Lisa Bednarz, LCSW, CMAC, ACM-SW, with input from Lisa George, MS, MHCI

In the mid-1980s, my mom spent her days raising her children and her nights moonlighting as an on-call visiting nurse. When she accepted the nursing job, they assured her she would “never be called”—but, of course, she was. All the time.

She recalls patients warning her, “I wouldn’t come around here if I were you.” My father worried about late-night calls in high crime areas. Without childcare, he would bundle us kids into the car and drive her to the patient’s home, waiting in the driveway until she re-emerged so we could all go back to bed.

Flash-forward two decades, when I’m a new graduate in my first “real job” as a home-visiting social worker in New York City, trekking around the South Bronx. Each time I stepped into a stairwell or heard the heavy click of a door closing behind me, I felt a hitch of anxiety.

Today I think about these experiences all the time when advocating for my patients in the hospital. In 1986, The Emergency Medical Treatment and Labor Act (EMTALA) obligated hospitals to treat anyone in need, regardless of circumstance. As an ideal, this resonates deeply, ensuring that access to health care remains paramount, particularly as we continue to strive for health equity.

However, as care shifts from hospitals to homes, a new challenge emerges: how do we ensure equitable health care access while also keeping our workforce safe in unpredictable, uncontrolled environments? We need to rethink how we support health care workers in the field—whether through enhanced safety measures, stronger community partnerships, or innovative technology that ensures help is always within reach.

The COVID-19 pandemic catalyzed a major shift in health care delivery: the rise of home-based care. Buoyed by an aging population and fueled by advancements in virtual care, remote monitoring, and artificial intelligence, home-based care is projected to be a major player in the health care landscape, with as much as a three- to fourfold increase in services delivered at home.

Hospital-at-Home (HaH) programs are a prime example of the rapid evolution in home-based care. These programs, which have existed in other countries for decades, are experiencing a surge in popularity in the United States. Fueled by the pandemic and CMS's Hospital Without Walls initiative, the number of hospitals offering HaH programs doubled from 2021 to 2023, with a projected market value of $300 billion by 2028.

At the same time, however, home health agencies are experiencing a drastic increase in service denials. In October 2023, referrals were denied at a 65.5% rate.  Staffing shortages and capacity constraints are part of the equation, but a growing concern is the complexity of patients' psychosocial needs. Referral data reveals a 16% increase in alcohol use disorders, a 12% increase in drug use disorders, and a 3% increase in psychoses among home health patients over the past several years. Emerging data about the complexity of patients now reflects what I, as a social worker, have always embraced: humans are messy.

The trend toward care at home has been steadily progressing for years, driven by factors like value-based care models and episodic payment structures. However, challenges remain, including patient suitability, reimbursement uncertainties, and workforce limitations. Additionally, the shift toward home-based care raises major questions about worker safety and health equity.

Forty years after my dad waited in the driveway for my mom, the specter of violence looms large for home health workers. A tragic example from October 2023 involved a visiting nurse from Connecticut who was murdered in the basement of a halfway house where her patient resided. This is not an isolated incident.  The rate of physical violence against health care workers is 20.8%, with greater than 50% of home health workers reporting experiencing or witnessing at least one incident of violence or harassment. Patient factors like violence history or mental illness/substance use disorders further elevate this risk. Not only is this unconscionable,it no doubt contributes to the growing scarcity of home health resources the system is currently experiencing.

The need to ensure worker safety is a major driver behind service denials by home health agencies. Unsafe neighborhoods, “high-risk diagnoses,” and patient non-adherence are all factors that can lead to denials. While this concern is understandable, the consequences for patient care and health equity are considerable.

Consider this real-life scenario: a local motel is used as emergency shelter by the municipality’s board of social services. That motel is also considered a “blackout zone” for homecare, given safety risks assessed by the region’s home health agency. While not deliberate, this decision has left unhoused individuals less access to care and more adverse health outcomes.

Individuals with mental illness, substance use disorders, or those living in poverty are more likely to face these obstacles to home-based care. They may reside in unsafe neighborhoods, lack social support networks, or be impacted by the digital divide. Paradoxically, the populations most in need from a health equity standpoint are also those most likely to be denied services due to worker safety concerns.

This can be seen in the emerging trend of health care systems "flagging" patients deemed at risk for violence in electronic health record. A 2022 JAMA study found that Black patients were more likely to be flagged for behavioral issues in the emergency department compared to white patients. This can lead to unequal care, with flagged patients experiencing longer wait times and less access to diagnostic testing. A 2023 Study in the Journal of General Internal Medicine found that Black patients were 1.37 times more likely to have a security emergency response than white patients in the same hospital setting.

Health care organizations have an obligation to keep their clinicians safe; this requires proactive risk stratification and planning.  Reacting after violence is never acceptable.  Assessing an individual’s potential for future violence, however, is highly subjective and susceptible to implicit bias. The genuine concern leading to judgments about perceived risk exacerbates health disparities, as does the blanket categorization of certain diagnoses and settings as “dangerous.”

In 1994, William Kissick introduced the concept of the health care “Iron Triangle” in his book Medicine’s Dilemmas. The idea was that health care cost, quality, and access are so intrinsically linked that advancements in one area could only come at the expense of the others.  For thirty years, health care scholars and leaders alike have studied this concept, crusading toward a way to break the triangle.

In 2025, we’re facing another iron triangle. The confluence of factors in the current health care climate have created a complex scenario where three critical health care priorities—worker safety, health equity, and the expansion of home-based care—seem to be on a collision course. Innovating to resolve these competing forces will be paramount in shaping the future of health care delivery.

Lisa Bednarz is a licensed clinical social worker and an industry leader in hospital case management and social services. She is a 2024 graduate of the University of Pennsylvania’s Master of Health Care Innovation program.

Special thanks to Lisa George, MS, MHCI, Master Improvement Advisor at UPenn Abramson Cancer Center, for her commitment to health equity and her contributions to the research for this post.