A recent article described what happened when researchers at Northwestern School of Medicine, posing as prospective clients seeking a caregiver for an elderly adult relative, contacted 180 agencies and asked about hiring, screening, and supervisory practices. Their findings aren’t pretty.
Sixty-seven percent of the agencies required experience, but this was typically assessed by self-report. Only 62% checked references. Ninety-two percent checked criminal backgrounds within the state, but no agencies checked other states, meaning that someone who had been convicted elsewhere would appear to have a clean record. English language proficiency was assessed via the interview, and no agencies assessed health literacy (ability to understand physician recommendations, dosage schedules, and so forth). Thirty-one percent conducted drug screening. Seven percent verified citizenship or visa status. Training and supervision were very limited. The researchers concluded with this warning:
“The screening and training practices in use by caregiver agencies are highly variable and often of poor quality. Using an agency to hire paid caregivers may give older adults and their families a false sense of security regarding the background and skill set of the caregivers.”
When my father, who lived 1,000 miles from where I was, lost his vision and entered the early stage of cognitive decline, my cousin, who was at a difficult point in his life, needed a place to live and moved in with him. He provided eyesight, companionship, and driving. My father paid for lodging and food, and provided avuncular guidance. It was a true win-win situation.
But this kind of good luck is the exception, not the rule. Agencies like the 180 surveyed in the study are filling a vacuum in our fragmented society. Home care for the elderly is a rapidly growing “industrial sector.” Unfortunately, as the study reveals, the fact that an aide has been hired by an agency is not a reliable stamp of approval.
In the same vein, the 2008 Institute of Medicine report, Retooling for an Aging America: Building the Health Care Work Force, cited a Bureau of Labor Statistics prediction that home care aides and home health aides would be the second and third fastest growing occupations from 2006-2016, but concluded:
“…the education and training of the entire health care workforce with respect to the range of needs of older adults remains woefully inadequate. Recruitment and retention of all types of health care workers is a significant problem…Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.”
At present the home care “industry” is in a wild west phase, with participants ranging from individuals who contract independently to outfits like Home Instead Senior Care that have 900 franchises in 16 countries. Seventy percent of those who are over 65 today will at some point need home care for an average of three years. The majority of home care services are provided by family and friends (primarily women), but the salaried home care workforce is already almost a million. Total “industry” revenue is close to $60 billion. Profits are growing, but direct care workers are not thriving: (a) their median wage is $10.59/hour, (b) fewer than half receive health coverage as a benefit, and, (c) half earn so little that they supplement their incomes with Medicaid and food stamps.
Home care for the elderly has the makings of a perfect storm. It brings together a vulnerable, stigmatized group – elderly people who need help with basic life functions – with a marginalized, stigmatized population of poor, primarily female, often immigrant, workers. This is a setup for exploitation – sometimes of the elderly by the “caretaker,” and sometimes of the caretaker by the agencies that hire them.
Ever since the so-called “companionship exemption” was put into law in 1974, personal care workers have not come under the federal requirements for minimum wage and overtime. The Department of Labor has proposed new regulations that would require agencies to pay no less than the minimum wage and to pay for overtime. Eleven senators recently introduced legislation to prevent the Department of Labor from doing this. We’ll see the ethical issue of respect and fair compensation for eldercare workers play out as a labor/management and political conflict.
James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.