Date of Degree


Document Type


Degree Name



Public Health


Emma K. Tsui

Committee Members

Steffie Woolhandler

Sherry Baron

Leslie Nickels

Subject Categories

Health Services Administration | Health Services Research | Inequality and Stratification | Occupational Health and Industrial Hygiene | Other Mental and Social Health | Politics and Social Change | Work, Economy and Organizations


home health care; home health aides; quality of care; public policy; well-being; occupational health


Home care workers are the lowest-paid and most precarious segment of the health care industry. Although these workers provide critical, non-medical support that allows elderly and disabled individuals to remain in their homes, the workforce is highly unstable, due to low wages, a lack of supportive benefits like health coverage, paid leave and retirement support, poor working conditions and a physically and emotionally demanding workload. But a lack of consensus around the nature and value of home care has made “quality”, in terms of both jobs and care provision, difficult to define, measure or improve. While home care is a physically and emotionally intimate job dependent on a trusting relationship between worker and client, the impact of providing this relational care is rarely considered. Instead, efforts to measure job quality do not consider the psychosocial impacts of caring work, and the caring labor workers perform is not reflected in quality indicators, which focus on task-oriented clinical measures.

This project addresses these gaps through a mixed methods approach. The first section draws on two national databases (the 2011 Medicare Home Health Compare (HHC) quality database and 2010 Medicare Home Health Agency Cost Reports) to examine whether agency characteristics (ownership status, agency size, chain status and geographic region) predict the level of benefits aides receive, and whether higher benefits are associated with better quality outcomes for patients. The analysis found that spending on aide benefits was well below national averages for the rest of the civilian workforce, with large agencies and non-profit and government agencies providing the highest level of benefits. While benefit level was not a significant predictor of quality measures, large size and chain status were strongly and consistently associated with higher quality ratings. However, it is unclear whether this reflects better quality care, or simply more capacity to complete these assessment tools. The second section uses data from four focus groups of unionized New York City home health aides to examine workers’ own perceptions of quality care and how providing high-quality, relational care affects their well-being. While aides felt that agencies considered “good care” to be completing the tasks on their care plan, their own definition of quality care also included a high degree of relational care. To perform this care, aides took conscious steps to build relationships with patients by employing communication, empathy, respect and love. However, these personal ties often meant setting boundaries with the client, client’s family and agency could be challenging, and aides largely felt unsupported by their agencies in negotiating these boundaries. While aides found their work emotionally satisfying and rewarding, they also experienced stress from balancing their professional and personal roles, and faced an additional strain of feeling undervalued both as individuals and as skilled professionals their agencies and at times their patients and patients’ families.

To improve the structure of home care jobs and care in the future, researchers should break down “silos” to more effectively link data on workers, patients and agencies; prioritize outcome measures over clinical processes; and investigate emerging trends such as for-profit franchises and new payment models. Policymakers must better align the definition of home care with the care clients need, invest in long-term care by providing living wages, benefits and paid time off, leverage home care workers’ expertise by elevating workers’ voices, integrating them into the care team and improving communication, and support workers’ emotional well-being with worker-focused training, mental health benefits, counseling and support groups.