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New England Regional

A Crisis in Caregiving

Longer-range solutions for long-term care

January-February 2002

Who will take care of our elders? Low pay, poor training, meager prospects for advancement, and major population shifts are creating a national shortage of caregivers for all but the very wealthy. Scholars are studying the dilemma, the government may spend more money to help out, and grassroots pockets of potential "deep system change" in the way elders and caregivers are treated do exist--but solutions to the shortage are not necessarily on the horizon.

"I don't think 'crisis' is too strong a word," says Susan C. Eaton '79, M.P.A. '93, assistant professor of public policy at Harvard's Kennedy School. The majority of people older than 75, many of whom need help with one or more daily activities such as washing, dressing, eating, and shopping, have historically relied on family members. Adult children comprise more than 40 percent of those "informal" caregivers (most of them are grown daughters); 25 percent are spouses. But for various reasons that dynamic is changing. Elders are increasingly dependent on formal caregivers: the entry-level paraprofessionals who perform the most direct, intimate tasks in nursing facilities, hospitals, and private homes. These aides are poorly compensated, which leads to problems attracting quality workers. Moreover, just as the demand for help is rising dramatically, the supply of available caregivers is shrinking--and, Eaton asserts, "there is every reason to think that it will become worse in the future."

The typical paraprofessional elder caregiver (certified nursing assistants and home health aides) is a single mother with a high-school degree, or less, living near the poverty line, Eaton reports. In many instances, she earns less than her entry-level counterparts at fast-food outlets and has access to fewer benefits: in 1999, caregivers made between $8.29 and $8.94 an hour compared to the $9.22 for service workers, and $15.29 for the average hourly worker, according to the General Accounting Office. New England states generally pay caregivers several more dollars, especially in what (until now) has been a tight labor market, Eaton says. "But even if they work full-time--2,080 hours a year--which many of them don't--it's still not enough to live on, especially in Boston with children to support." They usually have to work two or three jobs.

Caregiving is also emotionally and physically draining work--as anyone knows who has cared for children, ailing friends, or elders, says Barbara W. Frank, M.P.A. '98, director of state health policy for the Massachusetts office of the Paraprofessional Healthcare Institute, which advocates for front-line workers. The job requires reserves of patience and generosity as well as an ability to connect personally with human beings in a vulnerable position. It is these qualitative aspects of the job that most caregivers find appealing. "The whole field is about creating relationships," Frank explains. "Employees care about the wages and benefits, but they also care about the ability to do real caregiving--that's a factor that often keeps them there, instead of going to work at Starbucks or McDonald's. The question is, what kind of work environments are employers providing for people so they can provide real care? Can they do things to make the environment better for both the workers and the patients?"

Eaton concurs. She spent last summer touring nursing homes nationwide to study the correlation between management practices and nursing-staff turnover. Her report, for a government agency, is due out this year. "We found that benefits seem to be very important--more important than wages to many workers," she says. Caregivers also want to be more involved in decision-making, and to receive more respect from managers and patients' families. Long-term relationships with patients, she has found, do seem to help keep front-line workers in jobs, but many facilities are so poorly managed and chronically understaffed that proven, effective changes--like ensuring that the same caregivers take care of the same patients each day--are hard to make.

Statistical shifts in population and the labor force also help explain the shortage. In the simplest terms, "what you're seeing is a steady increase in the number of elders who need formal care and a steady decrease in the number of workers," Frank explains. The GAO report says the population of people age 85 and older will more than double--from 4.3 million in 2000, to 8.9 million in 2030--when the baby-boom generation first begins to hit "older old age." People are also living longer than they used to. Combining these trends, one study projects the number of elders who need help with daily activities will more than double--from 5 million to 11 million--by 2050. Healthier older people create more demand for at-home help and community-based support, while those who are ailing (who are also living longer) are staying longer in nursing facilities. Those facilities, Frank explains, have also had to absorb more acute-care patients who are released sooner from hospitals than they were a decade ago.

In contrast, the supply of long-term elder-care workers, traditionally drawn from a pool of women aged 25 to 44, is falling after decades of steady growth. In 1968, for example, 45 percent of all women were participating in the workforce; by 1998, the figure had risen to 75 percent, report Steven L. Dawson and Rick Surpin in "Direct-Care Healthcare Workers: You Get What You Pay For," published this past year in Generations, the journal of the American Society on Aging. But many of those working women are baby boomers who will soon start moving from being caregivers to needing care. Moreover, since 1998 the rate of women entering the workforce has slowed considerably--the pool of entry-level workers is projected to drop by 1.4 percent within the next six years, Dawson and Surpin contend. The movement of more women into the professional and higher-paying ranks of the labor market has also left vacancies in traditionally entry-level jobs for women. As Dawson and Surpin say, "The decades-old presumption of an endless supply of low-income women to feed, bathe, and comfort those in need of care is no longer valid." This begs larger questions: why aren't more men in the caregiving field, and should recruitment efforts start targeting them? "If this job were better salaried and had benefits, would we see more men in the field?" queries Eaton. "Maybe we had better start getting men interested in this, because in the future there aren't going to be enough women to do it."

Demographic shifts have also affected reliance on formal care. Changes in reproductive and family patterns during the last two decades have set the stage for more elderly, childless women, writes Lisa Alecxih in "The Impact of Sociodemographic Change on the Future of Long-Term Care," another recent Generations article. Adults who do have children generally have fewer of them, and grown children tend to live farther away from their parents, making daily care impossible. Alecxih also notes that the number of elderly people of color is rapidly rising, which will require different types of more culturally sensitive care settings. Hispanics are the fastest-growing elderly population in the United States, she adds, and are less likely than other groups to rely on institutional care as they age. That puts greater pressure on informal and paraprofessional home- and community-based care systems, such as visiting-nurse organizations.

Money and politics, of course, play a huge, and complex, role in the supply-and-demand cycle. The public sector is the primary source of financing for long-term care, and labor is the number-one cost, so debates about Medicare and Medicaid reimbursements directly affect the supply of workers and the ability of employers to compete for them, says Francis G. Caro, professor of gerontology and director of the Gerontology Institute at the University of Massachusetts at Boston. This is especially true for nursing homes--many of which are profit-driven; 70 percent of their revenue comes from Medicaid, and 10 percent from Medicare, which pays at a higher rate.

The Balanced Budget Act of 1997, for example, limited Medicare reimbursements for expenses, and led to severe financial troubles for many nursing homes and restrictions in the home-healthcare industry. In part, Alecxih says, the industry overreacted to the change in reimbursements, and can blame only itself for losing business because it cut services and took fewer patients. "I wouldn't put all the blame on the government," she says. Whatever the cause, many caregiving companies closed, filed for bankruptcy, or drastically cut staff, Caro explains. Some of the damage has since been repaired, but the act's widespread effect underscores the argument that any solution has essential financial and political components. Barbara Frank, of the Paraprofessional Healthcare Institute, says reimbursement rates have been "way too low for way too long. Providers need to aggressively increase wages or they won't be able to provide services."

But more money is not the only answer, Susan Eaton and others argue. "You still have to think about management practices--just because you pay more does not mean you get better managers," she says. Supervision and training of paraprofessionals is inadequate: the federal standard for nursing aides is 75 hours of training, but in most states, nursing aides receive much less training than hairdressers, she says. "You still need more career ladders, on-site education, and support, so these caregiving jobs are not dead ends. The next step up is to become a licensed practical nurse--but that requires two years of college, which is too much time and money for a lot of these workers," she continues. "We need more geriatric nurse practitioners--and others specifically trained in geriatric care--and more focus on systemic issues. And we're not really sure, as a society, how to do all that."

Dozens of states now have taskforces to address the labor-shortage issue. The U.S. Department of Health and Human Services has funded research at the Center for Health Workforce Studies at SUNY-Albany to assess the need for long-term care workers. The government has also joined with the Robert Wood Johnson Foundation to develop ways to build up the workforce; a report is due this spring. So far, proposed solutions have tended to focus on recruiting new immigrants as a source of entry-level labor; increasing government funding for wages, training, and supervision of workers; recruiting more people to the field of gerontology; and creating basic changes in the way elders and caregivers are viewed and treated.

Some people have suggested relaxing immigration policies to help fill caregiving and nursing vacancies. That idea smacks of a quick-fix that, in fact, raises other problems. There are already a rising number of caregivers from Haiti, Latin countries, Africa, and the Azores. "All of these different groups working together, and with predominantly white patients, creates complicated racial and ethnic politics," Eaton explains. "If you have Ethiopians and Eritreans in the same workforce, how do you build a team?" Caregivers of color often have to cope with an elder who has "old images of race relations," she adds. "They have been called names, or been treated like servants." Instead of exploiting a new group of workers, "we need to change the working conditions to begin with, so that neither the elders nor the caregivers are being marginalized."

Easier said than done, no doubt. The most promising ventures seem to be regional, or smaller-scale, projects that combine financial and systemic changes. In Massachusetts, the state's Nursing Home Quality Initiative, passed in 2000, has helped increase nursing-home wages, created career ladders in caregiving, and targeted $1 million for scholarship funds. Whether this initiative continues, however, depends completely on continued support from state legislators.

A nonprofit, multidisciplinary group, the Pioneer Network (www.pioneernetwork.net), led by former nursing executive Susan Misiorski, is developing "state coalitions for culture change" to improve working conditions at nursing homes. In January, five demonstration projects are starting in New Hampshire. Emphasis is on management-staff relations, she says: improving communication, participatory planning, examining absentee rates and sick time, and, in general, identifying ways that all employees can gain more respect within the organization. "We believe that life with meaning is possible in long-term care," she says. But that cannot happen unless working conditions, and views on elder-care, change. Misiorski herself has held "every job there is in caregiving--including nurse's aide. So I know that just as the staff treats each other, so do they treat the patients. The same place where the staff works is where the residents live--what affects one group affects the other. They really cannot be separated."