Homework: Human Service Direct Support Staff and Involuntary Smoking

1. Homework: Human Service Direct Support Staff and Involuntary Smoking Paula M. Minihan, PhD, MPH Tufts University School of Medicine APHA Annual Meeting November 17, 2003

2. Policy Question • Have public policies that support vulnerable populations in community settings instead of institutions created a direct support workforce that‘s at risk for involuntary smoking on the job, yet is ignored or exempt from most occupational health protections from secondhand smoke?

3. Overview • Background • Direct support workforce in human services • Competing policy interests: keeping worksites smokefree when clients and staff smoke • State MR/DD agency policies on occupational exposures to secondhand smoke • Administrators’ opinions about competing interests • Policy protections for employees overall and in residences • Influences on residential policies • Conclusions • Policy recommendations

4. Direct Support Workers • Help elderly and disabled Americans live in their own homes or community residences, instead of institutions. • “Personal and home care aides:” Federal Bureau of Labor Statistics (BLS) job title • Provide housekeeping and personal care services (help clients bathe, dress, toilet). • Many work in community residential systems administered by state government for people with mental illness or mental retardation. • Their worksites are their clients’ homes.

5. Workforce Characteristics • Number nearly 500,000 (BLS, 2000). • Deemed one of fastest growing occupations. • Predominantly female, with large minority representation and many recent immigrants. • Minimal educational requirements; low earnings; almost non-existent benefits. • e.g., many lack paid sick time, health insurance • Union membership is low. • Workforce itself is a vulnerable population.

6. Smoking-Related Issues When Worksites Are Clients’ Homes • Many human service recipients smoke (e.g., estimates of smoking rates among patients with major mental illnesses range from 50% – 90%). • Staff who work in their homes smoke passively. • Some staff are made to supervise clients when they smoke. • Many direct support staff are thought to smoke. • 34% in MA MR/DD system were smokers. (Minihan, 1999) • Employees who work in client’s homes are not covered by traditional occupational health protections, including workplace protections against environmental tobacco smoke (ETS).

7. Dealing with Occupational ETS Exposures in Clients’ Homes: Competing Policy Interests Direct support workers have the right to clean indoor air at work. Clients have the right to autonomy and privacy in their homes. Smoking may calm clients with mental illness. State human service agencies have statutory responsibilities to protect both client autonomy, and client and employee health and safety.

8. Occupational ETS Exposures in Clients’ Homes: Policy Responses of State MR/DD Agencies • National survey examined smoking policies in state MR/DD agencies nationwide (2000). • State government agencies administering largely privatized service systems in states; primarily Medicaid-funded. • Over 400,000 direct support staff work in state systems. • Administrators in 49/51 state agencies completed questionnaires describing agencies’ policies. • 32 (65%) agencies had smoking policies; 17 (35%) did not. • All 32 policies applied to state-operated programs albeit with some variation in their restrictiveness and in the percentage of clients and employees covered. • Only 6 policies applied to vendor-operated programs.

9. Agency Administrators’ Opinions About Competing Policy Interests of Clients and Direct Support Staff

10. Key Findings: Agencies’ Policies Regarding Occupational ETS Exposures • Only a minority of employees associated with state MR/DD systems were covered by smokefree worksite policies. • 22 agencies banned smoking in state-operated office space; just 4 extended policy to vendors. • Many agencies had different policies for residential and non-residential buildings. • Of 22 agencies banning smoking in offices, just 12 banned smoking in residences where direct support staff worked; only one extended policy to vendors. • Direct support workers were offered less policy protection from ETS than employees in offices.

11. Smokefree Worksite Policies for Direct Support Staff • Only one state agency (WY) policy nationwide offered every direct support staff associated with the agency full protection from ETS at work. • Policy prohibited staff and clients from smoking inside state and vendor-operated programs, including residences.

12. Emblematic Residential Policy: State-operated Residences in NY • “As these facilities and living areas are private residences, the desires of the persons who live there (about smoking) shall be given primary consideration when implementing these guidelines.” • Guidelines Regarding Smoking of Tobacco Products Within OMRDD-Operated Community-Based Residential Programs, Small Residential Units and Living Areas of Developmental Centers. New York Office of Mental Retardation and Developmental Disabilities.

13. Major Influences on Residential Exemptions • State clean indoor air statutes and executive orders that exempted residences. • Public concerns about privacy rights in homes coupled with emphasis in MR/DD systems on protecting clients’ autonomy in their homes. • Federal regulations that protect resident autonomy and self-determination in Medicaid-certified programs.

14. I. State Clean Indoor Air Statutes and Executive Orders • Most state agencies with policies were simply complying with state clean indoor air statutes (28) or executive orders (8) banning or restricting smoking in state government buildings or worksites. • Many clean indoor air statutes and executive orders focused on office worksites or exempted “residences.” • Examples of statutory exemptions for residences • CO – “residential portions of facilities” • ID – “custodial care and full-time residential facilities” • RI – “private home which may serve as a worksite” • CA – “private residences, except for … residences licensed as family day care homes” • DE – “private homes, private residences” • NY – “private homes, private residences”

15. II. Concerns About Privacy Rights And Client Rights • There is little public support for extending intrusive public policies, like smoking restrictions, into homes. • State MR/DD agency policies support clients’ lifestyle choices in their homes. • Clients who smoke at home are viewed as making a choice that state agencies should respect. • “Our service system is very person-focused and individual client-driven. …When a person makes an informed choice to smoke, he/she is supported in a way that is reasonable safest for him/her and all those living or working with him/her.” (KS)

16. III: Federal Medicaid Regulations • Regulations governing Medicaid-certified facilities protect the rights of residents to self-determination. • Some have interpreted “Interpretive Guidelines” as saying smoking inside is a “quality of life” issue for residents and must be permitted.

17. Union Role • In 5 states, state employee unions negotiated smoking policies with agencies under collective bargaining agreements. • These policies generally: • Protected rights of employees to smoke in designated areas, particularly if clients were allowed to smoke; • Neglected rights of non-smoking employees to clean indoor air at work; • Focused on non-residential buildings.

18. Conclusions • Direct support workers associated with state MR/DD agencies are vulnerable to chronic ETS exposure at work because: • Many clients and workers smoke. • Agency policies tend to support the rights of clients to smoke inside residences. • 17 agencies had no smoking policies. • Neither agency policies nor the state clean indoor air statutes & executive orders on which they were based: • acknowledged that residences may be worksites. • recognized health risks facing direct support workers in residences where people smoke.

19. Conclusions • Direct support workers in human services who are exposed to ETS when they work in clients’ homes appear to be an invisible workforce that is off the radar screens of those responsible for protecting worker health and safety. • “Behind closed doors”

20. Policy Recommendations • Smokefree workplace statutes and executive orders intended to protect “all workers” must include direct support and other home care workers. • State clean indoor air statutes and executive orders that exempt residences as “places of employment” indicate that the decision to exclude direct support and other home care workers was a deliberate policy decision, not an accident, and needs to be reconsidered. • Clients and direct support workers should smoke outside.

21. Policy Recommendations • Traditional occupational health and safety protections, in addition to workplace protections from ETS, should be extended to home care workers. • Meanwhile, human service agencies should inform direct support staff about potential exposure to ETS on-the-job and allow them to select alternative smokefree worksites.