Modest pay for home visits makes it hard to recruit certified nursing assistants, agencies say. But the problem isn't about to go away.
For most of the past year, Ferdinando Apostoli hasn't been sure whether his wife recognizes him. Nowadays Maryann's eyes are mostly still, staring blankly from her pretty face. A year ago, her eyes used to follow him around the room. Eight years ago, she was his constant companion, the life of the party, the organizer of family events.
Pick's disease, a rare condition that shrinks the brain's frontal and temporal lobes, slowly erased those attributes, and its blankness now leaves Maryann, at age 66, immobilized in bed. She could go to a nursing home, but Ferdinando wants to tend to her at home for as long as he can.
With her needs so great, he can keep her close to him only because a stream of certified nursing assistants (CNAs) comes to his North Providence apartment while he is at work at Citizens Bank. Each taking a two-hour shift, they wash and change her, brush her hair, turn her so she won't get bedsores, do her laundry and clean up a little.
"I'm very grateful to these ladies that come in," Apostoli says. "They're able to do everything. I trust them. They are expert in a sense.... But they put a little bit of heart in it also."
And, he adds, "They are really underpaid."
Few disagree with that statement - not the owners of the agencies that employ the CNAs, not even the government officials who reimburse them. But because so much of home care is financed by Medicaid, the state health plan for the poor, improving the pay requires taxpayer money and government action -- action that has been slow in coming despite more than a decade of discussion.
To Ruth Dickerson, this makes no sense. Dickerson is the CNA who comes five days a week at 7 a.m. to take care of Maryann Apostoli. A 57-year-old grandmother who lives in North Providence, Dickerson is paid $10.80 an hour, with no benefits and no raise for five years. She has to pay for her own transportation. When gasoline prices soared above $3 a gallon earlier this year, Dickerson says she -- and many of her colleagues -- questioned whether they could keep doing this work.
But without her, people such as Maryann Apostoli would have to live in a nursing home -- which costs a lot more. As Dickerson sees it, she's saving the state money. So why, she asks, won't the state just give her a raise?
Robert Caffrey, president and chief executive officer of Homefront Health Care, one of 63 licensed home-care agencies in the state, has been asking the same question for many years. He says Homefront routinely turns away business because he can't hire enough staff, and he's convinced that if he could pay more, he could meet the demand.
Rhode Island Medicaid pays the agencies about $18 an hour for a CNA's services, and agencies pay the CNAs roughly $9 to $11 an hour. Some agencies offer benefits; some don't. Caffrey does pay his employees' mileage, but many agencies do not. Homefront also offers health coverage, but the employees' share of the premium is too high for many.
Whenever home-care agencies approach the administration or the legislature, Caffrey says, "We hear, 'The budget's tight. There's no money. We can't do this.' " Increasing payments to home care would save money in the long term, he asserts, but probably not within a given budget year. "They are so year-to-year focused," Caffrey laments.
"Home care is kind of like a stepchild," says Alan Tavares, executive director of the Rhode Island Partnership for Home Care, a trade group of home-care companies. Nursing homes are better organized and more powerful, he says. They now get annual cost-of-living increases.
Donald C. Washington, a CNA, helps Jeff Mello, 34, in his apartment in Providence. A car accident injured Mello's brain stem when he was 19, causing muscle weakness.
Donald C. Washington, a certified nursing assistance, and Jeff Mello leave Mello's Providence apartment. Once Washington has helped him get ready, Mello heads off on his own, taking buses around the city. He is one of more than 25,000 adults with disabilities who are younger than 65 who depend on the state Medicaid program.
JOURNAL PHOTOS / KATHY BORCHERS
The home-care industry asked for a similar provision during this year's legislative session. Instead, it got a one-time 2.2-percent increase, effective Jan. 1. The legislature also created a study group to examine the financing system for long-term care. The committee is expected to make recommendations to the legislature next month.
"We have to compete with nursing homes for CNAs," Tavares says. "They obviously have more money to pay more benefits. We believe home care is going to start dwindling through the loss of CNAs."
While the Rhode Island Medicaid program pays home-care agencies about $18 an hour, Connecticut and Massachusetts each pay about $24 an hour, according to Tavares.
Tavares has another figure that he says illustrates the problem. Nationwide, about 75 percent of people needing long-term care stay in institutions, usually nursing homes, and 25 percent get care at home and in the community. In Rhode Island, the division is 90 percent in institutions, 10 percent at home.
John R. Young, state Medicaid director, agrees that the 90-10 split is not ideal. But he says it's not clear what the right balance is -- nor how to get there.
For people with many needs, a nursing home can be the cheapest place to provide care, Young notes. And home care often depends on hours of free labor from relatives -- so it has hidden costs that need to be taken into account.
"Yes, there's a need for more community-based alternatives to facility-based care," Young says. "Yes, I think there is consumer demand for it. The question is, how to make that so."
If he increased home-care payments by 20 percent, Young says, he would spent 20 percent more that year -- and probably not get an additional hour of home-care work as a result. Any effects would take time.
"This is a long-term investment that we probably need to make," Young acknowledges. "But everybody -- the people who send me money, me, people in the community and consumers -- are going to have be more patient than they really want to be."
Young adds that simply paying more to CNAs will not solve the problem, "because there aren't enough CNAs." More money, he says, isn't enough to attract people to work that's physically demanding and involves sick people in often-unpleasant situations. It's not for everyone.
But Ruth Dickerson loves it. "I love the people," she says. "I love taking care of them. When I walk in the house, those people light up. That makes my day."
One recent morning she adjusts the pillows around Maryann Apostoli. The patient makes a small, nervous grunt. "OK, Momma, OK," Dickerson says soothingly, as she changes the diaper. She puts Apostoli on her side, leaning against some pillows. "OK, Miss Maryann?"
Dickerson leaves her to do some laundry. She remarks that she can't make a living at home-health care, so she also works in a nursing home -- where she is paid $12.75 an hour. But she prefers home care.
When one of her patients died after seven years of care, Dickerson was devastated. She went to the funeral, and the family invited her to ride in the family car.
"Everywhere I go, they always want me back. I'm just good that way."
Later she turns Apostoli onto her back again, and props her up into a sitting position. Apostoli's arms are bent, her fingers curled. Dickerson gently brushes her hair, then briefly strokes her head, smiling.
