Following World War II, the American family changed dramatically. Marriages began occurring at a higher rate and the ages of those tying the knot became much younger. The result was something we have referred to before as “The Baby Boom” as births topped 75 million between the years of 1946 and 1964.
With so many children and so many newly married young people, the “American family” consisted of a home where dad went off to work while mom remained in the home to care for the children and run the household. There seemed to be a new factory opening everyday in major cities attracting workers but also increasing the crowding that made it difficult to raise an increasingly larger family. With a booming economy and families having a better standard of living, many wanted to leave the hustle and bustle of the city and as a result, suburbia grew rapidly.
The automobile industry also flourished in the 1950s as did the highway
system and other public works projects. Between the years of 1950 and 1980, the number of cars in this country increased by 200 percent. Shopping malls, big box stores and fast food restaurants sprung up in all areas of the country as the population of cities began to decline.
The GI Bill allowed 8 million Americans, to whom college was traditionally out of reach, to increase their education and walk away from traditional factory jobs and farming. Unions increased wages and corporations, seeking a cheaper workforce, moved their factories to foreign countries, which were looking to grow in a post war economy.
In the health care field, antibiotics, new vaccines and other medical procedures extended life for many who would have died just decades before. Television hit the scene and the invention of the transistor allowed small radios to be in every American’s hands allowing them access to the rest of America and even the world.
The country became a hotbed of affluence which led to larger families who sought better opportunities and were no longer forced to remain in areas where the rest of their family grew up. This affluence continued into the 1960s followed by a period of unrest in the country as the civil rights movement and opposition to the Vietnam War led to the development of a counter culture complete with drugs, sexual freedoms and rebellious attitudes against authority.
Changes in the family structure in just a few short decades was indeed striking. No longer were there family meals as mom and dad stayed late at work, grabbing a burger at McDonald’s for dinner while the children ate a crockpot meal – often unsupervised. With the decrease in the price of televisions and cable hitting the scene, homes now had multiple sets which led to a further separation of traditional family time.
Members of the baby boom generation were now confronted with the results of the miracle of technology, medicine and the affluence of America – parents lived longer and often independently – while they left home to live on their own at much younger ages. Problems began to arise as parents aged alone with children living elsewhere, popping in from time to time to say hello -- or borrow money.
Thanks to a prosperous economy of the 1990s, the “entitlement” belief over
took the baby boomers, who believed that the government would take care of everyone. As the new century started, the guarantees made by the government were being honored thanks to high tax collection, low unemployment, a balanced federal budget and a steady economic growth.
But one thing about history, it is cyclical and as in the past, economies rise and fall, and fall it did. Soon, favorable economic trends reversed, and America headed into a deep recession. Federal budget deficits ballooned out of control and cuts began in programs that just a decade earlier promised Americans care from cradle to grave. In the cross-hairs of this downward spiral were seniors, who began to realize that the promises of the government were just that – promises and not guarantees.
Today, we have come full circle. We now want to keep mom and dad in the home once again due to rising care costs and comfort. But what hasn’t changed is the family, continuing to be scattered around the country and sometimes the world, making it impractical to provide care for parents who do not meet the requirement of nursing home treatment.
We are now in the second decade of the new century and keeping mom and dad at home is the preferred choice and will probably be the future of elder care, but providing services for them is the presenting problem. Americans are getting older and less active, driving more of a need for home health and personal care aides across the country.
The demand now for home healthcare workers is expected to increase dramatically in the coming decades. Government employment specialists state that providing home care will be one of the nation’s fastest growing occupations with an additional one million employees needed by 2026, just eight years from now.
On the face of it, it sounds like a great opportunity for businesses to sprout up and provide this service to our aging baby boomers, but it is fraught with peril. The biggest one is the shortage of professional workers due to the low wages, poor advancement opportunities and inconsistent work schedules and benefits. The major problem, according to many of the Home Healthcare Agencies we spoke with, is the low pay due to the inflexible rates set by Medicare and Medicaid.
Don Drake, one of Connelly Law Offices, Ltd.'s Community Education presenters and retired human services program administrator, states that this has been a problem in the human service field for decades.
“It always amazed me of the price we put on taking care of people versus
material things. We have tremendous expectations of direct care staff, putting them through hours of training and supervision and placing the responsibility of another human’s well being upon them, only to pay them an hourly wage barely over what they could make at a fast food restaurant. Staying fully staffed for any significant period of time was something we aspired to but never achieved - and why would they stay when they could load trucks for nearly twice the pay with better benefits," said Drake.
"Unfortunately, human resource departments are forced to hire people who lack a real commitment to the mission of the agency and as a result, the client is not always getting the treatment they deserve. In residential facilities, much of this is forced upon the administration by the government who establishes staff to client ratios but refuse to provide appropriate funding to retain employees. Of course, you try hard to hire the right person but what happens is those who have the skill often move on because they become burnt out and those who stay behind aren’t always there for the right reasons. This problem is now facing home healthcare agencies and will only get worse. Even more problematic, these employees are in the home of a client unsupervised and the wrong person could wreak havoc in multiple ways.”
The demands placed on home health care workers who are overworked and underpaid, often holding down multiple jobs and laboring up to 60 or 70 hours a week to make ends meet, are often unmanageable. Their work includes helping clients with medical issues, picks up prescriptions, shops for groceries, prepares meals and assists with personal hygiene, such as showering. It's obvious when an employee is tired, poorly supervised or just burnt out, quality will suffer.
This is not an indictment on those who do this work as the overwhelming
majority are committed to their clients and love their jobs, but sadly, commitment and love does not pay the bills. According to the US Bureau of Labor Statistics, wages for home health caregivers are between $11 and $14 an hour, hardly enough to run a household or raise children.
In Massachusetts, the Home Care Aide Council, with a grant from the Tufts Health Plan, conducted an assessment of the Commonwealth’s home health-care workforce and found the following:
Almost 40% of the home health care aides currently employed indicated that they were likely to leave that work within the year
Home health agencies reported a quarterly health aide turnover of 16%
On a quarterly basis, for every 18 people hired, they lost 15 for just a net gain of 3
During the fall of 2016, nearly half of the agencies had difficulty filling openings both on weekends and weekdays
Nearly 9 out of 10 agencies reported that their top challenge was recruiting qualified people as well as retaining them
Nearly half of the aides working in the field reported to have at least one other job
4 out of 10 of the aides reported living in a household with an annual income of less then $20,000 and nearly half were on MassHealth (Medicaid)
Also of interest in this report was the fact that, at the time, nearly 50% of the home health care aides were born outside the United States with the highest immigrant population employed were from Haiti (27%).
“When you spend most of your time recruiting and filling positions, other areas will suffer”, said Drake. "Usually it’s the training and supervision component. It’s easy to point fingers and blame the agency directors when a problem occurs but if they don’t provide the coverage for the shifts, they are criticized for that as well. It’s a no-win situation for them.”
Drake continued, “When you look at the numbers in the Massachusetts survey that indicated that some home health care providers have turnover rates of nearly 80%, its really demoralizing. Imagine any other business where your employees leave as quickly as they are hired -- how long would they stay in business and what kind of product do you think they would put out?"
“Let’s put it this way, in any other business, if there is a demand for the product, there would be a corresponding price increase that would trickle down to those doing the work, but not in the healthcare field with the government being the payer,” said Drake.
However, there does exist some hope on the horizon as the Centers for Medicare and Medicaid Services (CMS) have approved reimbursement for non-skilled in-home care services for Medicare Advantage plans beginning in 2019. This marks the first time that CMS has permitted daily maintenance in Medicare Advantage plans.
This change will be available to the 21 million seniors who have opted in to the Medicare Advantage plans and is an important step in helping the rapidly growing senior population age safely in their own homes.
Under the new ruling, CMS will relax the previously prohibited coverage of
“daily maintenance” services. Although it is not completely clear, it appears that CMS will now “allow supplemental benefits if they are used to diagnose, prevent, or treat an illness or injury, compensate for physical impairments, act to ameliorate the functional/psychological impact of injuries or health conditions, or reduce avoidable emergency and healthcare utilization.”
Hopefully, this will lead to other reforms that benefit providers and their employees and starts the process of recognizing the importance of the work and the skills that these employees possess.
We have discussed the issues facing home health care providers, but how do the recipients of the services feel about the care they are receiving? Home Care Pulse, a company that gathers client/caregiver satisfaction reports and provides detailed feedback designed to help the home care industry provide better services to their clients, conducted a series of interviews with thousands of seniors and asked them identify the top ten areas of complaints they had about providers. Here’s what they found:
Confusion in communication due to multiple caregivers caring for one client - Clients like having the stability of one caregiver and one point of contact. Having a “point man” ensures responsibility is taken and assures clients that nothing will be lost in communication.
Caregivers who aren’t punctual - Home care clients commonly report that caregivers come late or leave early. Some clients are on a strict schedule, and having a caregiver show up late means they could be left unattended. It can be a huge inconvenience for family members who have to stay longer while missing out on those extra 10-20 minutes they’re paying for.
Inconsistent quality of care - Some caregivers are better at their job than others, but it can be really frustrating for a client when one caregiver is exceptional, then the next performs only basic tasks.
Caregivers spending too much time on phones - Clients get really irritated when caregivers are on the clock and wasting time on their phones, neglecting the client. Enforce strict rules about cell phone usage, set a standard penalty for those who break the rules, and hold your caregivers accountable.
Lack of caregiver training - Clients are sometimes upset when caregivers can’t perform basic cooking and cleaning requests. One woman we interviewed said when she asked her caregiver for a grilled cheese sandwich, the young woman stuck cheese on a piece of bread then dropped it in the toaster, creating a huge mess. Some caregivers may benefit from basic cooking instructions or recipes.
Cultural differences/language barriers - Many cultures have different standards for cooking and hygiene. If you hire someone from another country, teach them about our customs and basic words in English before they start working. Language barriers and cleanliness differences can be very troubling and frustrating for your clients.
No discounted rates for 12+ hour shifts - Clients who have a greater need for help will pay much more than those with only basic help needed. If your budget allows, try to take off a dollar or two for those long visits. This could be more difficult with the recent changes to caregiver exemptions, but clients will appreciate whatever effort you can make.
Pay schedule is inconvenient - Some companies send out a weekly bill, but some clients prefer monthly billing since it’s easier to keeping track of payments. Keep clients in mind when planning your billing schedule.
Being charged time and a half - Clients complain of being charged time and a half on holidays, which equals to about $30/hour. They feel that’s too steep and care shouldn’t cost that much. If you’re able to make adjustments, do so. At the very least, provide information for clients, so they understand why this policy is in place.
Not being told when caregivers call in sick - It’s not uncommon for caregivers to call in sick to the office, but the office doesn’t call the clients or send a replacement. This is a communication problem that could cause astronomical problems for your clients and your home care business.
It becomes obvious that there remains much work to do in order to meet the demands of the growing home healthcare field. But besides the issues we mentioned above, there are other concerns that continue to grow with the industry -- the increase in all types of elder abuse by unscrupulous in-home healthcare employees. In our next blog, we will explore this, how to prevent this from happening and how to find the right agency or person to provide care for your loved ones.
Attorney Connelly practices in the area of elder law. This area of law involves Medicaid planning and asset protection advice for those individuals entering nursing homes, planning for the possibility of disability through the use of powers of attorney for the both health care and finances, guardianship, estate planning, probate and estate administration, preparation of wills, living trusts and special or supplemental needs trusts. He represents clients primarily in the states of Rhode Island, Connecticut and the Commonwealth of Massachusetts. He was certified as an Elder Law Attorney (CELA) by the National Elder Law Foundation (NELF) in 2008. Attorney Connelly is licensed to practice before the Rhode Island, Massachusetts, Connecticut, and Federal Bars.