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The estimated 2.5 million people employed as home health and personal care aides provide crucial long-term care to elders and people with disabilities, yet their jobs are inadequately supported and compensated, according to a comprehensive new PHI analysis of the workforce.

The just-published 120-page report — entitled Caring in America — A Comprehensive Analysis of the Nation’s Fastest-Growing Jobs: Home Health and Personal Care Aides — is the most in-depth analysis of America’s home care jobs available.

The report concludes that despite being the nation’s most high-demand occupation, the home care and personal assistance workforce is characterized by:

• Poor wages
• Inconsistent training requirements
• Inadequate health care coverage
• High injury rates
• Unpredictable hours
• Heavy reliance on public benefits

As a result, the report warns, our nation is unprepared to meet the needs of its rapidly aging population.

“At a Crossroads”

“Carework in America is at a crossroads,” said PHI Director of Policy Research Dorie Seavey, Ph.D., a labor economist and the nation’s leading expert on the home care workforce. Seavey authored the report with PHI Policy Associate Abby Marquand, M.P.H.

Seavey continued:

“We can continue the status quo of poorly supported and poorly compensated jobs, consigning home care workers to near-poverty earnings and home care to a revolving door of caregivers. Or, we can leverage this workforce’s enormous potential as both an underutilized asset in our health care system and as one of the strongest job growth engines that our economy has to offer.”

Between 2008 and 2018, the home care workforce is expected to grow at rates four to five times faster than jobs in the overall economy.

Hopes for Report

“Our hope is that this resource will promote a better and broader understanding of the workforce, as well as the large and growing eldercare/disability services industry it supports,” wrote PHI National Policy Director Steve Edelstein in the report’s foreword.

“We also hope that it will facilitate a more informed public discussion of key issues shaping the future of in-home services, aiding the development of both effective policy solutions and a targeted industry response,” Edelstein continued.

For more information on the direct-care workforce, including the PHI State Data Center, Chart Gallery with downloadable graphs and charts, and Fact Sheets, visit PHI PolicyWorks.

– by Deane Beebe and Matthew Ozga

Direct-care workers in training

A new PHI analysis found that only 15 states require home health aides to have more training hours than are federally mandated, yet 30 states and the District of Columbia require certified nurse aides (CNAs) to have more training hours than the federal requirements.

In 1987, the federal government set a training standard of 75 hours, including a minimum of 16 hours of clinical training, for both home health aides and CNAs who are employed by Medicare-certified nursing homes or home care agencies.

“Our analysis shows that state home health aide training requirements have not kept pace with their nursing home aide training requirements, even though these direct-care workers provide essentially the same care and services,” said Steve Edelstein, PHI national policy director.

“Although it is clearly time to revisit the federal standards, having states move ahead on their own to upgrade training requirements is a step in the right direction.”

In Retooling for an Aging America, a 2008 report, the Institute of Medicine (IOM) recommends that the federal minimum training requirement be raised to at least 120 hours for both CNAs and home health aides and that competency in elder care be demonstrated as a criterion for certification.

Other Findings

The PHI analysis also found that:

• 4 states meet the IOM recommended training standard for home health aides;
• 14 states meet the IOM recommended training standards for CNAs;
• 13 states require more than 16 hours of clinical training for home health aides — the federal minimum training requirement; and
• of the states that exceed the federal training standard, 9 require home health aides to be CNAs, and 4 allow CNAs to become home health aides with supplementary training.

Trend Toward Home and Community-Based Care

Today, the majority of direct-care workers, including personal care aides, are employed in home and community-based settings (pdf).

By 2018, home and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.

“Current federal training standards have not kept pace with changes in public policy and services delivery and do not adequately prepare the direct-care workers who provide the lion’s share of paid hands-on long-term care,” Edelstein said.

“The federal government must modernize training requirements for direct-care workers to help them gain the skills and knowledge they need to help elders with chronic and complex medical conditions live as independently as possible where they prefer — in their homes and communities.”

To compare the training requirements for home health aides and certified nurse assistants in each state, visit the PHI PolicyWorks website.

– by Deane Beebe

The average private-pay rates for home health aides remained $21 for the third straight year, even as the overall cost of long-term care continues to rise in the U.S., according to a newly released study.

Meanwhile, adult day service centers, which employ direct-care workers, saw their daily cost-of-care rate increase slightly to $70, from $67 in 2010.

The study was published last month by MetLife Mature Market Institute, the research wing of the insurance company.

Only about half of the cost of home health aide services actually goes to the aide herself. According to PHI research, the median hourly wage for home health aides was $9.85 in 2009, the last year for which data are available.

Long-Term Care Costs Rising Overall

MetLife’s study shows that, overall, the cost of obtaining long-term care in most settings continues to rise.

In 2011, the daily average rate for a private room in a nursing home increased by 4.4 percent, to $239. In assisted living communities, meanwhile, the average monthly rate rose to $3,477, an increase of 5.6 percent.

The CLASS Program, a voluntary long-term care insurance program that was passed as part of the Affordable Care Act, was created to help people pay for the skyrocketing costs of long-term care.

However, the Obama administration could not demonstrate that the program would be financially solvent. While advocates continue to press for the program, its future remains uncertain.

A separate MetLife survey on the “retirement income IQ” of pre-retirees (aged 56-65) found that many are misinformed about how they will be paying for long-term care: 42 percent of respondents incorrectly believe that such care is covered by health insurance, Medicare, or disability insurance.

– by Matthew Ozga

PHI President Steven Dawson

PHI President Steven Dawson argues that both a flagging economy and efforts to move toward new models of care provide the opportunity for the health care industry to redefine the role of the home health aide.

In a guest blog post for the Collaboration for Homecare Advances in Management and Practice (CHAMP), Dawson writes that “greater person-centered, cost-effective care is standing before us.”

He recommends that home health aides be given the tools they need to practice at the top of their license.

The CHAMP Program, based at the Center for Home Care Policy & Research of the Visiting Nurse Service of New York, is a national initiative to advance home care excellence for older people. The online site provides home care clinicians with evidence-based tools, e-learning opportunities, and expert advice.

– by Deane Beebe

Massachusetts State House in Boston

PHI Massachusetts lent its support to two bills at a July 19 hearing on home and community health care provider policies, held by the Joint Committee on Public Health.

“An Act Relating to Training for Certified Nurses’ Aides and Direct-Care Workers,” Senate Bill 1121, calls for a review of current training standards for home health aides and certified nurse aides (CNAs) in the state.

“An Act Relative to Home Health Aides,” Senate Bill 1138, would expand the current role of home health aides (HHAs) in the state and, with appropriate training and oversight, allow them to administer some medications.

Facilitating a Career Lattice

Passage of the training standards bill would be well-timed: Massachusetts is one of six states to receive a Personal and Home Care Aide State Training (PHCAST) demonstration grant from the Department of Health and Human Services.

“The PHCAST demonstration grant will position Massachusetts as a leader on training standards for personal care attendants and personal care aides nationally — and also lay the foundation for a portable credential in the state,” said PHI Massachusetts State Director Amy Robins in her hearing testimony.

“A close examination of training standards for CNAs and HHAs could help facilitate the creation of a clearly articulated and intentional career lattice among direct-care occupations. This would allow workers to advance to new positions and move across settings — keys to cultivating, recruiting, and retaining the direct-care workforce Massachusetts will need in the coming years,” Robins’ testimony (pdf) concluded.

Medication Administration

Senate Bill 1138 provides a very attainable advancement opportunity for HHAs who are interested in medication administration.

“The experience of others demonstrates that this can be done safely and effectively — and that this strategy also helps ensure the best value for our health care spending, with all working to the top of their training and licensing,” Robins’ testimony (pdf) said.

The bill “would send a clear signal that the state recognizes the importance of this vital workforce and the need to do more to improve these jobs and create meaningful advancement opportunities,” her testimony continued.

There are nearly 100,000 direct-care workers in Massachusetts. Direct-care jobs are the second largest occupational grouping in the state and are expected to grow by 22 percent by 2016, dramatically outpacing the growth of other jobs.

Home and community-based direct-care jobs are among the state’s lowest-paying jobs, paying wages that fall below the state’s low-wage threshold.

“Quite simply, the state must do more to cultivate a high-quality, well-trained and stable workforce,” Robins says. “These two bills are important steps in the right direction.”

For more information on the direct-care workforce in Massachusetts, see State Facts: Massachusetts’ Direct-Care Workforce (pdf).

– by the PHI Policy team

NY Capitol Building in Albany

The New York State Budget for 2011-2012, passed on March 31, includes sweeping legislation that will dramatically alter the way New York pays for and delivers Medicaid services, particularly in home- and community-based settings.

Most of the recommendations of Governor Andrew Cuomo’s Medicaid Redesign Team (MRT), which was charged with identifying the best ways to reduce costs and improve the health delivery system, were incorporated.

PHI has been an active proponent for two key measures that were included in the budget:

• Wage parity for home health aides: Organizations providing Medicaid services in the downstate area — New York City and Westchester, Nassau, and Suffolk counties — are required to compensate their home health aides using the living wage of that geographic area, which will result in an hourly wage increase of $2. As a result, home health aides will earn the same wage as personal care aides.
• Care management models and the integration of services within capitated models of care: Beginning in April 2012, consumers who need more than 120 days of community-based long-term care will transition into care management models. And personal care will be incorporated into the Medicaid managed care benefit once the state gets approval from the federal government.

PHI and Independence Care System Provided Blueprint for Reform

PHI and its affiliated managed long-term care organization, Independence Care System, advocated for the wage improvements for home health aides as well as the greater use of care management models. Both of these provisions were in the blueprint (pdf) they presented to the MRT.

Once implemented, these provisions will increase efficiency and address a long-standing inequity in the pay for home health aides.

“Home health aides have always been underpaid for the difficult, sensitive, and important work they do,” says Assembly Member Richard N. Gottfried.

“At some home health agencies, the under-compensation has been shocking. The living wage provision in the state budget, together with other reforms, will bring more fairness to home health aides, reduce costly turnover that reduces quality, assure more appropriate services, and reasonably contain costs. However, it is important that these reforms be implemented carefully, to avoid disruption and unintended damage to good providers,” Gottfried said.

Living Wage Implementation

In New York City, parity with the personal care aides, who currently earn $10 an hour, would be implemented over a 3-year period. Home health aides will begin the transition to parity starting March 1, 2012.

Although Westchester, Nassau, and Suffolk counties have living wage laws in effect, the home health aides working in these counties will not receive an increase until March 1, 2013. However, aides in these counties may reach 115 percent of total compensation required under the New York City living wage law by March 2016.

Health care benefits and paid time off are determined by the collective bargaining agreement (CBA) in effect on January 1, 2011 or by the terms of the Living Wage law in the county in which care is delivered, if there is no union contract.

“This budget finally corrects an injustice that’s been in place for many years,” says PHI New York Policy Director Carol Rodat. “It’s not only good economic policy given the size of the home care aide workforce, but wage parity ensures continuity of care as it makes it possible for aides to remain with their clients when they transition to care management models.”

PHI Longtime Supporter of Wage Parity

PHI has been a strong advocate of improving jobs for home care workers as a means of reforming the Medicaid system. PHI has published several papers that detail the size, training, and health coverage of the home care workforce, including the inequities in the home health aide wages.

“The United Hospital Fund has long supported analytic work that focuses on the direct-care/home care workforce, beginning with the 1994 report, ‘Better Jobs, Better Care: Building the Home Care Work Force,’ and more recently through the support of three PHI reports on the aide workforce,” says UHF Senior Vice President for Program David Gould.

“We’re pleased that the state’s budget recognizes the importance of this workforce by providing a movement towards parity for the home health aides. This provision promises to encourage continuity of care while creating better jobs, and we applaud PHI for its work in this arena,” Gould added.

– by the PHI New York State Policy Team