STAMFORD, Conn. — Tuesday night was rough. A sharp scent drifted into Marjorie Salmon’s dream world at 4 a.m. She was still trying to rouse herself when its source, her 77-year-old client, pounded on her bedroom door, yelling that he wanted to go home.
“You’re home, Bob. This is your home,” Marjorie told him. She calmed him down, cleaned him off, showered him, dressed him and put him back to bed, but could not get herself back to sleep.
Now it was deep into a dreary Wednesday morning. Marjorie set out a bowl of Cheerios, a plate of strawberry and apricot slices in a star pattern, milk, juice and a plastic shot glass with six pills in it — blue, white, brown.
“Where are you, Bob?” she called. “Come in and have breakfast, finish your food, your cereal, then you have your medications.”
This was in late May, but it could have been pretty much any time this year. Since mid-January, Marjorie has been Bob Dettmer’sround-the-clock caretaker. Bob is fogged in by Alzheimer’s and unsteady from Parkinson’s. Marjorie’s job is called home health aide, but the term does not begin to encompass her duties. She is social worker, housekeeper, behavioral-modification expert, dietitian, diaper changer, day planner, de facto case manager, warden and more.
Marjorie agreed to do the job for a flat rate of $160 per day plus room and board. Her workday starts when Bob wakes up, or before, and finishes after he goes to sleep, and can stretch for 14 or 16 hours or more. She works 26 or 27 days out of the month. The pay is not much — at 16 hours a day, it would come to $10 an hour — but Bob’s family is deeply grateful, and that counts for a lot.
“If I take a client and I have the respect,” she said, “I will stay through to the end.”
Home health care is the fastest growing major job category in the country, one of the most emotionally and personally demanding, and one of the worst paid.
Elder-boomers living longer and seeking to “age in place” rather than in institutions have created a demographic explosion that even a 150 percent increase in home care workers in the last decade, to nearly 2.3 million, cannot keep pace with. Nationwide, hundreds of thousands of ailing people entitled to Medicaid-funded home care are on waiting lists.
But home care workers’ labor happens behind closed doors. The workers are mostly women of color, and about one-third are immigrants. As a result, many advocates say, their work is systemically devalued, dismissed as “domestic care” and reimbursed at rock-bottom rates by state Medicaid programs.
It is a vicious circle. Because these have always been poor-paying jobs, they are seen as lousy, low-skill jobs. And because they are seen as lousy, low-skill jobs, they pay poorly.
“Rather than calling them low-wage workers, I would call these workers professionals who are paid low wages,” said Robyn Stone, senior vice president for research at LeadingAge, an association of nonprofit aging-services providers.
“They are taking care of people with very complex needs, people who have multiple chronic conditions, who may have all kinds of varied living environments. A lot of the families are really dysfunctional and the aides have to deal with that, too. And they’re getting paid chump change, and it’s a travesty.”
Nationwide, home care workers — a category that includes home health aides as well as home care aides and personal care aides, who have less specialized training — average $11.52 an hour, and 45 percent of them who work full time are on public assistance, according to P.H.I., a research and consulting group focused on direct care workers.
In the New York region, inflation-adjusted wages for home health aides actually fell from 2007 to 2017. In New York, one of the most expensive cities in the country, the 91,000 full-time home care aides earned an average of $27,000 in 2017, according to the city Department of Consumer and Worker Protection.
The turnover rate, not surprisingly, is astronomical. As many as two-thirds of home care workers leave their jobs, their field or the work force every year, and more than 4.2 million jobs will have to be filled from 2016 to 2026, P.H.I. says.
Twenty-four-hour care is particularly grueling and isolating: long bouts of idleness, punctuated by spasms of disorder and intimate struggle. Home care workers are typically offered little support or counseling on how to deal with the stress or process the grief.
“All they tell you is, ‘Don’t get attached to the client,’” Marjorie said. “But how do you prevent that? If you have a heart, how can you not get attached?”
In some ways, taking care of an Alzheimer’s patient is like parenting a 170-pound toddler. In some ways, it is like being married to one.
Yet many aides who stick with the job consider it a calling.
“This job, it is total, it is total demand,” Marjorie said one day. “Sometimes they don’t pay you what they should, but you know what, I don’t know what the end of my time is going to be like. I believe that what goes around comes around, and I believe in distributing love equally and fairly.”