Tag Archives: low wages for direct care workers

A Not so Obvious Picture at the Grand Rapids Home for Veterans

Bob Goddard

In early August, a disturbing news story broke about the Grand Rapids Home for Veterans, my old workplace.  After an investigation by the State of Michigan’s Attorney General’s office, eleven former employees – all direct care workers – were charged with falsifying medical records. The caregivers charted that they had checked on members (the Veterans Home refers to the residents living there as members) while surveillance video shows that these checks were not done. In Michigan, falsifying medical records by a health care provider is a felony, punishable by up to four years in prison and a fine of up to $5000.

The investigation followed a scathing February 2016 report by the Michigan Auditor General. According to that report, the home failed to properly investigate allegations of abuse and neglect, took too long to fill prescriptions and operated with inadequate staffing levels. Both the Attorney General’s investigation and the audit came almost three years after the State privatized the entire direct care workforce at the home, thus replacing a dedicated, stable direct care workforce with contract workers from a demonstrably unreliable agency, J2S.

The eleven workers charged by Attorney General’s office were employed by J2S. That company was replaced by two other contract agencies last year after J2S repeatedly fell short of adequately staffing the facility.

As we have come to expect in media coverage of anything related to long term care, the local media treatment of this story displayed a superficial understanding of how a long term care facility operates and relied on sensational wording to make the story more compelling. In the process, the reporting presented a misleading picture of how caregivers go about their work. While reporters expressed outrage over the quality of care at the home, they seemed clueless regarding what it takes to make good care happen. I think it would be useful to correct this and offer a different perspective.

In one report following the announcement of the felony charges against the caregivers, a local TV reporter assured viewers that the Attorney General’s investigation “paints a pretty obvious picture of the situation” and concluded that bringing the charges does two things: “it holds people accountable for what they did,” and second, “I can guarantee you tonight at the home for veterans they’re going to be doing their member checks.”

The assumption in that last statement is that fear is a necessary and effective motivator in providing good care. This is a common fallacy among observers unfamiliar with the nature and practice of caregiving. You cannot get genuine compassion and caring from fear.

Yes, as our visibly self-satisfied watchdog reporter suggested, I’m guessing “those member checks” were indeed “being done tonight,” but as I will explain below, that form of diligence has little do with the actual quality of care at the home.

The media reports and statements from the Attorney General gave the impression that these hourly checks were at the heart of what caregivers do. They are not. In fact, the hourly checks are superimposed over normal care routines. In a typical institutional setting, each caregiver is assigned a group, usually ten or more residents depending on the shift, unit and facility, and is charged with completing a whole series tasks including assisting with the residents’ personal hygiene, bathing, grooming, dressing, toileting, bowel care, skin care, turning positioning, transferring, ambulating, transport, serving meals and feeding patients, offering fresh water and snacks, take vital signs, make beds, keep the residents’ room clean, answer calls lights and respond to requests, record intake and output information, observe and report changes in residents’ physical and mental condition. And of course, document these activities via flowsheets and other similar forms. The location sheet is one of these forms.

It’s important to understand that given the direct care staffing levels in a typical long term care facility, and this certainly includes the Grand Rapids Home for Veterans, assigned caregiver workloads are rarely possible to complete – not to the standards set forth by regulators, facility policy, and customary nursing practices, let alone family and public expectations.  This means caregivers are constantly engaged in a form of care triage, made necessary because no one above them in the Long Term Care hierarchy, including policy makers and legislators, seem able to provide the resources necessary to do the job according to standards. Either they lack adequate awareness of the problem or are simply not willing to make the hard choices. By default, this is left to the direct care worker.

Given the inadequacies of the system, the best a caregiver can do is to arrange these various tasks in some order that makes the most sense for everyone in the group, taking into account the unit’s mealtimes and other facility routines. While a good caregiver tries to plan ahead, working with human beings means that unexpected needs routinely arise and no can anticipate everything.  Each shift becomes a unique time puzzle that the caregiver must solve if the residents are going to receive the best care he or she can provide. But the puzzle is dynamic, the “pieces” change according to the immediate needs and expectations of residents, coworkers and management. The caregiver must continually adapt his or her time organization to ever changing circumstances and priorities. In essence, the caregiver spends the shift involved in perpetual problem solving with ethical implications.

At the Veteran’s Home, the check sheets are kept behind the nurses station while the majority of care is conducted in the members’ bedrooms and bathing areas. So, to properly document the checks consistently in a timely manner requires this absurdity: the already overwhelmed direct care worker must pause care and walk away from the members for whom she is providing care for the purpose of putting her initials on a sheet of paper that indicates she knows the location of the members she was just with. This may provide the facility with documentary evidence and meet an institutional need, but it does not necessarily address the needs of the members.

If we are truly concerned about the quality of care for our veterans, the real question is not whether or not the checks were properly documented, but what the caregivers were actually doing when they indicated they made the checks. Were they in the shower room with a member or making sure an unsteady member wasn’t tumbling off a commode or perhaps transporting a member to a therapy appointment? Were they in the middle of assisting a member with his meal or helping a coworker transfer a 350 pound man from his bed to his wheelchair? Were they responding to a member’s urgent request for help? Were they redirecting a confused member for the tenth time in the last five minutes? Were they assisting another caregiver who was trying to manage a combative member? Were they comforting a member who was experiencing some kind emotional turmoil? Were they on their way to nurses’ station to get the location checks clipboard when they noticed a call light? Were they with a sick member, maybe dealing with copious amounts of diarrhea or vomit? Were they cleaning up a spill that presented a fall hazard? Were they speaking with the family of a member regarding their loved ones’ care and status? Were they holding a dying member in their arms? Or perhaps they were engaged in a member’s post-mortem care.

I will leave it to the Attorney General and media reporters to decide to which of these activities caregivers ought to interrupt so that they might properly document the checks – and presumably stay out of prison.

Let’s be clear, if the workers were sitting behind the desk or off the unit or otherwise not engaged with the members when these checks were supposed to be made, then our sympathy and support for them evaporates. Not because they didn’t make the checks properly, but because they weren’t with the members and on task. Even in bad work environments, caregivers are ethically and morally obligated to the use the time and resources that they do have to do the best they can for the residents.

Of course, it could be argued that the hourly checks provide a more systematic way of accounting for the members’ location and condition. Regular checks ensure that no one gets forgotten.  It seems obvious, right?

However, when you start to look at how caregivers actually gather information and keep tabs on the members in their group, the hourly checks take secondary importance. Caregivers are routinely provided with a “cheat sheet,” a one or two page list of all the members in their assigned group. The cheat sheet includes basic care information for each member. The caregivers carry these sheets with them and will refer to them throughout the shift. Even caregivers who are familiar with the members in their group will often use the cheat sheet as an aid to help organize their time and, of course, to help make sure no one is forgotten.

Given the real needs of the members, the fact that the checks are hourly is completely arbitrary. The reality is that some members don’t need to be checked that often and some leave the grounds for long periods – as is their right, it’s a home not a prison. Other members may need to be checked even more frequently depending on their particular physical and mental status.  A lot can happen in 59 minutes and the hourly checks can no way guarantee the safety and well-being of all members. The best way to keep members safe and their immediate needs met is to have well informed, well supported, on-task caregivers. And by well-informed, we mean caregivers who are thoroughly familiar with the members – not just with their current medical status, but who they are as individuals, their daily needs, preferences, and habits.

By threatening caregivers with prison sentences and the like, we can make them jump through hoops and give the appearance that good care is being done, but we should wonder what is actually being missed while they’re putting on this show for us. As our watchdog reporter implied, fear will elicit a sure response. But with fear, the issue becomes not about the real quality of your work and how those in your care are experiencing it, it’s about how you think it’s being perceived by those who can punish you. Under siege, our actions are informed not by our sense of right and wrong nor even by common sense, but by the assessments and attitudes of those who are judging us. When those assessments and attitudes are based on faulty perceptions – which is often the case in long term care and certainly the case here – our priorities become skewed and we add yet another obstacle to good care.

Fear won’t take caregivers into the places where genuine compassion and caring will go. As a motivator, it’s a weak and insufficient substitute for the truly powerful motivations that result in the best care possible. On the other side of those closed doors and privacy curtains where caregivers engage members and actual care takes place, you really want people who are inspired by the better angels of their nature.

The quality of care in any long term care facility is directly tied to the facility’s investment in the caregivers who provide it. Paying direct care workers good wages with decent benefits not only helps attract and retain workers, but it also gives them the means to adequately provide for themselves and their families. Many caregivers have no choice but to work a lot of overtime or find second jobs just to make ends meet. The work itself is physically and emotionally demanding, and when you add the stress of double shifts and long hours, the result is a caregiver workforce perpetually on the edge burnout. You can’t get the best possible care on a consistent basis from workers who are physically exhausted and emotionally drained.

It should be no mystery why J2S had such difficulty staffing the place and why even now one of the current contract agencies continues to have problems. The shortage of caregivers has become a nation-wide crisis and annual turnover rates for direct care workers typically run between fifty and sixty percent. Prior to the State’s privatization of the direct care workers, the Grand Rapids Home for Veterans was immune to this crisis.

The cost of losing that stable direct care workforce cannot be overestimated. Caregivers who are unfamiliar with the members in their care groups cannot possibly provide the same level of care as those who have had long standing relationships. But we continue to routinely throw these workers into chaotic situations and expect them to perform a high level. Usually they feel fortunate just to get through the shift with no major disasters. Or investigations.

While a sense of duty and a good work ethic are necessary in providing adequate care, there is no substitute for the personal relationship that develops between the caregiver and resident. This bond is the single most powerful motivator in providing excellent care. In environments where these relationships are encouraged to develop and flourish, workers become more caregivers, they become advocates.

If the caregiver has a moral obligation to do the best for his or her residents despite difficult circumstances, then those above us in the hierarchy and those on the outside who seek to influence the activity of caregivers have an equally compelling moral obligation to understand the consequences of that influence. This requires a basic awareness of the real challenges faced by caregivers and insight into what really motivates them. From what I’ve seen, both the Attorney General and the local watchdog reporters have failed to demonstrate that awareness and insight.

  

A Step Backward for Long Term Care

 

 

Yang

Last week, PHI posted the third installment of their 60 Caregiver Issues Campaign. This issue brief highlighted how the Affordable Care Act brought coverage to many caregivers who previously had no healthcare insurance and discussed how proposed changes now before congress could impact the nation’s direct care workforce.  The link to PHI’s report is at the bottom of this post.

It boils down to this: among its many provisions, the ACA included an expansion of Medicaid that benefited the working poor and thus provided healthcare coverage to caregivers who did not previously qualify because they “earned too much.” 

Here are the numbers directly from the PHI brief:

  1. From 2010 to 2014, approximately 500,000 direct care workers nationwide gained health insurance following implementation of the Affordable Care Act.
  2. The uninsured rate decreased 26 percent during the same time frame, from 28 percent to 21 percent.
  3. These coverage gains are primarily attributable to a 30 percent increase in the number of workers insured through Medicaid programs.

The repeal of the ACA threatens this coverage and many caregivers may again find themselves without the means for adequate health care. In a field where workers are at high risk for injuries resulting in musculoskeletal disorders and face the risk of serious infection every day, this lack of healthcare coverage is devastating. It not only leads to higher turnover rates that negatively impact the care of our elderly and disabled, it also reinforces the tendency to view caregivers as short-term workers, an expendable resource that can be used up, disposed of, and replaced.

We cannot properly care for the most vulnerable of our citizenry if we overlook the health and well-being of those who care for them. The two cannot be separated. In a time when the demand for caregivers has reached a crisis, reducing direct workers’ access to adequate health care is an unwise – and unhealthy – step backward.

The PHI report can be found here.

 

 

 

60 Caregiver Issues: Whose Issues Will We Hear?

 

 

Minstrel

In his recent post Yang brought our attention to PHI’s campaign to educate the public about caregiver issues, and gave us a link to their introductory video.  In that video PHI posed these questions:   

1. How can we ensure caregivers get the training they need?

2. How can we keep care affordable to families? 

3. What data is needed to help policyholders take action? 

While these are important questions, if you ask caregivers themselves why some are leaving the field and others wouldn’t think of entering it, they’ll no doubt raise a different set of issues.  At nearly every conference or webinar I attend I ask about staff-to-resident ratios and caregiver wages.  Usually there is no reply, as if I were speaking from some parallel universe and couldn’t be heard.  If there is a reply it’s on the lines of “Yes, we know.  But it’s complicated.  These things take time. You can’t expect things to change overnight.” 

Yes, there is a shortage of caregivers.  And yes, good care isn’t affordable.  In fact good care can’t be bought.  By that I mean whatever you might be paying, either for in-home care ($20/ hour? $40?) or for care in a long-term care home of some sort ($6,000-10,000/ month), the more care the person needs as health declines, the wider the gap between the person’s needs and the quality of care the person actually receives.   

Everyone is selling solutions like workshops and videos and toolkits and new business models to long-term care administrators or home healthcare systems’ owners.  Some groups are advocating on a state or even national level and some gains have been won.  But from the outcomes I’d say that a lot of the effort is wheel-spinning.  (An increase in the NYC minimum wage for home care workers to $15/hour by 2021??)   Today’s aides have rare luck if they earn $15 an hour and have a regular 40-hour work week.  An aide may have six to ten residents/patients to care for, and many of those will suffer from dementia and/or be unable to walk alone safely or even support themselves standing.  (Yes, I know I’m a broken record…)  Do you know what it’s like to try to wash, toilet, transfer these residents several times a shift, and keep them from falling the rest of the time?  (If not, go back and read CNA Edge.)  This is before we even begin to provide enrichment a la ‘person-centered care.’   

I want the whole healthcare industry – including those championing reform — to acknowledge what the biggest issues are for caregivers: our obscenely low wages and our outrageously onerous, even unsafe, working conditions.  These organizations don’t yet tackle caregivers’ most urgent needs: a living wage, safe work conditions, and a work environment that supports person entered care.  We need to ask them, What are you doing about these issues and what can we CNAs do to support you in this?  

When Malcolm X called for a change in Americans’ attitudes on race and was told that such changes (culture change, if you will) take generations, he reminded us of this: At the beginning of World War II Germany became our enemy and Russia became our ally.  But when the war ended we, America, saw Germany as our ally and Russia as our enemy.  That attitude-change didn’t take even one generation.  The healthcare industry needs an attitude adjustment.  It is not okay for long-term care operators or owners of home healthcare agencies to charge exorbitant fees to clients and return a too-small fraction of these fees as wages to their direct-care workers, while management and professional staff and consultants are handsomely compensated.  It is not okay to hire employees unless you train them in the skills they need to work with the elderly frail, starting with English language skills.  It’s not okay for the industry to tolerate poor work ethics: last-minute callouts; texting while on duty; and most of all, failure to interact with residents in a way that says to them “I love being with you.  Thank you for letting me be part of your life.” 

There are thousands of followers of CNA Edge.  As Yang exhorted us, we need to support PHI in their effort to educate the public about caregiver issues.  Let’s ensure that when they frames their 60 Issues, they don’t airbrush our issues out of the picture they’re drawing.

Uphill Battles


Alice
The alarm clock cut through my dreams, it’s deceptively cheery jingle jarring my consciousness awake. I groaned, fighting the urge to hit the snooze button just once more. I had to go in early. No more time to snooze.
As I ran about the apartment in my pre-work routine of craziness, grabbing coffee, hunting my keys and making sure that I was wearing the same shoes on my feet, I mentally reviewed the day ahead. It was going to be an uphill battle.
Uphill battles are nothing new to me in this field. Both my experience in facilities and in private care have come with their fair share of obstacles. Not being one to shy away from adversity, more often than not I relish the challenges. It’s when I begin to view life as NOTHING but uphill battles that the trouble begins.
As a caregiver, I deal with a lot of loss. We all do. Death is inevitably part of our job. I’ve learned to view it not as a tragic necessity but as an inevitable conclusion. There is joy and peace in knowing that I have a part in making the last chapter of someone’s life as pleasant as possible, making certain that those in my care never feel alone. It is why I do what I do and that part of the gig I consider sacred.
As a woman in recovery who volunteers at a behavioral health center, I deal with a lot of loss as well. That kind of loss is different somehow. That kind of loss comes with a sort of survivors guilt that makes me choke on my own powerlessness. Why do I get this when others don’t? What could I have said or done differently that may have prevented another’s death or insanity or consequences? The answer is nothing. I can’t force a moment of clarity on another person. I can only share my experience.
I tell you guys this because I know we all have our baggage and we work in a field that can skew our perspective. Because I have to be vigilant, I recognize that change as it’s happening. When I start obsessing over the two people I was unable to help rather than the ten that I was, I know I need to check myself.
I cashed in all my “give up” chips years ago. Now as long as there is a breath in me, I will…I MUST keep moving forward. There is so much I want to do in life; so many people I want to reach and help. My fellow caregivers, my residents, anyone and everyone who feels lost and alone…we all have those shared experiences. I was given a second chance. I do not have the luxury of wasting it.
As a caregiver, I have the privilege of seeing the face of courage every shift. People who have survived cataclysmic and life changing events. People living with dementia, addiction, AIDS, strokes, PTSD, cerebral palsy; people of all ages and I SEE them…the very essence of who they are as individuals shine through their disorders. Their personalities, sometimes difficult personalities, may have been informed by their challenges but they are not defined by them. They laugh and cry and occasionally rage but they face their uphill battles every single day. They have no choice. Neither do I.
My keys were in hand, the same shoes were on my feet, my lid was tightly on my coffee cup and I was ready to face the day. I took a deep breath as I opened the door into the bright sunshine and reminded myself that it was uphill battles that made me who I am today. For that I am incredibly grateful.

Underneath our Scrubs


Alice
Underneath our scrubs beat hearts that celebrate each success and bleed for each loss of those within our care. We know that our time with them is limited and we can not cure them. We can’t turn back the hands of time and we can’t change the situation that led them to our care. But we walk with them. We do what we can to improve their quality of life. We tell them they are not alone. We try to coax smiles from weathered faces worn down by time and experience. We listen. We translate. And when they pass, we grieve.
Underneath our scrubs are muscles that ache from running up and down halls or up and down stairs as we do the work of three people because of short staffing. Sweat runs down our face as we prioritize needs on the spot in order to provide the best care we can in an imperfect situation. Carefully compartmentalizing the very real frustration that comes from being overworked and underpaid; constantly facing impossible situations and feeling unappreciated, as if what we do is of little value. As if we are disposable. And isn’t that how those in our care feel? Invisible? Overlooked? So we run harder. Try harder. Uphill battles become our bread and butter.
Underneath our scrubs are souls of true grit. Whatever we look like, whether we wear it on the inside or out, we do not give up. Caregiving does not stop for holidays or inclement weather. It is not nice and neat. The most important and necessary tasks fall between the lists of activities of daily living. We face our own mortality every single shift. We face worst case scenarios and see the people beneath; see the strength and courage of those living through them and their strength fuels our own.
Underneath our scrubs, we are tired. We are weary. We are disgusted with the poor pay and misunderstanding of what we do and why we do it. We are tired of being dismissed. Tired of those in our care being misunderstood and dismissed. Tired of “it looks good on paper” mentalities and tired of people with little experience on the floor and no real world knowledge of those in our care deciding what is best for them without our input. We deserve better. Our residents certainly deserve better. And until we get better, we will be relentless and consistent in speaking our truths.

60 Caregiver Issues: PHI and the Caregiver Shortage

 

Yang

Last week, the Paraprofessional Healthcare Institute (PHI), the leading expert on the nation’s direct care force, launched a two-year online public education effort called “60 Caregiver Issues.” Over the next two years, the campaign will identify 60 policy and practice ideas that can begin to address a problem that we, as CNAs, are all too familiar with: the growing shortage in direct care workers.

The first installment, “8 Signs the Shortage in Paid Caregivers is Getting Worse” can be found here.

The purpose of the campaign is to focus public attention on the problem and offer some real solutions. CNAs have a vital role to play in this effort. No one has greater awareness than we do of how chronic understaffing and turnover rates actually impact the care and well-being of individual residents on a day to day basis. We know what it looks like and we know what it feels like to our residents in a very real way. By sharing our real-life work experiences we can offer a perspective that gives these problems texture and a real sense of the human cost.

As advocates for our residents – and for ourselves – CNAs can become part of the solution by joining and supporting PHI in this effort. In the coming months, CNA Edge will share posts from the PHI campaign and, of course, we will offer our own take on the issues surrounding the nation’s caregiver shortage.

To kick off the campaign, PHI offers this 60 second video which highlights the problem:  Caregiving Crisis: 5 Million Workers Needed

 

See No Evil, Hear No Evil … Fix No Evil

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Minstrel

As aging impacts physical and cognitive health, many of us will eventually live in long-term care homes.  Thanks to poor standards of care, most people dread this prospect.  To improve care, experts advocate a person-centered model of care as an alternative to the traditional medical model.  Moving from one care model to the other calls for culture change.  Last year I visited the website of a leading culture change organization for information on their annual conference.  It was discouraging to see that among their many events, none included one of the critical elements of culture change, CNAs: our workloads, wages, and caregiving standards.  Hour after hour, day in and day out, CNAs are key caregivers.  Without us, there can be no culture change.  Yet CNAs aren’t heard.  Here is one CNA voice.

I first became familiar with LTC homes when a family member needed care.  I explored many places to find him a good home, then visited him frequently.  Since then I’ve worked in LTC homes and gone into others as a hospice volunteer.  When my uncle moved to a memory care home, I saw the aides who cared for him as angels: they did for my uncle and the other residents what we family members no longer could.  They did this with magical skill and saintly kindness.  And for wages that were obscenely sub-standard.  I was enormously grateful to them.  But in these years of being in and out of long-term care homes, this is what I’ve also seen: aides who sit talking to each other or texting while residents sleep in front of TVs or sit staring into space, alone.  I’ve seen a resident fall because an aide was busy texting.  Aides spend mealtimes noisily socializing with each other instead of engaging with residents, most of whom (at least in memory units) need some level of assistance.  Some aides announce, by their behavior, “Once she’s bathed and dressed and in the dining room, once he’s fed and toileted: once the ADLs are completed, it’s my time.”  Sometimes instead of interacting with residents, aides simply take time apart to rest.  It’s not that aides are intentionally mean or abusive.  And comradery among aides isn’t a perk; it’s essential.  But on every shift there are failures in attentiveness to residents, failures to engage them in an enriching way, lost opportunities for Creating Moments of Joy, as Jolene Brackey has written. 

Some will object, “Not in OUR facility!  We have awesome aides who go out of their way every day to make life better for residents.”  Yes, aides are often inspirationally caring.  But too frequently the quotidian reality is lackluster care, not the person-centered care promised.  Tellingly, the administrators who dispute this picture are often conspicuous for their absence from the daily fray.

Here’s something else I see: thanks to abysmal wages, many aides work two jobs.  Where I live, starting wages are $9 to $12 an hour.  Self-employed aides can earn more, but have no benefits.  Full-time aides are sometimes scheduled to work only 32 hours a week, to avoid overtime when an aide is asked to work a double shift to cover for someone who calls out at the last minute.  Many aides have children at home to care for.  By the time the aide starts his or her shift, which typically involves caring for six to ten residents, she is already tired in body and spirit.  How can this aide bring to work the physical and emotional energy needed to care for the chronically ill, the elderly frail, the cognitively impaired?  Is this what you want for your parent or spouse, or yourself?

How to improve care?  Administrators provide innovative training programs.  Workshops offer state-of-the-art information and creative care ideas.  Two questions not examined:  1. How do we get aides to buy into culture change and embrace person-centered care, once the trainer leaves?    2. Where do we find the money to increase staffing and pay direct-care workers a living wage, one that honors the physical and emotional demands they meet every day?  

Culture change seems focused primarily on training of direct-care workers and renovations to the physical environment.  A more effective approach might come from a change in what we expect of leadership.  Once upon a time, ‘Management-by-Walking-Around’ was the mantra.  An effective manager was expected to circulate on the factory or office floor, paying attention.  Not spying on employees, not micro-managing, but noticing things.  Sensing conflicts and stresses before these undermine performance.  Offering feedback when needed.  In care homes, how often do you see someone on hand whose role is to encourage, compliment, coach or critique?  To see that necessary supplies are on hand.  To offer an on-the-spot performance suggestion, transforming a moment of poor care into an opportunity to reinforce good care skills, per Teepa Snow’s  coaching model.  And at times, with a chronic slacker, to go down the road of discipline.  How much do managers engage with direct-care workers? 

Today’s code word for good care is engagement: aides need to engage with residents.  If administrators aren’t modeling this by meaningful interactions with direct-care workers, will aides believe that engagement is to be the ethos in their workplace?

We can’t improve what we don’t see.  If administrators don’t see the problems, it might be because they are buried in ‘CYA’ paperwork, medication management, marketing efforts, and time-stealing meetings.  Sometimes their offices are in some distant realm of the facility.  Culture-changing organizations might hire a clerk for paperwork and scheduling, freeing the front-line manager for a more constructive presence among staff.  Give this manager a mandate to convert ‘person-centered care’ from a slogan to a fact.   

Can LTC homes provide person-centered care, without the personnel?  Staffing levels are egregiously low.  They may meet states’ woeful requirements but we all know they are inadequate to ensure patient safety, let alone the person-centered care everyone espouses.   Inadequate staffing also leads to on-the-job injuries and CNA burnout.  Are any of the culture-change conferences addressing these issues?  Are leaders lobbying for better staffing and better wages for their CNAs?

Ah, wages!   One is tempted to wonder whether managers tolerate poor performance out of guilt or shame for what they pay their aides.  Even compassionate professionals don’t want to mention the issue of wages in public.  It may seem too daunting and discouraging a challenge—and an embarrassment.  Compensation levels reflect the fact that the job doesn’t require high-level academic or technical credentials.  But aides shouldn’t be thought of as unskilled.  Our skills lie in meeting the global needs of residents who are sometimes completely dependent on us.  A good aide needs to excel in kindness, patience, gentleness, flexibility, effective time management, communications creativity, appreciation for the diverse ethnic, racial, religious, cultural backgrounds of those in our care.  We care for residents regardless of their illnesses or diseases.  We don’t need to describe here the physical tasks we perform, sometimes difficult, often unpleasant.  When the person has dementia, the challenges are doubled, tripled.  We’re accountable to employers, to families, and to our residents.  Not everyone is up to the job.  Wages should reflect the importance of this work and the competencies it requires.  We need a mindset conversion among executives who still think it’s acceptable to sustain their LTC organizations by reliance on a bare-boned staff of underpaid workers who need public assistance to supplement their wages.  Care homes charge their CNAs to respect the dignity of residents.  What about respect for the dignity of CNAs, starting with a living wage?

“Where will we get the money to raise wages and increase staffing?” ask horrified LTC operators. The question is valid.  However, it begs the further question: How much are you spending now, and for what?  Until there is budget transparency (another piece of culture change), the industry’s position that these proposals aren’t affordable, isn’t credible or convincing.  Their question should be not the end of the discussion, but the beginning.  Reviewing the content of culture-change workshops, we don’t see these issues on agendas.  No one wants to touch staffing or wage issues.  Could it be that the profit motive plays too big a part in the culture of some LTC organizations? 

This isn’t rocket science: Be as zealous about improving supervision, staffing, and wages as you are about upgrading the chandeliers and countertops and holding conferences.  Put your assets where you claim your values are.  (Make your budget transparent!)  Invite CNAs to be co-leaders in culture change.  Then we might see culture change that leads to transformed care, transformed lives.  

Let’s Prove Them Wrong

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Alice

    We have received some wonderful and articulate emails from a reader who posed this question:  How do we make life better NOW for those living with dementia? She went on to explain how advocacy is what drives the flow of funding and most of the funding is going towards finding a cure for Alzheimer’s disease. While vitally important, it does nothing to help those currently living with the disease in the long term care communities. Who is speaking up for them? Who us speaking up for us?

       The frustration is that here on our level, there is little meaningful conversation of such things. We are expected to show up and take what is dished out. We don’t do it for the money, they say. It’s just a “stop-gap” job. If they were smart, they would have furthered their education. Treat someone as disposable for long enough and they begin to feel disposable; begin to act disposable. Is that what we want? Disposable people caring for the most vulnerable section of our society in their hour of greatest need?

      Or maybe it’s an indication of something deeper. They treat us as disposable because on some level they feel that those within our care are disposable. They have aged out. They no longer contribute to our society. Wisdom, experience, history, dignity are not valued commodities in this fast paced world of “me first and the give me! give me! mentality. Old, sick people barely make the priority list and those of us who care for them don’t make the list at all.

      No one SAYS that of course. I have never once seen a bumper sticker that reads Old People Suck and yet the situation in which many seniors and people with disabilities are forced to live is heartbreaking. There is no other word for it. They devalue them and by doing so they devalue us. And I’ve got news for you, folks…we allow it. Hell, sometimes we encourage it by our own behavior.

      One in four seniors will suffer from elder abuse. I’m no statistician, but I would say there is a probable correlation between quality of care and treatment of the work force. One in four. The injuries caregivers suffer on the job is sky rocketing. Again, this is supposition, but I would say exhaustion due to being forced to pull double shifts or multiple jobs to barely make ends meet would contribute to this. The standards for certification is low, the wages are low, the work is difficult, and the turnover is high. Why, why, why would ANYONE choose this quagmire? Because someone has to. Because those of us in the know have a moral obligation to do everything we can to be a part of the solution. Because it’s a battle worth fighting.

         How do we make life better NOW for those living with dementia? For all of those living with a disability that requires care? I have no idea. I’m winging it. I give the best possible care to my client. I write for this blog. I notice lonely people and try to make them less lonely. That’s the only way I know to make any difference that counts. I’ll tell you this though, the most meaningful changes are going to begin with us or not at all. They think we’re disposable. Let’s prove them wrong.       

Why are CNAs so Poorly Paid?

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Yang

This week there has been a lot of talk in the media about the movement to raise the minimum wage to $15 an hour.  While most of the attention was focused on fast food workers, advocates for direct care workers took the opportunity to highlight the negative impact that poor wages have upon caregivers and their residents. In a Wednesday article for McKnight’s, Matt Yarnell, the Executive Vice President of SEIU Healthcare Pennsylvania, pointed out that nearly one in six of the state’s nursing home workers are paid so poorly that they are forced to seek public assistance through the Supplemental Nutritional Assistance Program, Medicaid or both.

Yarnell wrote “If we are serious about providing the highest quality care for our residents, then we have to back our rhetoric with action. It means we have to provide living wages to caregivers to cut down on turnover, to not force caregivers to work excessive overtime and double shifts. It is about not forcing workers to have to look to the state for public assistance to provide for their families.”

Why are direct care workers so poorly paid? A common argument points to the low educational requirements necessary to work as a caregiver. Often this point of view comes from within the Long Term Care community itself.

It’s true that the technical skills of a caregiver can be taught relatively quickly. Things like the principles of basic hygiene, taking vitals, infection control practices and proper body mechanics are pretty straightforward and don’t require a lot of advanced study. However, while formal training serves to create a basic necessary skill set, the real education for a caregiver doesn’t begin until he or she starts working with residents and fellow coworkers. The art of caregiving is learned through a combination of practical experience and mentoring from other workers. For those open to it, this is a learning process that can last the duration of one’s caregiving career.

The real value of experienced caregivers cannot not be found in their technical skills – or in anything that formal education could provide. Rather, it is in their capacity to perform well under difficult – often unreasonable – circumstances without losing their basic sense of humanity. It can be found in their ability to engage residents on an emotional level while under the duress of constant time restraints. It can be found in their willingness to support and sometimes lead their fellow coworkers in an environment that lacks adequate formal supervision. It can be found in their desire to serve as an example of how one human being should treat another without regard to roles or circumstance.

Good caregivers have a monetary value to the Long Term Care industry beyond what their technical skills and education can provide. The industry could not exist in its present form without their effort and caring. CNAs are truly the backbone of LTC. And their heavy lifting does not always involve transferring a resident.

The real reasons why caregivers are so underpaid are rather complex and go beyond educational requirements or even greedy nursing home operators. It is a very real social problem with direct implications to the well-being of our elderly and disabled citizens and should be treated as such.  

One Reason Why the Green House Movement Can Grow

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Yang

Before moving on to the third core value of the Green House Project, meaningful life, I would like to address one key question regarding staff empowerment. Currently, only a tiny fraction of residents in Long Term Care in the United States live in Green House Homes. Something under 2000 nationwide, but it’s growing. If the Green House movement ever grew to the point where it became a major alternative to traditional institutional care, would there be enough direct care workers with the right blend of personal and professional qualities to meet the demand? Or is the potential shahbaz candidate a rare breed drawn from an elite group of exceptional caregivers, high in motivation and ability, but too small in numbers?

There is much about the feasibility of the Green House Model that I am not qualified to answer. I know very little about the financial aspects and I don’t have the administrative experience or education to speak to the problems involved in organizing and sustaining something like a Green House Home. But what I do know and what I am qualified to address is the caregiver issue. And my answer to the question of whether or not there would be enough direct care workers with what it takes to meet the demands of a large scale Green House movement is an emphatic “yes.”

Yes, they are out there. I’ve worked with them. I know them. I know that many strive to maintain high standards of care while practicing a deep and genuine brand of compassion that endures despite difficult circumstances. And while they are acutely aware that the system they work under is deeply flawed, they are no less motivated by a sense of pride in their work and by the strong personal connection they have with their residents. These are caregivers who refuse to define themselves by the environment in which they work.

This breed of caregiver is all over social media. There, as in the work place, they find like-minded caregivers and create bonds of mutual support and understanding. Whether onsite or online, good caregivers are drawn to one another. And as we witness this larger community of caregivers begin to take shape and develop a sense of itself, we can see an independent grassroots ethos form, expressed in a thousand different ways, but with a common theme: “As a CNA, I know I am underpaid, not appreciated like I should be and worn out. But I also know that under my care, I will do whatever it takes to make sure you will have the best life possible.” While the words are simple, the commitment behind them is profound. And it is the essence of what it means to be a shahbaz. 

Of course, there are administrators and LTC professionals who don’t see it that way. There are those who would look at the unique labor requirements of the Green House Model and tell you – at least in private – “It wouldn’t work here – we just don’t have that kind of people.”

I think this lack of faith in the average caregiver extends from the fact that the skeptics are judging caregivers from the outside and in an environment that limits them. Heavy workloads, rules and regulations that do not make sense at the caregiver level and a hierarchical system that stifles initiative masks a powerful underlying and largely untapped potential. Even well intentioned administrators often lack the awareness of what caregivers actually do and are capable of doing. You have to descend into the trenches and become a part of it to really see it and understand it.

I have little doubt that with proper support and training, most caregivers would thrive in an environment of staff empowerment. If the Green House Project fails to become a large scale movement, it won’t be because the right kind of people aren’t available.