Screening Paid Caregivers: “A False Sense of Security”

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A recent article described what happened when researchers at Northwestern School of Medicine, posing as prospective clients seeking a caregiver for an elderly adult relative, contacted 180 agencies and asked about hiring, screening, and supervisory practices. Their findings aren’t pretty.

Sixty-seven percent of the agencies required experience, but this was typically assessed by self-report. Only 62% checked references. Ninety-two percent checked criminal backgrounds within the state, but no agencies checked other states, meaning that someone who had been convicted elsewhere would appear to have a clean record. English language proficiency was assessed via the interview, and no agencies assessed health literacy (ability to understand physician recommendations, dosage schedules, and so forth). Thirty-one percent conducted drug screening. Seven percent verified citizenship or visa status. Training and supervision were very limited. The researchers concluded with this warning:

“The screening and training practices in use by caregiver agencies are highly variable and often of poor quality. Using an agency to hire paid caregivers may give older adults and their families a false sense of security regarding the background and skill set of the caregivers.”

When my father, who lived 1,000 miles from where I was, lost his vision and entered the early stage of cognitive decline, my cousin, who was at a difficult point in his life, needed a place to live and moved in with him. He provided eyesight, companionship, and driving. My father paid for lodging and food, and provided avuncular guidance. It was a true win-win situation.

But this kind of good luck is the exception, not the rule.  Agencies like the 180 surveyed in the study are filling a vacuum in our fragmented society. Home care for the elderly is a rapidly growing “industrial sector.” Unfortunately, as the study reveals, the fact that an aide has been hired by an agency is not a reliable stamp of approval.

In the same vein, the 2008 Institute of Medicine report, Retooling for an Aging America: Building the Health Care Work Force, cited a Bureau of Labor Statistics prediction that home care aides and home health aides would be the second and third fastest growing occupations from 2006-2016, but concluded:

“…the education and training of the entire health care workforce with respect to the range of needs of older adults remains woefully inadequate. Recruitment and retention of all types of health care workers is a significant problem…Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future.”

At present the home care “industry” is in a wild west phase, with participants ranging from individuals who contract independently to outfits like Home Instead Senior Care that have 900 franchises in 16 countries. Seventy percent of those who are over 65 today will at some point need home care for an average of three years. The majority of home care services are provided by family and friends (primarily women), but the salaried home care workforce is already almost a million. Total “industry” revenue is close to $60 billion. Profits are growing, but direct care workers are not thriving: (a) their median wage is $10.59/hour, (b) fewer than half receive health coverage as a benefit, and, (c) half earn so little that they supplement their incomes with Medicaid and food stamps.

Home care for the elderly has the makings of a perfect storm. It brings together a vulnerable, stigmatized group – elderly people who need help with basic life functions – with a marginalized, stigmatized population of poor, primarily female, often immigrant, workers. This is a setup for exploitation – sometimes of the elderly by the “caretaker,” and sometimes of the caretaker by the agencies that hire them.

Ever since the so-called “companionship exemption” was put into law in 1974, personal care workers have not come under the federal requirements for minimum wage and overtime. The Department of Labor has proposed new regulations that would require agencies to pay no less than the minimum wage and to pay for overtime. Eleven senators recently introduced legislation to prevent the Department of Labor from doing this. We’ll see the ethical issue of respect and fair compensation for eldercare workers play out as a labor/management and political conflict.

James Sabin, M.D., 73, is an organizer of Over 65 and a clinical professor of psychiatry at Harvard Medical School.

8 Responses to “Screening Paid Caregivers: “A False Sense of Security””

  1. Abraham Lurie Ph.D

    Would it be helpful to research what other countries eg Germany, England, Sweeden, China are doing? Many good ideas, good public policies, where’s the funding? Is there really a viable substitute for a national single pay system?

    • Jim Sabin

      Hi Abraham –
      It would be VERY helpful to bring the experience of other countries into policy discussion in the U.S. Unfortunately, doing that butts up against our national commitment to American exceptionalism. We’re actively seeking international perspectives for Over 65. Any knowledge you can contribute would be welcome.
      Re single payer: we know from international experience that systems of this kind work well in other countries. But so far the combination of (a) reflexive American exceptionalism and (b) reflexive distrust of government in our political culture, has (c) prevented serious consideration of the single payer option, despite (d) the fact that Medicare, our toe-in-the-water of government financed universal coverage, is the most popular health program we have!

      • Ted Marmor

        Abraham and Jim, The coping with frailty and the personal aides who can be relied upon sensibly is a substantial isue everywhere, but largely ignored in the cross-national health policy literature. I agree with both of you about how worthwhile it would be to explore the experience of others–if only to stretch one’s mind as opposed to hopes for direct transplantation. But Jim, you point about American exceptionalism is weakened by your own reference to Medicare, whose passage required a shift in the balance of power in the Congress, not a transformation of American political structure. And that shift was called for by persistent embrace of the argument for universal social insurance that would break from care on the basis of ability and willingness to pay to one that attempts to allocate on the basis of medical need and benefit possible. regards, Ted

        • Jim Sabin

          Hi Ted –
          You know much more about Medicare politics and the history of the program than I do. But I’m struck by the degree of bipartisanship in the original vote for Medicare in contrast to the bitter, unanimous Republican opposition to “Obamacare.” And I’m struck by the disconnect between how popular Medicare is and our failure to draw the conclusion that a government run insurance program that is “universal” for a segment of the population can be (a) efficient, (b) high quality (despite having lots of room for improvement), and (c) very popular, could (d) be a model for the kind single payer system Abraham was asking about.

  2. Faye Girsh

    Many of the older, disabled people dependent on caregiving might want the option of having their lives end peacefully and to be able to say goodbye to their loved ones before they disintegrated and lost their personhood. Now the default position is to continue to live regardless of quality of life; for many a voluntary, hastened death would provide an appropriate and dignified end. The choice should be available.

    • Jim Sabin

      Hi Faye –
      The issue of “voluntary, hastened death” is on the November 6 ballot in my home state of Massachusetts in the form of a proposed law based on the laws in Oregon and Washington. We’re seeing a lot of discussion and debate in the state. I’m impressed by the range of for and against opinions I’m seeing among colleagues and friends who I trust and admire. I think the discussion and debate the ballot initiative has stimulated is a good thing, whatever the outcome of the vote. (Polls suggest that a substantial majority of the population support the initiative.)
      Your use of the word “disabled” will set off alarms for folks who have conditions we label as “disabilities” but who are not near the end of their lives. But the rest of you comment sounds like you’re thinking of people who – like those envisioned in the ballot initiative – are nearing the natural end of their lives.

  3. Leslie Kernisan, MD

    Hi Jim,
    I thought of your post yesterday evening while at an Aging 2.0 event, as one of the presenters was They are basically trying to create a transparent Internet environment where families can hire caregivers. Will be interesting to see how this approach affects the issues you describe. The Internet facilitates community ratings and reviews; not a substitute for thorough screening but still probably helpful.
    More thoughts on using an Internet platform to hire in-home caregivers in todays post:
    best, leslie

  4. Monica

    My sister and I felt the same way about the pelpoe caring for my mom. They were incredibly caring pelpoe. As we got to know them, we realized (they did not push this information) that they were all struggling financially, with run-down cars, dis-connected phone service, fast-food stops, and second and even third jobs. After my mom died, my sister and provided every care-giver with a small gratuity. The manager told us that we were the first ones to ever offer a gift. We were shocked. Without the care given to my mom and yes the support for my sister, those last two months would have been unbearable.