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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

A new PHI PolicyWorks analysis of wage trends for personal care aides (PCAs) finds disturbing evidence that the already low wages earned by these aides are eroding in the midst of these difficult economic times.

For the first time since these wages have been reported (1998), the national median wage for PCAs reversed direction and crept downward slightly, due to a decline in PCA wages in one-third of states (17). In contrast, the average wage for all jobs in the economy increased from $15.95 in 2009 to $16.27 in 2010.

In 2010, 34 states reported average hourly wages that fell below 200 percent of the Federal Poverty Level, according to the analysis reported in PHI’s updated State Chart Book on Wages for Personal Care Aides.

Wages below 200 percent of the federal poverty level ($10.42) are low enough to qualify workers for many state and federal public assistance programs.

“Fully two-thirds of states continue to show very low wage levels for personal care workers,” said Dorie Seavey, PHI director of policy research. “And we know from other federally sponsored surveys that, in 2010, fewer PCAs worked full-time throughout the year than in previous years. These two things together — fewer work hours and stagnant or declining wages — translate into lower earnings and family income for these workers.

“These very low wages are a significant obstacle to meeting the country’s rapidly growing demand for personal assistance services,” Seavey continued. “They also jeopardize the economic security of hundreds of thousands of caregivers who make it possible for others to live independently.”

Data Spans 10 Years

The updated chart book tracks PCA wages in all 50 states and the District of Columbia, and presents data from 2000 to 2010.

Other highlights include:

• In 2010, within the continental U.S., state nominal median wages ranged from $8.14 in West Virginia to $12.53 in the District of Columbia; real median wages (in 2000 dollars) ranged from $6.41 to $10.14.
• Over the 10-year period, 26 states showed a decline in real median wages for these workers. Fourteen states saw real wages fall by 5 percent or more.

State of the Nation’s PCA Workforce

The forthcoming PCA Workforce Advisory Panel, established by the Affordable Care Act, is charged with examining the condition of the nation’s PCA workforce. Specifically, the panel is to advise Congress on its assessment of PCA workforce issues, including wages and benefits, and the adequacy of the workforce relative to expected future demand for in-home services and supports.

Additionally, the U.S. Department of Labor is considering whether the current regulatory scope of the “companionship exemption” under the Fair Labor Standards Act continues to be appropriate in light of substantial changes in the home care industry over the last 35 years. That exemption currently precludes a broad swath of the PCA workforce from wage and hour protection.

“Narrowing the exemption won’t result in an instantaneous improvement in PCA wages,” Seavey said, “but it will end the second-class status of these jobs, and help put them on a stronger footing.”

– by the PHI Policy team

An essay by Michael Ogg published in the January 2011 issue of Health Affairs provides a moving personal account of how two personal care assistants make it possible for him to live home alone independently in New Jersey.

Ogg, a 56-year-old retired physics professor who is severely disabled by multiple sclerosis (MS), details his day in “Running Out of Time, Money, And Independence?” in the health policy journal’s “Narrative Matters” section.

He describes how Nelita Dossous, his personal care aide, provides an invaluable hour and a half of care each morning, getting him up, toileted, bathed, and dressed; she also helps to get him breakfast, do laundry, and perform other household chores. The second aide, Louis Serge Michel, comes in at night and does “much of what Nelita did earlier, but in reverse,” Ogg writes.

During the day, Ogg manages the best his can on his own. He could use much more help but cannot afford it.

He recounts two emergency situations that occurred during the day — an incident where he spilled hot soup on himself and a wheelchair malfunction that left him in a maximum tilt — and how the home care agency immediately sent someone over to help.

Concerns About Cost

What most concerns Ogg is how he will be able to continue to pay for the personal care aides, whom he has grown to know and trust. His aides are very familiar with his needs and are able to attend to them efficiently and precisely.

He says that it is too late for him to be helped by the CLASS Act, the voluntary federal insurance plan established under the health care reform law to help people purchase long-term services and supports, but that it will help others in his situation down the road.

In “The Miracle Workers,” published in The New York Times‘s “New Old Age” blog on January 6, Jane Gross reports on Ogg’s essay and writes, “The value of the home aide’s work is rarely described in such eye-opening detail.

– by Deane Beebe

Direct-care workers in training

The Iowa Department of Public Health (IDPH) was awarded a $2.2 million Personal and Home Care Aide State Training Program (PHCAST) demonstration grant to develop and pilot a training and credentialing model for direct-care workers.

The three-year grant, which was awarded by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services, will be targeted to one urban and one rural region in the state.

Direct-care professionals who participate in the project will work in a variety of settings and provide services and support to Iowa’s elders and people living with disabilities.

“The focus of the project is to develop a direct-care training and credentialing system that can be replicated nationwide,” said Erin Drinnin of the IDPH Bureau of Health Care Access.

“The goal is to provide responsive and flexible training, promote the highest quality of care, and develop career pathways to professionalize the direct care workforce in Iowa,” Drinnin said.

One Step Closer to Professionalization

The funded project is based on the recommendations of the Iowa Direct Care Worker Advisory Council, which was established by the Iowa Legislature in 2008. The Advisory Council was previously known as the Iowa Direct-Care Worker Task Force, which was established in 2005.

“With the grant, Iowa will move one step further toward the establishment of a Board of Direct-Care Workers, which was legislated in 2010,” said Iowa Caregivers Association Executive Director Di Findley, who is a member of the Advisory Council. “Through the grant we will be able to pilot the recommendations of the Advisory Council that will ultimately credential, promote, and support the professionalization of this vital workforce.”

“Finally, direct-care workers will receive the professional status they deserve,” Findley continued. “We appreciate the Iowa Department of Public Health’s leadership in securing this grant to advance the work of Iowa’s governor-appointed Direct-Care Worker Advisory Council.”

Iowa is one of six states to receive a PHCAST demonstration grant. The five other states are California, Maine, Massachusetts, Michigan, and North Carolina.

– by Deane Beebe

Direct-care workers in training

The Michigan Office of Services to the Aging (OSA), Michigan State University-College of Human Medicine, and PHI have partnered to address the training needs of personal care aides (PCAs) who serve clients in MI Choice, the state’s Medicaid home and community-based waiver program.

Michigan’s Building Training…Building Quality (BTBQ) project will build and operate a sustainable “gold standard” training program and provide education to over 1,500 new and working PCAs.

PHCAST Award

The training project is made possible by a three-year, $2.03 million Personal and Home Care Aide State Training Program (PHCAST) demonstration grant awarded to OSA on September 29 by the U.S. Department of Health and Human Services (HHS) through Affordable Care Act funds.

Michigan is one of six states to receive PHCAST funding.

“Currently, there are no mandatory training requirements in Michigan for PCAs,” says OSA Deputy Director Peggy Brey. “This grant provides the opportunity to develop curricula and mobilize the aging and disability networks to increase and improve the skills of the long-term care workforce.”

Project Goals

The BTBQ project’s goals are to:

• Create a core curriculum that is based on competencies needed by newly hired PCAs to serve MI Choice clients.
• Build the state’s capacity to deliver adult learner-centered training for the entire PCA workforce, starting with 400 PCAs serving MI Choice clients during the grant period.
• Train PCA peer mentors to support the PCAs in the first six months of employment.
• Offer additional in-service training to PCAs on dementia, home management skills, and prevention of adult abuse and neglect.

The project will be evaluated by Michigan State’s Clare Luz, Ph.D., a gerontologist with clinical experience, who has worked closely with OSA to evaluate previous statewide training programs related to long-term care.

Rapid and Large Growth of Home Health Jobs

“This project also speaks to the huge number of home health aide jobs that the state projects will be created in Michigan in the coming years,” says PHI Midwest Policy Director Hollis Turnham. “Caregiving jobs in long-term care are growing at rates faster and larger than almost all other employment sectors in the state.”

More information on PCAs and the projected growth of Michigan’s direct-care workforce is available at PHI State Facts: Michigan’s Direct-Care Workforce (pdf).

– by Deane Beebe

Direct-care workers in training

The House Committee on Financial Services passed the Public Housing Reinvestment and Tenant Protection Act of 2010 (H.R. 5814) on July 27, which includes provisions to fund training for public housing residents to become home health and personal care aides.

If enacted, a three-year, federal pilot grant program would be established to train public housing residents to provide home health and personal care services and supports to public housing and federally assisted rental housing residents who are elderly or living with a disability, including veterans.

Home care providers, community health centers, faith-based organizations, labor organizations, public housing agencies, and state and local government agencies that have established — or provide assurances that they will establish — an employment training program would be eligible to apply for a grant.

The funding is targeted to programs that primarily serve urban, rural, or Indian populations, as well as people in Puerto Rico or the U.S. Islands.

Under the act, the U.S. Department of Housing and Urban Development (HUD) would receive $2.5 million for distribution in each fiscal year: 2011, 2012, and 2013.

Recognizing Workers’ Needs

In addition to supporting home health and personal care aide training, the grant money could also be used to cover transportation and child care expenses for the public housing residents in the training programs.

“This model recognizes the needs that many home care aides have as they transition to work, particularly child care and transportation,” said PHI New York State Policy Director Carol Rodat. “Funding for these critical supports is seldom available, which is why the grants envisioned in this legislation are so important.”

Income earned from providing home care services will apply toward the public housing residents’ eligibility for federal housing on a graduated basis for the first three years, with no income applying in the first year.

These provisions of the Public Housing Reinvestment and Tenant Protection Act of 2010, sponsored by Rep. Maxine Waters (D-CA), were taken from the Together We Care Act of 2009, introduced by Rep. Nydia Velázquez (D-NY) in December 2009 and cosponsored by Rep. Barney Frank (D-MA), the Financial Services Committee Chair, and Waters.

“Home care is a profession that will be in high demand for years to come and this legislation will offer hard-working public housing residents the tools they need to enter this field,” said Velázquez when she introduced the Together We Care Act last December.

– by Deane Beebe