Why They Leave: Estudo americano publicado em fevereiro/12 revela os motivos da alta rotatividade dos profissionais de saúde que atuam com Home Care, em especial os técnicos de enfermagem.

1. Why They Leave:
Turnover Among Washington’s Home Care Workers
February 2012
Sahar Banijamali, SEIU Healthcare 775NW
Amy Hagopian and Dan Jacoby, University of Washington
SEIU Healthcare 775NW

2. About the Authors
Sahar Banijamali is a Policy Analyst at the SEIU Healthcare 775NW. She earned her JD in
Health Law at the University of Washington in 2009 and is currently completing a Master of Public
Health in Population Health and Health Care Research at the University of Washington. She researches
Washington state long-term care and health workforce issues.
Amy Hagopian is on the faculty in the Departments of Global Health and Health Services at the
University of Washington School of Public Health. She earned her PhD at the University of Washington
in Public Health in 2003, and publishes academic papers on health workforce labor and labor migration.
Dan Jacoby is a Professor in Policy Studies at the University of Washington. He earned his PhD
in Economics from the University of Washington in 1985. He held the University of Washington’s Harry
Bridges Endowed Chair in Labor Studies and continues to publish in that field.
2

3. CREDITS
We would like to thank Lisa Morris, Candace Howes, and their research teams for publishing Quits and Job
Changes Among Home Care Workers in Maine: The Role of Wages, Hours and Benefits (2009) and Love,
Money or Flexibility: What Motivates People to Work in Consumer-Directed Home Care? (2008), respec-
tively, and for sharing their research tools with us.
We would like to thank the 1,303 home care workers who responded to the three telephone surveys that
provided the majority of the data for this report. Finally, we’d like to especially thank the home care workers
and individuals who receive home care services who generously shared their time and personal stories with
us: Charles P. Fawcett, Emerson Guillermo, Emily MacKersie, Kathy Mason, and Lisa Miller.
Methodology
This report relies on a number of data sources, including a literature review of national studies and studies
in other states on turnover among home care workers. As a part of this report, we drew a sample of former
Washington State home care workers and interviewed them about their work experiences and career choices.
Our sampling frame comprised the SEIU Healthcare 775NW Unionware database, which includes information
on 31,205 former home care workers who had been members of this union. To be eligible for our survey, work-
ers had to be: (a) aged 18 years or older; (b) able to complete the survey in English; and (c) have voluntarily left
the profession between August 1, 2007 and October 31, 2010. Individuals who were terminated, laid off, or
left the profession as a result of retirement, death or illness were excluded from the study.
The Feldman Group, Inc. conducted interviews in English on April 4 and 5, 2011. Calling hours were limited
to the evenings, from the hours of 5:00PM to 9:00PM. In total, 402 telephone surveys with former Washing-
ton State home care workers were completed. Challenges encountered in contacting and interviewing former
home care workers included disconnected and wrong phone numbers and home care workers’ failure to keep
interview completion/callback appointments.
For comparison purposes we also examined data on the current home care workforce from two prior surveys
conducted for SEIU Healthcare 775NW and the SEIU Healthcare NW Training Partnership. The first was a sur-
vey of 501 qualified respondents and the second was a survey of 400 qualified respondents, both conducted in
October of 2010. Both these telephone surveys were conducted by the Feldman Group in English, with calling
hours limited to evenings.
3

4. E X E C U T I V E S U M M A RY
Turnover in the long-term care industry home care aides, and other direct care work-
is at a crisis point and threatens quality of ers. National data on turnover rates show
care and quality of life for vulnerable adults wide variation, depending on the source
who rely on long-term care services. A of the data: One source suggests turnover
2005 national survey found more than 76 rates average about 25 percent for home
percent of states reported that home care care workers, while other data pegs the
worker recruitment and retention were average annual home care turnover at 200
major policy issues. Even given the eco- percent or more per year. Data for Wash-
nomic downturn and rising unemployment ington State suggest that about half of all
rates, the vast majority of states still ex- home care workers leave their jobs every
perience significant difficulty in recruiting year. High rates of home care worker turn-
and retaining qualified direct care workers. over have negative effects on providers, the
These shortages are likely to worsen over state, and consumers. The cost of replacing
at the same rate as the general population, the Medicaid caseload will
time as demand increases. workers is high (with the average cost of
grow by 56 percent by 2030. To meet this demand, Washington is
turnover estimated at $981 to $6,368); and
This paper, developed with support from estimated to need about 35,000 more home care workers by 2030. As-
quality of care declines for consumers expe-
Service Employees International Union suming a 35 percent annual turnover rate, nearly 440,000 total home
riencing significant worker turnover.
Healthcare 775NW, provides a broad care workers would need to be trained from 2010 to 2030 to meet this
overview of home care workforce issues The future availability of a sufficient num- demand.
in Washington State including findings ber of home care workers does not look
Washington’s Home Care Workforce
from a 2011 survey project and interviews promising. There will be an unprecedented
designed to further understanding of the increase in the size of the elderly popula- Washington’s home care workforce is comprised of approximately
needs of Washington’s home care workers tion as the “baby boom” generation ages. In 42,300 workers. The overwhelming majority of home care workers
and what motivates them to both enter 2012, the number of individuals in Wash- are women. About 72 percent of Washington home care workers are
and leave this profession. ington’s aged 65 and older is expected to White, 14 percent are Asian/Pacific Islander, 9 percent are Hispanic, 5
increase from 25,000 people per year to percent are Black, and less than 1 percent are American Indian/Native
A Crisis in Care: The Impending Short-
more than 40,000 people per year. By 2030, Alaskan. Most workers are disadvantaged economically and have low
age of Home Care Workers
individuals aged 65 and older will represent levels of educational attainment. While these workers are engaged in
Washington’s home care consumers and one-fifth of the state’s population. If the physically and emotionally tolling work, they are among the lowest
providers are facing a crisis in care related number of Medicaid consumers receiving paid in the service industry, making little more than the minimum
to the high turnover among and shortage home and community-based services from wage with few benefits. In 2010, over one in five Washington home
of nursing assistants, home health and home care workers in Washington increases care workers and their families lived in poverty.
4

5. Turnover in the Home Care Workforce: Why ment and support of a quality workforce. As such, The future of the home care workforce is a barom-
Do They Leave? policymakers, providers and consumers must work eter for the health of our communities. Stakehold-
in partnerships to create laws and policies that ers at the federal, state and local levels and in the
Efforts to recruit, retain and maintain a stable,
address both home care recruitment and retention public and private sectors must come together to
quality home care workforce rely on a variety of
goals by providing adequate compensation and find effective solutions for improving recruitment
interdependent factors. Our April 2011 survey
investing in the training, ongoing education, and and retention among this workforce.
of former Washington home care workers found
supports needed to produce and sustain quality
those who leave tended to be wealthier and more
home care workers.
educated, suggesting they had other options than
continuing employment in home care. This conclu- Recommendations
sion is supported by findings that re-employed job
State and private payers of home care services
leavers were substantially more likely to achieve
should focus their efforts on best practices to
better benefits, wages, hours and career mobility
recruit, retain and maintain a quality home care
in positions outside home care. Additionally, the
workforce. These policies should include the follow-
survey found the primary reasons cited for leaving
ing options:
this profession were the pursuit of better career
zz Raise the hourly wage to at least $17.58
opportunities and/or a job that would provide bet-
per hour – the living wage for a single wage
ter hours, wages, and/or benefits.
earner household supporting one depen-
Solutions to High Turnover: Improved Re- dent in Washington;
cruitment and Retention Strategies zz mplement strategies to help home care
I
workers find reliable hours of work and
Health and long-term care policies significantly
a stable predictable income, including an
affect workforce recruitment and retention. The
improved referral registry;
April 2011 survey respondents indicated increas-
zz mprove health insurance benefits for home
I
ing hourly wages, providing better training and op-
care workers by expanding eligibility, pro-
portunities for career advancement, and improv-
viding more comprehensive benefits, and
ing benefits are the best ways to create incentives
expanding coverage for home care workers’
for individuals to enter home care. Additionally,
spouses and dependents;
a literature review of prior research on home care
zz rovide Washington’s home care workforce,
P
turnover confirms these factors are most impor-
many of whom don’t even qualify for Social
tant to improve turnover.
Security, with some form of retirement
security;
State and federal funding through Medicaid and
zz Increase and improve training require-
Medicare accounts for the majority of long-term
ments; and
care expenditures and therefore play a substantial
zz evelop career advancement opportunities
D
role in determining worker wages, benefits and
that allow workers to develop additional
training opportunities. Given the unique and im-
skills and move into a job specialty within
portant relationship between home care workers
the home care profession or move into
and consumers, it is critical to understand what
more advanced health care or social service
home care workers need to sustain high quality,
positions (e.g. licensed practical nurse,
long-term care services. The future of cost-effec-
registered nurse). 5
tive, quality home care depends on the develop-

6. A Crisis in Care
over in long-term care costs government payers on the order of $2.5 billion
per year, not including costs generated by lapses in quality of care or workers’
compensation benefits to home care workers for injuries that may be cor-
related with turnover.16 Other studies have estimated the cost of turnover
to the home care industry at more than $4.1 billion annually. 17 The costs of
Home care workers play a vital role in our long-term care system. A shortage of quali- turnover to the public sector are tantamount to an implicit tax on reimburse-
fied workers is exacerbated by the rapid growth of the long-term care industry and the ment rates paid to publicly-financed providers – a hidden tax which ultimate-
increased demand for home care workers.1 High job turnover rates create quality and cost ly is paid by taxpayers for high industry turnover costs.
problems. Successful recruitment and retention of home care workers remains a challenge Several studies attempt to estimate the costs of recruiting, orienting, train-
for both the state and home care agencies.2 A 2005 national survey found more than 76 ing, and managing new workers, along with the increased management
percent of states reported that home care worker recruitment and retention were major expenses of supervising inexperienced workers and lost productivity of
policy issues.3 Even given the economic downturn and rising unemployment rates, the experienced workers who leave.18 One estimate pegs the cost of a turnover
vast majority of states still experience significant difficulty in recruiting and retaining event for a direct care worker19 at about $2,500 per year.20 Other studies
qualified direct care workers.4 These shortages are likely to worsen over time as demand estimate the average cost of a direct care worker turnover at between $981
increases. and $6,368 annually. Estimates vary depending on the type of direct care
Home Care Worker Turnover Affects needs of seniors and people with disabilities worker studied, geographic location and the factors considered in the model
Consumers’ Quality of Care and the close personal relationships that are (e.g. separation and replacement costs, lost services to client, lost revenue
frequently established between home care from funding sources, exit interview and evaluation time, training expenses,
Turnover is calculated as the ratio of the
workers and the consumers they serve, the etc.). A cross-industry rule-of-thumb for estimating the per-worker cost of
number of separations during an annual
reduced availability and frequent churning of turnover is that the cost of a lost employee is 25 percent of his or her annual
period to the total number of workers em-
such personnel may ultimately affect clients’ compensation amount.21 The 25 percent rule-of-thumb turnover cost for a
ployed. In Washington State, annual home
physical and mental functioning. Several Washington State home care worker, then, would be between $3,58022 (for
care worker turnover has been estimated at
studies have observed that inadequate care the average worker) to $5,390 (average full-time worker).23 (See Chart 1).
19 to 37 percent5 for individual providers
caused by high turnover and worker short-
and 27 to 67 percent for agency home care
ages can ultimately result in serious health Chart 1: Estimates of Average Annual Per Home Care Worker Turnover Costs
workers.6,7 Nationally, data on home care
consequences, such as client hospitalization, $ 6,000
worker turnover rates show wide varia-
poorer nutrition and even a client’s relocation $ 5,000
tion,8 with estimates ranging from a low
to an institutional setting such as a nursing
of 25 percent to a high of more than 200 $ 4,000
home.13 High home care worker turnover also
percent.9,10
places more pressure on family caregivers, $ 3,000
$ 5,390 $ 5,276
The high rate of turnover in the home care who are already providing the bulk of care to
$ 2,000
industry reduces the continuity of services the elderly and people with disabilities in the $ 3,362
$ 2,500 $ 2,592
provided to consumers and compromises United States. 14 $ 1,000
the quality of care they receive.11 High
Home Care Worker Turnover is Expensive $0
levels of turnover cause home care consum- Minimum cost of Rule of thumb
Cost of replacing Minnesota’s A Massachusetts
home care direct support human services or-
ers to face the bewildering experience of Turnover and workforce shortages are ex- low-wage service turnover estimate
agency worker in a professionals ganization for people
employment for avg. full-time
Midwestern certified turnover cost with disabilities
constantly changing home care workers.12 pensive for long-term care providers and for turnover WA HCW
public home care (Larson 2004) turnover cost (Vinfen
Because of the important role that home federal, state and local governments, which agency (Zahrt 1992) Corp. 2004)
care workers play in meeting the most basic together foot most of the bill for long-term Source: Dorie Seavey, “The Cost of Frontline Turnover In Long-Term Care,” Better Jobs Better Care,
care. 15 Nationally, the evidence suggests turn- October 2004, http://www.directcareclearinghouse.org/download/TOCostReport.pdf.
6

7. Charles P. Fawcett
Unprepared for
the Future:
The Impending Shortage of
Home Care Workers
Washington’s home care system already faces significant challenges in recruiting and
retaining home care workers, and the problem is expected to significantly worsen as My name is Charles P. Fawcett and I live in Spokane, WA. I am 54 years old and I have been
demand for qualified home care workers increases. Factors driving demand include receiving home care services since 1996. I have a “wasting” disease, AIDS, lymphoma, and a few
the aging of the “baby boom” generation and the climbing average age of the home other fatal illnesses. Last year was the worst year yet for me health wise. I was frequently in and
out of the hospital and had additional complications.
care workforce.
Washington’s Aging Population is Growing at a Faster Rate I get 69 hours of care per month during which my caregiver helps me do the things I need to sustain
than the General Population myself – driving me to my doctor appointments, cooking, cleaning, reminding me to take my medica-
tions, and the like. Since I’ve started receiving home care I’ve gone through 8 caregivers. They
The demand for long-term care million in 2030, and the number of indi- left for different reasons – some couldn’t handle the loss anymore, others couldn’t afford to live
home care workers for elderly in- viduals aged 80 years and older is expected as caregivers, and still others couldn’t physically handle the work. I’ve only ever had to fire one
dividuals is growing fast, and most to increase from about 9 million in 2000 to caregiver. I dread hearing a caregiver has to leave. The transitioning period is scary. Being able
to relate well with your caregiver is so important. I have 6 fatal illnesses and that’s enough to deal
states face worker shortages.24 The nearly 20 million in 2030.26 with. It’s important that me, my caregiver and doctors work well as a team and have a close trusting
Institute of Medicine report, Retool- relationship.
ing for an Aging America, identified Washington State is already experiencing
an unstable home care workforce as the impact of an aging population. The My current caregiver, Karen, is my ninth caregiver and she’s been caring for me since August. I’ve
a primary challenge for the growing population aged 65 and older has grown known Karen and her family for almost thirteen years. She is on the Board of the Inland Northwest
AIDS Coalition and we are on a bocce ball team together. She is loads of fun to be with and our
number of aging “baby boomers” in more than 22 percent since the 2000 client-caregiver relationship is that of a team.
the United States.25 The proportion census. In 2012, gains in the number of in-
of the U.S. population aged 65 years dividuals in the age 65-plus population are Caregiving is tough work and I think most people leave home care for financial reasons and because
and older is projected to increase expected to increase from 25,000 persons of personal hardship. The state should pay caregivers more, make sure they have enough hours of
from 12.4 percent in 2000 to 19.6 per year to more than 40,000 per year. This work, and provide them with counseling and bereavement when they lose a client. When caregivers
lose a client, they lose their job and livelihood, a client that was a friend or maybe even a family
percent (nearly 1 in 5 individuals) trend is expected to hold through 2028. member and they struggle getting a new client right away. That’s a lot to deal with. Valuing our
in 2030. The number of individuals caregivers is important for ensuring people stay in these jobs and clients get the best care.
In the longer term, the aging generation
aged 65 years and older is predicted
threatens to overwhelm our long-term care
to increase from approximately 35
infrastructure, as Washington’s population
million in 2000 to an estimated 71 7

8. aged 85-plus is expected to double by 2030, when the first members of the baby boom Aging of Washington’s Home Care Workers Will Exacerbate Workforce
generation reach 85 years of age.27 While Washington’s overall population is expected Shortages
to grow by 45 percent between 2000 and 2030, the over 65 population is expected to
Similar to the commonly known “nurse shortage,” 31 the home care workforce
increase by more than three times that amount (or 151%). According to the Washing-
also faces shortages due to the aging of the current workforce. In fact, the average
ton State’s Office of Financial Management (OFM) the number of individuals aged 65
home care worker in Washington is nearly 3 years older (i.e. 52 years old) than the
and older will represent one-fifth of the state’s population (i.e. about 1.7 million) by
average registered nurse (i.e. 49 years of age).32
2030.28 (See Chart 2).
Home care workers aged 55 years or older account for half of the home care
worker population in Washington, while those aged 30 years or younger account
Chart 2: Forecasted Aging of Washington’s Ederly Population
for a mere 7 percent of the workforce (See Chart 4).
$ 1,800,000
$ 1,600,000
Chart 3: People of Color Will Comprise an Increasing
Source: Washington State Aging and Disability Services Admin-
$ 1,400,000 Proportion of WA’s Senior Population
180%
istration (ADSA), “Washington State Plan on Aging 2010-
$ 1,200,000
Projected % Increase in Washington’s
160%
$ 1,000,000
140%
$ 800,000
Minority Populations
120%
$ 600,000
$ 400,000 100%
$ 200,000 80%
0 60%
2000 2005 2010 2015 2020 2025 2030
40%
Population Aged 65+ Population Aged 85+
Source: Washington State Office of Financial Management, Forecast of the State Population: No- 20%
2014,” (2010).
vember 2010 Forecast, (2010), http://www.ofm.wa.gov/pop/stfc/stfc2010/stfc2010.pdf 0%
Multi-racial Asian/ Hispanic/ Black American
Groups Pacific Latino Indian/
The Aging Population Will Be Increasingly Diverse Islander Alaska Native
In addition to the growing number of older adults, people of color will comprise an
increasing proportion of the senior population as a more diverse cohort of Americans Chart 4: Many Home Care Workers Nearing
reaches age 65. Washington’s Aging and Disability Services Administration (ADSA) Retirement Age, October 2010.
Source: Authors’ analysis of an October 2010
workers conducted by the Feldman Group for
survey of 501 current Washington home care
2010 report states, “Minority populations in Washington all show notably faster rates Age Under 30
of increase than their white non-minority counterparts.” 29 The report goes on to esti- 65 or older 7%
mate that by 2030, nearly one in three residents will be a minority, with Asian/Pacific 18%
Islander (API) and Hispanic populations constituting the largest and fastest growing Age
minority groups. Multiracial groups are projected to increase by 160 percent by 2030, 30 to 39
SEIU Healthcare 775NW.
APIs by 132 percent, Hispanics by 150 percent, Blacks by 60 percent and American 13%
Indian and Alaska Natives by 50.1 percent.30 (See Chart 3). These trends are expected
to continue and will generate an increased requirement to deliver culturally relevant Age Age
and competent long-term care services in Washington State. 55 to 64 40 to 54
32% 30%
8

9. At the same time, as the “baby boom” generation approaches old age, the pool of My name is Kathy Mason and I live in Bremer-
ton, WA. I am 64 years old and have been
middle-aged individuals—the population demographic on which we have tradi-
receiving home care services since the early
tionally relied to provide home care—will be substantially smaller. The growth 1990s. I used to work for a logging company
in the population needing care and smaller family size typical to the ‘baby boom’ and badly injured my back. After the injury
generation have combined to decrease the ratio of potential caregivers to those and subsequent back surgery my health con-
tinued to decline and I needed a caregiver to
needing care. The ratio of potential home care workers to the elderly population help me with many household activities.
will decrease by 63.6 percent between 1990 and 2050. By 2050, that ratio will Currently, I receive 163 hours of care per
be four to one.33 These demographic changes may limit access to long-term care month and have three caregivers. They help
unless the number of home care workers and other caregivers grows in propor- me bathe, dress, do housework, take me to my
tion to the rising elderly population. doctor appointments and grocery shop and do
other housework. They also help remind me to
Future Increased Demand for Home Care Workers take my medication, which is helpful since I’m
taking 20 different kinds of medicine plus in-
The need for home care workers is expected to grow considerably over the next sulin injections. My main caregiver is so great!
decade; of the 1.2 million jobs expected in personal care and service occupations She gets me up in the morning, helps me dress,
nationwide, home care workers will comprise nearly 46 percent of the total pro-
and makes my breakfast. She is a great cook Kathy Mason
and so helpful in so many ways more than just
jected growth (or about 375,800 new jobs).34 helping me with my physical needs. She’s become a great friend to me. I’m very thankful for her.
If the number of Medicaid consumers receiving services from home care work- Since 2004 alone, I’ve gone through eight caregivers, both agency and individual providers. One quit
because of a medical problem, another left because of burnout and the stress of the job. Caregivers don’t
ers increases at the same rate as the general population, there will be 56 percent stay in this profession because it is not stable enough when it comes to hours, benefits, and low wages. It’s
more Medicaid home care consumers in Washington in 2030 than there were very hard on me when a caregiver leaves because of the complexity of my medical problems, food aller-
in 2010. To meet this demand, Washington is estimated to need nearly 77,000 gies, and medications. It’s hard finding new caregivers – once, it took me three and a half months to find a
new caregiver. This was stressful. I had to do without a lot of things like cooking and cleaning that I really
home care workers by 2030 to provide long-term care for more than 88,000
need to get by.
Medicaid consumers. Ensuring an adequate supply of home care workers in
Washington will require training enough new individuals to meet the growing
demand for long-term care services as well as to replace those workers leaving Chart 5: Future Increased for Washington Home Care Workers
Workforce Studies, January 2011, http://depts.washington.edu/
Current Supply and Future Demand,” WWAMI Center for Health
is Exacebrated by High Turnover Rates, 2010-2030.
Source: Susan M. Skillman, Anne Basye, Martha Reeves, and
the field. Assuming a 35 percent annual turnover rate, nearly 440,000 total
Brenda Hoskinson, “Home Care Aides in Washington State:
80,000
home care workers would need to be trained between 2010 and 2030 to meet 70,000
the estimated demand. With a 60 percent annual turnover rate, more than 76,834
70,638
60,000
754,000 new home care workers would need to be trained in the same time 63,478
uwrhrc/uploads/Home_Care_Aides_Brief.pdf
50,000
period.35,36 (See Chart 5). 50,073 56,432
40,000
Washington’s Aging and Disability Services Administration (ADSA) has ob- 37,241 41,524 45,327
30,000
served, “The ability to provide services in home and community settings is con- 33,096
20,000 30,044
tingent on the availability of quality home and community options statewide.
21,724 24,222 26,458
Workers in institutional and home and community settings across the state are 10,000 19,306
struggling with attracting and maintaining adequate numbers of competent 17,526
0
staff. Rural areas have found it especially difficult to attract home care work- 2010 2015 2020 2025 2030
ers. Data on national trends indicate labor shortages will worsen over the next Total Home Care Workers (HCWs) required (estimate)
twenty years.” 37 New HCWs to be trained per year if 60% turnover
New HCWs to be trained per year if 35% turnover
Faced with an impending unprecedented demand for home care workers with
the training and experience needed to provide long-term care to the elderly pop-
ulation and people with disabilities, it is critical to understand the high turnover
rate associated with this occupation and the factors affecting job satisfaction.38 9

10. Turnover in the Home Care Workforce: viduals left their home care jobs was for better wages and/or benefits.
Insufficient pay and not receiving enough paid hours of work were the biggest
Why Do They Leave? problems respondents reported by leavers. Additionally, 18 percent of leavers cited
inadequate health benefits or the lack of a retirement plan as a major problem they
faced while working in home care.
The work of home care workers is vital, but it is also arduous, stressful, injurious, More Educated and Wealthier Workers Leave
and often unpleasant, with low compensation and little recognition. As Dr. Robyn
Stone, Executive Director of the Institute for the Future of Aging Services noted: The same survey found those who left home care tended to be more educated and
“Ironically, while these [home care] workers are delivering essential care to some of wealthier than current home care workers. More than one in four (27%) leavers had
the most vulnerable segments of our population, their peers flipping burgers at Mc- a bachelor’s degree or higher level of education, compared to 18 percent of the cur-
Donald’s make more, have much more financial security, and are treated with much rent workforce. Furthermore, one in four leavers had a current household income at
more respect.” 39 or above $55,000, far better off than current home care workers (only 10% of whom
enjoyed such a high household income). Those who left the home care workforce
Traditionally, home care workers have faced low wages, few or unaffordable benefits, were also less likely (than the current workforce) to be the primary wage earner
inadequate training, a lack of opportunities for advancement and upward mobility, (i.e. 49% versus 57%) for their household while they were working in home care,
and emotionally and physically challenging work.40 These workers also face a lack of indicating those who leave may enjoy the support of other household members and
respect, receiving little recognition from those they serve and the general public.41 therefore have the freedom to leave an unrewarding or unsatisfying job.
These factors cause the home care industry to experience high rates of turnover, Leavers were less likely to be caring for a family member or someone they knew prior
even when unemployment rates are high.42
Table 1: Dissatisfaction with Home Care Work and Reasons for Leaving
Source: Authors’ analysis of an April 2011 survey of 402 former Washington
Causes of Home Care Worker Turnover Among Individuals Who Left the Home Care Workforce
home care workers conducted by the Feldman Group for SEIU Healthcare
Issue Leavers
An April 2011 survey of 402 former Washington home care workers who voluntarily
Main reasons given for voluntarily leaving home care profession
left the home care workforce (“leavers”) between August 1, 2007 and October 31,
Left to go back to school, get a better job, or a job that would advance
2010 confirmed that many of the problems associated with turnover in this profes- their career and provide skills development opportunities. 28%
sion in other states’ or national studies hold true in Washington. Table 1 details Wanted a job with better hours 23%
Wanted better wages and/or benefits 16%
the problems people reported they had while working in home care, as well as the
Wanted a less physically and emotionally stressful job 13%
reasons for leaving the job. The pursuit of better career opportunities and/or better Tired of home care work, bored, or burned out 11%
hours, wages, and/or benefits were the primary reasons cited for quitting. Issues with the patient or the patient’s family 6%
Wanted a job that involved less travel or commute time 4%
More than one in four were going back to school or pursuing a better job that would Problems faced while working as home care worker
provide them with career advancement and skill development opportunities. The Insufficient pay for the work done 20%
next most important reason (23%) was the desire for a job with better hours. For Not getting enough hours of home care work 20%
No health benefits or inadequate health benefits 18%
these respondents, about half reported too few hours of work, 29 percent said the
No pension or retirement plan 18%
job required inconvenient hours of work, and 21 percent felt the hours were too Physical pain or discomfort 14%
inconsistent or unreliable. Only 3 percent of respondents wanting better hours said Finding a new client when you needed one 13%
their home care job required too many hours of work. The third reason why indi- No paid sick time 12%
775NW.
Too little control over hours or days of work 12%
Finding a replacement when sick or needed time off 11%
10

11. Data in Table 2 describes job character- My name is Emily MacKersie and I live in
to becoming a home care worker: 41 istics of the former home care worker Spanaway, Washington. I am 90 years
percent of leavers cared for consumers old, but wild and young at heart! I have
respondents. While working in home been receiving home care services since
they did not know prior to becoming their care, 86 percent worked only part-time April of 2008. I receive 150 hours per
caregiver, compared to 28 percent of the in home care (less than 35 hours per month from two agency providers.
current workforce. This suggests motiva- week) and more than one-third were Since April of 2008 when I first start re-
tions for entering the home care profes- also employed in other non-home care ceiving home care, I have gone through
sion may predict leaving or staying. 13 caregivers. They left for different
jobs. After leaving home care, newly reasons. One didn’t show up after
Additionally, the majority of leavers employed workers were significantly the first day, some moved away, some
had been serving individuals previously more likely to be working full time and couldn’t handle my care needs, one was
unknown to them. let go because of behavior issues and
much less likely to be working two or others came into it without any training.
Our study suggests those who leave are more jobs. (See Table 2).
What’s been hardest for me during tran-
slightly better off (i.e. wealthier and Leavers had an average final hourly sitions is getting used to new caregivers.
more educated) and probably had other wage of $10.36 per hour in home
It takes me some time to get comfortable Emily MacKersie
enough with my new caregivers to really
options besides continuing in home care. care. On average, currently employed let them know what I need done. It can be uncomfortable asking for restroom help or other kinds of
This conclusion is supported by findings leavers have enjoyed a $4.53 per hour really personal care until you get familiar with your caregiver and form a close and trusting relation-
that re-employed home care job leavers spike in wages. Additionally, currently ship. This can take months and continually needing to rebuild these relationship with new caregivers
were substantially more likely to achieve can be a bit frustrating.
employed respondents indicating they
better benefits, wages, hours, and career I’ve been fortunate to have family members that were able to step in as caregivers and help me with my
were “very satisfied” with their new needs when someone quits or never came back so transitioning between new caregivers has not been too
mobility in their new positions outside jobs increased from 39 percent (while difficult. However, if it wasn’t for my family members being there to care for me during transition periods I
home care. in home care) to 56 percent in their would have been in serious trouble. I can’t survive one day without care from my caregivers.
Individuals Who Leave Home Care current positions. I think many caregivers leave because of the poor treatment they get from their employers and
Fare Better In Their New Jobs clients. Caregiving is very difficult work especially without respect. Caregivers get low pay, few
Currently employed home care leavers benefits, and little training. They also have tremendous emotional stress, including the heartbreak
they may suffer after the passing of a client.
Table 2: Characteristics of the Home Care Job versus Current Non-Home Care Jobs If we want caregivers to stay in this profession the first thing we must do is treat them with respect
Washington home care workers conducted by the Feldman Group for SEIU
“Leavers” because they are not slaves and they deserve our respect. I think they also need to respect them-
Variable selves because you can’t get respect from employers if you don’t respect yourself. Finally, we need
Home Care Current Job
Source: Authors’ analysis of an April 2011 survey of 402 former
to show them we value them by giving them better pay and better training. This will benefit both the
Benefits –
caregivers and their clients alike.
Health insurance for yourself 22% 25%
Health insurance for dependents 9% 17%
Paid vacation time 39% 26%
also improved their benefits in their new jobs, compared to their former home care
Paid sick and personal days 17% 27% jobs. On average more reported an increase in health insurance for themselves and
Paid holidays off or extra pay for holidays worked 22% 30% their dependents. There was also an increase in the number of currently employed
Retirement benefits 6% 21%
respondents who now have paid sick and personal days, and an 8 percent increase in
Reimbursement for transportation costs 50% 12%
Average current/final hourly wages (principal job) $10.36 $14.89 the number that received paid holidays off or extra pay for holidays worked. Fur-
Total paid hours per month in home care jobs ther, the proportion of currently employed former home care workers who now have
Part-time (Less than 140 hours) 86% 52% retirement benefits significantly increased. Currently employed leavers did, howev-
Full-time (140 hours or more) 14% 49%
Very satisfied with job 39% 56%
er, report a reduction in transportation reimbursement and paid vacation time. This
Healthcare 775NW.
Number of years paid in home care decrease in paid vacation time may be offset by the increase in paid sick or personal
Less than 1 year 31% days and paid holidays.
1 to <5 years 52% N/A.
5 years or more 17%
Working multiple jobs 34% 8% 11

12. Solutions to High Turnover:
Improved Recruitment and Retention Strategies
Our 2011 survey of former Washington home care workers asked of salary increases, improved benefits, guaran- fication programs to ensure quality of care and
respondents how best to recruit more people to work in home teed number of paid work hours, and increased career advancement opportunities; (4) provid-
care. (See Chart 6). Respondents overwhelmingly (51%) indicated training and support on retaining workers. ing a path to citizenship for the diverse home
higher wages would be the best way of attracting more workers to The case-control study (with a sample of 1,289 care workforce; and (5) supporting individuals
enter the home care workforce. Another one in four (23%) said home care workers in five cities) found that and families in their access to affordable quality
providing more support and better training and opportunities for in the aggregate, these interventions success- care and supports for unpaid family providers.47
skill development and career advancement was the best way of fully reduced turnover rates between 11 to 44
Given the consensus among former workers
incentivizing individuals to enter the home care workforce. Ad- percent.43 Several other studies have similarly
and studies of effective retention strategies, we
ditionally, 12 percent listed improved benefits (e.g. paid vacation, found improvements in wages, benefits, train-
recommend Washington State improve recruit-
health insurance coverage for spouse/dependents, sick pay, etc.); ing and career ladders, and stable paid work
ment and retention of home care workers by:
9 percent said providing more hours of paid home care work; and hours are important and effective strategies
providing living wages, ensuring stable-full time
6 percent indicated improved communication or advertising of for improving recruitment and retention in the
work, improving benefits and increasing train-
home care jobs. home care workforce.44 A 2002 study of wage
ing and career opportunities.
increases for home care workers (individual
Chart 6: Best Ways of Recruiting More People to Work in Home Care providers) in San Francisco County, California, 1) Lifting Home Care Workers
found a $5 per hour increase in home care wages Out of Poverty
conducted by the Feldman Group for SEIU Health-
Source: Authors’ analysis of an April 2011 survey
Providing Living Wages, Stable Full-Time
of 402 former Washington home care workers
was associated with a 54 percent increase in
the number of workers entering the home care Work, and Better Benefits
51% profession over the 4-year course of the study Former Washington home care workers report-
and a 30 percent decline in the annual turnover ed that providing higher hourly wages and im-
23%
12% 9%
rate of the home care workforce.45,46 proved benefits are among the best ways to cre-
6%
On a national level, the Caring Across Genera- ate incentives for individuals to enter the home
Higher wages
tions campaign is calling for evidence-based care workforce. In fact, many former workers
Better training and opportunities for career advancement
found themselves both more satisfied with their
care 775NW.
policy solutions that reflect findings from state
Improved benefits
and national studies on how to improve home post-home care jobs and earning more per hour
More hours of paid work
care workforce recruitment and retention. with better benefits. Most notably, home care
Improved communication or afvertising of home care jobs
Caring Across Generations calls for five interde- leavers experienced a 17 percent increase in job
pendent interventions, which include: (1) the satisfaction, a $4.53 per hour increase in wages,
The most comprehensive study of home care worker satisfaction
creation of home care jobs to meet the growing 15 percent increase in the population with
and turnover conducted more than 20 years ago assessed the role
need; (2) improved wages, benefits, and job retirement benefits and other improvements in
quality in the home care industry; (3) building their fringe benefits (e.g. health care coverage
12 career ladders and improved training and certi- for their spouse/dependents, paid sick leave,

13. etc.). (See prior section “Individuals Who Leave Home Care Fair unreasonable expense.56 living wage to a single wage earner household
Better In Their New Jobs” for more details). Several studies have supporting one dependent in Washington
Raising Home Care Wages to an Hourly Liv-
found improved wages and benefits help significantly decrease State.59 (See Table 3). This is a starting wage
ing Wage of $17.58 Will Lift Tens of Thou-
turnover and improve retention rates.48 that would significantly reduce poverty among
sands of Washingtonians Out of Poverty
the home care workforce, since a typical home
Current Situation: Most Home Care Workers Work Hard,
A living wage is a wage that allows families to care worker is the primary and only wage
Yet Live in Poverty
meet their basic needs, without public assistance, earner in the majority of their households (at
In 2011, more than one in five (21%) Washingtonian home care and that provides them some ability to deal with 53.4%) and 57.7 percent of home care workers
workers and their families lived in poverty. About 43 percent emergencies and plan ahead. In its annual Job financially support one or more dependents.
of Washington’s home care worker families live at or below 133 Gap report, the Alliance for a Just Society calcu- Instead Washington’s home care workers earn
percent of the federal poverty rate.49,50 The vast majority (69%) lates living wages for various states on the basis between $10 and $11 per hour.
of home care worker families live at or below 200% of the federal of family budgets that include basic necessities,
Improvements in Wages Must Be Coupled
poverty rate51, not accounting for regional differences in the cost such as food, housing, utilities, transportation,
With Policies that Promote Job Security
of living. In 2011, the federal poverty level (for the 48 contiguous health care, child care, clothing and other per-
and Stable Hours of Paid Work
states and the District of Columbia) was defined as $22,350 for a sonal items, savings, and state and federal taxes.
family of four, irrespective of geographic differences in the cost of Living wage calculations assume individuals will A dependable and adequate number of hours
living.52,53 While Washington State’s population as a whole fares be able to work full-time, year round.57 of work is critical to provide financial stability
slightly better than the United States, Washingtonian home care and adequate support for home care worker
According to the 2010 Job Gap report, raising the
worker households are actually worse off. The level of poverty families. Most home care workers work part-
hourly wage to $17.58 per hour58 would provide a
among Washington home care worker households is 6.6 percent
higher than the national average and 9.1 percent higher than the Table 3: Washington Family Budgets 2010
statewide average.54 (See Chart 7). Household 1: Household 2: Household 3:
Single Wage Earner Single Wage Earner + Single Wage Earner +
Chart 7: Percentage of Population Living in Poverty, 2011 Dependent (no health- Dependent
25.0% care or child care costs)
20.0% Food $188 $356 $356
Housing and Utilities $752 $919 $919
15.0%
Transportation $605 $564 $564
10.0% 21.4%
Healthcare $112 $ -- $278
14.8% 12.3%
5.0% Household, clothing & personal (18%) $414 $529 $529
0.0% Savings (10%) $230 $294 $294
United States Washington WA Home Care Child care $ -- $ -- $310
Worker’s Households Total annual state and federal taxes $4,165 $4,621 $4,621
Source: Authors’ analysis of October 2010 survey of 400 current Washington home care workers conducted by the
Feldman Group for the SEIU Healthcare Northwest Training Partnership; and U.S. Census Bureau, Current Population Gross Income Needed
Survey (CPS): Annual Social and Economic Supplement – Poverty Status By State: 2010, http://www.census.gov/hhes/
www/cpstables/032011/pov/new46_100125_09.htm. Monthly Income $2,649 $3,047 $3,634
Annual Income $31,783 $36,565 $43,611
If the higher cost of living in urban Washington locales were
taken into account, the poverty rate would be even higher. From Hourly Living Wage (at 40 hours/week) $ 15.28 $17.58 $20.97
2006 to 2009, the number of home care workers reporting their
Source: Julie Chinitz et al., “Searching for Work that Pays: 2010 Job Gap Study,” Alliance for a Just Society, December 2010,
personal financial situation had worsened from the previous year http://nwfco.org/wp-content/uploads/2010/12/2010-1209_2010-Job-Gap.pdf.
increased from 11 percent to 32 percent.55 Most workers strug-
gled to pay housing, transportation and health care costs, with
about a third of workers rating each of these items as their most 13

14. time and have difficulty finding enough workforce. (See Chart 6). Addition-
hours to earn a stable income. In addi- ally, 18 percent of the former home
tion, when a worker’s case is closed— care workers surveyed indicated in-
such as when the consumer s/he serves adequate health benefits were either
is hospitalized—the worker suddenly a major problem they faced while
loses not only the case, but also the working in home care or the reason
hours and the associated wages that they decided to leave their home care
she had counted on to support her job. Currently, most home care work-
family. This unpredictable fluctuation ers in Washington can qualify for
in hours—and therefore income—forc- health insurance coverage by working
es many dedicated home care workers 86 hours per month for 3 consecu-
to seek more reliable employment. Ad- tive months. The health insurance
ditionally, a series of cuts to Washing- coverage is only for the home care
ton’s Medicaid long-term care services worker and does not include spousal
has reduced not only paid hours of care or dependent coverage.
for the consumer, but also wages for
In Los Angeles County, California, the
Lisa Miller
the home care worker who serves her.60
Personal Assistance Services Council
My name is Lisa Miller and I live in Marysville, Washington. I worked in home care for about three
To ensure a robust home care program (PASC) studied the effects of expand-
months back around 2007-2008 caring for a client who had just undergone a hip replacement
that is ready to meet the future need ing home care workers’ health care surgery. What I liked most about being a home care worker was knowing that things were getting
for care, while also reducing the high benefits eligibility requirements by done and done well. It feels good knowing that all your client’s needs are being met. When you’re
cost of turnover, Washington should reducing the minimum eligible num- the home care worker, you’re the one providing the client help with their daily needs, so there’s no
question for you about what those needs are and if you’re doing all that’s required to fulfill them.
work to pursue strategies to allow ber of monthly work hours from 112
I was working about 15 hours per week, helping my client get around, preparing his meals, doing
home care workers to achieve reliable hours to 80 hours. The study found laundry and other household tasks and driving him to his medical appointments. He also had some
hours and a stable, predictable income, it was affordable and advantageous, limited mobility issues and I provided him assistance getting in and out of a chair and bed correctly
such as an improved referral registry. from both economic and pragmatic as he had been trained to do in physical therapy.
viewpoints, to lower the benefit eligi- Home care jobs are difficult, both physically and emotionally. If you have to lift someone and you
Need for Affordable Healthcare
bility requirements and increase the are a small person – like me – that can be challenging. In a home setting you don’t usually have
Several studies have found that af- special equipment or other workers to help you do this. Additionally, some people can be very diffi-
number of home care workers with cult to work for. If someone is cranky, crotchety, or ill tempered, you have to learn to put up with this
fordable health insurance (available health insurance coverage. Shortly and handle it delicately. At times, my client could be grumpy sometimes and frustrated that he could
to part-time workers and their depen- thereafter, PASC, in concert with Los not do what he was able to do before. Overall, I was lucky not to have a lot of difficult moods/
dents) and retirement/pension plans Angeles County and SEIU Local 434B, behavioral issues to deal with, but some people have these issues with their clients. You add to these
stresses – the fact that the profession pays so poorly you need to work more than 40 hours per week
are among the most important predic- lowered the health insurance eligibil- and you can’t rely on the job being full-time without significant coordination of schedules and caring
tors of home care workers’ job satisfac- ity criteria to 80 hours per month for multiple clients – and it’s no wonder people leave.
tion and turnover rate.61 Former Wash- level.62 I’m constantly seeing ads for people wanting and needing caregivers. It’s kind of too bad that
ington home care workers reported it doesn’t pay better because then you’d probably be able to draw more interest and qualified
improving benefits is among the top people to the profession. It’s sad because someone needs to care for these people. Right now with
the economy the way it is we need better jobs. There’s no incentive to work if you are only earning
three best ways to improve incentives minimum wage or just above that.
for individuals to enter the home care
This line of work is very important and can be very physically demanding. People just aren’t going to
do this work without a living wage and quality benefits. It’s a hard job taking care of people who are
elderly and disabled and not one everyone can do or stomach. I think it takes a special person to both
want to do this work and who has the skills or ability to do it. If we want to attract these people to the
14 profession and get them to stay awhile we need to make this job worth their time.