Employee and patient safety concerns represent a barrier to hospice care among underserved, urban communities, particularly those with higher crime rates.
Seniors in high-crime communities are often disproportionately impacted by the hazardous conditions of their neighborhoods, including the seriously and terminally ill.
An “unhealthy” neighborhood yields dysfunction, imbalance and uncertainty, which can create barriers to hospice access, according to Dr. Lenny Marshall, director of diversity, equity and inclusion at Big Bend Hospice Inc. The hospice provider has an eight-county service region in the Tallahassee, Florida area.
“High crime is a main ingredient in producing health inequity by introducing the issue of safety in delivering much needed health services,” Marshall told Hospice News in an email. “The higher the crime rate, the more difficult it is in providing services to all parts of a community due to fear, which in turn introduces the issue of access.”
A complex web of causes
A variety of historical reasons contribute to these issues, including neighborhood segregation, increased poverty rates, lower education levels, among others, according to Nicole McCann-Davis, vice president of communications and chief health equity officer at Empassion Health.
Seniors who live in high-crime areas often come from diverse backgrounds and have lower incomes, according to a report from the U.S. Department of Health and Human Services’ (HHS).
Frequently, these aging populations face a host of social determinants of health needs, and violent crime can impact equitable access to end-of-life care, the HHS report indicated.
Hospice workers’ personal biases and perceptions of these communities also contribute to inequities, McCann-Davis said. In addition to her role at Empassion Health, she is also chair of the National Hospice and Palliative Care Organization’s Diversity Advisory Council.
“When considering care that is provided in the home, personal implicit biases and discrimination can, at times, influence who is willing to serve all patients — where they need it and when they need it,” McCann-Davis told Hospice News. “Stories that reflect hesitation to serve certain zip codes after dark (or at all), which forces a fragile patient to be transferred to a facility for after-hours acute needs rather than complete a home visit, have been discussed at length in Diversity Advisory Council meetings. What we often fail to acknowledge is that crime can happen anywhere and isn’t solely based on the race, ethnicity, or socio-economic status of a community.”
Recent data on hospice home health care workplace violence are sparse. But overalll, ann estimated 27,400 injuries occurred among upwards of 896,800 home health care workers in 2007, according to a report from the National Institute of Occupational Safety and Health (NIOSH) and the U.S. Centers for Disease Control and Prevention (CDC).
Risks for workplace violence and other safety concerns for home-based care workers are expected to increase alongside demand for those services, according to a 2021 analysis from the CDC.
Between 18% and 65% of home health care workers said they had experienced verbal abuse from patients during the past two decades, the CDC and NIOSH indicated in the report. Roughly 41% reported being sexually harassed in the workplace, and as many as 44% experienced a physical assault during that time.
Hospice clinicians delivering home-based care come across unique safety risks because they often work alone and may be exposed to a “variety of potentially serious or life-threatening hazards,” according to a recent study in the American Nurse Journal. Common workplace hazards for community-based hospice providers include guns and other weapons, illegal drugs, verbal abuse or other forms of violence, as well as higher levels of overexertion and stress, the ANA cited.
In addition to physical harm, workplace violence can include psychological abuse, harassment, intimidation and other threatening and disruptive behaviors that occur at the worksite, according to NIOSH.
Workplace violence has been associated with higher likelihood of instances of burnout, depression, anxiety and post-traumatic stress disorder (PTSD) among staff, a 2021 Healthcare study found.
Navigating safety concerns, risks
In addition to the risk of crime and violence, workers may have other concerns, such as the ability to reach patients in urban communities in a timely fashion, according to Megan Carrol, social worker at Ascension Illinois – Rainbow Hospice and Palliative Care. The hospice and palliative care providers services the Chicago area and surrounding communities.
Some areas can be more challenging than others, particularly as workers navigate parking limitations, Carrol stated.
“Just trying to get to the patient when they’re living in some of these harder situations can be difficullt, especially if you have nowhere to park in these more urban areas and you have someone in distress waiting for you,” Carrol told Hospice News. “It takes longer to see them and sometimes when you get inside you can see just the basic human needs not being met, because these seniors are sometimes living alone without caregivers in poverty situations.”
Other contributing factors include the employee’s unfamiliarity with the area, the time of day services are provided, crime rates and poverty levels, Marshall indicated.
“A few ways to ensure both worker and patient safety is providing services in the daylight hours as much as possible, provide technology that can track a hospice worker’s location [and] provide an emergency hotline for workers and patients to receive immediate assistance,” Marshall said.
Some hospices have clinicians travel in pairs for patient visits, for instance, she stated. Hospices have also assigned security escorts to help ensure the safety and welfare of everyone involved.
“Everyone has a different comfort level, and it’s helping your workers understand actions they can take to be and feel safe,” Carrol said. “Sometimes it’s two of us, a nurse and a social worker, or maybe an aide, that go together if that works best for both their comfort level and the patient’s. Maybe it’s keeping your car locked and looking as empty as possible inside with nothing in view. It’s essentially respecting patients’ wishes, yet keeping them and us safe at the same time. The biggest concern is their comfort and safety and how we can support that.”
Having an established workplace violence prevention program in place can help ensure overall safety for employees and patients alike, according to the U.S. Occupational Safety and Health Administration (OSHA).
Prevention programs should include management commitment and employee participation, worksite analysis, hazard prevention and control within a home environment, safety and health training, along with recordkeeping and evaluation, per OSHA guidelines.
While requesting a security escort can be an important and sometimes necessary safety step, it can also carry an implicit messaging that comes at a cost building trust among community members — an additional barrier to hospice access, according to Rabbi Adam Scheldt, director of spiritual care at Hospice & Palliative Care Buffalo Inc., based in New York.
Developing relationships with local law enforcement agencies can be helpful to gain better and more efficient access to both information, as well as safety when needed, Scheldt stated.
Employee training is a crucial strategy for addressing these concerns, Scheldt indicated — particularly those that use detailed scenarios.
“Helpful, constructive training for all employees is a great place to start,” Scheldt told Hospice News in an email. “This includes training regarding not only how to remain physically safe, but also training around unconscious bias and mental health to help ensure that staff can better assess situations and remain calm with greater clarity. Active steps toward relationship and trust building in troubled communities and neighborhoods can make a significant difference when it comes to safety and well-being of both staff and patients. While this kind of relationship building is an investment, ultimately the trust and respect garnered can result in better outcomes for everyone.”