As On-The-Job Violence Rises, Mitigation Is Up To Home-Based Care Organizations 

Home health workers can be vulnerable as they face an unprotected and unpredictable environment each time they enter a patient’s home. The spectrum of violence ranges from verbal abuse to stalking or threats of assault to homicide, according to the National Institute for Occupational Safety and Health (NIOSH).

Violence impacts not only the individual, but also the employer. Exposure to violence may lead to low employee morale, poor job satisfaction and high turnover rates, according to one study on violence in nursing.

In 2021, the Occupational Health and Safety Administration began acting against providers who failed to protect their employees adequately; however, statistics show the problem shows no signs of abating.

Over 75% of workplace violence victims in 2024 worked in health care and social assistance, and 48% of nonfatal injuries due to workplace violence are experienced by health care workers, according to the Centers for Disease Control and Prevention (CDC).

For example, in an extreme act of violence, Joyce Grayson, a home health care nurse, was found dead in a Willimantic, Connecticut, halfway house in October 2023. In response, state officials outlined a $6 million safety program for home health care workers.

Among the initiatives are providing emergency response buttons to each worker for quick access to assistance, implementing a buddy escort system to ensure the safety of staff members during visits to high-risk areas, distributing GPS tracking devices to monitor the location and safety of home health workers in real-time and establishing dedicated phone lines for staff in the field to access immediate support and report concerns.

“The type of violence that I’m seeing increasing more than any other is where the violence is directed at an employee by a patient or client,” Will Vail, an employment attorney at Polsinelli Law Firm, told Home Health Care News. “There are a lot of causes; mental health is certainly one. You’ve got people who are not mentally well in high-stress situations regarding their health and the ability to live as they had been in the past.”

Studies have shown that up to 65% of home health workers experience verbal abuse from patients. Providing home care services to patients with a history of violence, mental illness or substance abuse disorders is associated with experiencing physical or verbal threats of violence.

Vail mentioned that his company has experienced an increase in clients seeking workplace violence policies to enhance the safety of employees in home-based care settings.

“Many of our clients are implementing workplace violence plans, and some states require that,” he said.

A majority of states have criminal statutes addressing assaults on emergency medical providers, and 32 states make it a felony to assault health care workers or emergency medical personnel.

Six states – California, Connecticut, Illinois, New Jersey, Oregon and Washington—require health care employers to implement workplace violence prevention programs. These programs train medical staff to recognize and respond to potentially violent situations.

“One of the policies we are developing includes conducting a criminal history check on the client,” Vail said. “Depending on the state, it is possible to run a background check on the client under certain circumstances. This will help determine the necessary steps and procedures to ensure that caregivers entering a person’s home are kept as safe as possible.”

Vail said that background checks must be conducted with the client’s consent. Although they provide an extra layer of protection, they do not guarantee whether an organization will work with that client. However, they do provide crucial background information for making a decision.

“Even in states that don’t have specific legislation, we are seeing a growing emphasis on home safety assessments before the start of service, training for caregivers on de-escalation techniques and protocols for addressing concerns or signs of potential violence,” Angelo Spinola, chair of home health, home care and hospice at Polsinelli, told HHCN.

Are reimbursement rates partially to blame?

Before entering a client’s home, Robyn Gershon, a researcher at the New York University School of Global Public Health, suggested that someone experienced in security conduct should do an assessment.

In her experience, home health care providers frequently report dealing with demanding patients, aggressive pets, neighborhood violence or crime, challenging family members, personal security fears, drug use by the patient or family, firearms in the home and racial discrimination.

“Caregivers should understand if the neighborhood has a higher prevalence toward violence,” Gershon said. “The employer should ask if the caregiver should go to the home only during daylight hours or if they should go with a security guard.”

However, Gershon pointed out that sending caregivers with security guards or other workers poses an issue regarding the cost of care.

“The problem is this,” she said. “Home care providers are not reimbursed at rates that they need to do the work to protect these workers properly. The CDC says to send workers in pairs. Then, you’re doubling the hourly rate. It’s not financially sustainable.”

Gershon said that in her research, she had contact with caregivers who were sent into homes without cell phones due to the cost of plans.

“Caregivers must have constant contact,” she said. “They should check in at least once an hour so the organization knows everything is fine.”

Gershon suggested that home care organizations implement a zero-tolerance policy against violent behavior. This means that if a caregiver faces any form of violence, they should be able to leave the home immediately after the first occurrence rather than waiting for a second or third incident.

“They must be taught to pick up, walk out the door and leave immediately. Then, that client should be denied service,” she said.

Employers should provide support

Gershon said employer-provided support services can impact health care workers’ well-being and should be explored. These services might include peer support, formal debriefing, trauma counseling or employee-assistance programs (EAPs).

“EAPs are being adopted at a higher rate where there have been issues,” Spinola said. “These programs help with the emotional impact of workplace violence and provide counseling on how to be proactive and hopefully avoid catastrophic incidents.”

Post-incident support through debriefing has been shown to increase workers’ awareness of workplace violence risks and boost reporting. Reporting workplace violence is crucial for understanding the extent of the issue in the industry and for collecting data to guide future prevention strategies, according to NIOSH.

Workers may under report violence because they believe it’s a normal part of the job, think no action will be taken, fear negative consequences or don’t have easy access to reporting systems. To address these issues, it’s essential to implement user-friendly reporting systems and ensure that leaders provide support and take action. This can help reduce the barriers to reporting, lessen the burden on workers and prevent burnout.

In addition to addressing barriers to reporting, health care leaders should communicate that the organization, rather than the victims, is responsible for ensuring provider safety.