DIRECT CARE WORKERS DCWS IN COMMUNITYBASED SETTINGS Sandra

DIRECT CARE WORKERS (DCWS) IN COMMUNITYBASED SETTINGS Sandra Butler, Ph. D University of Maine

Role of DCWs Centerpiece in long-term services and supports (LTSS) Provide 70 -80% of paid handson LTSS received by Americans Make up 30% of US healthcare workforce

Who Are Direct Care Workers? In 2012, almost 4 million workers � 3. 2 million employed by facilities and agencies tracked by BLS � 800, 000 independent providers employed directly by consumers Among those working for agencies/facilities � 1. 5 million are nursing assistants � 850, 000 are home health aides � 1 million personal care aides

Among Nation’s Fastest Growing Jobs Personal care aide is second fastest growing occupation � Predicated to increase 49% between 2012 -22 Home health aide is third fastest growing occupation � Predicted to increase 48% between 2012 -22

Growth in Need for Personal Care Most people needing LTSS prefer to stay in the community Number needing personal assistance increasing � 13 million in 2000 to 27 million in 2050 “Care gap” exists: Demand > than supply � Only 1 worker per 10 potential consumers

Fewer Family Caregivers Need formal caregivers is increasing as availability of family caregivers is decreasing � Decreasing family size � Ever more women in the workforce � Rising divorce rates � Increasing childlessness

Job Titles Across country many titles used for DCWs in community-based settings: � Home health aide, home care aide, personal assistant, home attendant, personal support specialist, homemaker, companion, etc. � Official titles in US Occupational Code: Personal Care Aide (PCA) Home Health Aide (HHA)

Tasks Performed HHAs perform paramedical tasks � e. g. , catheter hygiene, changing dressings PCAs assist with acts of daily living (ADLs) and instrumental acts of daily living (IADLs) � Including both personal care and social supports Often referred to together as Home Care Aides (HCAs)

Characteristics of HCAs Average age: 45 91% female Majority women of color � 44% White � 32% African American/Black � 17% Latina/o � 7% Other 24 -28% born outside US 58% high school diploma or less

Seen as “Women’s Work” The profession is dominated by women � Predominantly women of color All of whom are poorly paid Rooted in history of exploitation and devaluation of women’s work 1 in 7 low-wage female workers is a home care aide

HCAs Are Older Workers 28% of home care aides are 55 and older � 18% of all female workers are 55 and older This proportion will increase as workforce ages There exists the phenomenon of older women taking care of older women (as most

Reliance on Immigrants comprise over one quarter of inhome-care workforce � In NYC: 74% � In Florida: 83% Limited pathways to legal status � HCAs unlikely to qualify for employment visas Either � Family temporary or permanent sponsored visas can take years to obtain

Undocumented HCAs One in five immigrants in DCW is undocumented � Higher More vulnerable to exploitation by employers � Very proportion within in-home care low wages Even legal immigrants may not be eligible for benefits such as: � TANF, SNAP, and Medicaid

Poverty Among HCAs 56% are part-time Average annual income: $17, 000 (for full-time workers) � $13, 000 for part-time workers Median hourly wage: $9. 38 >50% live in households below 200% of FPL 1/3 lack health coverage (in 2014) >50% receive public benefits http: //phinational. org/sites/phinational. org/files/phi-facts-5. pdf

Work Conditions Low wages, few benefits, uncertain hours � According to PHI, the median hourly wage for all DCWs was $10. 63 in 2012, which is less than the median wage for all U. S. workers ($16. 71). http: //phinational. org/sites/phinational. org/files/p hi-facts-3. pdf Insufficient training Can be physically challenging with high rates of injury Turnover rates range from 40 to 60%

Low-Status Work Neither socially nor economically valued by society “The intersection of gender, race, and immigration status are reflected in the low status and negative work conditions of direct care workers. ” -Nancy Hooyman (2010)

Training Certified nurse aides and home health aides have a federal training requirement of 75 hours, including 16 clinical hours Personal care aides have no federally required training requirement � Varies by state

Affordable Care Act Initiatives Created a demonstration program: Personal and Home Care Aide State Training (PHCAST) Program, with goals to: � Develop competencies � Pilot training curricula � Created certifications Personal Care Attendant Workforce Advisory Panel created

Advanced Roles for Aides HCAs are currently underutilized � Have few options for advancement or pay raise � Other than to pursue nursing, which not all can or care to do Ideally positioned to improve lives of their clients if provided opportunities for skill development

Advanced Role of Aides Eldercare Workforce Alliance (EWA) advocates for the advanced role of DCWs: http: //www. eldercareworkforce. org/files/EWA_Advanced_Direct_Car e_Worker_brief_-_FINAL. pdf Held roundtable discussion in 2012 with social workers and found that: � � � Social workers agreed that an advanced aide could improve care with training on skills for observing, recording, and reporting Also thought an advanced aide could play a helpful role in dementia care, end-of-life care, and also in interactions with family caregivers The group agreed that supervision by a social worker would be important for the success of advanced role for aides

Training for Advanced Role Workers would complete training specific to: � Geriatric syndromes � Unique needs and symptoms of older adults � Effective communication with interdisciplinary care teams, consumers, and family members

Training to Exceed Current Levels The enhanced training would include: � Cultural diversity � Person-centered care � Advanced illness and palliative care � Communication � Disease education and interventions Current training varies by state for HCWs, the advanced role training would bring some uniformity

Functions of Advanced Role Clinical observation, monitoring and reporting Health education for clients Medical adherence Care coordination See PHI’s website for additional information: http: //phinational. org/policy/issues /advanced-roles-aides

Benefits of Advanced Role HCWs could fill current gaps in care, e. g. , � Identify shifts in consumer health and mood, then report changes � Perform some nursing tasks such as monitoring insulin levels, maintaining catheters � Share information on community resources and support services with consumer and family � Assist consumers in doing exercises

Recent Policy Changes Companionship Exemption � For years, home care workers considered “companions” by Fair Labor Standards Act Excluded from overtime and minimum wage regulations � After a long fight involving Congress, Supreme Court, and Department of Labor, that exemption finally lifted in 2015 � This is discussed in podcast on later slide

Other Federal Policy Initiatives Direct Care Worker Empowerment Act � 2010 bill in Congress to remove “companionship exemption” and provide grants to improve recruitment, retention, and education � Ultimately died Together We Care Act of 2015: � Current bill to provide public housing residents training and certification to become home care workers � Find more here: https: //www. congress. gov/bill/114 thcongress/house-bill/3467/text

State Level Wage Increases In February 2016, wages for HCWs in Orange County, CA will increase from $9. 30 to $10. 20 Wages for Oregon personal care attendants will increase to $15/hr in 2017 Legislature in Maine currently considering bill to raise wages and improve benefits for HCWs paid through Medicaid Efforts ongoing in states throughout country

Policy in Action: Washington State is reinventing the home care industry to improve wages and training opportunities SEIU Healthcare NW Training Partnership is the nation’s first large-scale career pathway for home care aides; it also includes an apprenticeship program for more advanced training - Policy. Link http: //www. policylink. org/blog/wa-state-home-care- workers

Social Workers Can Partner Social workers and HCAs often work together on interdisciplinary teams We have a role in advocating for these undervalued, but essential workers

Class Exercises Access the following two links: http: //www. insocialwork. org/episode. asp? ep=11 2 � This is a podcast of an interview with Dr. Sandra Butler titled: “Should I stay or should I go? : Home care workers and factors affecting turnover and retention. ” http: //www. youtube. com/watch? t=1201&v=Mr 6 x 3 Z 7 d. VSw � This is a video of former Secretary of State Hillary

Exercise 1: The Experiences of HCAs Listen to the first two thirds of the podcast and at least the following two stories on the video clip � Suzie Young (start at 19. 5 min; finish at 27. 5 min) � Artheta Peters (start 36 min; finish 44 min) In a 2 -page paper: � Describe the challenges and rewards of a HCA’s job � Discuss how social workers might partner with HCAs to improve their job conditions

Exercise 2: Policy Related to HCAs Listen to the last third of the podcast In a 2 -page paper: � Describe the history of the “Companionship Exemption” including how statutes (legislative law), Supreme Court decisions (judicial law), and Department of Labor rules (administrative law) interrelate � Research what has happened since the 2012 podcast with regard to rules related to the “companionship exemption” (including 2015 judicial decision) and provide an update in your

References Butler, S. S. , Brennan-Ing, M. , Wardamasky, S. , & Ashley, A. (2014). Determinants of longer job tenure among home care aides: What makes some stay on the job while others leave? (2014). Journal of Applied Gerontology, 33(2), 164 -188. Doi: 10. 1177/0733464813495958 Butler, S. S. , Wardamasky, S. , & Brennan, M. (2012). Older women taking care of older women: The rewards and challenges of the home care aide job. Journal of Women & Aging, 24 (3), 194 -215. Hess, C. , & Henrici, J. (2013). Increasing pathways to legal status for immigrant in-home care workers. Washington, DC: Institute for Women’s Policy Research. Hooyman, N. (2010, August 30). Social justice for direct care workers. Post to Direct Care Alliance blog. Retrieved from http: //blog. directcarealliance. org/2010/08/social-justice-for-direct-careworkers/ Paraprofessional Healthcare Institute (PHI). (2013). Facts 3: America’s direct -care workforce. Retrieved from

References Paraprofessional Healthcare Institute (PHI). (2014). Facts 5: Home care aides at a glance. Retrieved from http: //phinational. org/sites/phinational. org/files/phi-facts-5. pdf Paraprofessional Healthcare Institute (PHI). (2015). Advanced roles for aides. Retrieved from http: //phinational. org/policy/advanced-roles-aides Paraprofessional Healthcare Institute (PHI). (2015). Paying the price: How poverty wages undermine home care in America. Retrieved from http: //phinational. org/research-reports/ Seavey, D. & Marquand, A. (2011). Caring in America: A comprehensive analysis of the nation’s fastest growing jobs: Home health and personal care aides. Retrieved from http: //phinational. org/research-reports/

Additional Websites Caring Across Generations: http: //www. caringacross. org/ Eldercare Workforce Alliance: http: //www. eldercareworkforce. org/ Leading Age: http: //www. leadingage. org/workforce. aspx National Domestic Workers Alliance: http: //www. domesticworkers. org Paraprofessional Healthcare Institute: http: //phinational. org/direct-care-workers-glance Service Employees International Union: http: //www. seiu. org/ United Domestic Workers of America: http: //www. udwa. org/ United States Department of Labor: http: //www. dol. gov/whd/homecare/ See the Direct Care Workers Bibliography on the Gero-Ed