LeadingAge Expert Robyn Stone: ‘Career Lattices,’ Healthy Relationships Key to Keeping In-Home Care Staff

Home health and personal care aides are often referred to as “the eyes and ears” of the U.S. health care system. Still, they’re infrequently used in care teams and often undervalued by the providers they work for.

Changing the recognition of in-home care professionals is going to take hard work, innovative approaches and dedicated advocacy, according to Dr. Robyn Stone, senior vice president of research at LeadingAge and director of the LeadingAge LTSS Center at UMass Boston.

Home Health Care News recently caught up with Dr. Stone to learn more about the evolution of care teams and how in-home care aides fit into health care’s future. During the conversation, the noted researcher also shared best practices for recruiting and retention, common pain points for home health and home care providers alike.

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Highlights of HHCN’s conversation with Stone are below, edited for length and clarity.

HHCN: We’re focusing a portion of this conversation on something you’re very passionate about: the role that home care aides play on care teams. Why should we pay more attention to that?

Stone: That’s such a great question. For me, it’s a no-brainer. Next to family members, in home care workers are the primary, hands-on providers of care, particularly long-term services and supports (LTSS) to older adults  and people with disabilities or chronic conditions — in the United States and across the world.

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These folks are what we call the “eyes and the ears” of the health and LTSS systems. They have very strong relationships with the people that they care for. They may be the only person in the home. Often, it’s the home care worker who’s actually not only understanding the client, but really understanding the environment in which that client lives. These care professionals — I  like to call them care professionals, not workers — are essential in terms of improving quality of care and quality of life.

You once wrote: “Behind every successful health care professional is a strong home care worker.” What did you mean by that?

If you think about the goals of health care — to keep people living as long and successfully as possible in the community while trying to avoid higher-risk environments like the hospital, ER or being institutionalized in a nursing home — the real bulwark of our system is the home care worker.

These individuals in the home are the links between the client and the rest of the world, either on the medical side or the LTSS side. But I think we’re starting to recognize that this workforce is often invisible to the health care professional, despite the fact they’re at the center of the home care environment with client or patients. They are really important in terms of having a successful episode of care and a good trajectory in terms of quality of the services delivered and the quality of life that people are engaging in as well.

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Who are your typical in-home care aides? Or even more broadly, who are your typical home care professionals?

This workforce is extremely diverse and primarily women. The workforce is much more likely to be non-white, as well as immigrants. This is distributed differently across the country, but almost one-third, on average, of the home care workforce are folks who are not not born in the United States. Many come from the Caribbean, from Mexico, from Africa, from points all around the world.

And it’s a very diverse workforce with low wages. The average wage for a home care aide is a little bit over $11 an hour. Again, that varies tremendously depending on the market. Many of these folks are on public benefits. It is not unusual to have the home care aide who is on Medicaid, who may be receiving SNAP benefits or some other publicly-subsidized benefits. It’s a fairly vulnerable group.

You mentioned foreign-born workers. We’ve heard about the need for new immigration policy or visa programs tailored to home care. What do you think about that idea?

I think it’s a really important issue. I think we have to understand that for this frontline workforce, many individuals have been coming into the country through family unification. They are not coming through visa programs like folks who are nurses. So, there’s a couple things we have to recognize. Any changes in immigration policy in this country– particularly as they relate to family unification and less flexibility — will have a grave impact on who can actually be in this labor force.

At the same time, I do think we need to be thinking about new mechanisms for bringing folks in, too. LeadingAge is working on some proposals to create a new guest-worker program for the home care workforce. That could be particularly used in shortage areas such as rural communities, which are overly represented by the elderly. We absolutely need to be thinking about immigration policy and its role.

What are some general cultural challenges or opportunities that arise due to the fact a lot of nurses and aides come from outside the U.S.?

In order to successfully employ nurses and aides in our LTSS jobs — and especially home care — we need to be recognizing the cultural, ethnic variations and backgrounds that people bring as they enter these jobs. There might be certain difficulties engaging with clients who are not from the same demographic group. Right now, about 80% of the elderly population in the U.S. is white. Foreign-born home care workers might speak different languages, have different attitudes toward caring for the elderly, different attitudes toward dementia, or toward death and dying. There are a lot of challenges to acculturating both the people who are coming here doing these jobs, but also the clients and the families who have to be culturally competent. Agencies also have to really recognize the challenges that this workforce brings and is facing.

At the same time, evidence shows that, on average, the immigrant workforce is more loyal than native-born workers. And they also tend to have less turnover and are more committed than native-born workers. So they are a really important part of the home care workforce.

How can we better incorporate in-home care professionals into care plans, broadly?

I don’t think it’s a simple answer. I think often informally, aides are incorporated into care plans by virtue of just them being in the home. But I think there needs to be intentionality in terms of recognizing the important roles home care workers play in delivering services and being the link between the client and the rest of the health care system.

A number of things have to occur. First, we need highly trained, skilled home-based care workers. If you look at the requirements for training — even for Medicare-certified home health aides — it’s an average of 75 hours of training, which is not very rigorous and doesn’t necessarily give you confidence that you have folks who really know what they’re doing and can deal with highly complex situations.

In addition to that, we need much more specificity in terms of how we train aides around special kinds of issues. Cognitive impairment is one. Depression and mental health is another. Chronic conditions, too, including CHF and COPD.

There’s training, certification and competencies, then there’s the support that an aide needs to have when they are in the home alone. Supervisors at the agency level who actually work with the aides need to provide the backup and the support to allow the aides to be part of a formal plan. We also need to have the recognition of the whole care team as we move more primary care into the home and as other kinds of models are developed around home-based teams.

Upskilling is often cited as a key strategy to boost recruitment and retention, whether we’re talking about non-medical home care or Medicare-certified home health. What else can providers do to beef up their recruiting, improve job satisfaction and reduce workers’ desire to leave?

I actually think that we need to be paying dual attention constantly to recruitment and retention. I would say that if we paid more attention to retention, we wouldn’t have as many challenges around recruitment.

Right now, we are in a pretty strong economy. And when local markets are tight because the economy is so strong, we’re likely to see more turnover, particularly in lower-wage occupations. Obviously, the first thing providers need to ask themselves is, “Are we paying a living, sustainable wage that is commensurate with the competencies that are required these days for a care professional to do her work in the home?” Forward-thinking agencies and organizations are paying attention to wages, benefits and other kinds of compensation.

But that’s not the only thing that they can do, because we have seen many examples of workers who have left and have come back to organizations that are high quality and provide a good work environment. Agencies need to be thinking about how they create a healthy workplace. What is the role of supervisors? All of the empirical work that we’ve done and that others have done largely says a good supervisor, a coach, an educator, a supporter is the linchpin to mitigating turnover challenges. If you have a great supervisor and a connection with that supervisor, you are much more likely to have a frontline workforce that is going to stay.

Another retention strategy of exemplary organizations has to do with onboarding. Peer mentoring programs — where workers are assigned a peer-mentor for a certain period of time — help. Peer-mentors have been demonstrated to have very positive outcomes.

Are there any specific predictors or signs that a care professional might be positioning himself or herself to leave the job?

Well, as I said, the major predictor of somebody getting ready to leave is the quality of the supervisor. My suggestion at every talk that I give to to our members here at LeadingAge and to other organizations throughout the globe is that, if you do one thing, pay attention to the quality of your supervisors. Are they connecting with their direct reports? A lot of times, a home care aide may not even know who their supervisor is. They may know who their scheduler is, but not necessarily their supervisor. That is a travesty.

While preparing for this conversation, I read through a lot of your research. One thing that stood out was how hospice aides are actually less likely to leave their jobs. Why is that?

We did identify that as clearly an outcome, but we have not explored exactly why. It may have to do with a couple of things. First, average hospice workers make a lot more than other types of home care workers. They are paid better, which isn’t just financially an issue, but it is also an empowerment and value issue. I also think that hospice itself — the concept and the underlying philosophy of person-centeredness, of the holistic approach to palliative and end of life care — resonates with a lot of caregivers.

Lastly, I wanted to ask about your 2020 plans. Anything interesting you’re currently working on or plan to look into later this year?

Sure. We’re just about to finish up a project that we had funded through a foundation looking across states to identify what states have been doing in terms of training, certification and career pathways, particularly as it relates to advanced home care roles. That report will be coming out later this year. We’re also working on some new projects that would delve much more deeply into what an exemplary work environment really looks like for home care aides and how that gets operationalized in the different models of home care, including your more traditional visiting nurse type of an agency as well as franchises.

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