, was most probably a stranger. The older person's life patterns are changed by the ongoing presence o f the care giver, an ad- justment that is more difficult for some than others. The following vi- gnette from the group studied is one example o f a constellation of per- .

sonality factors which impact upon the homecare relationship:

Ms. Smith, an 81-year-old amputee, required I2 hours daily attendance by a homecare worker in order to remain in her small apart- ment in the community. A very private woman, who admitled to having al-

. ways been wary of forming relationships. Ms. Smith experienced consider- able stress in attempting to adjust to her homecare worker, whose habits and interests substantially differed from her own in such areas as choice of enter- tainment and desire for conversation and companionship. Lacking any sup- port from the provider agency in resolving these problems, Ms. Smith changed workers three times in five months, each time with little improvement to the overall situation. Ms. Smith eventually chose to be institutionalized, where she felt she could have greater distance from other people, rather than to con- tinue such a close relationship withonecaregiver.

In the samplegroup studied, a number o f disruptions in client-work- er relationships were noted which resulted from a poor match between client and worker. Some involved complex factors in the'client and worker personality structures, such as the ability t o tolerate closeness and form relationships. Other problems related t o more concrete dif- ferences between the client and worker, such as tolerance for smoking, differences in languages, and preferences in food and entertainment, all of which was translated into significant stress upon the relationship.

Attitudes toward aging on both the part o f the client and homecare worker also appeared to exert an influence over the success o f a home- care relationship. For the older person, hornecare may come as the cul- mination of an aging-related life crisis which may include a multiplicity o f radical and disruptive changes.12 AS suggested in a n earlier study," the homecare worker may become both the symbol o f that crisis and those losses, accentuating the dif'ference between the client's present state o f being and an earlier period o f more independent functioning. Thus, acceptance o f the homecare worker also can be tied t o the older

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person's ability to accept in a positive way the changes in his own life. For the homecare workers, who in this study were for the most part middle-aged, the ability t o interact effectively with their aged clients may have also been affected by their feelings and fears about their own aging, or that of asignificant person.2P

The impact of attitudes towards aging appeared from the group studied to focus upon the issue of dependency. While a reality of nor- mal aging is increased dependency for long duration, the excessive em- phasis in western society upon self-reliance often makes acceptance of realistic dependency states d i f f i c~ l t .~ ' In a number of cases from the sample group, response to increased dependency resulted in fearful and anxious behavior on the part of the client. This behavior manifest- ed itself in two diametrically opposed fashions. Certain clients demon- strated demanding and controlling behavior and a range of unreason- able responses to worker performance. This response was similar to the neurotic dependent behavior described by G ~ l d f a r b , ? ~ in which the in- dividual, who feels that he is no longer able through familiar means to attract and hold persons upon whom he can be dependent, becomes more overt with regard to formerly masked manipulative dominating behavior. Other clients refused to place any demands upon their work- ers, and confided to the monitor that they feared their workers might abandon them if they do so. Worker responses to dependent behavior could not be determined. However, the study did make clear that homecare workers were not always equipped to constructively handle the results of such dependent behavior, as indicated in the following case:

Ms. B.. a client with a severe case of arthritis, became over time very depressed about her future and very emotionally dependent upon her worker. Although her worker was assigned to attend her only eight hours a day, Ms. B. frequently called her at her home in the evening pleading for the worker to return and care for her. As Ms. B. had become very isolated from friends and family, the homecare worker found herself having to cope alone with Ms. B's intense emotional needs. This responsibility appears to have frightened the worker, who began to suffer from "spells of illness" and was increasingly absent from work.

Thus, the quality of the client's care was diminished by the worker's inability to deal with the stress of theclient's dependency.

Also, problematic were three cases in which workers appeared to

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Susan Rosenfeld Friedmanand Lenard W. Kaye 117

force their clients into dependent roles, removing the opportunity for independent functioning even around simple tasks. One client com- plained bitterly to the monitor that her worker would not allow her to prepare any food for herself or to make her own bed; another felt that her daily routine was determined too often by her worker's decisions about what was good for her rather than by her own preferences. A major goal of homecare, the maximization of opportunities for self- reliant functioning, is undermined by such destructive attitudes of uninformed workers. Again, quality of care is affected.

The special problems raised in. the hornecare relationship by the mental impairment of the older person cannot be fully explored with the data available from this small sample (41 '70 of total cases). How- ever, again it appeared that deeply ingrained attitudes towards aging in general and mental impairment in particular (such as those which in- fluenced one worker to refer to her mildly confused client as "her baby") extracted a human cost. The experiences of two cases, in which clients suffered definite declines in their mental capabilities, are worth noting. In one case, the older person exhibited increasing paranoid be- havior, and frequently accused her worker of stealing money or food. Although the worker appeared to understand that these accusations were a result of her client's forgetfulness, she nonetheless took them personally and responded in anger. In the other case, the worker ap- peared to be denying the changes in the client, demanding more inde- pendent functioning from the client than that which she was capable. Clearly, both situations indicate a strong need for interpretation and support for workers providing care to this special population.

Thus, the constellation of personality factors which both clients and workers bring to the hornecare relationshipare intimately related to the success or failure of the homecare plan and may be sources of strength and support, or debilitating stress which can serve to undermine the basic goal of the service.

ROLE PERCEPTIONS

A third area of stress that became apparent through- out the monitoring of these homecare cases related to role perceptions and the need of both the client and the worker for clarification in this area. As none of the clients in this study had been provided with any pre-homecare discussion to clarify their expectations, and as none of

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the 48 workers had received any formal training or supervision, their expectations with regard to the homecare plan was influenced by a var- iety of factors.

At the beginning of the homecare relationship, both clients and workers appeared to have developed impressions of what would be in- volved in their cases. Unfortunately, these often did not have a basis in fact. Expectations were derived from what doctors, other clients, or homecare workerssaid; were inferred from what they did not say; or in other cases, were based on client and worker wishes. Typically, they learned through experience that some expectations were realistic, and some were not, but not without an emotional cost. The case of Mrs. Brown is illustrative:

The relationship between Mrs. Brown and her home at- tendant, which had been amicable, rapidly deteriorated to the point that the home attendant threatened to quit. Mrs. Brown was verbally abusive and over- critical of her homecare worker and expressed to the monitor her great disap- pointment in the homecare plan. After some exploration, i t became evident that Mrs. Brown's anger and disappointment related to her inaccurate expec- tations of a homecare worker's job. Mrs. Brown assumed that the worker had been made awareof her particular physical needs and preferences by her doc- tor (such as standing rather than sitting in her bath). Though Mrs. Brown was perfectly competent to instruct her home attendant, since she felt it was the home attendant's job to takecharge, she remained silent. When this rigid mis- conception was clarified by the monitor, Mrs. Brown became more appropri- atein her expectations and thesituation significantly improved.

In the pilot group, 25% of the clients had specific problems in terms of their expectations about homecare. An additional 12% of the clients made demands or requests of the workers which were judged to be in- appropriate by the social worker monitoring the case. In only three of these cases did problems occur 25% or less of the total monitoring time. In the majority of the remaining 13 cases, inappropriate expecta- tions about homecare lasted the full monitoring period.

In analyzing these misconceptions, five major groupings were used: First, in several cases tasks to be done by the homecare worker were

expected to be different from those included in the role prescription. In none of these cases were clients given a copy of the worker's role pre- scription; therefore, there was no way for the client to differentiate be- tween a worker who refused to do an assigned task and a worker who knew that the task was outside her role prescription.

Second, some clients expected companionship after hours of work

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Susan Rosenfeld Friedman and Lenard W. Kaye 119

from the workers. If the need for companionship had been identified early and the client has been given clarity in terms o f reasonable op- tions, then the expectations could have been modified and possibly met. Instead, feelings ranging from rejection to hostility were engen- dered by the inability for clients and workers to resolve this issue.

Third, some clients maintained unrealistic standards with regard to the performance of the homecare worker. For example, a number of .clients expected certain tasks to be done in a specific way and were highly critical of the homecare worker for not meeting the expected standard. While thestandard may havenever been explicitly stated, the client's discouragement about the worker's performance was mani- fested by either increased demands on the part of the clients, or by asking for the replacement of the worker. In some cases the client did become more realistic over time; however, the early weeks of their homecare relationships were filled with tension.

Fourth, race, religion, and age of homecare workers were overt or covert problems in several cases. Clients often expected that the home- care worker would be very similar to themselves, and were very disap- pointed when the workers were younger and/or of a different race from the client. In two cases the racial bias of the client triggered a ra- cial reaction on the part of the worker. This served to reinforce the ra- cial stereotypes of both theclient and the worker.

Just as clients and workers appeared confused as to their respective roles, families of clients also appeared to suffer from a lack of clarity with regard to their rolevis-a-vis the homecare plan.

Brody and Sparks succinctly have noted that "the aged are family members,"" who affect and are affected by the larger family network. That families remain involved with their elderly is clear; nonetheless, in, none of the cases monitored did the provider agency evince any com- mitment to prepare the family for their role in the homecare relation- ship, or to draw upon family strengths in the maintenance of the plan. In 19% of the cases mentioned, this resulted in disruptive family influ- ences upon the homecare plan.

There appeared to be a number of origins for this disruption. In some cases, relatives seemed to feel guilty or inadequate about the way in which they were demonstrating their care for the client. Some ex- pressed uneasiness that a stranger was providing intimate care to the client, and thus may have become overly involved in giving directions to the homecare worker in order to demonstrate their continued in- volvement.

Another source of difficulty in the sample group was the lack of clar-

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ity the relatives had in terms of the homecare worker's role. In three cases relatives were demanding services for the client which were be- yond the role prescription of the worker. In two cases, serious prob- lems were created as the client's relatives became embroiled in argu- ments with the worker. The clients thus found themselves in the middle of a struggle which threatened to estrange them either from their fam- ily, or their worker, or both.

A third source of difficulty was the small group of friends and rela- tives in three of the monitored cases who requested services for them- selves from the homecare worker. One family member interpreted the homecare plan as free care to which he was entitled. Two other family members expressed feeling displaced by the homecare worker, who they felt had taken over their position in theclient's life. The attempt to get service for themselves might have been a desire to stay connected to the client, without the role which had formerly been the means for that closeness.

Clarity of role expectations on the part of all members of the home- care relationship appears to be basic to the effective functioning of that system.

SUMMARY AND CONCLUSIONS Based upon the findings of the study, this paper has

defined homecare as an interactional system in which all members of the relationship affect the viability of the entire plan. Three sources of stress have been identified deriving from the organizational function- ing of the bureaucratic system, and the personality structures and the incongruity of role perceptions of the prime actors. In terms of the over- all homecare system, it is suggested that there is a need for the recogni- tion of this interdependence between subsystems and the development of structures to enhance their interrelationship.

For the frail elderly, the authors recommend that homecare should be defined as a core service, to which other services may be linked as part of a total coordinated and integrated system. A vital component of that system is the role of case manager, in which the functions of supervision and service management should be lodged. The dichotom- ization of supervision of the worker from the service management functions which relate to the client denies the interrelationship inher- ent to this service.

Homecare does not exist in a vacuum; besides the homecare bureau-

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Susan Rosenfeld Friedrnan and Lenard W. Kaye 121

cracy studied in this paper, the recipient of publicly-funded homecare is most likely involved with a myriad of other formal entitlement sys- tems which must beregularly negotiated. The ability to develop service packages for the hornecare client, which link the older person to the available service system, and which can be flexibly modified as needs change, is fundamental if the individual is to remain in the community. Basic to this is the development of integrated systems of service deliv- ery.

The experience of this study indicates that homecare is not merelya relationship between systems, but rather, it is also a relationship be- tween people, bringing into play the constellation of factors usual to forming relationships, but intensified by the physical intimacy and closeness inherent to this service. Placing the responsibility both for re- solving problems in the relationship, as well as assuring worker ac- countability upon the frail older person, can constitute a stressful bur- den which may undermine the goal of service. The case manager's role in assessing and matching client need to the service provided; in pre- paring all participants for the relationships; and in providing the sup- portfrom which that relationship can grow, is vital.

Equally important is the role of the individual homecare worker who, i t is suggested, must be linked through supervisory mechanisms to the case manager and function as part of a service team. Training and support of homecare providers are essential to augment their abil- ity to deal effectively with the special needs of a frail aged service popu- lation. Supports are also necessary to enhance the homecare worker's capacity to be "a primary-change agent,"" who can identify through her intimate association with the client, potential problems before they become crises.

With regard to the frail elderly, the homecare worker could, with the appropriate supports, assume the role of "significant other," which has been defined by the Federal Council on Aging as so necessary to this population. Thus, a viable homecare model must stress the import- ance of the homecare worker's role with regard to its preventive func- tion, as well as in terms of the vital relationship which the worker can provide for theisolated elderly.

This paper has provided only a cursory look at a number of factors operating in the homecare relationship. Further study is necessary to identify the full range of variables that affect its functioning, in order that the full benefits of hornecare services can be realized.

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JOURNALOFGERONTOLOGlCALSOClAL WORK

REFERENCES

I. Moore, F. "New Issues for In-HomeServices," Public Welfare. 332). ISpring. 1977). pp. 26-37.

2. Morris. R. "Approaches to Long-Term Chronic Illness: Dilemmas and Opportunities." Paper prepared for the Institute on Continuity of Long-Term Care. Arden House. Harriman. NY, December 1977.

3. State Communities Aid Association. Report of Arden House lnsrirure on Conrinuir~ 01 Long-Term Care. Harriman, NY. 1977, pp. 18-20.

4. Barney. 1. L. "The Prerogative of Choice in Long-Term Care." Geronroloetst. 17(1l. (1977), pp. 309-314.

5. Noelker. L. and Harel. 2. "Aged Excluded from Home Health Care: An Interorganiza- tional Solution," Geronrologist. 18(I), (February, 19781, pp. 37-41.

6. Craig, J. "Cost Issues in Home Health Care." in M. Callender and J. LaVor. "Home Health Care: Developments. Problems and Potentials." Office of the Assistant Secretary ior Planning and Evaluation. DHEW. April. 1975. pp. 48-54.

7. Greenberg. J. "TheCostsof In-HomeServices. Part 11." intheGovernor'r Citizens Coun- cil on Aging. A Plannin,? Studv o/Services to Non-1nsrirurionali:ed Older Persons in .Winnewla (Minneapolis: Schoolof Public Affairs. University o f Minnesota. 1974).

8. Sager, A. "Estimating thecosrsof Diverting from Nursing Homes to Home Care." Paper presented at the 30th Annual Meeting o f theGerontological Society. November. 1977. San Fran- cisco.

9. Scharer. L. K. and Boehringer, J. R. "Home Health Care for the Aged: The Program u i St. Vincent's Hospital. New York City," prepared for the Florence V. Burden Founda~ion. Frb- ruary 17-, 1976.

10. Trager. 0. Homemaker/Home Health Aide Services in the Unired Srares (Washington. D.C.: U.S. Government Printing Office, 1973).

I I.Shinn. E.B. and Robinson, N.D. "Trends: In Homemaker-Home Health Aide Services." Absrracrs/or Social Workers. 1q3). (Fall. 1974), pp. 3-8.

12. Morris, R. "The Development of Parallel Services for the Elderly and Disabled." Grron- rologisr. 14(1 I). (February. 1974), pp. 14-19.

13. Shinn, E. B. Case Management in Homemaker-Home Heplrh Aide Services. . A Rrporr on Phase I; The Task Analysis Studv (New York: National Council for Homemaker-Home Henlth AideServices. Inc.. 1976).

14. Pfeiffer:E. (Ed.). Multidimensional Funcrional Assessment: The OARS Merhorlolo@.v (Durham: Center for thestudy of Aging and Human Development. Duke University. 1975).

15. Wilker, L. "A Methodof Estimating Major Kinds and Degreesof Physical Functional In- capacity of Elderly for New York City Subareas as an Aid in Planning Home Care Serwces Pro- grams," New YorkCiry OfficefortheAging,Februarv, 1975.

16. Shanas. E. "The Healthstatusofthe Aged. 1962and 1975: ComparisonsolTwo Nnlional Surveys." Paper presented at the 29th Annual Meeting of the Gerontological Society. Ouobcr 13-17.1976. New York.

17. Kovar. M. G. "Health ofthe Elderly and Useof Health Services." Ptrblic Healrh Reporrs. 92(1). (January-February, 1977). pp. 9-19.

18. LaVor. J. "Long-Term Care: A Challenge to Service Systems." Office of the Assi~tant Secretary for Planning and Evaluation. DHEW. September. 1976(Revised April. 1977).

19. Monk. A. "Home Support Services and the Ecology of Aging." Columbia Un~versity Schoolof Social Work. New York. January. 1978.

20. Friedman. 5.. Kay. L. and Farago. S. "Maximizing the Quality of Home Care Services for the Elderly." Paper presented at the301h Annual Meeting of theGerontological Society. Novem- ber 21.1977, San Francisco.

21. Butler. R. WhySurvive:BeingOldinAmerica. Harper and Row. New York. 1975.

Dow

nloa

ded

by [

Yor

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nive

rsity

Lib

rari

es]

at 0

7:20

07

Nov

embe

r 20

14

Susan Rosenfeld Fr iedman and Lenard W. Kaye I23

22. Field. M. Aging wirh HonorandDipni(v, Thomas. New York. 1968. 23. Farkas. R. "The Function of a Social Agency Homemaker. Her Auitudes and Relation-

~h ip toac l ien t Family." New York University. 1958. 24. Janchill. M. "Svsrems Concepts in Casework Theory and Practice," Social Casework.

50(2). 1969. 2 5 . Blenkner. M. "The Normal Dependencies of Aging." in Occasional Papers in Geronro-

l o p No. 6; TheDependenciesolOlderPeople, ed. by R. Kalish. Ann Arbor. 1969. 26. Goldfarb. A. "Psychodynarncis o f Dependency and the Search for Aid," in Occasiono/

Papers in Geronro1og.v No. 6: The Dependenciesof Older People, ed. by R . Kalish, Ann Arbor, 1969.

27. Sparks. G. and E. Brody. "The Aged are Familv Members." Farnib Process. %?1, June. 1970.

28. Sleeno. J.. Moorehead, 0. and Smits. J. "Homemakers as Change Agents." Social Case- work, 58(5). May, 1977.

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