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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

The Huffington Post has published a column about home health aides written by Marki Flannery, president of the New York-based home care agency Partners in Care.

In the column, Flannery writes about how critically important home health aides can be to elders who require regular caregiving.

“Trained home health aides are highly skilled, compassionate caregivers,” Flannery writes, adding that “the job of a home health aide cannot and should not be done by just anybody — contrary to all-too-popular belief.”

About 22,000 home health care workers in Washington State will be awarded $57 million in back pay, the result of a Thurston County jury decision delivered on December 20.

From 2003 to 2007, the Washington Department of Social and Health Services (DSHS) made across-the-board 15 percent pay cuts to people with Medicaid who received care from a home care aide who lived in the consumer’s home.

The reason the state gave for what was called “shared-living-expense cuts” was that tasks performed by the in-home health aides, such as cooking, shopping, and doing laundry, were considered household services that the aides would be doing anyway, according to the Seattle Times.

“The state knew that many of these people had family, relatives, and friends who would take care of them no matter what,” Greg McBroom, who represented the workers, said in the Times. “They knew they could take advantage of them.”

In 2007, however, the Washington Supreme Court ruled that the cuts violated federal Medicaid law, which requires that all people with Medicaid benefits be treated equally. The state did not first assess the individual needs of each client as required by law.

Large Sum for Minimum Wage Workers

The workers filed a class action suit against DSHS in 2007, seeking the amount of pay that had been withheld over the years. The award is reported to be the largest damage award against the state.

“The jury, after hearing from both the workers and Medicaid beneficiaries, and from DSHS personnel who implemented the pay reduction, found that DSHS breached its duty of good faith and fair dealing with the workers,” McBroom said. “This case has always been about whether DSHS should pay for work it required these folks to do.”

“While the total recovery is very large, the award to the workers amounts to about $2,500, on average,” said Darrell Cochran, another attorney who represented the workers. “That $2,500 is a very large sum to someone making the minimum wage.”

The state is deciding whether to appeal the jury’s decision, according to Bloomberg News. A statement (pdf) released by one of the law firms representing the plaintiffs says that the state will “probably” appeal the jury’s verdict.

– by Deane Beebe

The average private-pay hourly rate for a home health aide was $21 in 2010 — the same price as last year, according to a recently published survey of long-term care costs.

The daily average cost of care at adult day service centers — which employ direct-care workers — also remained constant, at $67.

Meanwhile, other types of long-term care increased in cost according to the survey (pdf), which was published in October by MetLife Mature Market Institute, the research wing of the insurance company.

For example:

• The average daily cost of renting a semi-private room in a nursing home increased by 3.5 percent (to $205 from $198);
• The average daily cost of renting a private nursing home room increased by 4.6 percent (to $229 from $219);
• And the average monthly rate of living in an assisted living community went up by 5.2 percent (to $3,293 from $3,131).

Home Health Aides See No Gain

Although private-pay home health aide services cost an average of $21 an hour, only about half of those dollars goes to the aide.

In 2009, the last year for which data are available, the median hourly wage for home health aides was just $9.85.

In terms of real dollars, however, home health aides’ wages have gone down over the last 10 years, from $8.21 in 1999 to an inflation-adjusted $7.85 in 2009.

“It is clear that consumer preference is shifting away from more institutional facilities such as nursing homes and to home and community-based care settings,” said Dorie Seavey, Ph.D., PHI director of policy research. “However, this report, combined with PHI’s own research on direct-care worker compensation, shows that home health aides and homemaker/companions are not reaping any benefits of that increased demand in terms earning more competitive wages for their work.”

– by Matthew Ozga