The Road to Quality

Andy Hines was a mechanical engineer 10 years ago when experts in Charlotte found that his 3-year-old son had autism.

Hines and his wife wanted their child to have the best treatment possible. They decided to try a type of autism therapy called Applied Behavioral Analysis, which is done at home with trained workers. They hired six workers from home-health agencies and flew an expert in from California at a cost of $1,500 to train them.

Within weeks, the investment was lost. The workers had all quit. They left their home health-care agencies to find higher-paying jobs elsewhere.

"We realized at that time that (agencies) were paying minimum wage and people were just using these as fill-in jobs," Hines said.

He decided to try to change that. After six months of researching the field, Hines started his own home health agency, Charles Hines and Son. He now has 150 clients, many of whom are receiving services through Medicaid. He has 165 employees and low turnover. He pays his workers between $10 and $14 an hour, about the same amount that the nonprofit N.C. Budget and Tax Center calls a "living wage" in North Carolina.

But the average home-health worker makes significantly less - only $8.28 an hour or $17,210 a year.

"Part of the reason that some of these agencies may be making these awful decisions is there's a dearth of really good, qualified people going into this field," said Carmen Hooker Odom, the secretary of the N.C. Department of Health and Human Services, the agency that oversees home health care.

"If they're going to take care of our loved ones, we can't have them being the lowest-paid workers in the entire industrial complex, for crying out loud. And that's the way it is. McDonald's workers make more than these people do.... It's scandalous."

In an industry where many workers are teetering on the edge of poverty, it's easy to lose them to another job, said Tim Rogers, the executive vice president of the Association of Home and Hospice Care of N.C. Turnover rates average 53 percent a year in home-health agencies - a number that has grown in recent years.

"Aides have been known to go across the street for 30 cents more an hour," Rogers said.

Hard to keep

Even a troubled economy can't keep people in direct-care jobs. In December 2001, when North Carolina's unemployment rate was 6.5 percent - a 17-year-high - shortages were still a problem, according to a report done by the Task Force on Long-Term Care to the N.C. Department of Health and Human Services.

The problem is especially acute in places where workers have other options. Wilmington loses workers every June when hotels and restaurants hire more people for slightly more money, association officials said.

Pressure to find workers is expected to intensify in the next few years.

There are 24,400 home- health workers in North Carolina right now. By 2012, 32,720 home-health aides will be needed to help with the aging population, according to the U.S. Department of Labor Bureau of Labor Statistics.

Medicaid's starting rate for services, which goes toward the aide's pay and expenses and the agency's operating costs, was recently increased to $14.40 an hour. Medicare reimburses home-health aides at a rate that starts at $44.76 an hour per visit for patients who need only a few visits. That rate often includes include additional health services, according to the U.S. Centers for Medicare and Medicaid Services. That figure can also vary based on such factors as the wage index in the area where care is delivered. But there is no legislation that says what percentage of the Medicare payment must go to pay the home-health workers.

State officials say they are trying to find a way to keep more people in the business.

"We've been looking at means to maybe address the pay, but I suppose the only way we could do it is increase the stipend we pay for the services and make the provider pay some of that to the people on the front lines," said N.C. Rep. Edd Nye, a member the Legislative Study Commission on Aging. "We couldn't do it by telling companies they have to pay a certain amount without giving them the resources to do it."

Experts say that another problem with recruiting home health-care workers is the lack of advancement opportunities within the field.

"For them to advance in their career, there has not been much of a career path for them," said Susan Harmuth, who recently retired from the office of long-term care at the department of health and human services.

The state is creating a pilot program to test the idea of creating specialties within the direct-care industry, including medication aide and geriatric-nurse aide. "They've been identified as the kind of workers long-term-care people have said they need," she said.

The medication aides would help with medication administration, which includes taking orders from doctors and getting the prescriptions filled and ensuring that they are given accurately. The geriatric nurse-aide certification would focus on the type of skills and knowledge needed by people who work in long-term-care settings.

Legislation is needed to establish the specialties, Harmuth said.

Some owners of home-health agencies have already tried to make home health a career-type field.

Sherry Hedrick, the executive director of Piedmont Home Care, said that including her home-health aides in discussions about patients has helped her keep turnover low.

"Hopefully, it's because of the environment we create, where we make everyone feel that what they have to say is important to the patient," she said. "We take a team approach to things. We don't treat them as sub-service types."

Hedrick has staff meetings every week where her aides can talk about their patients and any problems they have encountered. They also have training once a month about such things as how to safely move patients.

Hedrick would like to see the state develop further certification for home-health workers as long as the requirements wouldn't be too expensive. "You don't want to make it such a difficult thing to do because many of them can't afford it," she said.

The pay and some other aspects of the job are not always great, but some home-health workers still say that they love what they do. "The one thing I do love about my job is we're giving back," said Stephanie Grubb, a home-health worker with Piedmont Home Care.

Hines also takes pride in his role as the owner of a home-health agency by paying his workers more than the state average and by offering such benefits as health and dental insurance and a simple IRA.

But it's not always easy.

He did just over $3 million in business in 2003, the last year for which he has figures . He estimates that after paying staff and administrative and overhead expenses, he made less than 10 percent of that back in profit.

"Every now and then I look at my cash flow and I get very nervous because we have very high payroll expenses," he said. "I guess we just take less home at the end of the day than a major corporation would."