The nation's 3.3 million home health-care workers are the other front-line heroes in the war against the coronavirus. While hospitals' physicians and nurses tend to the sickest COVID-19 victims, the in-home workforce is caring for millions of the most vulnerable Americans.
Yet they lack personal protective equipment, too. According to a March survey of 1,200 in-home workers by the Home Care Association of America, 77% don't have enough masks and 57% don't have enough gloves. Many are underpaid and lack health insurance and paid sick leave. The pandemic is putting additional pressure on a workforce already in crisis suffering from shortages, especially in hard-hit states such as New York, New Jersey, Louisiana and Washington. In response, the largest home health-care union, industry providers and advocacy groups are urging Washington to respond to this crisis.
Home health workers — comprising nurses, therapists and personal care aides — provide a range of medical and daily-living services to nearly 12 million people, most of them elderly and many chronically ill, disabled, bedridden or coping with Alzheimer's disease and other cognitive issues. And while they are a critical link in fighting this deadly pandemic, they're overlooked in daily briefings by the White House Coronavirus Task Force and ubiquitous media reports.
"We have boots on the ground today, out there in people's homes for three to six hours a day, caring for folks who are most at risk," said Vicki Hoak, executive director of HCAOA, a Washington, D.C.-based trade group representing nearly 3,000 companies that employ more than 500,000 caregivers across the U.S. "Our mantra over the past few weeks has been protect and prevent."
That this workforce toils unheralded is surprising, considering that stressed hospitals are discharging noncritical patients and postponing elective surgeries to make room for mounting COVID-19 cases. And that skilled nursing facilities and assisted-living communities are losing residents because of widespread infections and visiting restrictions on families.
Suddenly, private homes are the go-to refuges for both medical and personal care. But unless family members can provide for this influx of patients, home-care workers will be the best solution, heaping an exponential burden onto an already stressed profession.
The private and public entities — such as Home Instead Senior Care and California's In-Home Supportive Services program — that employ in-home caregivers are rapidly responding to the fast-rising demand, even as some workers are forced to stay home to care for their own families, clients cancel visits for fear of becoming infected and the paucity of personal protective equipment lurks.
It's a crisis at a tipping point. The work of these caregivers may never have been more vital than right now, yet worker shortages are a real threat.
Once the pandemic hit the U.S., the home health-care industry immediately began preparing its workers to add coronavirus to their already full plates. They launched education and training programs, provided as much PPE as possible and stepped up telehealth services.
"I mandated that our global franchise network retrain and recertify all our caregivers on basics like washing hands, avoiding touching their face, avoid contact with people who are sick, and if you're sick to stay home," said Jeff Huber, CEO of Home Instead, a private company based in Omaha, with more than 1,000 independent franchises.
Home Instead established a coronavirus task force to disseminate essential information, materials and resources for franchisees and their caregivers. "The front line has everything at their fingertips," Huber said.
Kindred at Home, based in Atlanta, has taken a similar approach with its 779-community care, home health and hospice operations across 40 states. "We have provided a comprehensive document detailing the coronavirus, its signs and symptoms and patient risk assessment, as well as staff and patient education resources," said COO Nick Stengle.
"The challenge for our caregivers is making sure they can do their work safely," said Sterling Harders, president of the Service Employees Union International 775, which represents 45,000 health-care workers, including 42,000 in-home personal-care aides, in Washington state and Montana. "They are providing what oftentimes is very intimate care that is difficult to do while social distancing from 6 ft away."
SEIU Healthcare — the largest division of the union, representing nearly 1.1 million health-care workers, 740,000 of whom provide non-medical care in homes — is keeping members up to speed on coronavirus through local chapters in about a dozen states. SEIU 775, for example, is regularly sending updates via email and social media. "We also have a call center that's able to field calls in over a dozen languages," Harders reported, alluding to the ethnic diversity among not just its members but the home health-care workforce overall.
In California, SEIU Local 2015 has a comparable outreach for its 400,000 health-care workers, 380,000 of whom work mostly for IHSS. "PPE is the first thing on our members' minds," said chapter president April Verrett, "because they want to continue going into homes but don't want to get sick" or risk infecting households. SEIU 2015 workers have adequate supplies of antibacterial soap and hand sanitizer, she said, but not sufficient PPE.
The risks to in-home caregivers extends beyond the scarcity of PPE to screening for coronavirus, said William Dombi, president of the National Association for Home Care and Hospice, a Washington-based industry advocate mostly for nurses, therapists and other medically trained in-home workers. "I can't speak for every location and employer," he said, "but the protocol under way is for screening of every worker before going into the home, so they don't create a risk for their clients, and it's also screening clients to see that there's no risk to the workers."
Even so, according to the HCAOA survey, nearly 90% of respondents reported clients canceling one or more visits, because they fear aides may spread the disease. Despite those worries, however, 80% said that no clients or employees had reported COVID-19 symptoms.
This overlap of fear and precaution is impacting in-home caregiving. "We've been hearing about numerous cases where providers are scrambling to find workers," said Robert Espinoza, vice president of policy at PHI, a Bronx-based nonprofit that advocates for home health workers, though shortages are hard to gauge, because states don't collect enough data on direct care workers.
"We have been hearing from some agencies that they have had a slight decline in workers, as well as clients," HCAOA's Hoak said. Kindred reported fewer patient visits, but not a shortage of workers.
It's been a mixed bag for Home Instead. "We've seen some clients not needing as much care, due to family being home from work," a company spokesperson said. "But on the other side of the spectrum, we have new clients starting care at home, including those in heavily impacted areas where seniors are being discharged for non-COVID-19-related illness to free up hospital beds."
Those developments help explain the dramatic expansion of in-home telehealth. The technology allowing patients to remotely connect by voice and video with medical practitioners via smartphones, computers and tablets has been around for years, but the coronavirus pandemic is fueling a meteoric rise in usage.
"We've never seen anything like this," said Mike Baird, president of customer solutions at Amwell, a Boston-based telehealth services and technology company. "Overall, our volumes of engagement are up sevenfold from where they were in peak flu season just a few weeks ago." Amwell customers that were seeing a few hundred patients per week just one week ago are now seeing 1,000 or more per day, with notable activity in hard-hit states including Washington, New York, New Jersey and Louisiana.
Amwell works with more than 2,400 hospitals, 240 health systems and 55 health insurance plans, with about 85% of its telehealth services going to in-home patients. "Our in-home volume is so big due to the influx of patients being told by hospitals, health systems and primary care providers not come in, because they don't have the tests or capability to do assessments," Baird said. "In contrast, we have a network of more than 10,000 doctors available on demand."
Two years ago Home Instead made a strategic investment in GrandPad, an Orange, California-based maker of a proprietary telehealth tablet designed for seniors. "It's an effective tool not just for clients but for our in-home caregivers," Huber said. "When we're not there, it allows us to do virtual check-ins, quality assurance visits and reduce the amount of time we [risk] being in homes."
Not all health insurance plans offer telehealth, but the federal Centers for Medicare and Medicaid Services recently announced some reimbursement expansions, but only during the coronavirus crisis. "Telehealth is an essential focus of our advocacy efforts," Dombi said. "We're hoping to see more coming from CMS" in the near future, especially regarding in-home access and reimbursements.
This moment, too, is a fortuitous occasion to shine a bright light on the need to address long-overdue reforms in the home care industry. "We look for historical and political moments where everything we advocate for rises to the highest level," Espinoza said. "This crisis shows people what it means to have a disenfranchised workforce."
Nearly 90% of home health-care workers are women, and their median age is 46, according to PHI. More than 60% are people of color, 31% are immigrants, and half have no formal education beyond high school. Only about a third of the workforce unionized.
According to the latest analysis by the federal Bureau of Labor Statistics, median annual pay was $24,060 in 2018, or $11.57 per hour. Overall employment of home health aides and personal-care aides — as BLS categorizes the workforce — is projected to grow 36% from 2018 to 2028, adding a total of 4,438,700 new jobs over the decade, per the agency.
The coronavirus crisis is putting additional stress on a workforce that was already facing shortages due to the aging of America. With nearly 10,000 baby boomers turning 65 every day — a population including millions of individuals already living with long-term health conditions or likely to develop one or more — and the growing trend of aging in place, experts have been warning that the demand for in-home care is outpacing the supply of both medical practitioners and care aides.
But even now, as the urgent need for home health care is clear, there's little focus in Washington, D.C., on this looming dilemma. Some short-term loosening of regulatory and reimbursement burdens have been implemented by the Centers for Medicare and Medicaid Services, but advocates insist that permanent fixes must be addressed once the coronavirus crisis abates.
"For years we've been advocating for stronger training programs across the board, but especially for personal care aides," Espinoza said. "This is a great example of what it means when we don't train them right, that they're not prepared to deal with something of this scale."
The National Domestic Workers Alliance, based in New York, is pushing for better pay, benefits and rights for home care workers, as well as nannies and house cleaners. "Our increasing need for [home] care will remain even when the coronavirus has passed," said executive director Ai-jen Poo. "The reasons to protect domestic workers and make sure that care jobs are good jobs are now stark."
If nothing else, the COVID-19 crisis offers a timely opportunity to recruit home care workers to fill the dwindling pipeline. "The [tight] labor market has been a restriction on our growth," Huber said. "A lot of our owners are ramping up their recruitment efforts to target people from other industries who are out of work."
No matter where they come from, now is the time to consider this noble career, Harders said. "With all of these people aging and needing care and not having enough caregivers, this is a great opportunity for folks to give it a try."
This story has been updated to reflect that Kindred At Home is based in Atlanta, not Louisville, and is a standalone company owned 40% by Humana.