Laughter and gentle ribbing distract from the well-timed movement as Sarah Morningstar slides from bed to wheelchair with Amanda Salazars help.
Its clear the two have formed a bond in the four years theyve known each other. Morningstar, 80, of New Haven, has arthritis and is unable to walk. Salazar, 25, is a paid caregiver who cant imagine doing anything else.
Shes such a good girl, Morningstar says of Salazar. I treat her just like my kid.
Salazar is equally attached.
Basically, when you have this sort of job its like a family, she said.
A seemingly perfect match in an ever-changing health care industry, the two also are part of a trend that more and more families will face in the years ahead: As the nations population ages, untold more millions will need help from people such as Salazar.
In 30 years, the number of people age 65 and older is expected to double to 81 million, led by retiring baby boomers. A longer life expectancy, a desire to stay in ones home and costs lower than traditional nursing homes have led to a dramatic growth in in-home care.
Many, like Morningstar does now, will need nonmedical help with such routines as bathing, dressing, applying makeup, meal preparation, driving to appointments and cleaning house. Called attendant care in Indiana, the U.S. Bureau of Labor Statistics has other names for the job.
Personal care aides and home health aides – two closely aligned jobs – are the first and second fastest-growing occupations in the nation, according to the Bureau of Labor Statistics. The industry is projected to add 1 million more of those jobs by 2020, for a total workforce of more than 3 million.
Indiana is projected to add more than 15,000 personal care and home health aides between 2008 and 2018, a 49 percent increase, according to the Paraprofessional Healthcare Institute in New York City.
To meet the rising need, half of the nearly 80 northeast Indiana businesses that offer some type of in-home care have sprung up in the last five years, according to Aging & In-Home Services of Northeast Indiana. (Providers contract with the agency, which covers nine counties and distributes state and federal money for programs benefiting the old or people with disabilities.)
Even as some question whether there will be enough, the growth of these mostly nonskilled workers has some groups asking for more training and screening in an industry already characterized by low wages and quick turnover.
Morningstar said she made the decision to get in-home care about five years ago and receives funding through Aging & In-Home Services of Northeast Indiana. While family members are a great help – I dont know what Id do without my family – she didnt want to rely entirely on them.
I just knew it was too much for them, with their own kids, to fit me in, she said.
Its a decision that many families will make. In another time, the looming option was a nursing home, which can cost more than twice the amount of in-home care.
Currently, one in three caregivers is an unpaid family member, said Mary Wiemann, senior vice president for advancement at Aging & In-Home Services of Northeast Indiana.
Hoosiers can buy long-term care insurance to pay for nursing home or in-home care and ease the burden on their families, but the price is prohibitive for many people.
Medicaid and Medicare, using federal and state money, are the primary sources of funds for older people and people with disabilities. In the mid-1990s, Medicaid waivers, which allow money to be used outside of nursing homes, paved the way for in-home care, said Susan Waschevski, deputy director of the Division of Aging at Indianas Family and Social Services Administration.
Since 2003, community and home-based waiver programs have seen a 188 percent increase in participation, while nursing home growth has been less than one-half percent, Waschevski said.
In-home care businesses have grown accordingly statewide.
In just the last year, the number of personal service agencies, which provide non-medical in-home care, grew by 12 percent, said Evan Reinhardt, executive director of the Indiana Association for Home & Hospice Care, an industry group.
While Waschevski said some rural areas lack in-home care providers, Reinhardt said he believes there are enough to fill current needs.
Its really going to be interesting, especially within the next five to 10 years, to see exactly how things progress, Reinhardt said. As demand increases, the question is: Can the system respond to that as it grows?
Reinhardts group was instrumental in pushing for a state law that now requires personal service agencies to be licensed. That calls for certain reporting requirements such as preparing a service plan for clients, alerting family members of a clients declining health and conducting a routine client satisfaction survey.
While the law requires provider agencies to assure their employees are competent to perform duties, it leaves it to providers to determine what training may be needed. Federal law does not require training, and neither do most states, according to the Paraprofessional Healthcare Institute, a nonprofit that works to improve elder-care and disability services and calls itself the nations leading authority on the direct-care workforce.
In Indiana, personal care staff must be at least 18 and able to effectively communicate. They also have to submit a negative tuberculosis test or chest X-ray, have CPR certification and complete a criminal background check.
While voluntary, a training curriculum for personal care attendants, homemaker and companion services and home health and hospice aides has been developed with the help of Reinhardts group.
Reinhardt calls personal care attendants the eyes and ears of in-home care who are first to notice a clients declining health, which can keep them out of a hospital or nursing home. While no training is mandated, there are certain efficiencies and levels they have to meet, he said.
These particular individuals, they are employed to perform certain tasks, and those tasks are not on the side of the coin that would require them to do anything in terms of medical care, he said.
Their wages are and expectations are reduced because of that fact.
The Paraprofessional Healthcare Institute, in research published last year, calls for standardized training nationwide and higher wages for personal care aides.
In a separate report published in October, the institute lists the 2011 national median wage for those workers at $9.49 an hour. Indianas rate is $9.20. Both show a 10-year decline when adjusted for inflation, according to the group.
Salazar, Morningstars helper, said she makes $9.25 an hour working part time for one of the regions service providers.
Her husband works in a factory.
Its hard, but I love my jobs. I love my clients, said Salazar, who cares for a couple of other people besides Morningstar.
AARP, the senior advocacy group, also supports higher wages to counter the high turnover that is common in the industry. Still, finding money just to keep the in-home care industry rolling will continue to be a challenge, said Paul Chase, public policy directory for AARP Indiana.
Chase believes there isnt enough money now. In particular, the state-funded CHOICE program, which pays for Morningstars services and other in-home and community programs for older adults and people with disabilities, needs to expand, he said. Chase said CHOICE is a $48.7 million program.
As of October, 1,288 people were on the CHIOCE programs waiver waiting list, Waschevski said.
Every couple of years we fight these battles to protest that funding, and weve been in a hold-the-line mode over the last several budget cycles where were trying to prevent them from cutting it, and weve been successful, Chase said.
Back in New Haven, there are two people glad for that.
As Salazar prepares to wheel Morningstar to her morning shower, Morningstar asks about Salazars three children. Salazar responds and then counters with a good-natured joke about Morningstar, who never curses, and her frequent use of the phrase, fudge ripple.
Thats her favorite phrase – fudge ripple, Salazar says with a grin. I sometimes go home and say it.
If not for a care worker that Salazar recalls tending to her brother with disabilities, she might not be in this business. She was inspired then and doesnt plan to change jobs.
And Morningstar seems more than glad to have her.
Its nice they have in-home service so people dont have to leave their homes, she said. You feel more comfortable at home.
Hiring a caregiverQuestions to ask agencies:
1. How do you recruit caregivers, and what are your hiring requirements?
2. What types of screening are performed on caregivers before you hire them? (State/federal criminal background check? Drug screening? Other?)
3. Are caregivers certified in CPR or have any health-related training?
4. Are the caregivers insured and bonded through your agency?
5. What competencies are expected of the caregiver? (for example, lifting and transfers, homemaking skills, help with bathing, dressing or toileting). Are they trained in behavioral management or cognitive support?
6. How do you assess a caregivers capabilities?
7. What is your policy on providing a substitute caregiver when the regular caregiver is unavailable?
8. If there is dissatisfaction with a caregiver, can he or she be replaced without reason?
9. Does the agency provide a supervisor to evaluate the quality of home care on a regular basis? How frequently?
10. Does supervision occur over the telephone, through progress reports, or in person at the home of the older adult?
Source: Hiring and Screening Practices of Agencies Supplying Paid Caregivers to Older Adults, Journal of the American Geriatrics Society,