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Who will care for me when I am older or if I become disabled? Will a family member have to quit their job to do so? What if I can’t afford institutional care or would prefer to stay in my own home?

These are questions that have become more and more worrisome to millions of Americans as healthcare costs continue to rise and the care work industry faces serious workforce shortages.

With a growing elderly population and extremely high turnover in the low-wage field of care work (reportedly as high as 65 percent), many speak of the coming “care crisis”. As more and more Baby Boomers are hitting retirement age, and Americans on a whole are living longer, our elderly population will continue to grow. As many in this population begin to require extra help with daily activities and more women—those traditionally tasked with care work—join the formal workforce, the demand for professional care workers will far outstrip supply. Furthermore, though the majority of home-based care work is currently performed by unpaid family members, the ratio of available family caregivers to older adults is decreasing. In 2010 the ratio was seven potential caregivers to every one person over the age of 80, but it is projected to shrink to four to one over the next fifteen years.

This care crisis may be particularly acute in rural areas where the proportion of the population of individuals 65 and older is higher and where a significantly higher proportion of the population already utilizes long-term services and supports. The proportion of older individuals as well as individuals with disabilities also increases with rurality. Furthermore, rural areas experience higher rates of unemployment and lower educational attainment, both powerful social determinants of health. And even though both consumer preference and policy at the state and federal levels are shifting to support more home and community-based services, rural populations have a greater reliance on institutional services than their urban counterparts with nursing homes remaining the only long-term option available in many rural communities.

Across both rural and urban areas, the shortage of care workers is becoming more acute. The Bureau of Labor Statistics estimates that by 2024, America will need an additional 1.1 million homecare workers including personal care aides, home health aides and nursing assistants—a 26 percent increase in the workforce over 2014. Since the majority of homecare is currently paid for with Medicaid and Medicare dollars, the low reimbursement rates of these programs have contributed to the industry’s wages remaining depressed for years. In fact, the average wages of home health aides and personal care aides fall below 200 percent of the federal poverty line in all fifty states and over 50 percent of homecare workers rely on public assistance themselves. Some have speculated that one of the dynamics that may contribute to this fact is the makeup of the homecare workforce itself. Most of the people employed in the field are women, immigrants and people of color. Since much of the industry is not unionized, these disadvantaged populations lack the collective bargaining power to improve their working conditions, from wages to hours and benefits.

But without some changes to working conditions for this labor force, will people be clamoring for the 1.1 million new jobs in the industry? If many of those jobs go unfilled, who will care for the millions of Americans that require assistance with daily activities?

Anchoring the future of homecare:

While no single strategy is likely to be the address to the multiple challenges faced by the care work sector—and by the individuals that require their care—one group that is particularly well-placed to make a difference is health systems themselves. Hospitals and health systems could use their status as anchor institutions to positively impact this landscape. Recognizing that role, health systems across the U.S. are already pioneering strategies that leverage their substantial economic resources towards community health and well-being and the UK’s NHS is exploring similar strategies as part of its current long-term plan. Anchors could extend that commitment to inclusive local hiring and local procurement by partnering with existing local homecare organizations or directly contracting a homecare workforce themselves.

In addition to providing a stable flow of referrals for the homecare workforce, partnerships like these could also contribute to better coordination of patient care between the clinical and home setting. Furthermore, it would present an opportunity for health systems to develop targeted training and pipeline programs for local residents facing barriers to employment, starting with homecare positions for which local residents are well-suited given their connections to the community. A strategy like this would increase access to stable jobs rooted in place, which can contribute to the overall transformation of disinvested neighborhoods over time and help improve community health.

Healthcare anchors investing in homecare could be a particularly powerful strategy in rural areas where the distances many must travel to reach a hospital or clinic impede patients’ access to care and support. As the healthcare sector becomes more acutely aware of the health disparities between urban and rural America, it should consider centering interventions to increase access on social determinants like good jobs and educational opportunities. Only then will its interventions produce enduring results.

Empowering the homecare workforce:

Because of high attrition and turnover in the homecare industry (which can be detrimental to employers, workers and patients), any anchor initiatives to offer homecare services should consider the institutional arrangements that would most benefit the homecare workforce itself. Developing a pipeline and allowing homecare positions to serve as a stepping stone to further work in the healthcare field is one important strategy to consider. Another is to contract with worker-owned homecare cooperatives whose ownership stake can provide caregivers more control over their work environment, which can in turn lead to higher wages, lower turnover and higher employee satisfaction. This is why the Centers for Medicare and Medicaid Services recommend cooperatives as a way to strengthen the homecare workforce, particularly in rural areas.

The pioneer homecare cooperative is Brooklyn’s Cooperative Home Care Associates, founded in 1985. Now one of the largest cooperatives in the country, it employs around 2,000 mostly African American and Latina workers. Inspired by the success of Cooperative Home Care Associates, workers have since founded homecare cooperatives in rural areas of Washington State, Hawaii and Wisconsin, but the total number of cooperatives in the sector remains quite small. However, now may be the perfect time to support cooperative development and partnerships in the homecare sector as the AARP and Capital Impact Partners recently announced a major investment to significantly scale homecare cooperatives.

Another noteworthy innovation in the field is the first union-platform cooperative collaboration in the American homecare industry, NursesCan. With the support of United Health Workers West, a group of nurses launched an app that allows local hospitals to dispatch them directly to patients’ homes. The cooperative members have a collective bargaining agreement with the union and have benefitted from the union’s legal advisors and their connection to potential clients in the area.

NursesCan piloted their approach with the St. John's Well-Child and Family Center Clinics in Los Angeles, California and it was deemed a success by both parties with a drop in patient no-show rates for the clinic, and increased work opportunities for the licensed vocational nurses involved. This strategy of seeking contracts with specific health systems helps ensure homecare workers more steady work and contribute to cooperatives like NursesCan being able to offer more hours—and more regular hours—to their members.

Our ability, as a nation, to care for our elders, for the sick and disabled, will ultimately depend on our ability to ensure that the jobs in the care work sector are good jobs. While federal or state action to provide greater protections, better wages and enhanced training for care workers would go a long way to ensuring a stable workforce into the future, anchor institutions are well-placed to lead the way. Taking the lead on homecare as anchors would also mean contributing to the overall health and wellbeing of their communities and therefore help health systems meet their own missions.

Dana Brown is the Director of the Next System Project at The Democracy Collaborative, a think-do tank for the democratic economy. Her research focuses on health & care systems, the pharmaceutical sector, and economic transformation for health and wellbeing. She is based in Washington, DC. 

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