Caring for the caregivers

The need for caregivers is ramping up while the interest in caregiving jobs is tanking. Will help be there when we need it?

From the pages of In Business magazine.

Caregivers may be among the fastest growing professions due to the graying of America, but unfortunately the caregiver shortage is in crisis mode.

“The problem is acute now with many facilities unable to employ adequate staff, and it will only get worse as more people reach retirement age and live longer,” notes Melanie Ramey, CEO of The HOPE of Wisconsin, an organization that represents Wisconsin’s licensed hospices and palliative care facilities. Workers traditionally receive low pay for what she terms “a very difficult job.”

Those at assisted living facilities are not required to have any special training, she says, while certified nursing assistants (CNAs) are most often hired in nursing homes, hospice, hospitals, and private agencies. “[CNA] training is not extensive but it does cover some basic issues,” Ramey adds.

Wisconsin is one of 14 states requiring at least 120 hours of CNA training according to the Paraprofessional Healthcare Institute, and that’s well beyond the national requirement of 75 hours. However, when it comes to skilled nursing facilities, Wisconsin ranks among the worst in the nation for Medicaid reimbursement, resulting in the highest losses. “A Wisconsin facility will lose $56 a day for each Medicaid patient it serves,” notes John Vander Meer, executive director, Wisconsin Health Care Association and Wisconsin Center for Assisted Living (WHCA/WiCAL). “That’s unsustainable.”

He blames a perpetual underfunding of skilled nursing care, federal mandates implemented over the past 10 years, and workforce challenges. “We’re facing a reality where [facilities] advertise for frontline caregivers and don’t receive any responses,” Vander Meer says.

National statistics show that 10,000 baby boomers will turn 65 every day until the year 2030, promising a massive influx of residents and patients in long-term and acute care for years to come. Meanwhile, new workers aren’t exactly flocking to the caregiving field. “The number of people in nursing is going down,” says Vander Meer, “and the numbers on the nurse-aide registry are going in the wrong direction.”

With reimbursements so low, as determined by state and federal governments, Vander Meer says the provider community cannot supply competitive wages to frontline caregivers. “If we can’t raise wages to cover our costs, we can’t compete with other employers who can.”

To get a handle on the situation, the Wisconsin Health Care Association, the Wisconsin Center for Assisted Living, the Wisconsin Assisted Living Association, LeadingAge Wisconsin, and Residential Services Association of Wisconsin recently joined forces to survey the state’s caregiving organizations.

The results, based on responses from 689 providers, were published in “The Long-Term Care Workforce Crisis: A 2016 Report.”

Among the findings:

  • One in seven caregiving staff positions are currently unfilled, with one in four providers reporting caregiver vacancy rates of 20% and higher;
  • Nearly 50% of providers received no applications for vacant caregiver positions;
  • 70% said there were no qualified applicants for caregiver openings;
  • A lack of applicants forced 18% of providers to limit the number of patients they accepted;
  • By 2022, the need for personal care workers is projected to grow by 26.4%;
  • 56% of providers reported personal caregivers leaving for jobs outside health care; and
  • More than 30% of providers feel they are unable to compete with other employers.

Vander Meer explains that the problem weighs heavily on skilled nursing facilities operating 24 hours a day, seven days a week and 365 days a year because they have more regulatory restrictions and require a greater level of clinical staffing, but others are equally affected.

Helping from the heart

Gil Atanasoff, executive director at Senior Helpers, a locally owned and operated franchise, says the best caregivers are motivated from within and compassion-oriented. “They won’t get rich being caregivers, but it is more fulfilling than flipping burgers.”

Senior Helpers primarily offers in-home assistance from companion care to dementia care and monitoring, to menu planning, personal hygiene assistance, and housekeeping. “Less than a year ago we realized that you don’t need to be a CNA to work [with us] as long as you have compassion and a clean record,” Atanasoff says.

Senior Helpers employees vary in age from 18 to 70, he says. His ideal candidate is female, 50-plus, semi-retired and wanting to earn some extra spending money, but he’s also optimistic that the ability to “give back” will resonate with millennials and entrepreneurs. It’s about recognizing the importance of helping someone who would not otherwise be able to eat a meal, buy groceries, or get in and out of bed without their help, he explains.

Senior Helpers pays caregivers between $11 and $13 an hour and incentive programs are also in place. Turnover hovers around 60% annually, fueled in large part by the number of young students leaving after they graduate.

Atanasoff says the caregiver crisis is very real. “Ten-thousand people a day are turning 65 or older yet 25% fewer people are getting into caregiving, and that’s expected to drop by another 25%. It’s very scary.

“I could probably hire 50 caregivers tomorrow that want to do this type of work if I was able to hire undocumented workers. That’s not a political statement, but something’s got to give.”



Reshaping Oakwood

The worker shortage is certainly not lost on one of Dane County’s largest continuing care retirement communities, Oakwood Lutheran Senior Ministries, which operates two campuses in Madison and employs about 680 full- and part-time staff, many of which belong to the Service Employee International Union.

Kathy Groth, vice president of human resources, says Oakwood must be proactive from a leadership standpoint when facing challenges. “We have a young workforce,” she notes, “so in an industry where we do see a lot of turnover, how do we reshape our thinking to attract and lead these people?”

Recognition may be one area. “People want to be told they’re doing a good job and we need our management to think like that.” Younger workers are also looking for flexibility, input in decision-making, career ladders, and paid time off, she notes.

Michelle Godfrey, vice president of operational support at Oakwood says today’s residents require more care than they ever did, which affects worker qualifications. CNA certifications are required and Oakwood provides additional clinical training, as well.

Godfrey says many of its nursing employees are satisfying a prerequisite for nursing school and never intend to stay long-term. That can be a win-win, she says, but it also means Oakwood must compete for those positions against other entities such as hospitals that can offer more career opportunities.

Resident assistants, or RAs, can receive a their state-approved curriculum at Oakwood or other community-based residential facility (CBRF) locations. Required courses include fire safety, first aid and choking, medication administration, and standard precautions, and Oakwood provides additional training on-site.

“RAs have a hard role,” notes Godfrey. “Not only are they doing personal care, but they’re also passing medications and have less nurse availability and supervision because the regulations are a lot less stringent.”

Oakwood RAs generally earn between $10 and $13 an hour and have about a 30% churn rate, while CNAs can make between $13.70 and $17 or more per hour, depending on experience. “Surprisingly, we have 80% to 90% retention in memory care,” Groth adds. Benefits are available based on the number of hours worked.

Keith VanLanduyt, Oakwood’s vice president of marketing and donor relations, says it is hard to compete for caregivers on a dollar-per-hour basis, so Oakwood emphasizes being part of a community. “We try to invest more in our employees and hope that they’ll become emotionally invested and want to see their residents thrive and succeed.

“At $13 or $15 an hour, why would you choose this field unless you have a specific personality and want to care for others? This is more than a paycheck. It’s being a part of something special.”

HOPEful solutions

What does the future of caregiving look like?

Groth chooses her words carefully. “We have a shrinking workforce that is attracted to this type of work,” she says. “This group wants to climb quickly into positions that pay well and gives them status and input into decisions and flexibility, but this is a 24-hour industry so how we mesh the reality of the industry with the goals of the upcoming worker will be challenging and, in my opinion, will require some very strong, innovative leadership.”

Vander Meer says the first priority must be skilled nursing facility payment reform and paying caregivers a higher wage.

Ramey (The HOPE) would also like to see assisted living RAs paid to become licensed CNAs. CNAs are listed in a registry, she explains, and can be removed should they be found guilty of a crime. With the number of assisted living facilities rapidly rising, she’d also like to see more rules and oversight overall. Most importantly, Ramey hopes that Medicare, Medicaid, and private insurers will agree to pay for supportive care in a patient’s home where it can be administered much less expensively.

Budgetary balm

The caregiving workforce crisis affects the long-term and post-acute care continuum including assisted living facilities, Vander Meer says. “That’s why our provider coalition is requesting $40 million GPR (general purpose revenue) in the 2017–2019 biennial budget for family care providers, a program which is a payer more commonly associated with assisted living facilities including CBRFs, residential care apartment complexes, and adult family homes.”

WHCA/WiCal, along with LeadingAge Wisconsin, is currently lobbying the state legislature for $91.2 million in the 2017–2019 biennial budget to provide nursing facility providers with the tools needed to recruit and retain staff. That includes $56.6 million GPR to fund the nursing facility direct care target at the median; a $5 per day per resident increase in support services ($19.2 million); $6.5 million GPR to increase funding for four labor regions in rural counties around the state; and $9 million GPR to provide a 2.6% inflationary increase to fund these increases in year two (2018–2019) of the biennial budget.

“We didn’t ask for what we thought we could get,” Vander Meer states, “we asked for what we need. If we don’t have an adequate and sustainable source of funding given the fact that this silver tsunami of Wisconsin’s aging population is coming our direction in the next 15 years or so, we’re not going to have the workforce, the facilities, and the operational capacity to ensure that these aging Badgers get the care and services they deserve.”



A caregiver's story

David (name changed) is a 31-year-old caregiver with a family including two pre-teen children. He provides in-home care for two paralyzed men in their 30s. -One can speak, the other cannot.

The families of the two wheelchair-bound patients hired him separately to become part of their care teams. His job is administered by a local nonprofit, but he’s paid through two different entities, including a state program. David works six days a week earning between $10 and $11.70 an hour depending on how his time is allocated. One agency pays him $15 an hour on holidays, the other doesn’t offer holiday pay. Still, he says he enjoys the flexibility of being able to schedule his hours around his own family’s activities. “I work about 30 hours, give or take,” David says, typically 7 a.m. to 3 p.m. three days a week and then again from 9 to midnight plus some weekend work.

If one of his clients is hospitalized, David doesn’t work. “I can call the agency and try to get more work in those cases, but it’s hard for them to match the hours I need.”

Insurance is available but unaffordable, he notes, and because he’s paid through two different sources, chances for overtime are nil. He receives no paid sick leave or paid vacation, and even if he did, he worries that a replacement worker would not be able to adequately care for his patients while he’s gone. Still, he’s a long-timer in the industry, caring for one patient for six years and the other for a year and a half.

“I like the work and helping people out,” he says. “They’re my friends. It’s not like work-work.”

David had no prior experience in personal care before this. Three days a week he helps one patient into the shower, gets him dressed, feeds him a pureed breakfast, and assists with his bathroom needs. On alternate days he gets his other client dressed and ready to be bused to exercise class. Both of his clients have catheters.

“If I didn’t have kids I probably couldn’t do it,” he admits. Now he’s just used to it.

His speaking patient has very limited use of his hands and mostly relies on David at the end of the day. “I get all of his drinks ready, give him his toothbrush, undress him, and wash him up. Then I get him into bed using a Hoyer Lift and set him up with remote controls, a fan, a computer, phones, and medications. His mother checks on him in the morning.”

David’s other patient has a tracheotomy tube and speaks only with the aid of a computer. “I was overwhelmed at first,” David admits, about all the required medications, feeding tubes, and other responsibilities required. His initial training consisted of three hours of job shadowing but he requested more because of the added complexities.

When necessary, David drives his patients to doctor appointments and serves as an advocate and voice of the voiceless man, but agencies don’t always pay for time spent outside the home. Still, he peppers in occasional trips to WalMart or a movie. “Sometimes people get reimbursed. Sometimes not,” he says.

David has been accompanying his non-speaking patient to computer classes, and they’ve also been waiting for a personal computer for more than a year because he says everything must first be approved by the state. It took three months to get an air mattress. “Getting anything is a hassle,” he notes.

Even a raise. “Raises are set by the state based on funding. So maybe once every two or three years I get a letter saying I’ll get an additional 15 cents or so.”

If David could change anything it would be his pay and benefits. He knows turnover is high and he’s heard of people quitting in the middle of a job. “A lot of people think they can do this but then they go to a home and the patient is a mess and they can’t deal with it so they quit. That’s why I’m reliable.”

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