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A FUTURE FOR HAWAII'S HOME CARE AIDES
FAITH ACTION FOR COMMUNITY EQUITY
CAMPAIGN FOR GOOD JOBS REPORT SERIES
Prepared By: Kim Harman, Policy Director
June 14, 2012
“Right now, home care is one of the fastest-growing industries in America, partly because we're getting older as a society. And as the baby boom generation heads into retirement, more and more Americans are going to need the services of these outstanding workers. ... Many home care workers are forced to rely on things like food stamps just to make ends meet. That's just wrong. In this country, it's unexcusable. I can tell you firsthand that these men and women, they work their tails off, and they don't complain. They deserve to be treated fairly. They deserve to be paid fairly for a service that many older Americans couldn't live without.” President Barack Obama, December 15, 2011
TABLE OF CONTENTS
Introduction..................................................4 Background & Purpose of Study............. .....5 Findings.......................................................6 Employment Projections..............................7 Skills & Working Conditions.........................7 Wages & Benefits.........................................9 Training & Certification................................11 Summary.....................................................12 Recommendations......................................12
Tables Table 1: Table 2: Table 3: Projected Employment Growth Rate for Home Care Aides by County, Page 7 Mean Wage Comparison Across Entry-Level Occupations in Hawaii, Page 9 Annual Mean Wages of Full-Time Home Care Aides in the Pacific Region of the US, Page 10
Faith Action for Community Equity is a statewide, faith-based multi-issue organization committed to training grassroots leaders to identify key problems facing Hawaii's families and fight for concrete and lasting solutions to those problems. Above: Photos from FACE's continuous fight to organize entry-level healthcare workers, support aging-in-place and improve Medicare reimbursement levels in Hawaii.
At FACE Hawaii, we work for justice based on the value of dignity and respect of the human person. When FACE members from Maui and Oahu urged us to address the issue of “good” jobs, the question was “where do we start?” From the faith traditions of our Episcopal, Catholic, Methodist, UCC, Jewish, Evangelical, and Buddhist members, we asked where to do we find justice for our brothers and sisters in most need for work. As a Catholic, I turn to the declaration of the late Pope John XXIII who said that “all people have a right to life, food, clothing, shelter, rest, medical care, education and employment.” The more we talked and listened to our members, the more we heard loud and clear that too many of our hardworking brothers and sisters do not have employment that allows them dignity and respect. I was surprised, saddened and angered to learn that some of the lowest paid workers in Hawaii are Home Care Aides, the people we rely on to care for our kupuna, and that this is projected to be the fastest growing job in our state for many years. This study raises several questions for me: Why are Home Care Aides paid so low? Is it because they are women - mostly immigrant women? What message does it send to our kupuna that we do not value their long-term care enough to pay their caretakers a fair wage? I don't like that message, and as a person getting older myself (every day, in fact!) I have a self-interest in helping make this a “good” job in my state. I am proud to offer you this study of the conditions of Home Care Aides in Hawaii and our conclusions about how improving Home Care as an occupation will also improve opportunities for successful aging-in-place in Hawaii. Aloha,
Stan Franco, MSW Deacon of the Catholic Diocese of Honolulu Former Chaplain’s Assistant at Maui Memorial Medical Center Former President of Face Maui Former Executive Director of Maui Catholic Charities
“Home Care Aide” is projected to the fastest growing employment sector in Hawaii over the next six years1. This vital, demanding and low-paid work does not provide enough income for even full time workers to get their families out of poverty. The career ladder from Home Care Aide to Certified Nursing Assistant and other better paid health care jobs is broken, leaving thousands of talented, caring Home Care Aides in dead end, low paid jobs. Now consider that Hawaii's residents have the longest life-expectancy in the US and life-expectancy is growing. According to the AARP, Hawaii's 85+ population is projected to grow by 136% over the next 25 years. There is also a growing desire to “age in place” throughout the state, and studies show that providing care at home rather than in a long-term care facility is desirable for families and cost-effective for the state. Faith Action for Community Equity has been working to improve employment opportunities for low-income and entry level workers and has been fighting to expand opportunities for aging-in-place for more than 15 years. Securing respect, a living wage and proper training for our Home Care Aides so that our seniors have access to the home care they need and deserve is a necessary extension of our organizing. In preparation for this study, FACE's Statewide Jobs Committee conducted 34 interviews with local and national experts, politicians and health care workers to determine how FACE could make the greatest impact on employment for as many of Hawaii's families as possible. This report is an important step toward that goal.
PURPOSE OF STUDY
The purpose of this study is to investigate the disconnect between the vital and demanding work that Home Care Aides perform in Hawaii and the low-wages and lack of benefits the workers receive. To this end, this report will define the current status and conditions of Home Care Aides in Hawaii, provide insight from Home Care Aides and experts and propose recommendations to improve the work and lives of Home Care Aides for the benefit of both the caregivers themselves and their patients throughout Hawaii. Most reports and studies of long-term care, aging-in-place, and health care jobs do not include any analysis of Home Care Aide as a career. In fact, FACE could not find any in-depth studies or analysis of Home Care Aides in Hawaii. Hopefully, this report will help to fill this gap. This study will also help to clarify the job classification “Home Care Aide”.
1 State of Hawaii Department of Labor and Industrial Relations
• • • •
Home Care Aides are projected to be the fastest growing occupations throughout Hawaii from now through 20182. Home Care Aides in Hawaii now the lowest paid in the Pacific Region of the US3. Wages for Home Care Aides dropped 2.7% in Hawaii between 2010 and 20114. Home Care Aides face strenuous and often dangerous working conditions yet often work without receiving workers compensation insurance coverage or access to Temporary Disability Insurance (TDI). There is an ongoing misconception that Home Care Aides provide mere “companionship” and are therefore in a non-skilled occupation. This is incorrect; many of the skills and duties identified by the Department of Labor are skilled and para-medical duties. Many Home Care Aides in Hawaii work for agencies that are not required to be licensed by the state. In order to advance their careers and earn more income, Home Care Aides often attempt to pursue certification to become a Certified Nurses Aide. However, courses to become a Certified Nurses Aide are more burdensome in Hawaii than almost any other state and the exams to become a Certified Nurses Aide cost more in Hawaii than almost any other state. Many Home Care Aides who pay $1,500-1,775 for Certified Nurse Aide training and exams are forced to give up their certification after their first two years because the requirements for attaining recertification are only available to CNAs who work in specified facilities and not for those providing home care.
2 State of Hawaii Department of Labor and Industrial Relations 3 US Department of Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May 2010 and May 2011 4 US Department of Labor, Bureau of Labor Statistics, Occupational Employment Statistics, May 2010 and May 2011
As of May, 2010, there were 4,730 Home Care Aides in Hawaii. (BLS) and that number is projected to grow to 7,237 by 2018. Employment for Home Care Aides is projected to be the fastest growing occupation in every county in Hawaii through 2018 5 and Home Care Aide job growth is projected to be 7% higher in Hawaii than the national average6. TABLE 1: PROJECTED EMPLOYMENT GROWTH RATE FOR HOME CARE CARE AIDES BY COUNTY HI County Projected Growth Rate by 2018 Hawaii County Honolulu MSA Kauai County Maui County Statewide 55% 47% 42% 87% 53%
Employment Projections for Industries and Occupations, 2008-2018, revised September 2011, State of Hawaii Department of Labor and Industrial Relations
Many states are reporting shortages of Home Care Aides due not only to the growth of the employment sector, but also the high turnover rate within the sector. Many fast food and entry level tourism industry jobs offer higher pay, more dependable hours and better benefits than many Home Care Aide jobs. Combined with the lack of opportunity for advancement within the sector, even Home Care Aides who excel at providing home care must often leave the job in order to better support their families.
HOME CARE AIDES: SKILLS & WORKING CONDITIONS
Terms such as “Homemaker Services” and “Companion” are misleading and often obscure the level of skill and rigor of the duties Home Care Aides perform. Genworth Financial, for example, a leading long-term care insurance provider, conducts an indepth nationwide comparative study of long-term care costs every year and their study refers to the duties of a Home Care Aide as “Homemaker Services”, which implies dusting and making beds, not the actual bathing, hand-feeding, dressing and personal grooming care that is actually required. If you read the methodology section of Genworth Financial's 2011 study, they clearly defines “Homemaker Services” to include all the same skills and duties as the Department of Labor defines for Home Care Aides.
5 State of Hawaii Department of Labor and Industrial Relations 6 US Department of Labor, CareerInfoNet.org
Misleading terms aside, there is a dizzying range of terms for the person who performs the duties referred to here as Home Care Aide. For the purposes of this study, FACE is relying on the definition of skills and duties outlined by the US Department of Labor, Occupation Network. According to this body, Home Care Aides provide: “...supportive care including but not limited to: bathing and hand-feeding patients, assisting in dressing and grooming, monitoring vital signs and medication, advising clients and their families on hygiene and nutrition, preparing and maintaining records of client progress, lift and transport patients to medical and other appointments, reporting changes in condition to supervisors, and administer first aid when necessary.” Working as a Home Care Aide is also physically demanding and potentially dangerous occupation. According to the National Institutes for Occupational Safety and Health (NIOSH): “Home Care workers are frequently exposed to a variety of potentially serious or even life threatening dangers. These dangers include overexertion; stress; guns and other weapons; illegal drugs; verbal abuse and other forms of violence in the home or community; blood-borne pathogens; needlesticks; latex sensitivity; temperature extremes; unhygenic conditions including lack of water, unclean or hostile animals, and animal waste.” 7 In addition to those dangers identified by NIOSH, Home Care Aides are confronted with difficult situations on a daily basis. Patients are often desperate for companionship, suffer from serious undiagnosed illnesses and dementia, may give different directions than family members, and can be violent or accuse Home Care Aides of stealing, abuse or other criminal acts. Patients often reject Home Care Aides of certain races or ethnicities due to stereotypes. Too often, Home Care Aides are also the only person in a patients' daily life to observe changes in patients' medical and mental condition, financial situation, and relationships with family members and neighbors. It is vital that Home Care Aides understand where and how to report potentially dangerous situations. While some of these issues are included in the courses that lead to certification as a Certified Nurses Assistant, many Home Care Aides have no formal training on these issues.
7 NIOSH Hazard Review, Occupational Hazards in Home Health Care, January 2010.
WAGES AND BENEFITS
Hawaii is ranked as the 7th costliest state for Home Care in the country, with Home Care costs 18% higher than the national average8. However, Home Care Aides in Hawaii are some of the lowest paid in the Pacific Region of the US and now even those low wages are dropping (see Table 2). Further, Home Care Aides in Hawaii are paid less than the national average for all Home Care Aides. This is especially important when you consider that many Home Care Aides are the primary breadwinner for their family. Home Care Aide as an occupation is one of the lowest paid health care jobs across the country. But here in Hawaii, Home Care Aides are paid even less compared to other entry level jobs and are paid less than their Home Care Aide counterparts across the country. Home Care Aides also struggle to achieve full-time hours and often work without even basic benefits like Workers Compensation Insurance. TABLE 2: MEAN WAGE COMPARISON ACROSS ENTRY-LEVEL OCCUPATIONS IN HAWAII
Mean Hourly Wage Mean Annual Wage $30,500 $25,990 $25,850 $24,590 $23,590 $18,880 How Much More Above or Below Each Year Than A Poverty Level for a Home Care Aide Family of 3 $11,620 $7,110 $6,970 $5,710 $4,710 N/a Above Above Above Above Above Below
Housekeeper $14.66 Janitor Security Guard Dishwasher Veterinary Assistant Home Care Aide $12.50 $12.43 $11.82 $11.34 $9.08
May 2011State Occupational Employment and Wage Estimates, Hawaii, United States Department of Labor, Bureau of Labor Statistics
The mean hourly wage for all occupations in Hawaii in 2011 was $21.44, more than twice the hourly wage of Home Care Aides in our state. This low pay and lack of benefits is one of the key reasons there is such a high turnover rate among Home Care Aides. In Hawaii, full-time Home Care Aides earn a mean hourly wage of $9.08 an hour and $18,880 per year, which is $3,0809 below the poverty level for a family of three in
8 Pacific Business News, April 27, 2010 9 US Department of Human Services, Federal Register Notice, Volume 77, Number 17, January 26, 2012.
Hawaii, Hawaii's Home Care Aides mean hourly wage is $1.57 less per hour and $3,269 less per year than the average for Home Care Aides in the Pacific Region and $.74 per hour and $1,540 less per year that the national average for Home Care Aides. None of these figures account for the hundreds of Home Care Aides working for cash, sometimes at hourly rates as low as $2.00 an hour. TABLE 3:
State Alaska Arizona California Hawaii Idaho Oregon Nevada
ANNUAL MEAN WAGES OF FULL TIME HOME CARE AIDES IN THE PACIFIC REGION
2010 Hourly 2010 Annual Mean Wage Mean Wage $14.27 $9.97 $10.53 $9.33 $9.29 $10.77 $10.32 $10.70 $29,690 $20,750 $21,900 $19,410 $19,320 $22,400 $21,420 $23,120 $22,251 2011 Hourly Mean Wage $13.83 $10.53 $10.58 $9.08 $9.13 $10.70 $10.21 $11.14 $10.65 2011 Annual Mean Wage $28,770 $21,900 $22,000 $18,880 $18,980 $22,260 $21,240 $23,160 $22,149 % change from '10-'11 -3.1% +5.6% +0.5% -2.7% -1.7% -0.6% -1.1% +0.3% -0.50%
US Department of Labor Bureau of Labor Statistics, Occupational Employment Statistics, May 2010 and May 2011.
Wages for Home Care Aides in Hawaii dropped $0.25 per hour or $530.00 per year between 2010 and 2011, when wages in California, Arizona and Washington increased. Hawaii's mean wages for Home Care Aides dropped more than 5x the average in the Pacific Region, adding to the financial instability Home Care Aides face in our state. The low and dropping wages presented in Table 3 are compounded by the lack of fulltime hours available to Home Care Aides. In order to secure enough hours, many Home Care Aides in Hawaii report “piecing together” several part time home care jobs, working some hours through one or more agencies and working with additional patients on their own. Wages are not the only area where Hawaii's Home Care Aides are falling behind. Many Home Care Aides in Hawaii, even many of whom are working for agencies, work without the benefit of Workers Compensation, Temporary Disability Insurance (TDI), unemployment insurance, Social Security contributions, any health care insurance for themselves or their families, and no form of retirement benefit or pension. Many Home Care Aides are not paid a mileage reimbursement for travel between patient assignments and not paid for the time it takes to travel between those patients.
TRAINING AND CERTIFICATION
In 2011, members of the Hawaii House of Representatives introduced a bill that would require all Home Care agencies in the state to be licensed with the State, provide criminal background checks on employees, require background checks of all Home Care Aides, and employ a Licensed Practical Nurse (LPN) to oversee the Home Care Aides and patients10. This bill did not get a hearing and was not reintroduced in the 2012 legislative session. While Home Care Aide positions do not require credentials, certification is required to perform certain medical tasks for patients in the home. The most common certification required of home health workers is the certification as a Certified Nurses Aide, or CNA. The two primary requirements to become a CNA in the United States is to complete a training course that meets the federal minimum of 75 hours and pass a certification exam. Hawaii requires 100 hours of classroom and clinical training and passing the certification exams, which cost more in Hawaii than in most states. On the west coast, for example, the average cost for final exams is $119, but the cost of final exams in Hawaii is $275, more than twice California's cost. Finally, there is the problem of re-certification in Hawaii. Hundreds of Home Care Aides pay $1250-$1500 plus $275 for exams in order to move up the career ladder and achieve certification as a Certified Nursing Assistant. But unlike Registered Nurses or Licensed Nurse Practitioners, these CNA's are not allowed to get re-certified after two years because they do not work in an state certified facility.
There are barriers to succeeding as a Home Care Aide in Hawaii that are frustrating and illogical and these barriers are limiting our access to quality home care and reducing our ability to safely and successfully age in place. From the lack of oversight of the industry to the very low pay and lack of benefits to the broken career ladder and re-certification process it is clear that Home Care as an industry and an occupation must be reformed in Hawaii.
10 HB737, http://www.capitol.hawaii.gov/measure_indiv.aspx?billtype=HB&billnumber=737
The following policy recommendations will require cooperation across many organizations and agencies, a widespread and ongoing commitment of Home Care Aides and their patients committed to aging in place. These recommendations include: • • • • • Improved and affordable training and certification Promoting professional development opportunities for Home Care Aides Identifying standards for hours, pay and benefits that will give committed Home Care Aides a real opportunity to live above the poverty line. A statewide commitment to public outreach and education State and national policy changes
Enacting these recommendations will require organizing and changes at the local and state level in Hawaii and would be aided by improvements at the national level as well.
I. Training and Certification
Affordability: Training and Certification for Home Care Aides must be more affordable and accessible on all of our islands. We need to investigate why CNA exams are so costly in Hawaii and find a way to bring down that cost. We must also find ways to reduce the training costs for talented and committed Home Care Aides who want to move up. For example, in 2006, FACE Hawaii partnered with Kilohana Methodist Church, Our Lady of the Mount and the UH School of Nursing and Dentistry to provide low-cost CNA courses for women with very low incomes who were committed to providing quality home care. FACE was able to offer these courses for only the cost of the course textbook, a $1,100-$1,250 savings for caregivers. Certification: In Hawaii, we need to develop an affordable certification process for Home Care Aides. Home Care Aides deserve a structured and formalized course of training and skills development that allows them to prove their proficiencies, advance in their careers and assure their clients. For Home Care Aides who want to achieve training and distinction beyond the entry level. the state should recognize a CNA certification that honors the particular challenges of nursing aide work in the home. This certification should meet the federal guidelines for CNA, but be specialized for Home Care. Re-certification: It is vital that Home Care Aides that achieve certification be allowed to get re-certified. The current system that bars CNAs who provide Home Care from getting re-certified is broken and penalizes Home Care Aides who want the pride and professional development of maintaining certification.
2. Promoting Professionalism for Home Care Aides
Develop a Voice: Build a statewide Professional organization for Home Care Aides. This organization should be run by Home Care Aides and have an advisory board of local health care experts and leaders. The goal of the organization should be to organize and represent Home Care Aides views and needs at the local, state and national level. Develop a Successful Business Model: Create a community organizing based model of a worker-owned home care cooperative. Draw on the expertise of Hawaii's only worker owned cooperative Paradise Home Care on the Big Island, as well as other home care cooperatives across the country. Agency Licensing: Hawaii must join the 31 other states that require Home Care Agencies to be licensed. This will raise the standards for the Home Care Aides and provide patients and their families more peace of mind. The requirements for this licensing should be determined with significant input from Home Care Aides and their patients.
3. Support for Full-Time Home Care Aide Jobs Hawaii's Home Care Aides need better access to full-time employment if they are going to stay in this field. The state needs a report on Best Practices from states across the country that are currently investing in improving conditions for Home Care Aides, as well as a commitment from state organizations and agencies to make this a priority. 4. Pay and Benefits
Hawaii needs a standard for pay and benefits for Home Care Aides. There is no way to enforce this standard, but it should be used as a goal for agencies in determining rates of pay, Home Care Aides in negotiating with employers, and for patients and their families to better understand the cost of care. This standard needs to address the following: • • • • Hourly rate of pay Mileage reimbursement Workers Compensation Temporary Disability Insurance (TDI) • • • • Unemployment Insurance Health Insurance Pension options Paid sick
A panel of Home Care Aides, Health and Aging-In-Place experts, and community leaders should take on this challenge to develop this standard.
5. Public Outreach and Education
Public Outreach: We must make a public effort to get seniors and their families to think about and plan for their future health care needs before a crisis hits. There needs to be intensive outreach through the existing organizations and institutions Hawaii's families are already linked to: religious and labor organizations, schools, banks and cultural and civic organizations. This outreach should include information about the types and cost of care, how Medicaid and Medicare reimbursement work, training available for family members who could provide care, and more. Easing the burden on families will also help Home Care Aides. FACE is currently conducting a survey of 200 families statewide to determine what resources our families need to make proactive, informed and cost-effective decisions about their family's long-term care needs. Results from this survey will be available in July 2012.