Health, work and policy in California's consumer-directed model of homecare

California's In-Home Supportive Services program (IHSS) employs over 200,000 workers through a consumer-directed model of care. This paper examines the Los Angeles County IHSS workforce (half of those employed statewide), an ethnically diverse group of primarily women (86%), half of whom are immigrants, and three-quarters of whom care for family members. Data are derived from a survey of 1,614 respondents and from multilingual focus groups with 71 workers. Results were analyzed to: 1)examine the relationship between job-related stressors and health outcomes (health status, fatigue and job satisfaction), 2) determine if support or control mediates that relationship, and 3) identify policy changes to ameliorate job stressors. Thirty-seven percent of workers report fair-poor health, 24% have difficulty recovering from fatigue, and 41% report low job satisfaction. Multivariate analyses found that emotional and physical demands, schedule demands such as hours of work and overtime, and financial strain were significantly associated with one or more outcomes. Support and control (decision latitude, job security and union involvement) demonstrated both direct and mediating effects. These results have implications for government policies that determine health benefits, sick leave, the availability of respite care, wages and employment security. They also raise questions - how can policy makers assure that authorized hours of care are sufficient to meet consumers' needs for affective and physical care? Who is reponsible for providing training and protective equipment for workers in consumer-directed models of care? How can the union-consumer coalition be proactive in advocating for policies that enhance both worker and consumer health?