By Thomas Goldsmith

The long-term care landscape in North Carolina was already in flux when the COVID-19 pandemic landed in 2020 — direct care workers faced 10 years of stagnant wages, nursing homes had waning numbers of residents, and the call for in-home aides had dramatically increased.

Ongoing trends among residents, care workers and the industry have crisscrossed and profoundly affected each other. One example came in the desire of increasing numbers of older people to be cared for in the community rather than in nursing homes.

Then in spring 2020, residents and staff began contracting the coronavirus and dying. As hundreds died, the pandemic laid bare problems that had been growing in plain sight, according to researchers and stakeholders who spoke at a statewide virtual conference Feb. 11.

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Front-line employees often relied on heart and dedication to keep going, experts and workers said, but many eventually drew a line when their low-paying jobs suddenly included a risk of illness or death from COVID.

“You’re already going into the settings with very low return to yourself and then you know that the responsibility of someone’s well-being falls on you, especially in a time of pandemic and of crisis,” said C.C. Croxton, a speaker and state organizing director of the National Domestic Workers Alliance. “And that is that is an unfair thing to do to someone who is coming with the passion of care and in the kindness of their heart.”

Direct care workers — mostly women of color — fill the growing ranks of Americans who look after other people’s parents, their own friends and other loved ones with disabilities. Certified nursing assistants in nursing homes, residential care aides in assisted living and workers who provide home care were not only discussed at the meeting but also spoke for themselves.

Overworked, overtired

Darrion Smith is a direct care worker who started his career with public schools, then joined the Department of Health and Human Services. Also a local official of the North Carolina Public Service Workers Union, he speaks out for workers as well as working as a therapeutic support specialist at Central Regional Hospital in Butner, a psychiatric facility.

“You have certified nursing assistants that work eight-hour shifts, but we know that with low staffing and things like that, those eight-hour shifts may turn into 12,” Smith said to about 75 people via the Zoom-ed event. “And sometimes it turns into 16, unfortunately. So you have people that are overworked, that are tired, that want to give the best care because they actually care about the people.”

The conference, part of a multi-state effort called “Essential Jobs, Essential Care,” was organized by the NC Coalition on Aging and the national research nonprofit PHI. Speakers unrolled data and figures alongside human stories, each piece of information giving a sort of witness to the others.

Stephen Campbell, data and policy analyst for PHI, introduced grim statistics: Fifty-three percent of direct care workers in North Carolina live in or near poverty. And 44 percent of that group are supported in part by some form of public assistance.

“And one in five lacks health insurance in the context of a global pandemic,” Campbell said. “That’s especially concerning because these workers are fearing for their lives and literally laying their lives on the line to provide care. And yet one in five is not sure how they’re going to afford medical bills if they incur them.”

A federal DHHS report singles out the wage-driven practice, common in North Carolina as elsewhere, of facility-switching by employees who want more hours: “Low pay and part-time work has prompted some nursing home staff to work more than one job, which increases the risk of COVID-19 transmission across multiple facilities.”

During a 10-year span ending in 2028, the direct-care workforce in North Carolina is projected to grow by 20,000 jobs, more than any sector except fast food. Nationally, direct care workers will be some of the most needed employees in the coming decade.

The state Commerce Department projects that North Carolina’s health care and social assistance workforce will grow by 16 percent, or about 93,000, by 2026. That would mean it was growing at the highest and fastest rate in the state.

Meanwhile, more people in North Carolina have jobs as home-health workers than as certified nursing assistants. And they make even less — $10.57 hourly in home health, and $12.76 in facilities, according to 2019 data, the most recent from the federal Bureau of Labor Statistics. That means many must beware what’s called the “benefits cliff”, a financial state where a raise in pay of a few dollars can push a family above eligibility for government-sponsored day care, food assistance and other benefits.

Direct-care workers got a temporary pay increase via Medicaid grants to long-term care facilities, but the hike won’t appear in this year’s state and federal budgets unless specifically allocated by federal and state governments.

shows a map of the US with the lowest wage workers in the Southeast
Data, map courtesy: U.S. Bureau of Labor Statistics

‘$9 an hour worth of work’

“We need to fund a $15 hour minimum wage for direct care workers in North Carolina to really achieve that parity with state employees,” said Heather Burkhardt, executive director of the NC Coalition on Aging.

Raises for direct-care workers were blocked from passage, along with other senior-targeted bills, when Gov. Roy Cooper and Republican legislative leaders locked horns in 2019 over expanding Medicaid, the state and federally supported health insurance for low-income people.

“It looked like it was going to be funded and then the budget was vetoed,” Burkhardt said.

Helah Smith, of Durham, who also spoke to attendees, had worked as a health-care administrator before taking on work in a long-term care facility. Then grew appalled at the care provided.

“You have to do this type of work with a different type of love because you’re not gonna become a millionaire doing this,” Smith said. “But it was literally a recipe for disaster. The CNAs are overworked and underpaid. There’s never enough staffing.

“Listen, if you’re paying somebody $9 an hour, trust me, I’m going to be at work looking for another job. I can’t give you my all. So you’re going to get $9 an hour worth of work.”

Representing an industry perspective on this equation was Tracy Colvard, a veteran of the state Medicaid office and vice president of government relations at the Association for Home and Hospice Care of North Carolina. He’s seen the fight over direct-care worker pay go on for years.

“We haven’t made a whole lot of progress in this area,” Colvard said. “We’ve done a lot of things; we’ve had tons of meetings, you name it, work groups, whatever you want to call it, focus groups.”

Apart from accepting a COVID-related federal pay hike, the state legislature has shown no zeal for pouring the sums it would take to move direct-care workers into what advocates consider a sustainable wage. The potential appropriation coming to North Carolina for fighting the novel coronavirus remains temporarily unknown pending passage of a massive relief bill under debate in Congress.

Timing, money, politics

The ongoing effects of the pandemic loom large but are far from the only forces at work in the private-public-nonprofit dynamic that governs pay for the people who do the hands-on care for many thousands of older adults and people with disabilities.

“When you look at the full gamut of what we deal with it’s very complicated,” Colvard said. “You have timing issues, obviously politics comes into it, money comes into it — finding these bodies to work, and the different layers that come with that.

More pay for workers more involves increased reimbursement from taxpayers to various types of providers, Colvard said: “You know they deserve a ton of money and we’re unable to give it to them based on those reimbursement rates.

“When you look at Medicaid in general if you raise the rate say a dollar an hour across the board, you’re talking about hundreds of millions of dollars that the legislature has to  appropriate.”

Kezia Scales, PHI director of policy research, suggested that attendees consider the nonprofit’s five pillars that support higher-quality jobs:

  • Better wages and benefits,
  • Quality training,
  • Quality supervision and job support,
  • Recognition and respect, and
  • Real opportunities, as in “Meaningful ways to advance as a direct-care worker within that career pathway or moving on to other roles as well.”

For direct-care veterans such as Helah Smith, the range of benefits suggested in PHI’s five pillars can seem at once desirable and distant from present reality.

“We may be working with people with mental illness, or some of us, you know, we have conditions as well,” Smith said. “After four hours, with anxiety, you need to leave, I need a different scenery. I need to breathe.”

This story has been updated to correct Darrion Smith’s name. 

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Thomas Goldsmith

Thomas Goldsmith worked in daily newspapers for 33 years before joining North Carolina Health News. Goldsmith is a native Tar Heel who attended the UNC-Chapel Hill, and worked at newspapers in Tennessee...

2 replies on “As the long-term care industry shifts, COVID-19 shortchanges NC’s frontline workers”

  1. OK Tommy- it’s time to get the true story out there about how our loved ones in long term care are faring (or not). Here’s what we know: as of the period March 13, 2020 (the infamous day of lockdown) until now, ALL of the Covid infection in skilled nursing facilities have come in via staff members, and there are none, ZERO, nada infections traced to visitors following the established protocols. It is time the true horror stories make the front page. Talk to me, talk to members of the task force at North Carolina Caregivers for Compromise- because isolation kills too! Every day we get postings on our Facebook page about denial of compassionate care visits, stingily offered visits, retribution against a resident for asking for visits repeatedly, real neglect resulting in needless suffering, on and on it goes.

  2. Thank you for writing about this absolutely critical issue that has a direct impact on the lives of not only our direct care workers, but our most vulnerable citizens in the state who benefit from their care and service.

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