The most challenging part of Kulix Vibonele’s first job in long-term care was not getting injured.
Originally from Kenya, Wibonele worked as a certified nursing assistant in Atlanta in 2014. She visited the homes of mostly elderly clients, helping them with everything from bathing to cooking. Vibonele worked alone and sometimes had to lift clients much larger than herself.
It was hard work and she was paid only $9 an hour with no benefits. If it weren’t for Vibonele’s second job as a nanny and her husband’s income, they wouldn’t be able to make ends meet supporting their four children.
“My salary, you know, was literally nothing,” Vibonele said. “I was kind of shocked at the amount of work we had to do and the salary you get at the end.”
Wibonele’s experience reflects broader trends in the long-term care workforce. Those caring for older adults in private homes and nursing homes across the U.S. face low pay and risk of injury while the industry struggles with staffing shortages. CNHI News and Associated Press established during the inspection The State of Long Term Care in America.
Meanwhile, demand for these workers is growing as the population ages. According to the U.S. Census Bureau, by 2030, approximately 20% of the U.S. population will be age 65 or older, and this proportion will continue to grow.
“This is a national problem, and it’s everywhere,” said Dr. Steven Crystal, director of the Rutgers Center for Health Research. “Almost everyone is understaffed.”
“No manpower”
For years, the industry has faced labor shortages and high turnover, problems that have been exacerbated during the COVID-19 pandemic.
Nursing facilities have been laying off workers since the pandemic began, and the workforce has not fully recovered, federal data shows. A March survey of hundreds of nursing home providers by the American Health Care Association found that nearly all had open positions and were having trouble recruiting them. And recent nursing home staffing The Biden administration has panicked agency administrators who say they are already scrambling to fill vacancies.
Turnover at nursing homes is so low that some see all their employees leave within a year, said Alice Bonner, director of strategic partnerships at the Center for Innovative Care for the Elderly at Brown University.
“The people who remain are working much harder, double shifts, overtime and working with agency and temporary workers,” Bonner said.
Noel Kovaleski, administrator of the Carbondale Nursing and Rehabilitation Center in Pennsylvania, says the biggest challenge in hiring is the lack of applicants. One nurse supervisor position at her facility went unanswered after being posted on a leading job site for two years.
“The labor is not coming,” Kovaleski said. “They just don’t exist.”
Workers are turning away from these jobs for many reasons, including low pay and a competitive labor market. Nurses, for example, can earn more working in hospitals than in nursing homes, Bonner says.
Experts see a potential shortage looming as the industry grows. Overall demand for full-time workers in long-term care and support facilities will increase 42% between 2021 and 2036, according to the federal Health Resources and Services Administration. Demand for direct care workers, who make up the bulk of the workforce, is expected to grow 41%.
Low salary
Direct care workers play a vital role in the lives of their clients: a certified nursing assistant bathing a patient with incontinence dementia, a home health aide helping an elderly widower with his medications, a personal care aide helping group home residents eat lunch. These workers are mostly women and people of color, many of them immigrants.
Victoria Gardner, who suffers from tetraplegia after a car accident left her unable to stand or use her arms, considers her in-home caregiver a lifeline. A caregiver helps a 57-year-old Pennsylvania woman 16 hours a day. Without this care, Gardner would not be able to bathe, cook, do laundry or clean the house.
“My situation now: I have one guardian. This is a very fragile position. I’m not alone in this,” Gardner said.
The industry added about 1.5 million new direct care workers between 2012 and 2022, an AP-CNHI analysis of Bureau of Labor Statistics data found. About 800,000 new direct care jobs are expected to be created through 2032, which experts say will be difficult to fill.
Payment is an important factor.
Home health and personal care aides earned a median annual salary of $33,380 in May 2023, according to the bureau. These earnings were similar to those of cafeteria workers and retail workers.
Direct care workers typically have low wages. About half of them rely on government assistance, according to a January report from the Department of Health and Human Services.
Experts point to funding as a reason for low wages. Medicaid is the primary payer for long-term care, but many stakeholders argue that Medicaid reimbursement rates are insufficient to adequately compensate workers.
Some states have made efforts to increase the workforce, such as requiring a percentage of Medicaid reimbursements to go toward direct wages for care workers. Others used American Rescue Plan Act 2021 funding to boost wages and recruiting efforts. Meanwhile, in April, the Biden administration finalized a rule requiring 80% of Medicaid payments for home care services to be used to pay workers.
Respect factor
Zulma Torres, a longtime home health aide working in New York City, said she cried after work because of the way people treated her.
For years, she earned $6.25 an hour. Sometimes clients treated her like a maid, expecting her to cook for the whole family. On some occasions, when she had to take a client to the hospital, she felt that nurses and doctors were judging her.
“A lot of times you just want to go out and think, you know, this isn’t for me,” Torres said.
Researchers say a lack of respect both inside and outside the industry is another factor keeping long-term care workers away.
“I think there is a perception among the public that there are fewer people working in long-term care,” said Barbara Bowers, founding director of the Center for Aging Research and Education at the University of Wisconsin-Madison. “I don’t think they even come close to getting the respect they deserve for their hard work.”
Reasons to stay
Kulix Vibonele, a certified nursing assistant in Atlanta, now makes $18 an hour at a nursing home. But she has endured years of low pay, layoffs and long migraines since she was stabbed by a disturbed resident at the facility. Her salary is still not enough.
“I can go to Walmart and make more money than being a CNA,” Vibonele said.
However, Vibonele said she plans to stay in the industry for now. In addition to working as a CNA, she is attending Georgia State University with the goal of becoming a registered nurse in long-term care.
“I love [the] the older generation, their wisdom, their stories. I like to know that I’m doing something while they [are] still here on earth,” Vibonele said. “As long as we don’t get paid enough, I won’t change that.”
Keleti reported from Phoenix and Schiccitano from Shamokin, Pennsylvania. AP journalist Niki Forster in New York contributed.