The Direct Care Workforce
Direct care services that have been available have been fraught with problems brought on by a high-turnover workforce that is thus inconsistent in its delivery of care. Low wages, worker isolation, lack of peer support, lack of benefits, and lack of opportunities for career advancement all contribute to exceptionally high turnover rates in the direct care workforce. Today’s direct care workers also are more likely than other workers to live in poverty, to lack health insurance, and to rely on food stamps.
In rural areas, the direct care workforce faces additional challenges:
- Geographic isolation – There are fewer agencies to provide services and fewer workers available to be hired by these services. Service regions are large and the distances between individuals needing services and service agencies are great. This results in direct service workers spending more time traveling to and from clients and less time providing services to their clients.
- Transportation limitations – There is a lack of public transportation and there are seasonal road and weather conditions.
- Challenges in recruiting and retaining direct service workers – Rural areas are sparsely populated and the population has a higher proportion of seniors than do urban areas.
Service providers also face additional challenges in rural areas:
- Rural areas have a higher proportion of seniors than do urban areas.
- Rural areas have more people who lack health insurance than urban areas, resulting in lower financial incentives for licensed care providers to work in rural areas.
- Rural home agencies have a smaller and more dispersed client base compared to urban areas.
- Rural home agencies tend to be smaller than urban ones, are more likely to be non-profit, and generally provide fewer services.
Both rural and urban home care agencies struggle with recruiting and retaining workers in a tight labor market where they compete with hospitals and nursing facilities in their area, which generally offer higher wages and benefits.
In spite of this bleak profile of the direct care workforce, the U.S. Census Bureau reports that, between 2006 and 2016, direct care work will be one of the fastest-growing occupations in the nation, with the demand for personal and home care aides expected to grow by approximately 50 percent. Aging “baby boomers,” along with adults that are living longer, account for much of the increased demand for services. Veterans and those with disabilities also are part of the demand. The Affordable Care Act reinforces the demand with its stated preference for home- and community-based services, which acknowledges the need for a bigger and better long-term care workforce and includes incentives for workforce recruitment and training programs. The challenge is to make direct care jobs an attractive alternative and to build stability and quality care into the direct care workforce.
Increasing the size of the direct care workforce is the most direct solution to the shortage of rural direct care workers. Much of the shortage of consistent workers can be alleviated through effective recruitment and training. Consideration should also be given to a more innovative model for the direct care business itself: a work-owned business.
Home Care Cooperatives – An Innovative Solution
Direct service jobs are generally not structured to support a strong and stable workforce as this work is part-time, hours are irregular, wages are lower than for similar jobs, and health insurance and other benefits are not offered. This leads to an unstable work force and inconsistent and often low quality of care. The home care cooperative provides a stark contrast and is emerging as a way to overcome direct service workforce challenges.
What sets home care cooperatives apart from other providers of home care is their focus on the workers — their training, their compensation, their peer relationships, their relationships with their clients, and their ownership and governance of the business. A cooperative is a business model in which the workers are members and owners of their own business, participating in the control of the business on the democratic basis of “one person, one vote.” Home care cooperatives are owned and operated by the workers; home care cooperatives give direct service workers the opportunity to become owners and managers of their own business. Rather than being independent contractors providing home care services in an isolated setting, members of a home care cooperative have a peer group, a role in decision making, opportunities for training and professional interaction with fellow members, a benefits package, workers compensation coverage, patronage refunds, and a living wage. The direct care workers, mostly lower-income women, are empowered because they own the business. The home care cooperative thus provides a dependable, mutually supportive and stable workforce to meet the home care needs of its clients.
Home care cooperatives all share a common governance structure, but there are several basic approaches that have received the most attention: creation of a new worker-owned business, conversion from a private agency to a cooperative, or a multi-stakeholder cooperative in which ownership is shared by at least two classes that can include clients, workers, and possibly external interests such as family members of clients, advocacy groups, or hospitals. Our neighbors in Canada have much more experience with the multi-stakeholder (or “solidarity”) model of cooperative home care than the United States. Since 1997, 30 of these cooperatives have been organized in Quebec province. In the United States there are several well-established urban home care cooperatives, but the rural model is recent and there are three rural home care cooperatives in the United States: Cooperative Care (established in 2001 in Wautoma, WI), Circle of Life (established circa 2005 in Bellingham, WA), and Paradise Home Care (established circa 2007 in Volcano, HI).
All three of the rural home care cooperatives in the U.S. received support from CDF’s MSC Fund.