Home health workers: Big hearts, small paychecks
April 19-- Apr. 19--M elissa Longval arrived at Robert Carpenter's Concord apartment Friday afternoon with a big smile and a bigger surprise: a homemade turkey dinner.
Longval is a personal care attendant who works for Ascentria In-Home Care of Concord. She said Carpenter is more than just a client.
"He is my friend," she said. "He's kind of like a grandpa to me."
Carpenter, a retired factory worker who has the lung disease COPD, said he feels the same way. "I think of her as a friend," he said. "She really cares about her clients."
Longval is among thousands of caregivers who visit the homes of the most vulnerable Granite Staters. They help their elderly and disabled clients to bathe, dress and use the toilet; for others, they buy groceries, clean their homes and take them to appointments.
Now, in this time of pandemic, these home health workers are on the front lines, with little recognition or acclaim. Even as the death toll in nursing homes rises, the work they do to keep people safe in their homes is saving lives.
"They are rock stars, there's no two ways about it," said Deborah Ritcey, president and CEO of Granite State Independent Living (GSIL) in Concord.
They are also among the lowest-paid workers in the state.
A study by the research group PHI found that the average hourly wage for home health aides in New Hampshire was $12.90 in 2008. Ten years later, it was $13.72.
The problem, agency heads say, is the reimbursement rates for the Medicaid Choices for Independence program, which covers home health services for individuals who qualify for a nursing home level of care.
GSIL has 750 employees who visit the homes of about 700 clients, Ritcey said. "I employ more front-line workers than some hospitals in New Hampshire do," she said.
Some of their clients have severe medical needs, she said. Some rely on ventilators to breathe; others are quadriplegic and can't get out of bed without help, she said.
What's worthwhile work worth?
Ritcey said these caregivers are doing difficult, crucial work every day. "They are the salt-of-the-earth people," she said. "They do it because they're compassionate, because they care."
Last year, the Legislature raised the Medicaid reimbursement rate for home health care by 3.1%, effective last Jan. 1, with another 3.1% increase coming next January. But some agency heads say that doesn't even cover their costs.
During the coronavirus crisis, providers worry about what they say is a disincentive for some workers to stay on the job. Between unemployment and a new federal program that provides $600 a week to employees affected by the coronavirus crisis, workers can make more money staying home.
"Right now, there's a perverse incentive to go on unemployment because they're going to make more money," Ritcey said.
In response, Gov. Chris Sununu last week unveiled a new program, funded by federal dollars, to help support those who work in long-term care facilities or in patients' homes. It provides a $300 weekly bonus for full-time employees and $150 for part-timers.
As of last Monday, before the program was announced, 125 GSIL employees had filed for unemployment, Ritcey said, and projections showed that number could reach 200 by the end of April. Some employees had to stay home with young children or were in quarantine. In other cases, clients had asked her agency not to send caregivers until the COVID-19 threat is over, she said.
Ritcey welcomed the new state bonus program. "I'm hoping it will change our trajectory," she said.
Caregivers provide lifeline
Amy Moore, director of Ascentria In-Home Care, says all of her 450 clients statewide qualify for nursing home care, "but they want to remain at home."
When the coronavirus threat first emerged, Moore and her staff went through their client list, determining who could get by with fewer home visits or with someone just dropping off groceries. "It became clear the best thing we could do is really limit who's going into their homes," Moore said. "They're all really vulnerable."
Ordinarily, she said, the biggest challenge for such clients is isolation. But in this pandemic, "that's the one thing they have going for them." she said.
Some of her employees had their hours cut, while others have had to stay home to care for their own family members with compromising medical conditions. But Moore said she is "blown away" by the dedication she sees in these front-line workers to their clients during this crisis. "They are just absolutely incredible," she said.
Longval has had to cut back on some of what she does for Carpenter, but she still drops off groceries and stays to chat. During Friday's visit, she convinced him to take a walk with her. They joked and ribbed each other as they strolled outside in the sunshine.
The toughest part of this whole crisis? "The isolation," Carpenter said. His medical condition puts him at high risk for COVID-19, so he reads the paper, watches TV, does some puzzles. "I don't really do much," he said.
Keeping essential workers
Jim Culhane, president and CEO of Lake Sunapee Region VNA Hospice, said the Medicaid CFI reimbursement rate doesn't actually cover the cost of providing in-home services. His agency has to use money made in other areas to offset the losses on home health services -- a "shell game," he called it.
His agency has 190 employees, about two-thirds of whom are full-time. They include nurses, a nurse practitioner and some doctors, but most are homemakers, licensed nursing assistants or personal care service providers (PCSPs).
Culhane said they have had to cut back on some services, reducing the caseload from about 650 to 570. "People don't want to see a physical therapist in their home; they're concerned about exposure," he said.
But personal care attendants are essential, he said. "Sometimes these services are the difference between someone staying in the home and having to look at a facility."
Culhane said he initially worried that the extra federal money for those affected by the coronavirus crisis would be a disincentive for people to work, but he said, "we haven't seen that." Some of his employees have had to stay home for health reasons, or to take care of young children at home, but his agency is trying to keep people on the payroll even if they're not working full-time.
"It is in our best interest to retain these employees and keep them whole financially, because it's hard to find good LNAs," Culhane said. "That's the reality of it."
The system is working
Beyond recognizing the compassionate care these employees deliver every day, providers say there's also a financial reason to pay them more. Even if there were enough nursing home beds to care for all their clients -- and there aren't -- the cost would be astronomical, they say.
GSIL's Ritcey said she hopes the current crisis will get state leaders to recognize the work that home health aides provide is as important as that of doctors, nurses, police and paramedics. "Our staff are first responders because they are going into the homes of people that are at risk," she said.
The system is working, she said. GSIL has not had one case of a client infected with COVID-19, she said, even as outbreaks have been reported in six long-term care facilities.
Jeff Dickinson, GSIL's advocacy director, is also a client.
Dickinson, who has muscular dystrophy, relies on two personal care attendants and an overnight nurse for his care.
Louise Boucher, a licensed nursing assistant, works for him every weekday. "She's the one that gets me up out of bed in the morning, helps me wash up, shave and get ready for the day," he said. "She prepares meals if I need them and feeds them to me."
She takes care of his service dog, Aspen, too. If Dickinson needs to travel for work, Boucher drives him. "Louise really is sort of my right-hand person," he said. "I'm really fortunate to have her because she's extremely reliable and very caring."
'They are heroes, too'
Boucher said she "fell in love" with this career after her daughter went to nursery school. She trained as an LNA and has worked for GSIL for 15 years. "It's the mom in me, I guess," she said. "I just like helping people out, and people with disabilities a lot of times need help."
Since the coronavirus outbreak, Boucher said, she only goes between Dickinson's home and her own. "I don't want to get Jeff sick," she said.
Culhane from Lake Sunapee Region VNA said the new state bonus for home health workers announced last week "is a wise investment in these very difficult times, and we're very thankful for that."
But he said, "This is a short-term patch for a system that has been underfunded and underpaid for a considerable number of years. The long-term fix is really a look at the reimbursement rates associated with Medicaid for these clients."
Culhane called the under-funding of home care a "silent crisis" that will only worsen as the state's population continues to age. "To me, the equation is not that complex," he said. "This is a valuable service that benefits not only the state but the individuals who stay in their homes and would otherwise be in nursing homes."
Gina Balkus, president and CEO of the Home Care, Hospice Palliative Care Alliance of New Hampshire, said in this time of pandemic, there's been a lot of well-earned praise for the doctors and nurses who are on the front lines of caring for COVID-19 patients.
"But we can't forget the people who are going into homes and providing essential care to our most at-risk patients," she said.
"They are heroes, too, and we really do need to recognize that."