You鈥檙e ready to leave the hospital, but you don鈥檛 feel able to care for yourself at home yet.
Or, you鈥檝e completed a couple of weeks in rehab. Can you handle your complicated medication regimen, along with shopping and cooking?
Perhaps you fell in the shower, and now your family wants you to arrange help with bathing and getting dressed.
There are facilities that provide such help, of course, but most older people don鈥檛 want to go there. They want to stay at home; that鈥檚 the problem.
When older people struggle with daily activities because they have grown frail, because their chronic illnesses have mounted, or because they have lost a spouse or companion, most don鈥檛 want to move. For decades, surveys have shown that for as long as possible.
That means they need home care, either from family and friends, paid caregivers, or both. But paid home care represents an especially strained sector of the long-term care system, which is experiencing an intensifying labor shortage even as an aging population creates surging demand.
鈥淚t鈥檚 a crisis,鈥 said Madeline Sterling, a primary care doctor at Weill Cornell Medicine and the director of Cornell University鈥檚 . 鈥淚t鈥檚 not really working for the people involved,鈥 whether they are patients (who can also be younger people with disabilities), family members, or home care workers.
鈥淭his is not about what鈥檚 going to happen a decade from now,鈥 said Steven Landers, chief executive of the National Alliance for Care at Home, an industry organization. 鈥淒o an Indeed.com search in Anytown, USA, for home care aides, and you鈥檒l see so many listings for aides that your eyes will pop out.鈥
Against this grim backdrop, however, some alternatives show promise in upgrading home care jobs and in improving patient care. And they鈥檙e growing.
Some background: Researchers and elder care administrators have warned about this approaching calamity for years. Home care is already among the nation鈥檚 fastest-growing occupations, with 3.2 million home health aides and personal care aides on the job in 2024, up from 1.4 million a decade earlier, , a research and advocacy group.
But the nation will need about 740,000 additional home care workers over the next decade, , and recruiting them won鈥檛 be easy. Costs to consumers are high 鈥 the median hourly rate for a home health aide in 2024 was $34, shows, with big geographic variations. But an aide’s median hourly wage .
These remain unstable, low-paying jobs. Of the largely female workforce, about a third of whom are immigrants, 40% live in low-income households and most receive some sort of public assistance.
Even if the agencies that employ them offer health insurance and they work enough hours to qualify, many cannot afford their premium payments.
Unsurprisingly, the turnover rate approaches 80% annually, according to , a nonprofit organization that promotes co-ops.
But not everywhere. One innovation, still small but expanding: home care cooperatives owned by the workers themselves. The first and largest, Cooperative Home Care Associates in the Bronx borough of New York City, began in 1985 and now employs about 1,600 home care aides. The ICA Group now counts 26 such worker-owned home care businesses nationwide.
鈥淭hese co-ops are getting exceptional results,鈥 said Geoffrey Gusoff, a family medicine doctor and health services researcher at UCLA. 鈥淭hey have half the turnover of traditional agencies, they hold onto clients twice as long, and they鈥檙e paying $2 more an hour鈥 to their owner-employees.
When Gusoff and his co-authors interviewed co-op members for in JAMA Network Open, 鈥渨e were expecting to hear more about compensation,鈥 he said. 鈥淏ut the biggest single response was, 鈥業 have more say鈥欌 over working conditions, patient care, and the administration of the co-op itself.
鈥淲orkers say they feel more respected,鈥 Gusoff said.
Through an initiative to provide financing, business coaching, and technical assistance, the ICA Group intends to boost the national total to 50 co-ops within five years and to 100 by 2040.
Another approach gaining ground: registries that allow home care workers and clients who need care to connect directly, often without involving agencies that provide supervision and background checks but also absorb roughly half the fee consumers pay.
One of the largest registries, . Established through agreements with the Service Employees International Union, the nation鈥檚 largest health care union, it serves 40,000 providers and 25,000 clients. (About 10% of home care workers are unionized, according to PHI鈥檚 analysis.)
Carina functions as a free, 鈥渄igital hiring hall,鈥 said Nidhi Mirani, its chief executive. Except in the Seattle area, it serves only clients who receive care through Medicaid, the largest funder of care at home. State agencies handle the paperwork and oversee background checks.
Hourly rates paid to independent providers found on Carina, which are set by union contracts, are usually lower than what agencies charge, while workers鈥 wages start at $20, and they receive health insurance, paid time off, and, in some cases, retirement benefits.
may be operated by states, as in Massachusetts and Wisconsin, or by platforms like , available in four states. 鈥淧eople are seeking a fit in who鈥檚 coming into their homes,鈥 Mirani said. 鈥淎nd individual providers can choose their clients. It鈥檚 a two-way street.鈥
Finally, recent studies indicate ways that additional training for home care workers can pay off.
鈥淭hese patients have complex conditions,鈥 Sterling said of the aides. Home care workers, who take blood pressure readings, prepare meals, and help clients stay mobile, can spot troubling symptoms as they emerge.
Her team鈥檚 recent clinical trial of home health 鈥 鈥渢he No. 1 cause of hospitalization among Medicare beneficiaries,鈥 Sterling pointed out 鈥 measured the effects of a 90-minute virtual training module about its symptoms and management.
鈥淟eg swelling. Shortness of breath. They鈥檙e the first signs that the disease is not being controlled,鈥 Sterling said.
In the study, involving 102 aides working for VNS Health, a large nonprofit agency in New York, the training was shown to enhance their knowledge and confidence in caring for clients with heart failure.
Moreover, when aides were given a mobile health app that allowed them to message their supervisors, they made fewer 911 calls and their patients made fewer emergency room visits.
Small-scale efforts like registries, co-ops, and training programs do not directly address home care鈥檚 most central problem: cost.
Medicaid underwrites home care for low-income older adults who have few assets, though the Trump administration鈥檚 new budget by more than $900 billion over the next decade. The well-off theoretically can pay out-of-pocket.
But 鈥渕iddle-class retired families either spend all their resources and essentially bankrupt themselves to become eligible for Medicaid, or they go without,鈥 Landers said. Options like assisted living and nursing homes are even more expensive.
The United States has never committed to paying for long-term care for the middle class, and it seems unlikely to do so under this administration. Still, savings from innovations like these can reduce costs and might help expand home care through federal or state programs. Several tests and pilots are underway.
Home care workers 鈥渉ave a lot of insight into patients鈥 conditions,鈥 Sterling said. 鈥淭raining them and giving them technological tools shows that if we鈥檙e trying to keep patients at home, here鈥檚 a way to do that with the workforce that鈥檚 already there.鈥
The New Old Age is produced through a partnership with .
