Who Cares for Them: Workers in the Homecare Industry. – book reviews
For years, I have believed that, in the short run, we in the United States “save” money by having poor women deliver home care services for low wages. But, in the long run, the price we pay for such a short-sighted policy is high indeed. For one thing, we are creating a large contingent of poor elderly women in the future–without pensions, disability or health insurance, savings, or Social Security credits. In addition, through this policy we do a disservice to these poor (often minority) women in not paying them well to do very difficult work; we also do a disservice to the older clients and families in need of good care.
Sadly, my intuitions have now been more than confirmed by an important recent book, Who Cares for Them: Workers in the Homecare Industry, by Feldman, Sapienza, and Kane. This book gives us a detailed overview of the growing numbers of disabled older persons and the paid workers responsible for their home care. In Part 1, the authors look at the labor market, the workforce, and general industry conditions. Part 2 looks at three case studies or demonstrations designed to improve the work life of aides (these were located in San Diego, New York, and Syracuse/Milwaukee). Part 3 is an overview of programs concerned with changing working conditions for home care aides and also discusses such factors as worker participation, turnover, and continuity-of-care problems. Part 4 provides recommendations and policy implications. The book ends with a methodology section and a glossary of names and abbreviations.
The authors document the sharp growth in the demand for home care services, accompanied by a rapid expansion in the numbers of home care agencies and providers. This expansion, however, has not altered the deplorable working conditions for home care aides. Aides are poorly paid, with no paid vacation or sick days, no health insurance, leave time, or pensions. In fact, home care workers generally earn less than fastfood workers but have much more difficult jobs. Also, home care workers have virtually no opportunity for advancement or training to acquire new skills, degrees, or certifications. Training is highly variable from state to state and community to community, even though aides are often called upon to care for extremely difficult patients, including those with developmental disabilities, mental retardation, severe psychiatric disorders, Alzheimer’s disease, and terminal illness. Due to a lack of organizational support, home care workers often feel isolated and lonely as they care for difficult clients and their families.
Aides report a number of problems that seem almost overwhelming. Some experience difficulties with client and family behavior and sexual harassment. Workers also report working in unsafe neighborhoods and buildings and experiencing transportation problems in getting to the job. In addition, they encounter difficult sleep-in arrangements, boredom on the job, problems with week-end and replacement aides and with inadequate equipment and supplies.
However, despite the difficulties, home care aides also report positive aspects to their jobs. Their work allows them to feel personally responsible for the health and well-being of their clients, which makes their work meaningful.
The research, demonstration projects, and writing of this book were supported by funding from the Ford Foundation. The demonstrations sought to determine if improvements in working conditions and benefits would result in greater worker satisfaction, decreased turnover, and thus, improved quality, reliability, and continuity of care. The demonstrations did result in these positive outcomes. Improvements in working conditions and benefits included extended training in basic home care skills, specialized training for Alzheimer’s disease and other dementias, pay hikes of 30 to 50 cents an hour and fringe benefits, support groups, and status enhancements such as uniforms and badges.
Based on the results of the demonstration projects, the authors have made a number of recommendations for home care employers and managers: * Employers should focus their
recruitment efforts on more mature
(i.e. older) workers, and should
develop better methods to screen
potential employees. * Employers should allocate training
resources to reinforce and supplement
basic training, and develop
special skills and career tracks–both
administrative and clinical–within
the home care workforce. * Specialized training programs
should focus on the skills needed
to deal with difficult categories of
clients. * Employers should develop training
and support programs to provide
organizational support for aides
and to reduce their feelings of isolation
and loneliness. These
programs should focus on the special
needs of new workers, and
minority and non-English-speaking
workers. * Employers should work to achieve
parity in wages and benefits of
home health aides and aides working
in institutional settings.
Further, employers should use
wage differentials, expanded benefits,
and visible status symbols to
reward aides for length of service,
reliability, and acquisition of
advanced skills or certification. * Transitional pay should be made
available to valued workers to tide
them over between closings and
reassignments. In addition,
employers should strive to provide
full-time, year-round work to
encourage workers to make the
necessary commitment of time,
energy, and responsibility to the
job. * Finally, home care employers
should lobby together to seek sufficient
reimbursement to provide
decent jobs to workers, and work
with unions and consumer groups
to improve both worker satisfaction
and quality of service.
For their part, say the authors, states could change licensing laws to allow aides to assume more responsibility. At the same time, states could contract with agencies to provide most of the publicly funded home care services and phase out individual provider programs. Through the competitive bidding process, states could specify minimum compensation requirements for all bidders to avoid low bids based upon substandard wage and benefit packages. States and localities could also approve increases in publicly funded home care programs to make wage and benefit packages competitive with those in hospitals and nursing homes.
I have gone into these recommendations in some detail because while they are good, they do not go far enough. It seems to me that this might have been an excellent project in which to use more innovative research methods, based upon the contributions of the workers themselves. For example, home care aides could have formulated the research questions, specified the research methods, and reviewed and edited drafts of written reports.
These research methods, designed for and by home care aides, and not administered to them, could have empowered these women. In addition, this approach might have prevented some of the methodological problems listed in the methodology section–language problems on surveys; low rates of response; selection bias toward stable, long-term employees and away from those who had left the agency and therefore were likely to be most dissatisfied with the system; inability to conduct pre- and post-tests; and difficulty in achieving comparability site to site and in operationalizing the concept of “turnover.”
Instead of working within a system that is often exploitative of poor minority women, instead of offering “band-aid” solutions such as promotions, we should all work toward basic improvements in working conditions for these women. For example, Larry Campbell, the Chief Executive Director of the Visiting Nurse Association of Southeast Missouri, has developed several measures to manage home care aides with dignity and respect. His agency provides health care benefits and good rates of pay. The average length of stay for aides in this agency is 11 years; during 1990, there was not a single instance of turnover–compared to an industry average of 50 percent annual turnover. Furthermore, Campbell has developed a profit-sharing system whereby the bulk of the profits go to the home care aides, with less to administrators and directors.
Nor are these health care workers left alone in the home; they come into the office regularly for team care conferences, training, and professional support. Through these and other mechanisms, Campbell has devised ways for all workers to feel genuinely as though they own the agency for which they work. These aides care about all aspects of their agency, even suggesting that the VNA building needed painting and coming in on a weekend to do it. Campbell believes that if Medicaid were to reimburse a few cents an hour more to home care agencies nationwide, and to specify that the extra money be used to purchase health care insurance for all home care aides nationwide, hundreds of thousands of aides could be covered for the benefit they and their families need most.
While Who Cares for Them is, in some ways, a groundbreaking book, and we should be grateful to the authors for their years of effort, we need to go much farther in our attempts to improve working conditions for home care aides. Instead of seeking ways to ensure a large force of home care workers for the future, we should institute these basic changes for ethical and moral reasons. A society that pays baseball and basketball players $12 million a year, while home health aides–often single women with children–receive poverty-level wages, has its priorities out of line. We need to begin an aggressive public education program explaining to families, legislators, and policymakers why it is important that home care aides get decent wages and working conditions.
Who Cares for Them was published by Greenwood Press, Westport, Connecticut, in 1990. It costs $39.95 in hard cover. Note that the high price of this volume virtually guarantees that home care aides, the very ones most affected by its contents, will never see it. I wonder if the authors would consider sending an executive summary of this study free of charge to all state home care associations for them to share with aides throughout their state. In addition, those of us who do research about home care and aides might consider putting fees and royalties into a fund to pay for educational scholarships for these workers and their children.
Marcie Parker is a doctoral student in family social science at the University of Minnesota.
COPYRIGHT 1992 U.S. Government Printing Office
COPYRIGHT 2004 Gale Group