Let’s Call Home Care Work What It Is: Skilled Work

During a recent workshop at the National Academies of Sciences, Engineering, and Medicine in Washington, DC, another panelist and I raised a complaint familiar to many leaders working in the long-term care field.

“‘Unskilled’ is the most inappropriate moniker you could ever hear,” said Joanne Spetz, Health Economics Professor at the University of California, San Francisco and Director of its Health Workforce Research Center on Long-Term Care, referencing a term frequently used to describe home care workers.

Dr. Spetz’s comments were part of a daylong session titled “Building the Workforce We Need to Care for People with Serious Illness.” Like her and others in the field, I regularly encounter—among individuals and the literature—problematic terms that wrongly classify home care work and underplay its complexity.

“I worry that the classification of ‘unskilled’ really understates their knowledge and what they bring to the table,” Dr. Spetz told the group. “We’ve got plenty of skill, talent, and passion to draw from in this workforce.”

Plenty of Skill

In the presentation that followed, I continued this thread, refuting the notion that home care should even be considered low-skilled work. With examples from my own experience, I described that on a given day a home care worker might have to:

• Obtain and synthesize clinical knowledge about clients’ physical and behavioral conditions, like understanding the changes in the brain that cause dementia and their effects on memory and emotions;
• Understand the client’s plan of care, including how to support them in managing symptoms—like pain, nausea, or confusion—in the home;
• Observe and respond to signs that could indicate a client’s condition is worsening, such as abnormal breathing or wound progression, as well as to environmental and social risks like obstructed walkways or loneliness;
• Provide hands-on assistance with activities of daily living, such as dressing, toileting, and bathing, while maintaining clients’ comfort and dignity;
• Physically maneuver clients, ensuring their safety (and the worker’s) by employing appropriate techniques for mobility transfers and operating assistive devices;
• Communicate effectively and respectfully with clients and their family members, remaining attuned to individual styles and preferences;
• Self-manage emotions, especially when navigating interpersonal conflicts or supporting a client who is in pain or distress; and
• Remain flexible and responsive to emergent needs in a work setting with a high level of unpredictability.

These examples show that home care, and other direct care work, requires far more than the completion of a few repetitive tasks. Rather, it draws on a diverse set of skills, knowledge, and abilities that are constantly at interplay.

But paid caregiving jobs are still labeled “unskilled” in relation to other health care roles and among “low-skilled” occupations broadly. Here’s what I’ve learned about why:

Checking the Labels

Clear criteria for what makes work “unskilled,” “low-skilled,” “middle-skilled,” or “high-skilled” are elusive. The most common distinction focuses not on the effort involved in a given occupation, but on the formal education and experience level of the worker who performs it: low-skilled jobs require the equivalent of a high school education or less, while middle-skilled jobs call for education beyond high school but short of a four-year degree. Key segments of the home care workforce meet the latter definition: home health aide certification requires 75 hours of federally mandated training, and some states have similar standards for personal care aides. Yet home care jobs are never identified as middle-skilled.

A few thoughtful op-eds have pushed back against how these categories are used. In 2016, Hanna Brooks Olsen pointed out that the conflation of the terms “low-wage” and “low-skill” ignores the fact that low-paying jobs can be as demanding and skill-intensive as those that pay better. Looking closely at workers’ shift-by-shift experiences makes it harder to distinguish, for example, the skill levels needed to succeed as a food service worker as compared to a manufacturing worker, or between a personal care aide and a sanitation worker. Yet the skills applied in manufacturing and sanitation are considered more valuable, or higher, than those applied in service jobs. Similarly, fields like carpentry and contracting, which do not require postsecondary education, are considered “skilled trades” while care work is not.

“The difference,” Olsen argues, “is who’s doing the work and what work they’re doing.”

Who’s Doing the Work

The typical demographic profile of people who perform direct care has both shaped, and been shaped by, the low wages in this sector. Home care positions, like many jobs that pay at or near the minimum wage, are disproportionately held by women (87%), people of color (62%), and immigrants (31%). Systemic cultural devaluation of these groups over time has been paired with underpayment for their labor. As Lisa Iezzoni, Naomi Gallopyn, and my colleague Kezia Scales discuss in a recent article, the exclusion of home care workers from labor protections and wage improvements in the U.S. can be linked directly to efforts to preserve inexpensive domestic labor arrangements that originated in slavery. The influence of gender and race in depressing both wages and the perception of workers’ skills in this field should not be ignored.

The Work They’re Doing

Compounding these effects are the challenges of measuring the outputs of home care. An effective home care worker helps improve or maintain a client’s abilities and quality of life. The home care worker’s impact extends to the client’s family and community, reducing strain and allowing clients’ family members to go to their jobs knowing that their loved ones are cared for.

But many care outcomes are, as economist Nancy Folbre describes, public goods that accumulate over time. While they may have very real economic impacts—among them, reduced health spending and enhanced labor participation for family members—care outcomes are difficult to trace to the input of a single worker, given the level of collaboration and customization involved in the delivery of home care. (Difficult but not impossible, though there has been little research attention afforded to this calculation and to the home care workforce overall. PHI is trying to change that.)

If you’ve been a provider or recipient of quality home care services, you know the skills involved in their delivery. But the fact that home care work takes place in private rather than public spaces further complicates its valuation. Home care workers, and the range of competencies they employ to do their jobs, are invisible to much of the public.

For some, it is difficult to count skills that you cannot “see.” That makes it all the more important that those who write about, research, and speak publicly on this workforce call home care what it is: skilled work.