Organizational form and quality of care in the home health aide industry

An aging population in the United States, changes in family structure and the labor supply, and a rapidly increasing need for home-based care for the elderly are contributors to a crisis in the home health care industry. This crisis includes severe worker shortages and, for those who cannot pay for costly home health care themselves, an indeterminate quality of care provided to clients. Direct-care industry-focused research has shown that for nursing homes, ownership type can be linked to the quality of care provided to residents (Comondore et al., 2009; Eaton, 2000). Kruse, Freeman, and Blasi\u27s research (2010) also links an organization\u27s ownership, along with participatory decision making by employees, to increased firm performance. Home health care organizations operate under a variety of ownership structures and ownership may affect the productivity of caregivers. My research question in this exploratory study is How does a home health care organization\u27s ownership structure affect the quality of care that home health aides provide to clients? Home health care businesses operate predominantly under government, for-profit and nonprofit ownership structures. A few worker cooperatives are also present in the industry. In this study of the latter three organization types, I examine how, in the context of various institutional pressures, these ownership structures and associated decision making processes affect organizational outcomes and influence quality of care. I investigate whether isomorphism (DiMaggio & Powell, 1983) in the industry may also influence organizational practices and the work environments across home health care organizations. In support of the primary research question, I explore the meaning of quality care. Using a case study framework, I collect in-depth data from company and publicly available documents, interviews, observation, and a survey administered to 628 home health aides. I use it in examining quality of care and other worker and organizational outcomes. My findings reveal that ownership and participatory decision making can be linked to lower levels of turnover, and higher levels of job satisfaction, organizational commitment, and an exploratory construct of quality of care. These positive outcomes are more closely associated with the worker cooperative business than with the other forms of organization