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Pandemic highlights weaknesses in home care

In March, Amy Carrier asked one of the two women who provided home care for her mother to stop coming to work.

Her mother, 74, has Alzheimer’s disease and lives with her in Corvallis, Ore. To protect her from the new coronavirus, “it was clear that I needed to lock down my house,” said Carrier, 45, a foundation executive. She allowed one helper, who lived with only an adult daughter, to continue helping her mother bathe, take walks and play puzzles and games.

But the other helper has a household of six, including four teenagers, and was visiting other clients’ homes. “There’s too much chance of exposure,” Carrier decided. When she explained that to her employee, she said, “she totally understood, and she wanted to be home with her family, too.” At least, because Carrier hires and pays caregivers legally, the worker is receiving unemployment benefits.

Home Care Partners, a nonprofit agency serving the Washington, D.C., area, said about 20% of its clients, primarily low-income older adults, had suspended their service.

Those aides who are still working face arduous conditions. “They have a higher level of risk because they’re going into a number of different homes,” said Marla Lahat, executive director. “They’re often traveling on public transportation, which is severely curtailed here in D.C.”

Acquiring protective equipment, for workers accustomed to hand washing and gloves but not to masks, proved difficult and expensive. “Hospitals and nursing homes were the priorities; we weren’t,” said Lahat, who eventually had to buy sanitizer from repurposed distilleries. “It’s been totally disruptive.”

Much of the attention to the toll COVID-19 has taken on older adults has rightly focused on long-term care facilities. Their residents and employees account for almost 40% of the nation’s deaths, according to an updated New York Times analysis.

But far more Americans — nearly 6 million, by one estimate — rely on paid home care than live in nursing homes and assisted living combined.

Already among the nation’s fastest-growing job categories, personal care and support at home can help older adults age in place — as almost all prefer, surveys repeatedly show — and prevent or delay institutionalization. (Personal care is distinct from home health care, which Medicare covers after hospitalization.)

Such aides — almost 2.3 million of them, according to research nonprofit PHI — help with everyday nonmedical needs like bathing, dressing and using the toilet; they might prepare meals, do light housekeeping and remind clients to take their medications.

Even when consumers pay $22.50 an hour (the national average, according to an annual survey by the insurance company Genworth), a daily four-hour visit costs far less per month than a residential facility and could allow family caregivers to keep their jobs.

When governors issued shutdown orders across the country this spring, they exempted home care aides as essential workers. “Home care workers can’t socially distance,” said April Verrett, president of SEIU Local 2015, which represents nearly 400,000 home care aides in California.

But as with so many other parts of the health care system, the pandemic has spotlighted weaknesses and dilemmas.

Even more than nursing home employees, home care workers are poorly paid hourly workers (average wage in 2018: $11.52 an hour, according to PHI) and often lack health insurance; half rely on some form of public assistance.

Analyzing federal data, PHI researchers found that from 2012 to 2017, only 1 in 5 home care workers who needed time off for medical or family reasons could take paid leave.

Unsurprisingly, among the for-profit agencies and franchises that employ most home care workers — leaving aside the uncountable private hiring arrangements known as the gray market — turnover nears 70% annually, said Vicki Hoak, executive director of the Home Care Association of America.

“If you don’t have the heart for this, you’ll go work in retail and get paid just as much,” she added.

Now both workers and clients have more cause for worry.

“Home care workers are probably unknowingly involved in the transmission of COVID-19, especially when they’re not equipped with sufficient PPE,” or personal protective equipment, said Dr. Nathan Stall, a geriatrician and researcher at the University of Toronto and a co-author of a recent article on home care.

Not only do many home care workers serve several clients each week, increasing their exposure, but to piece together a living, they might simultaneously work for several agencies or for nursing homes, or hold outside jobs. One aide at Home Care Partners cleans hotel rooms at night.

Those conditions increase infection risks, and not only for their frail older clients. Almost a third of home care workers, a heavily female workforce, are themselves over 55, and most are black or Hispanic, groups that have proved particularly vulnerable to COVID-19.

Researchers expect the demand for home care to increase sharply as the population ages. Already, older people preparing for previously postponed elective surgery or recovering from COVID-19 will want or need care at home. These days, moreover, “a lot of people justifiably have fears of entering nursing homes,” Stall pointed out.

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