In-depth interviews were conducted with 54 home care clients and their home health aides and personal care attendants. The interview data reveal that home care relationships tend to be both formal and informal, in that job responsibilities tend to be diffusely defined and home care workers often become involved in the "backstage" world of their clients. The study also suggests, however, that personal bonds may be problematic for both workers and clients. For workers there is the risk of exploitation; for clients, there is the potential for loss of control over their own care. The quality of relationships also affects quality of care.

Using data from diverse sources, we conclude that the jobs of paraprofessional home care workers who provide ongoing care for older clients would be more intrinsically rewarding and offer better conditions for high-quality care if workers had more contact with supervisors and peers, more information about clients and care plans, clearer accountability, and more authority. The home care worker's relationship with clients, which also affects quality of care, can be improved by addressing such issues as adequate compatibility, communication, boundary maintenance, balance of power, commitment, and flexibility.

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The lifetime outcome for individuals diagnosed with affective disorders is generally more favorable than for those diagnosed with a schizophrenic disorder. We determined if a similar differential outcome could be detected among 139 patients hospitalized on the admissions unit of a state psychiatric facility between 1998 and 2001, and diagnosed with a Schizophrenic, Schizoaffective or Affective Disorder. The placement of each patient on discharge was categorized as an outpatient environment, a minimum-security treatment unit, a locked ward, or a highly secure forensic facility. Patients with an affective disorder were significantly less likely than the other two groups to have a co-occurring diagnosis of substance abuse, and they performed better on the neuropsychological assessments. However, the groups did not differ in their discharge placements, or in their length of stay. These findings suggest that resolution of more acute symptomatology may be unrelated to factors associated with long-term outcome for individuals suffering from severe and persistent mental illness.