MANSFIELD — Kim McWilliams starts her workday at 8 a.m., but instead of clocking in at an office, she’s knocking on someone’s front door.
McWilliams, a state tested nursing assistant (STNA), is a community care specialist with the Ohio District 5 Area Agency on Aging.
Her job is giving senior citizens the support they need to continue living at home. Unlike most fast-paced medical professions, she spends hours at a time with a single client.
“What I enjoy the most is talking with our clients and listening to their life stories,” she said. “Some of our clients we help give showers, do their laundry, go grocery shopping for them.
“Some we just sit and talk or play games with them.”
Locally, nationally and statewide, the share of the populace that’s 65 and older is on the rise.
The last census found that one in five Richland County residents were age 65 or older in 2020. That’s an increase of almost six percent since 2000.
Local experts as well as the U.S. Census Bureau predict the older adult population will continue to rise until 2030 — when the last of the baby boomers turn 65.
In the meantime, there’s a lack of trained professionals in the under-appreciated field of in-home care.
In-home caregivers allow older adults to live independently in their homes longer. They may also provide respite care for unpaid family caregivers.
Duana Patton, AAA5’s executive director, said in-home services can also reduce stress on family members and allow them to continue working, which minimizes the economic impact of their own caregiving responsibilities.
“When you think about the impact, it’s so much bigger than one person,” Patton said.
“We lost three employees over the last 18 months because they had to go home and do caregiving. I think about other employers whose businesses and whose productivity is impacted because their employees are caregivers.”
Agency program reduced number of seniors waiting for care
Like other Area Agencies on Aging, the AAA5 connects adults in need of services with providers in the area.
But staff found adults in need of personal care services often had to wait due to workforce shortages.
So the agency decided to hire its own community care specialists to fill the gap.
“We obviously value our provider relationships. In our region, we have a strong network of providers that do in-home services,” said Trae Turner, chief of community living for the AAA5.
“But like a lot of different employers, their pain point has been the workforce and being able to hire and retain, specifically, STNAs.”
The AAA5 now employs four STNAs who provide in-home services, as well as a registered nurse who oversees the program.
Patton and Turner said the agency’s goal isn’t to compete with local providers. Instead, the program allows the AAA5 to prioritize clients providers can’t serve until another agency can step in.
It’s a unique approach because AAAs typically don’t provide direct services.
“I think it’s a great idea. The area agency saw a gap that needed to be filled,” said Beth Kowalczyk, executive director for the Ohio Association of Area Agencies on Aging.
“In the last several years across the state in varying programs, we’ve had thousands of people at any given time going with out care and that’s result of the workforce shortage.”
The creative strategy even earned the AAA5 an Aging Innovations & Achievement Award from USAging last year.
“This program drastically decreased the number of vulnerable older adults going without care or on the waitlist for care,” a USAging publication stated.
“The overall response to client satisfaction surveys has been positive. Additional benefits include smooth transitions from AAA5 to providers and positive work experiences for STNAs, who are learning new office skills and report feeling valued.”
Pilot served Richland County residents, funded by levy
The AAA5 serves nine counties in north central Ohio. It was able to pilot the community care initiative in Richland County due to a unique funding source — the county’s senior services levy.
Area Agencies on Aging were created as part of the Older Americans Act, which limits how agencies can spend federal funds. Agencies are designed to create a “care infrastructure” — connecting seniors to resources and services in the community — rather than providing direct services.
Funds generated from local levies don’t come with such restrictions.
“That was what the the intention of those funds — to allow us to be innovative and provide services and supports where our grant funds can’t,” Patton said.
With a couple of STNAs on staff, the program served about 130 Richland County residents, providing a total of 2,371 hours of in-home personal care, in 2023.
The outcomes were significant enough that the state offered the AAA5 a direct service waiver.
This waiver allows the agency to use its federal funding to hire STNAs for in-home care. Now the program is less reliant on local levy dollars and can expand outside Richland County.
“It was really unprecedented,” Patton said. “It’s really rewarding to see that, not only did it make an impact here in our community, but that our funders across other funding streams saw the value in it.”
Since receiving the waiver, the AAA5 has offered personal care services to clients in Knox, Crawford, Morrow and Wyandot counties. The agency now employs four STNAs and one nurse.
Patton said the agency’s STNAs have the option of doing some non-traditional tasks, like office work, if they choose.
“Regardless of where someone works in this organization, we embrace them and whatever their development goals are,” she said.
“If they want to be a community health worker, if their aspiration is to be a registered nurse or an licensed clinical social worker, then we find ways in which we can help support them in that.”
Red tape could be keeping home care agencies from accepting Medicaid
Patton and Turner believe creating a positive workplace culture has been key to the program’s success and ability to retain staff.
“We wanted them to have that sense of team even though they’re out in the field,” Patton said.
Care specialist Shana Fraser said she enjoys that aspect of her job at the AAA5.
“It is different being able to have opportunities for learning new skills, going to conferences, being here when making decisions and being part of an amazing team,” she said.
Christina Littleton of Freedom Caregivers has worked in the personal care field for more than 25 years. She said she didn’t mind the AAA5 hiring a few caregivers of their own.
“We work very closely with the Area Agency on Aging,” she said. “There’s a lot of individuals that go through the AAA to find companies that support them. It’s a phenomenal one stop shop.”
On the other hand, Annie Lykins of Altercare Home Health in Mansfield said she’s concerned initiatives like this one could harm small businesses like hers.
“I feel like they should not hire their own STNAs because that’s now how our economy is set up to work,” she said. “They should contract out for that, which they have done in the past.”
Lykins said a better solution would be streamlining the process for private home care agencies to accept government-funded insurance reimbursements like Medicaid.
For the first few years, Altercare only accepted private pay. Lykins said she’s been pursuing a certification to bill Medicaid for the past six months.
“Their rules for participation in their program are so broad and expensive, it’s difficult and a hassle to become a provider,” she said.
Low pay may hinder prospective caregivers from entering the field
While the AAA5’s small staff of caregivers may help alleviate local care shortages, experts say systemic challenges make it difficult to recruit and retain professional caregivers.
Kowalczyk said increased funding has been a top advocacy priority for a number of years.
Last year, Ohio lawmakers increased funding in the state budget for reimbursements through the PASSPORT Medicaid Home Care Waiver.
According to Kowalczyk, in-home care providers qualified for reimbursements between $10 and $12 per hour under previous state budgets. Low reimbursement rates often translate to low wages.
According to the U.S. Bureau of Labor Statistics, the average hourly wage for home health and personal care aides in Ohio was $13.42 per hour as of May 2022.
“We were advocating for funding that would support $20 per hour. What the legislature approved was funding to ultimately support $16 to $17 an hour,” Kowalczyk said.
“We’ll continue to advocate for increases because we believe the value of the work is closer to the $20 per hour.”
A report by the National Association for Home Care & Hospice and the Home Care Association of America found that 50 percent of direct care workers are receiving some form of public assistance.
Some workers may decline promotions or full-time work because the increased income will disqualify them for public benefits like food, housing and childcare assistance.
When small raises aren’t enough to compensate for the lost assistance, workers actually end up worse off than before — a phenomenon known as the benefits cliff.
“There needs to be more outreach and encouragement so people understand what the work is and how valuable it is,” Kowalczyk said.
“We take caregiving for granted in this country, so really emphasizing the need and the fulfillment you can get from helping older adults in this situation, it’s really important. But the pay has to make it worthwhile, too.”
Littleton said she regularly visits high schools in the area to talk with students about career options in the home care field. Her agency hires individuals 18 and older with a valid license and car insurance.
She said being a helper and friend to a senior citizen is rewarding work — whether or not you choose to make a career out of it.
“We have individuals that just need to get to the store or maybe it’s just a little too hard to reach down and clean the bathtub,” she said. “Even if they don’t want to do healthcare for the rest of their lives, it’s customer services and it’s life skills.”
Littleton said she sees the field as a viable long-term option as well.
“Even if you don’t want to be a caregiver forever, we have girls who came in as caregivers and now run the office,” she said. “You don’t have to have a degree on the wall to do something amazing.”
