Forgotten ‘health care heroes’: At $10.51 an hour, in-home aides can't afford to stay

Thompson looked on, enjoying the respite. “See, that’s one of the blessings — doing her hair. I’m not good at it,” she said. 

“She’s a good old braider, too,” Stanfield praised.

Because Stanfield has help from Turner and from a day program, Thompson can work part-time, run errands, exercise, manage her life. Without these services, Stanfield might be in a nursing home. 

More and more Americans want to stay home as we age — especially after COVID-19 hit nursing facilities so hard. But there already aren't enough home care aides, and the pay is far too low to attract many more. Unless North Carolina starts paying aides like Turner more, more and more elderly people will probably end up in nursing homes. And if we're lucky, we all get old. 

Two years ago, medical clinics and hospitals put signs outside declaring HEALTH CARE HEROES WORK HERE. No one put a sign in front of Stanfield and Thompson’s door. But health care heroes work there, too.

Home care workers play a necessary, underpaid role

Home care workers play a critical role in the health care system. They are the coal miners who watch for the canary – catching small changes in patients before they spiral into big problems.

“We keep our patients out of the hospital. We keep our patients from falling,” Turner said. “When you can keep people in their environment, they live longer.”

By preventing hospitalization, HomeCare Providers is on track to save insurance payors such as Medicaid $3.6 million this year, said Michelle White, the program’s director of home and transitional care.

That money doesn’t trickle down to the agencies or the workers themselves, however. Home care aides occupy the lowest rung of the ladder for both prestige and pay. In 2020, North Carolina’s 44,270 home care workers earned a median wage of $10.51, which had not improved in a decade, according to analysis by the research institute PHI. More than nine in 10 are women, and six in 10 non-white.

Home care programs “oftentime run at a loss,” White said. HomeCare Providers can offer benefits and cover travel time because it’s owned by Cone Health.

There are two reasons the pay is so poor, PHI policy research director Kezia Scales said. First, Medicare typically covers only short-term services for an acute situation such as an illness, a wound or a recent hospitalization. When Turner provides long-term care – helping a patient take care of themselves and their homes, the assistance that is needed for a patient to live at home – technically, it’s not considered “medical” care. It’s usually covered by Medicaid, Scales said. And “those budgets are always really strained and inconsistent.”    

The second reason is the field’s historical roots “as women’s work, as a calling, as an inclination … [a] labor of love,” Scales said. The Fair Labor Standards Act excluded home care workers until 2015.

American society assumes that grown children will care for seniors. But even if a family member can help, like Thompson, one person can't do it alone -- there are too many hours in the day.

“Our system has not caught up to the realities,” Scales said. The U.S. needs formal care services for the elderly “just as we have day care and school in place when people are younger.”

Which means paying the people who do it.

Learn more: Caregiver fatigue left millions suffering in silence during COVID-19

Compression stockings and word-search puzzles

Turner, 58, has thick eyelashes, sculpted brows and curls as bouncy as a morning cup of coffee. She’s worked in senior care for 14 years, all but one in people’s homes. “I can better serve my patients one-on-one. Rather than a whole hallway,” she said. “I like giving my patients my full attention.”

She gave up her second job driving a bus for the school system when COVID started, and doubled down on home care. "This is more my calling, I would think," she said. All of HomeCare Providers doubled down. Even when patients got COVID-19, aides kept coming. They had to, White said: Otherwise “they would surge the ED.”

The company fit-tested its aides for N95 respirators, set up a food pantry in the office so people could avoid supermarkets and periodically sent masks to patients. That said, Cone couldn’t make them wear those masks. Because they were in their homes.

To stay safe, Turner, who always hosts Thanksgiving for her family, made the 2020 event a drive-through: She and her daughter “took their orders, we fixed their plates and we took them out to their cars.”

At the same time she distanced from family, she carried out intimate tasks for patients. A care plan might include items such as tidying the bathroom, laying out clothes, shaving, making a meal, providing oral care, cleaning their perineum.

To do these, Turner employs not only dexterity and skill but encouragement and banter.

“You have to wear these … they keep the circulation going good in your legs,” Turner’s voice came from the bathroom, where Stanfield was sitting, accompanied by snapping sounds. “It’s all right. I’ll get it. You got this. Flowers on, good job! We’ve about got this licked, Tricia.”

Later, she helped Stanfield do her word-search puzzles. “I do one word at a time so I don’t get messed up,” Stanfield explained, clutching a mug of her beloved black coffee.

“Your nails is real purty,” Turner observed, hanging over the loveseat arm.

“Thank you,” Stanfield said.

“Hands is soft,” Turner continued, stroking Stanfield’s hand.

“I do what I do.”

“You don’t do nothing!”

How to improve home care pay

To serve our aging country, we’ll need a lot more Donna Turners.

The home care worker shortage is longstanding, Scales said, “but providers are saying now the challenge is on a whole different level.”

HomeCare Providers always has a waiting list, White said. To help, Cone Health is starting its own certified nurse assistant school. Participants will earn a stipend while in class—removing a major barrier to going to school--and be promised jobs.

Turner would like better pay and more respect. She is a certified nurse assistant II, trained at Alamance Community College. The title “aide” feels a little demeaning and outdated, she said: “I’d rather be called a nursing assistant or a nurse tech.”

However, there are solutions, said Scales, the PHI policy expert. The American Rescue Plan Act sent more money to Medicaid for long-term care, including home care. The North Carolina General Assembly “strongly encouraged” providers to pass it along to direct care workers as a wage increase, with the goal of raising wages to at least $15 an hour, she said. The fact that the Legislature specified a wage increase and not a one-time bonus signaled a commitment to continuing the support, Scales said.

Biden caregiving plan: How Medicaid might be used to boost in-home care

That plus the defunct Build Back Better bill catalyzed “an unprecedented amount of national discourse on the care economy,” Scales said. She is optimistic that the federal government will indeed invest more into home care services.

Apart from money, Scales wants to see education for home care workers that will let them change roles more easily; more attention to supervision and peer support, so they don’t feel isolated; and “a public education campaign that really communicates the value of these jobs and the importance of these workers.”

'There's no place like home'

Turner’s last client of the day, Dudley Clinard, 85, lay in his wood-paneled living room surrounded by the artifacts of 55 years. The portraits of his blonde little girls that his mother painted. The two family sets of World Book encyclopedias — one his wife’s, the other his daughters’. The daughters are grandmothers now.

Twice in the past year, Clinard had to go to rehabilitation facilities, where he stared at sterile walls. “The old saying, there’s no place like home,” he said. His eyes filled with tears. “I’m glad to be where I can at least see some of my things.”

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Turner intervened. “If you’re tired, Mr. Clinard, you don’t have to keep talking. I know you like to get your rest,” she said. Graciously posing it as a preference, not a need.

In the kitchen, Turner recorded his increasingly shallow breathing. A do-not-resuscitate order hung on the refrigerator. She waited for him to call out for help.

“They don’t want to leave their homes,” she said. “And it’s people like us that can keep them in their homes.”

Danielle Dreilinger is a North Carolina storytelling reporter and author of the book The Secret History of Home Economics, an NPR Favorite History Book of 2021. Contact her at 919-236-3141 or ddreilinger@gannett.com.

This article originally appeared on Times-News: Forgotten ‘health care heroes’: At $10.51 an hour, in-home aides can't afford to stay