ISSUES
Who Are Direct-Care Workers?
They are home health aides, certified nursing assistants (CNAs), personal attendants, et al. working in nursing homes, assisted living facilities, adult care homes, group homes for the mentally and physically disabled, and individual clients' residences-accounting in 1993 for more than 2.25 million positions, or 20% of our nation's healthcare workforce. These workers are also called paraprofessional caregivers.
Over 90% of them are women aged 22 to 45-a demographic bracket that will see an absolute decline in size in the coming decade.
They are disproportionately women-of-color - 30% of direct-care workers nationwide, and the majority of paraprofessionals in many urban centers. One fifth of all African-American women employed in the United States work within healthcare-most of them in these direct-care jobs.
Many are women previously on public assistance.
What Are Their Jobs Like?
Hourly wages for CNAs and home health aides average between $6.00 and $8.50 an hour. Since many paraprofessionals are offerred only part-time employment, annual incomes for CNAs and home health aides range from $7,000 to $12,600 (home care) and $14,500 (CNAs) for more experienced workers - putting the typical direct-care worker below the poverty line.
Over 70% of home health aides, and over 30% of CNAs in nursing homes, are able to secure only part-time work - forcing many of them to try to juggle two or more such jobs simultaneously with different employers.
Health insurance is rarely offered by direct-care employers - or if it is offered, it is usually too expensive to be accessed by these low-income workers. This is especially true for paraprofessionals who cannot secure full-time employment.
Increasing numbers of home care paraprofessionals are not even "employed" in the typical sense of the word; they are working as "independent providers" hired by individual long-term care consumers who then pay them either with public Medicaid dollars or cash out-of-pocket. These workers have little recourse to Fair Labor Standards Act (FLSA) protections, and they have no means for securing health insurance or other benefits.
Training for direct-care workers, where mandated at all, is usually short (75-100 hours) and often inadequate to help caregivers succeed at their demanding jobs. Many categories of direct-care workers receive no training at all, even though they are doing much the same work as "trained" paraprofessionals. And there are few opportunities for skill upgrading or advancement for incumbent direct-care workers-contributing to the attrition of experienced caregivers.
Who are our Nation's Long-Term Care (LTC) Consumers?
Thirteen million people in this country need daily assistance with personal maintenance, hygiene, eating, and-for those living at home-a range of basic household tasks.
About one-third of these LTC consumers are aged 80 and over-a population that is expected to grow by over 35% (from 7.8 million to 10.6 million) between 1994 and 2006.
Seven in ten nursing home residents, and six in ten home care consumers, are women, making LTC very much a "women's health" issue.
What do these LTC Consumers Want?
Consumers consistently cite the quality of the paraprofessional workers with whom they are in contact on a daily basis as the primary determinant of their care quality.
Consumers want a stable caregiving workforce with whom they can develop ongoing relationships-and despair at caregiver turnover rates typical in home care (40-60% per year) and nursing homes (70-100% per year).
As the typical LTC consumer gets older, more frail, and more likely to suffer from dementia, she will need a more skilled direct-care workforce than the current one-which is now typically undertrained and inexperienced.
Who Are Long-Term Care Providers?
Long-term care providers can be nursing homes, home health agencies, assisted living facilities, board and care facilities, adult day care or adult health centers, or group homes for individuals with mental illness or mental retardation.
They can also be community-based providers such as area agencies on aging, hospice, or even transportation carriers.
Long-term care providers can be nonprofit or proprietary. They can be free-standing entities or associated with a larger provider, a chain or a multi-facility provider. For example, consumers may access long-term care through an independent nursing home, a hospital, a visiting nurse association or a managed-care organization.
Any of the entities described above hire paraprofessional workers to deliver personal care, or assist clients in maintaining a home, with shopping and financial tasks, or medical visits.
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