At an apartment building in the Highland Park neighborhood of Richmond, Dr. Amy Paul is making a housecall. But the person who greets her at the front door isn’t the patient. It’s home health aide Vickie Grady.
Paul is a doctor with VCU’s House Calls program. She’s in and out of patients’ homes all the time. And it’s taught her a lot about the role aides play.
“Before I never had to think about. It was never a thought. I just did like everybody else, patient has gone home with an aide. Full stop,” Paul said. “But now that I’ve worked in it and been to patient’s houses and seen the result of that full stop, I can see the benefit.”
Nationwide, about 3 million people work in home healthcare - and most do so for a poverty wage. Demand for their work will continue to explode as the population ages. But some say the role of aides could be reimagined, making the job more desirable while lowering healthcare costs for us all.
'They Always Add a Flavor'
Today Paul is visiting Arnita Thompson, a 92-year-old whose health, Paul says, has improved a lot since aide Vickie Grady began working with her.
Both Paul and Grady gather around Thompson. Paul takes her blood pressure, pulls out a chart with her weight over time, and begins asking questions.
“So tell me about your eating?” she says.
She’s talking to Thompson but also glancing towards Grady.
“She was sitting there yesterday and had candy on the bed,” Grady chimes in. They all laugh.
Paul says a good aide can help keep a patient honest. Her elderly clients aren’t always willing to admit when they’ve had a fall, or maybe haven’t been eating as well as they should.
Throughout this visit, Grady sits in the corner, taking careful notes on the doctor’s instructions. It’s hard to imagine how it would go without her there.
Paul says good healthcare isn’t episodic -- it’s continuous. But doctors and nurses just can’t be there all the time. Good aides, she says, can be the key to filling in the gaps.
“They always add a flavor,” she says. “An extra bit of information about a patient.”
'Less Nursing Homes, Less 911 Calls'
Aides are the front lines of care. They’re the first to know about a change in diet, or a bruise that could become an infected bedsore. And when they’re good at their jobs, they’re saving taxpayer money.
“Less nursing homes, less 911 calls,” says MIT labor economist Paul Osterman. “People staying healthy at home for longer periods of time. All that aides up to is savings.”
Osterman is the author of Who Will Care for Us: Long Term Care and the Long Term Workforce.
He argues that empowering aides to play a greater role in healthcare won’t just save money, but it could also help prevent the looming workforce shortage.
“If you can make this a better job, and you can increase the competition, and you could even make the case that this is an entry level job into healthcare. You’ll attract people,” he says.
One way to improve the job is by allowing aides to do more -- like helping with physical therapy or wound care. In many states, including Virginia, limited scope of practice laws mean aides are highly restricted in what they can do.
Another way is to improve training. In Virginia, the standard training is just 40 hours. And more than half the workforce is consumer directed, meaning there are no training requirements.
Angelina Drake is with the Paraprofessional Healthcare Institute, a nonprofit advocacy agency in New York. Its 4-week training program is often held up as the industry standard.
“With a better trained better valued homecare worker -- that worker is going to be able to do more in the home and contribute more meaningfully to client health and wellbeing,” says Drake.
Drake points to one easy change in home aide training that can yield big results: focusing on observation and communication.
“So empowering home care workers to report on what they’re seeing in the home: changes in behavior, changes in healthcare status among the client,” she says.
‘That’s A Loss to Us’
Communication, though, is a two-way street. Aides I spoke with say they’re often overlooked by nurses or doctors. I heard stories of doctors getting irritated with an aide for speaking out of line.
Dr. Peter Bolling is chair of geriatrics at VCU, and founder of the House Calls Program.
“That’s a loss to us. Because my own experience has been that a few minutes of conversation with the right person is time well invested,” Bolling says.
He agrees aides could be better integrated into the system, but says there are serious challenges. One is the wide variety of commitment in the workforce that largely stems from poor pay.
Another is the way the system is structured. Aides are employed by agencies, and the state determines their pay and training.
“They don’t report to us. They’re not under our employment. We don’t direct their rewards. Or their evaluations,” Bolling says. “We recognize their value. But we aren’t directly involved in their business operations.”
Back at the patient’s apartment, Dr. Amy Paul is finishing up. She and aide Vickie Grady have just finished going through Thompson’s cupboard -- pulling out the canned food items with too much sodium.
Paul says she likes to empower aides, give them the tools necessary to help keep their clients out of the hospital.
But Grady says not all doctors, or even nurses, do the same. They should - she adds - because they’re all working for the same purpose. To care for someone.