Dawn Luciano spends her weekends working as a personal care attendant, caring for seniors and people with disabilities in their homes. She'd like to spend her weekdays doing it, too.
"Unfortunately, I can't," Luciano, of Killingly, said. That's because she relies on her other, full-time job as a financial sales representative to get health insurance and enough income to support her and her two sons in college. The home care job doesn't provide either.
Ensuring that there are enough direct care workers to meet the growing demand is one of the most significant challenges facing state officials as they try to dramatically expand the availability of home-based long-term care.
One frequently cited 2010 estimate developed by the state Department of Social Services suggested that by 2016, the state would need 9,000 more home care workers. But the need is now expected to be even larger.
Home care work is often sensitive, challenging and poorly compensated; unlike their counterparts in nursing homes, home care workers who serve people in state-administered programs don't receive benefits and tend to earn lower wages and work fewer hours. The jobs can be more isolating than in a typical workplace since they often involve working with a single person at a time.
"It's a certain type of person that can do this type of job," said Deborah Migneault, community liaison for the Connecticut Commission on Aging, who has been leading efforts to address work force issues. "We have to value these people that are doing these jobs that are critically important ... but they're devalued in general, and that's a real issue. Attracting workers to an industry that sort of isn't valued is really difficult."
Migneault and other experts have identified multiple potential solutions to the work force crunch. Some are controversial, particularly the recent push to allow personal care attendants like Luciano to unionize.
Many people with disabilities take issue with the idea of professionalizing or centralizing all home care jobs. They say that creating certification standards or centralized training, for example, could undermine a model that works for them and is based on flexibility and their ability to control the services they receive.
State officials expect that the increased demand for home care will be accompanied by a drop in demand for nursing home beds, potentially leaving nursing home workers available to serve clients at home. But that could also mean trading jobs with health insurance, retirement benefits and paid time off for jobs with lower wages and no benefits. Nationally, more than half of home care workers live in households that rely on public benefits like Medicaid or food stamps.
"It might be good public policy to save money on Medicaid expenses" by replacing nursing home care with home care, said Deborah Chernoff, spokeswoman for the New England Health Care Employees Union District 1199, SEIU, which represents nursing home workers and is seeking to unionize home care workers.
"Is it good public policy to, in the course of doing that, destroy a lot of jobs?"
"Not rocket science"
So far, home care agencies have been able to handle the demand, although there are challenges in some pockets of the work force, such as speech and occupational therapy, said Deborah Hoyt, president and CEO of the Connecticut Association for Home Care & Hospice.
But she called the projected demand "staggering," and said it will likely be a challenge to meet -- though one that the agencies are eager to address.
Agencies generally hire licensed staff with medical training, although some are branching out to include unlicensed workers like personal care attendants or companions and homemakers.
Many people receiving state funding for home care hire personal care attendants, or PCAs, on their own. There's no formal mechanism for doing so, and Migneault said people are having a hard time finding PCAs. Some put ads on Craigslist.
Julie Robison, a professor at the UConn Center on Aging who researches the state's long-term care system, said there's already evidence of gaps.
"That work force crisis is already here," she said.
The potential strategies to address it are wide-ranging. Among them:
• Develop career ladders so home care workers could take on other jobs as they get more experience. It could be easier to attract people to $10-an-hour jobs if they see opportunities for growth, experts say.
• Provide training for nursing- home workers to transition to home care work.
• Let people pay family members to serve as caregivers. Many people already care for relatives without getting paid -- representing the largest group of home care providers. Some state programs already allow family members to be paid in some circumstances.
• Expand the use of assistive technology, which could range from thicker pencils that are easier to grip to machines that move a person from bed to a wheelchair. Technology could reduce the number of hours of care or the number of workers a person requires, although Robison said it shouldn't replace human contact altogether.
• Improve recruitment efforts by focusing on what makes home care jobs attractive, like the ability to work one-on-one with someone. Target retiring workers, particularly nurses who might find home care work appealing.
Then there's wages and benefits.
"It's not rocket science," Chernoff said. "If we regard that work as valuable, we have to act as if we regard the work as valuable."
That means giving workers the tools they need, like training, the opportunity to interact with other home care providers, and benefits and pay that can support their families, she added.
In Connecticut, the median hourly wage for PCAs in the public and private sectors was $10.37 in 2010, according to PHI PolicyWorks, which focuses on the direct care work force. For nursing aides, orderlies and attendants, jobs typically done in facilities like nursing homes and hospitals, it was $14.49.
"If you want people to be attracted to this work, you need to decrease that gap between what nursing aides are earning and what PCAs are earning," said Dorie Seavey, PHI's director of policy research
But Peter Gioia, vice president and economist for the Connecticut Business and Industry Association, sees a pool of potential workers that hasn't been tapped.
"We have 8.5 percent unemployment," he said. "We have, every week, extraordinary numbers of people who have run out of their benefits. My guess is if you had a job fair somewhere around the state and said, 'OK, we've got 5,000 positions open for home care,' my guess is you'd have 20,000 people show up."
"Wonderful part-time job," or a career?
Luciano, the weekend PCA, sees hope for the field through unionization. Giving PCAs a way to bargain collectively would help the people they serve, she said, allowing people like her to do the work full time and cut down on the turnover that can leave some people to rely on more workers than they'd like for personal tasks.
The effort to unionize home care workers has been a major source of contention, and tensions escalated last year when Gov. Dannel P. Malloy issued an executive order allowing PCAs in state-administered programs to unionize. It also established a work group to recommend ways to structure collective bargaining rights for PCAs.
Opponents have argued that a union would get in the way of the relationship between people who receive services and their PCAs. Some people with disabilities say they're wary of centralized training because it can make it harder to get PCAs to do exactly what they want.
The concept of a PCA grew out of the push by people with disabilities to live in the community, rather than in institutions, where residents had little control over how their care was delivered. The workers in institutions typically have medical training that people with disabilities say leads them to regard people as patients in need of protection, not people with functional issues who should be empowered.
PCAs, by contrast, generally don't have medical training; their jobs are to help people live independently. The person receiving services dictates what a PCA does and how. PCAs have more flexibility than other types of direct care workers in what tasks they can perform, which can include getting people out of bed, driving them to work, cleaning feeding tubes and folding laundry. Some are sensitive, like helping a person bathe or use the bathroom.
"They really are the hands and feet of people that perhaps don't have the use of hands or feet," Migneault said.
Opponents of unionization say PCAs should have good wages, but they worry that increases in PCA pay could mean fewer hours of services for people who rely on them, because the state limits how much total funding each person can get to pay PCAs. Medicaid, the largest funder of long-term care in Connecticut, pays for most state-administered home care programs, and the rules governing the home care programs are subject to federal approval.
Catherine Ludlum, who hires PCAs and has led the opposition to unionization, said the work should be marketed as a "flexible, wonderful part-time job," not as a full-time career.
"A lot of people think the answer to all of this is to make home care a full-time job, and what I keep saying is it's very different working at a facility that's maybe 10 people that you're responsible for and some other staff working one-on-one with someone in their home," she said.
"You can have two very wonderful people working together, but at the end of a 40-hour week, doing that long enough, they're not going to like each other anymore. There's just too much of one thing and too much opportunity to start rubbing each other the wrong way," Ludlum said.
Union officials say they want to support the PCA model, not undermine it, and that giving PCAs representation could help ensure that there are enough of them to support the growing demand.
Seavey said she believes there's room for more centralized training that could be acceptable to both PCAs and the people who use them, such as training in basic health and safety precautions -- workers who lift people are susceptible to injuries and could learn lift techniques, for example -- and understanding what it means to deliver care based on what the person receiving services wants.
"There are some users of long-term supports and services, particularly people with physical disabilities, and what they don't want is bad training. They don't want a medical model of training," Seavey said.
And giving home care workers collective bargaining rights could benefit the system by requiring the state to review what it pays for home care programs, Seavey said. "Because otherwise what happens is it's just a budget thing, and rates go up or down based on the state of the state budget and the strength of various lobbyists," she said.
Migneault and her colleagues at the Commission on Aging are trying to address the broader work force issues without getting bogged down in the union dispute.
"There's a common goal that everybody shares," said Julia Evans Starr, the commission's executive director. "The difference is how we get there."
The Commission on Aging is holding a forum on the direct care work force at 10 a.m., Friday, in room 1D of the Legislative Office Building in Hartford.