Despite the rising demand for long-term care, providers are struggling to find staff

The hardest part about Culix Wibonele's first job in long-term care was not getting hurt.

Wibonele, originally from Kenya, worked as a certified nursing assistant in Atlanta in 2014. She went to the homes of mostly elderly clients and helped them with everything from bathing to cooking. Wibonele worked alone and sometimes had to lift customers who were much taller than her.

It was demanding work and paid only $9 an hour with no benefits. Without Wibonele's second job as a babysitter and her husband's income, they would not have been able to make ends meet while supporting their four children.

“My salary was literally nothing,” Wibonele said. “I was a little shocked at the amount of work we had to do and the reward you get in the end.”

Wibonele's experience reflects broader trends in the long-term care workforce. Those who care for the elderly in settings such as private homes and assisted living facilities in the United States face low wages and risk of injury, while the sector faces workforce shortages, CNHI News and The Associated Press found as part of an investigation to the state of America. long-term care.

Meanwhile, demand for these workers is increasing as the population ages. By 2030, roughly 20% of the U.S. population will be age 65 or older, and that share will continue to grow, according to the U.S. Census Bureau.

“It's a national problem, and it happens everywhere,” says Dr. Stephen Crystal, director of the Rutgers Center for Health Services Research. “Almost everyone is short-staffed.”

The industry has faced labor shortages and high employee turnover for years, issues that have become even more acute during the COVID-19 pandemic.

Nursing facilities laid off workers after the pandemic began, and the workforce has not yet fully recovered, federal data shows. An American Health Care Association survey of hundreds of nursing home providers in March found that nearly all have open positions and are having difficulty recruiting. And a recent nursing home staffing mandate from the Biden administration has panicked facility administrators, who say they are already scrambling to fill vacancies.

Nursing home turnover is so bad that some are seeing all their employees leave within a year, said Alice Bonner, director of strategic partnerships for the Center for Innovative Care in Aging at Brown University.

“The people who are left are working much harder, working double shifts, working overtime and working with temporary and agency workers,” Bonner said.

Noelle Kovaleski, administrator of the Carbondale Nursing and Rehabilitation Center in Pennsylvania, said the biggest challenge in hiring is the lack of candidates. One nursing supervisor position at her facility went unfilled after being posted on a leading job site for two years.

“There are no staff coming in,” Kovaleski said. “They're just not there.”

Workers pass on these jobs for many reasons, including poor pay and a competitive job market. For example, nurses can earn more working in hospitals than in nursing homes, Bonner said.

Experts see looming potential shortages as the industry grows. According to the federal Health Resources and Services Administration, overall demand for full-time workers in long-term services and support settings is expected to increase 42% between 2021 and 2036. Demand for direct care workers, who make up the largest share of the workforce, is expected to grow by 41%.

Direct caregivers play a crucial role in the lives of their clients: a certified nursing assistant bathing an incontinent dementia patient, a home care aide helping an elderly widower with his medications, a personal care assistant helping group home residents make lunch. These workers are mostly women and people of color, and many are immigrants.

Victoria Gardner, who is tetraplegic after a car accident left her unable to stand or use her hands, sees her home caregiver as a lifeline. The caregiver helps the 57-year-old Pennsylvania woman 16 hours a day. Without this care, Gardner would not be able to bathe, prepare meals, do laundry or clean her home.

“My situation right now is that I have one caregiver. That's a very vulnerable position to be in. I'm not alone in that,” Gardner said.

The industry added about 1.5 million new direct health care workers between 2012 and 2022, according to an AP-CNHI analysis of Bureau of Labor Statistics data. Nearly 800,000 new direct care jobs are expected to be created by 2032, which experts say will be difficult to fill.

Payment is a big factor.

According to the agency, the average annual salary for home health and personal care aides was $33,380 in May 2023. These incomes were comparable to those of cafeteria attendants and store employees.

Direct care workers are typically at the lower end of the pay scale. About half of them rely on government assistance, according to a January Department of Health and Human Services report.

Experts point to financing as a reason why wages are low. Medicaid is the primary payer of long-term care services, but many stakeholders argue that Medicaid reimbursement rates are insufficient to properly compensate workers.

Some states have made efforts to strengthen the workforce, for example by requiring a percentage of health care providers' Medicaid reimbursements to go toward health care providers' direct wages. Others have used funding from the American Rescue Plan Act of 2021 to boost wages and recruitment efforts. Meanwhile, the Biden administration finalized a rule in April that would require 80% of Medicaid payments for home health care services to be used to pay workers.

Zulma Torres, a longtime home care worker in New York City, said she cried after work because of the way people treated her.

For years she earned $6.25 an hour. Sometimes customers treated her like a maid and expected her to cook for the whole family. In some cases where she had to take her client to the hospital, she felt like the nurses and doctors were judging her.

“A lot of times you feel like just walking out and saying, this isn't for me,” Torres said.

Researchers say a lack of respect both within and outside the industry is another factor driving long-term care workers away.

“I think there is a general perception among the public that people who work in long-term care are inferior,” said Barbara Bowers, founder and director of the Center for Aging Research and Education at the University of Wisconsin-Madison. “I don't think they get anywhere near the respect they deserve for the hard work they do.”

Culix Wibonele, the certified nursing assistant in Atlanta, now makes $18 an hour at an assisted living facility. But she has endured years of low wages, layoffs and persistent migraines since she was injured by an agitated facility resident. Her pay still doesn't feel like enough.

“I can go to Walmart and make more money than I could as a CNA,” Wibonele said.

Still, Wibonele said she plans to stay in the industry for now. In addition to her work as a CNA, she is attending Georgia State University with the goal of becoming a registered nurse in long-term care.

“I love (the) older generation, their wisdom, their stories. I like knowing that I am doing something while they are still here on earth,” Wibonele said. “Even though we don't get paid enough, I won't change anything.”

___

Kelety reported from Phoenix and Scicchitano from Shamokin, Pennsylvania. AP data journalist Nicky Forster in New York contributed.

___

The share of the U.S. population over age 65 continues to rise—and will do so for decades. Because nearly half of Americans over 65 will pay for some version of long-term health care, CNHI News and The Associated Press examined the state of long-term care in the series The High Cost of Long-Term Care , which looked at day care for adults. to high-quality assisted living facilities, to understand the affordability, staffing, and equity challenges that exist today and lie ahead.

___

The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute's Science and Educational Media Group and the Robert Wood Johnson Foundation.

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