Over 2.3 million home care workers are responsible for caring for millions of Americans who are unable to fully care for themselves and need assistance to remain in their homes. Their importance has been magnified during the pandemic, largely due to the work they perform (e.g., grocery shopping, cleaning, taking blood pressure, administering medications) for clients who might be socially isolated and receive companionship and support only from these workers. This importance has translated into greater demand for home services due to COVID-19, given the increased number of aging adults and decreased nursing home care utilization. Despite the demand for these workers, their working conditions remain fraught with danger.
Home care workers, by definition, work in very close proximity to their clients as they help clients bathe, prepare meals for them, and clean their homes. Many of these workers also come into close contact with others in the general public, either because they are running errands that clients cannot do themselves (e.g., grocery shopping) or accompanying clients to medical visits outside the home. Both situations mean that these workers are at an increased risk of contracting COVID-19 from their clients or those in public. Further, being in these situations increases the likelihood of transmitting the coronavirus disease to their clients.
We highlight three policy options that decisionmakers might consider taking to improve the conditions and well-being of these workers.
Policy Option 1: Prioritizing Provision of Personal Protective Equipment (PPE) for Home Care Workers
Given that one of the two main behaviors encouraged by experts to reduce infection—physically distancing from others—is impractical for home care workers, a premium could be placed on ensuring that they have adequate PPE. Unfortunately, this premium is not universally applied across the United States. For example, the state of Michigan identified (PDF) home care workers in their second priority tier to receive PPE. In contrast, the state of Washington initially (PDF) (April 2020) prioritized home care workers in some settings to receive surgical masks if their clients did not have COVID-19 (and N-95 respirators if the client had COVID-19) yet currently do not appear to prioritize home care workers—other than those working in long-term care facilities—to receive PPE. Not surprisingly, PPE shortages or inadequacies had led to home care workers needing to find their own PPE or work without them. This is troubling, as home care workers are on the front line providing care to vulnerable clients in their homes. Thus, they are a critical piece of an overwhelmed health care delivery system that could become even more overextended if workers, and by association their clients, are not properly protected. If PPE provision is prioritized for home care workers, states and home care organizations will need to develop specific distribution and monitoring plans to ensure an adequate supply of suitable PPE to these workers for consistent use on the job.
Policy Option 2: Increasing Home Care Worker Compensation During the Pandemic
Home care workers are the lowest compensated direct care workers, earning a median income ranging from $13,300 (PDF) to $17,200, based on caseloads. The federal government passed a large stimulus package—known as the CARES Act—that allowed states to allocate funding at their discretion to address the impact of the pandemic. Under this act, some states provided an hourly wage increase as a hazard-pay premium for certain worker categories, such as first responders and teachers, but this was not consistently provided to all home care workers. For example, in Michigan, only direct care workers who provided care covered by Medicaid were eligible to receive hazard-pay premiums. Other states implemented bonuses or a lump-sum payment during the height of the pandemic. For example, Vermont, retroactively rewarded frontline employees—including home health agency workers—with a lump-sum payment up to $2,000 for working between March and May of 2020. In addition to state efforts, home care organizations have tried to be innovative in incentivizing their employees, with some using funds from the Paycheck Protection Program to provide an hourly hazard-pay wage increase for workers. While the efforts from some states and home care organizations are encouraging, these approaches were time-limited and inconsistently applied across the United States. One possible option to address this inconsistency might be for all home care workers to receive hazard- or bonus-pay premiums throughout the pandemic to compensate them for the additional risk they are undertaking in continuing to work.
Policy Option 3: Classifying Home Care Workers as Essential
An “essential” classification might improve the likelihood that the first two mentioned options are implemented. FEMA developed guidance for preserving PPE in non–health care settings and specifically focused on essential workers; in fact, the guidance noted that nonessential workers “do not need PPE currently” and “should be following stay-at-home orders and practicing social distancing, making use of telework options, etc.” Such guidance is counter to the way that home care workers need to perform their jobs, given that social distancing and telework options are not feasible for them. Classifying home care workers as “essential” might also likely have implications for forthcoming vaccine distribution as an additional form of protection. The CDC has included the term “essential” in its developmental plans (PDF) for phased approaches of COVID-19 vaccines, noting essential workers will be prioritized to receive the first phase of vaccines. It could help if home care workers are formally categorized accordingly to help ensure their timely access to a vaccine.
In sum, we owe home care workers our gratitude for the risky and challenging work they perform. It's worth considering policy options to provide them with better access to PPE, improved compensation during the pandemic, and formal recognition that the work they perform is essential to our society. If policies improve the experiences and safety of these workers—and by extension their clients—during the pandemic, we may have developed a foundation from which to build to continue ensuring better conditions for home care workers after the pandemic, a change which could have broader societal benefits.
Julia Rollison is a senior policy researcher and Jason Etchegaray is a senior behavioral social scientist at the nonprofit, nonpartisan RAND Corporation. The Ralph C. Wilson, Jr. Foundation provided funding for them to study home care workers' challenges and concerns at the start of the COVID-19 pandemic.
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