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The Undervalued Work of the Home Care Aide

1 School of Social Work, University of Maine, Orono, United States
*Corresponding author: Sandra S. Butler, School of Social Work, University of Maine, Orono, United States. Tel: +207-5812382, Fax: +207-5812396, E-mail: [email protected].
Women's Health Bulletin. 3(2): e33105 , DOI: 10.17795/whb-33105
Article Type: Discussion; Received: Sep 11, 2015; Revised: Oct 18, 2015; Accepted: Dec 5, 2015; epub: Mar 26, 2016; collection: Apr 2016

Keywords: Home Care Aides; Home Health Aides

1. Introduction

The United States (U.S.) 2015 white house conference on Aging recently released its report on long-term services and supports drawing attention to the growing need for home care aides and the difficulties in recruiting and retaining workers in the field. Approximately one in five older Americans needs personal care assistance, with the likelihood of needing assistance increasing dramatically with age; nearly two out of three adults 90 and older need assistance. Although family members and friends provide most caregiving, about one third of older adults who need assistance rely at least partially on paid workers. With more women in the workforce, higher divorce rates, and smaller family sizes, informal caregivers are in ever-shorter supply, resulting in increased demand for direct care workers (1). The decreasing availability of informal caregivers due to smaller families and increased labor market participation by women has also increased demand for formal care in Europe (2). In the U.S. and internationally, women make up the majority of frail elders receiving care and also are the primary caregivers both paid and unpaid (3).

The phrase, “informal caregivers” refers to unpaid family members, friends and neighbors who provide assistance to individuals with disabilities with acts of daily living (ADLs), such as bathing, toileting and dressing, and instrumental acts of daily living (IADLs), such as cooking, shopping, and cleaning. “Formal caregivers,” on the other hand, are paid workers who provide this assistance and are referred to by a number of titles. In the U.S., the phrase “direct care worker” is the umbrella term for formal caregivers, including workers in both institutional and community settings. Direct care workers providing personal assistance to individuals in their homes are simultaneously referred to as home care aides, personal care assistants, and home care workers, among other titles. In this article, they will be referred to as home care aides.

The vast majority (80%) of older adults that need long-term services and supports in the U.S. live in the community, and most prefer to remain at home as long as possible (4), making the demand for home care workers particularly acute. The preference to age at home is equally prevalent in Europe (2). The U.S. department of labor has predicted that the position of personal care aide to be the fastest growing occupation in the U.S. between 2010 and 2020 (5). It has also been reported to be one of the fastest growing segments of the healthcare industry in Europe (6). Paid personal care workers are almost always women, and often, older women themselves. Moreover, nearly two-thirds of home care consumers are women (7). But despite the increasing demand, home care aides in the U.S. face difficult job conditions including physically difficult work; few opportunities for job advancement; low wages; irregular hours; and few, if any, employee benefits. Home care aides face similar difficult conditions in Canada (8), the Netherlands (9), and Northern Ireland (10, 11). Turnover rates in the U.S. range from 44 to 65% annually (12), which can result in compromised care for elders and increased costs for home care agencies. Retention and recruitment of these workers is reported to be difficult in other countries as well (8, 10).

2. Arguments

2.1. Difficult Job Conditions and Efforts to Improve Them

My own research regarding predictors of turnover among home care aides in the rural New England state of Maine revealed issues of compensation to be of considerable concern both to those who terminated as well as those who stayed. The mixed-method study collected data through two mail surveys and one telephone interview with 261 home care aides. Study participants were tracked for 18 months through their employing home care agencies to identify job terminations; during the data collection period, over one-third (n = 90) left their employment. Factors predicting termination included younger age, lack of health insurance, lower household income, lower scores on a scale measuring mental health, and higher scores on a scale measuring personal accomplishment (7). Qualitative data from the interviews supplemented the quantitative data by demonstrating the importance of compensation issues. The low wages along with lack of reimbursement for mileage, health insurance, paid sick days or vacation were particularly difficult for younger workers raising families. Older workers, some even with retirement income through Social Security and health insurance through Medicare, appeared to be more able to withstand the irregular hours and low wages than their younger co-workers, though they too felt their work was devalued (13-15).

In the U.S., there have been recent efforts to raise wages, provide health insurance, and in some instances even guarantee hours, but progress is slow and uneven. Since 1974, a U.S. department of labor rule has exempted home care aides from minimum wage and overtime laws, considering their work to be similar to informal companions and babysitters, rather than the formal agency-regulated work that it is. It is only in the past two years that home care aides have been guaranteed minimum wages and overtime pay with the removal of what has been known as the “companionship exemption” in the Fair Labor Standards Act. But even this attempt to bring fairness to home care aide wages was challenged in courts by home care agencies, and was only recently (August 2015) resolved in favor of workers.

Unlike most developed countries, the U.S. does not have universal health care coverage. The Affordable Care Act, passed in 2010, expanded government health insurance through the Medicaid program to individuals living at 133% of the federal poverty line or below. This expansion would have covered many formerly uninsured home care aides. Unfortunately a challenge to the law by governors in numerous states resulted in a supreme court ruling that allows individual states to decide whether or not to expand this program for the poor. To date 17 of the country’s 50 states have opted out of the expansion, leaving many home care aides in those states without health insurance. Moreover, among developed countries, the U.S. is unusual in not requiring paid sick time, and many low-income workers including home care aides lack this benefit, leaving them in the no-win situation of needing to decide whether to take care of their health (or their children’s health) or go to work sick, ultimately a public health concern.

Campaigns to raise the minimum wage at the federal level, in some state legislatures, and even at the local level through city councils, are ongoing and a few have met with some success. Similarly, a few cities and states throughout the country now require employers with a certain number of employees to provide sick leave. There has been some small success unionizing home care workers, with resulting better work conditions and compensation (16). The cooperative home care association in New York City is an exemplary employer, which provides members guaranteed hours something that is very important to stabilizing income for this group of workers.

There are also efforts to create real opportunities for advancement for home care aides, thereby allowing them to be a better-utilized resource in the current health care system. For example, the paraprofessional healthcare institute advocates an “advanced role” for direct care workers who seek further training, but who are not able or interested in pursuing a nursing degree, which requires a larger investment in time and resources. The advanced roles would include clinical observation, monitoring and reporting; health education and outreach; medication adherence; and care coordination. Having home care aides perform at this more advanced level could have far reaching results in terms of both patient care and enhanced communication among health care providers, and be empowering to home care aides who, to date, have not been adequately utilized on health care teams. Similar case management has been shown to lower the risk of institutionalization for frail elders in eleven European countries (6).

Figure 1 illustrates the current situation of increased need for home care aides, the difficult job conditions that lead to high turnover rates, and potential interventions to increase retention. These efforts are important and will hopefully ultimately bring positive results, but for now most home care aides in the United States are faced with a difficult choice. Should they continue to do a job which they enjoy and believe makes an important contribution to the lives of their clients, or should they take another low-skill job perhaps in retail or food service which they find less rewarding, but which pays more and may even offer benefits? Many are choosing to do the latter to the detriment of our long-term care system and the frail elders needing personal care assistance at home. This tension of needing to give up the home care work they love for better paying jobs in other sectors of the labor market work they may find less appealing has been documented among home health aides in Canada as well (8).

Figure 1.
Preventing Turnover and Valuing the Work of Home Care Aides

3. Conclusion

While doing my research and being attuned to the conditions of home care workers in the U.S., I have often wondered how their counterparts fare in countries with greater unionization, more job protections and/or more generous social welfare programs. For example, does having universal health care and guaranteed sick time substantially improve employment conditions or the status of this important job of providing personal care for people at home? Or does the devaluation of care work typically done by women persist across nations despite these differences? Research on home care work in Canada, Northern Ireland, and the Netherlands, mentioned earlier, indicates that difficult job conditions for home care aides continue to exist even in countries with more generous social welfare programs than exist in the U.S. The aging of our population is a global phenomenon and aging at home is a nearly universal preference. Given this context, it is essential that we adequately compensate and value home care aides of whom, nearly all are women, so they can afford to do their very important work.


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Figure 1.

Preventing Turnover and Valuing the Work of Home Care Aides