Low Pay & High Turnover a Barrier to Quality Home Care
Geraldine O’Rourke knew that she was going to need help for the rest of her life when she returned to her Bronx home after spending nine months in the hospital. She was bedridden due to two hip operations gone wrong and recognized that her husband and family wouldn’t be able to tend to all of her needs.
“I needed help right then and there,” she says of the moment 10 years ago, while sitting in her wheelchair, television remote in hand. “I couldn’t walk and then what happened is the good hip kept coming out of place. I could hardly do anything for myself.”
The 83 year-old former bank worker lost her husband to rheumatoid arthritis six years later and now relies on two home health aides who clean and cook for her and help her bathe and climb into bed at night. Yvonne Garcia is from the Dominican Republic and spends four days a week with O’Rourke. Ifua Morson is from Ghana and is responsible for the other three days. Both Garcia and Morson spend the night at their client’s home but they are only compensated for 12 hours out of a possible 24. This is common in a field where home care agencies often refuse to split long shifts between home health aides in order to save on costs.
“We’re only responsible for one client but my previous one wanted me to take care of her husband as well when we visited his nursing home,” says Morson. “And she wouldn’t allow me sleep at all. She called on me all night. That was really challenging for me so I left.”
Morson’s first case only lasted a week. She refused to stay on permanently after the client’s son sexually harassed her. Morson and Garcia represent just two of the 2.5 million home health aides in the US and are part of the 23 percent who came from abroad. With 210,000 workers, New York State currently has the most extensive home care network in the country. Approximately 130,000 live and work in New York City, making them the single largest occupational group, ahead of schoolteachers and registered nurses.
Despite their high numbers and the rising demand for them as America ages, median wages for home health aides have actually decreased over the years. When adjusted for inflation, an aide makes $9.91 on average today compared to $10.22 in 2001.
“Maybe I would switch jobs if a better one comes along. I need a better job that pays well so that I can take care of other things. I have a family back in Africa that I have to take care of,” says Morson who has been in the field since last February and makes a little over nine dollars an hour, with no health benefits.
Morson is not the only one who would quit if a better opportunity presented itself. Low wages, difficult schedules, high injury rates, and the demanding nature of the job mean that turnover rates in long term care hover at around 50 percent according to Steven Edelstein, the Paraprofessional Healthcare Institute’s National Policy Director. This is problematic for older and disabled clients as well considering that the quality of care that they receive improves as the worker spends more time with them.
“If we’re really serious about providing services to people in their homes, where they want them, we really need to do better at making these home care jobs good jobs. That way we can attract people into them and meet the demand for services that we know is coming over the next decade as the baby boomers age,” said Edelstein at PHI’s headquarters in the Bronx.
O’Rourke agrees, adding that she has a much better relationship with Yvonne who has been working with her for three years than she does with Ifua who is on her third client since she came to the United States from Ghana at the beginning of 2012. Due to high turnover and rising demand, the field is expected to add 100,000 positions by the year 2016.
According to the Bureau of Labor Statistics, employment will grow by 69 percent by 2020, representing a growth of 1.3 million jobs. As of right now, none will be covered by the Federal Fair Labor Standards Act despite President Barack Obama announcing new proposals last year that would include home care workers under federal minimum wage and overtime protections.
These proposals are yet to be adopted. New York is one of 15 states that does provide such protections but workers receive overtime at a reduced rate of 150 percent of the minimum wage, not 150 percent of their regular pay and it does not kick in until live in workers reach 44 hours, as opposed to the regular 40 hours. In addition, workers are not compensated for the time it takes to travel between clients’ homes, if they have more than one.
“Home care isn’t your typical labor market because a lot of these services are paid for by government programs,” explains Edelstein. “The government sets the standard for what reimbursement to agencies is and therefore what workers can be paid. So it doesn’t respond in the same way to your basic supply and demand and it keeps wages low.”
Susan Perlstein, a long time advocate for older people and former geriatric social worker has her own take on the poor compensation. She has trained home healthcare workers and knows how difficult a job it is. Her late mother went through 13 foreign home health aides over the last four years of her life. Perlstein found the last one through a private home care agency.
“Low wages reflects the lack of value that society has for older people, for end of life care, and for the importance of making sense and meaning out of people’s lives as they pass away,” says Perlstein, founder and board member of Elders Share the Arts.
Most clients, including O’Rourke, rely on Medicaid to help them shoulder the costs of long term services. Nearly four million people pay for such care through Medicaid, representing 62 percent of all spending on it. This especially relevant in New York where the nation’s largest Medicaid program is undergoing a redesign with a view to cutting costs that have reached $50 billion on entitlements.
Caryn Resnick, the Deputy Commissioner at New York City Department for the Aging, admits that given the size of the redesign effort, there are many unknowns with regards to how it will ultimately be implemented and as community-based long term care recipients make the move to capitated managed care models.
“The advocates are very concerned. There’s a huge fear for people getting dumped, for people ending up in nursing homes,” she says. “HRA (Human Resources Administration) was particularly generous in giving out hours. So there’s a huge fear that what’s going to happen is that they’re going to give out eight hours and if you’re someone who’s been getting two 12 hour shifts or a 24 hour, that’s going to be virtually impossible to get anymore.”
That would obviously pose a problem for O’Rourke and others like her but PHI’s Steven Edelstein says that consumers and worker advocates who are involved in the redesign are doing their utmost to make sure that older and disabled clients do not start seeing reductions in the quantity or quality of their care.
Aside for its stated goal of improving efficiency, New York’s Medicaid redesign initiative aims to create wage parity between home health aides and less skilled personal care aides who currently earn more due to differences in how their respective services are delivered. Jenette Mitchell, an instructor at Cooperative Home Care Associates, believes such action is long overdue. She became a home health aide in 1995 but switched to training those going into the field two years ago to benefit from better pay.
“Progress has been made but I’m hoping more can be done as far as getting a better salary for these ladies who help people stay in the comforts of their own home,” says Mitchell. “They are certainly saving the government a lot of money because many of their patients could end up in nursing homes without them. That would surely be a lot more expensive.”