The shortage of direct-care workers and CNAs is going from bad to worse. How will Oregon find the labor needed to care for an aging population?
Felipa De Torres knows she is an anomaly.
Raised by nuns in a small town in central Mexico, she loved spending time with and eventually caring for the older sisters who moved to the facility to retire and die.
“I enjoyed them so much,” she says. “Their stories, their wisdom. It was an honor to be with them when they departed from earth.”
De Torres carried that passion with her when she moved to America and settled in Woodburn. It drove her to apply for a job at Avalon Healthcare French Prairie Nursing & Rehabilitation Center, despite having no training and speaking limited English. Being rejected did not dampen her spirit.
“My friend did get hired, and she told me the graveyard shift is short, so I just showed up and started working,” she says. Management was impressed but cautious. They kept De Torres on the graveyard shift with two caveats: She had three months to earn a certification and learn some English. De Torres did both.
That was 28 years ago. Since then De Torres has earned more certifications, tended to dozens of people, and watched as COVID restrictions and the subsequent labor shortage made it more and more difficult to deliver care.
“We have the hardest workers. They don’t drink water. They don’t go to the bathroom. But even with these heroic actions, residents are not getting taken care of in time,” she says. “This work is hard, but the residents are the ones that suffer the most.”
The direct-care workforce — certified nursing assistants (CNAs), home health aides, and personal- and home-care aides — is in crisis. The need for workers to take on this physically demanding, emotionally draining and historically poorly compensated job was always high. But at this stage of the pandemic (whatever this stage may be), the shortage looks critical.
Where are Oregon’s residential and home health care workers? And, as the state’s population continues to age and needs keep growing, will we have enough for tomorrow?
The problem is not unique to Oregon. Nationwide, nursing homes are down more than 240,000 employees since the start of the pandemic, according to the Labor Department as reported by NPR. But those numbers might be conservative; another estimate puts the number of lost caregivers at a whopping 400,000.
The statistics for Oregon also look grim. Residential care facilities account for only about 20% of the overall health care and social-assistance sector, but as of February 2022, they accounted for a little more than half the job losses.
Unlike other sectors hit hard by the pandemic, this problem has yet to show any real signs of turning around, according to Josh Lehner at the Oregon Office of Economic Analysis. Lehner also reports that about 17,000 of the state’s overall 100,000 job vacancies are in health care and social assistance, according to survey results from Oregon’s Employment Department.
As expected, this lack of workers is having a tangible effect on the quality of care residents receive. Prepandemic, the Office of the Long-Term Care Ombudsman, the organization that works as an advocate for residents, received about 60 case calls a week. Now those numbers run between 75 and 80, with some weeks seeing as many as 120 calls.
“In general, we are hearing more complaints about delayed care and neglect — things like lack of hygiene care, teeth that are rotting and residents not being turned so they develop decubitus ulcers [dangerous bedsores],” reports long-term care ombudsman Fred Steele.
Boosting pay seems like the no-brainer solution to attracting more people to this difficult, underpaid work. And lots of money has been thrown at the problem. In one example from the height of the pandemic, the ODHS Office of Aging and People with Disabilities deployed the Employee Retention Payment Reimbursement Program, which put a $500 retention bonus into the pockets of 5,866 direct-care staff across the state.
Today $1,000 sign-on bonuses are not uncommon along with referral bonuses, the promise of flexible schedules and high hourly rates. In 2021 Oregon was already the fifth-highest-paying state for nursing assistants, according to the U.S. Bureau of Labor Statistics, with a mean hourly wage of $15.99. Today a quick glance at the job-posting site Indeed shows facilities offering hourly rates of $20 and more.
“We are doing everything under the sun to recruit staff,” said Sharon McCartney, executive director for Mirabella Portland, a nonprofit senior-care facility, via email. Along with bonuses and higher hourly pay, they are also offering growth opportunities between departments, and management tracks through various leadership programs. They are even helping workers find careers outside health care by offering scholarships for leadership programs, trade schools and university scholarships.
Mirabella is also focusing on retraining managers, McCartney told Oregon Business.
“We find that employees don’t leave places, they leave managers,” wrote McCartney. “So we’re investing in providing our managers as many tools as possible to help with retention.”
Improving management speaks directly to Sam Browne, a CNA at Avamere Beaverton. Browne started at Avamere in 2012 as a dishwasher. His rapport with residents was so positive that management encouraged him to enroll in the company’s free CNA-training program. After six years on that job, he has seen plenty. “There are a lot of bad administrators and managers out there.”
Sam Browne, a CNA at Avamere Beaverton. Photo: Jason E. Kaplan
Browne appreciates the higher wages his union, SEIU 503, won for him and the union’s more than 4,000 workers in 57 Oregon nursing homes. But more money does not erase the physical and emotional burden that comes with this work, he says.
“There are a lot of jobs that are easier,” Browne says. “Management is giving these kids too big a workload and throwing them into the hardest sections. There’s not a good support system for them, and we’re losing older staff to burnout.” Browne himself says he is planning to exit the field in a couple of years.
The problem has grown large enough to grab national attention. Earlier this year, the White House outlined an ambitious plan to improve the safety and quality of nursing-home care by establishing a federal minimum staffing requirement for nursing homes funded through Medicare and Medicaid.
The nursing-home industry, however, is skeptical of this proposed solution. “Unfortunately, unfunded workforce mandates would only make this situation worse,” according to a press release put out by the American Health Care Association/National Center for Assisted Living.
Moving to a skilled-nursing or assisted-living facility is not the only option for Oregon’s older population. The state has a robust home care-worker system designed to allow Oregonians to age in place for as long as possible. These direct-care workers help their clients with everyday tasks: bathing, cooking, running errands and the like.
Qualifications for the position are pretty basic. Home care workers must be 18, pass a background check and be legally able to work in the U.S. The job itself, however, is difficult, dangerous and isolated.
These workers experience twice the on-the-job injury rate of the overall workforce. Sixty-one percent of female home care workers in Oregon have experienced workplace abuse. They are particularly vulnerable to wage theft and compassion exploitation, all according to a report from the University of Oregon Labor Education & Research Center.
These statistics sound familiar to Dianne Catlin. She provided direct care to clients as a home care worker for almost 10 years. Now, at 74 years old, she only works two or three hours a week.
“That’s the minimum I need to keep my union health benefits,” she says. “I’m too old to be wiping butts or transferring patients for 40 hours a week.”
Home care workers also suffer a high poverty rate, according to that University of Oregon report. The Oregon Home Care Commission currently pays a base rate of $15.77 per hour. Further certification leads to slightly higher wages, but pay is still low, especially considering the job’s physical and emotional risks. Union membership, however, does deliver valuable benefits like the health insurance that is keeping Catlin on the job.
The ODHS Office of Aging and People with Disabilities is trying to attract more people to this field by providing new, culturally sensitive training programs and partnering with regional workforce boards. But is that enough when home care is among the top 10 fastest-growing occupations in the country and Oregon is bracing for a silver tsunami of an aging population needing care?
And none of these interventions address the inherent isolation and safety risks we ask home care workers to bear.
The need for CNAs and home health workers is already critical and poised to grow. Boosting the pay for these positions will certainly help with recruitment and retention, but right now even the most generous raises can’t keep up with inflation. What CNAs like Browne and De Torres really want is lower caregiver-to-resident ratios, which would allow them to deliver compassionate care in a timely manner.
“These buildings tend to staff the bare minimum,” says Browne. “If they were less focused on budgets and more on care, it would be a better place to work.”
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