You’re ready to leave the hospital, but you don’t feel able to care for yourself at home yet.
Or, you’ve 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’t want to go there. They want to stay at home; that’s 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’t want to move. For decades, surveys have shown that they prefer to remain in their homes 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.
“It’s a crisis,” said Madeline Sterling, a primary care doctor at Weill Cornell Medicine and the director of Cornell University’s Initiative on Home Care Work. “It’s not really working for the people involved,” whether they are patients (who can also be younger people with disabilities), family members, or home care workers.
“This is not about what’s going to happen a decade from now,” said Steven Landers, chief executive of the National Alliance for Care at Home, an industry organization. “Do an Indeed.com search in Anytown, USA, for home care aides, and you’ll see so many listings for aides that your eyes will pop out.”
Against this grim backdrop, however, some alternatives show promise in upgrading home care jobs and in improving patient care. And they’re growing.
Some background: Researchers and elder care administrators have warned about this approaching calamity for years. Home care is already among the nation’s 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, according to PHI, a research and advocacy group.
But the nation will need about 740,000 additional home care workers over the next decade, according to the Bureau of Labor Statistics, and recruiting them won’t be easy. Costs to consumers are high — the median hourly rate for a home health aide in 2024 was $34, the annual Genworth/CareScout survey shows, with big geographic variations. But an aide’s median hourly wage was less than $17.
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 survey by the ICA Group, 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.
“These co-ops are getting exceptional results,” said Geoffrey Gusoff, a family medicine doctor and health services researcher at UCLA. “They have half the turnover of traditional agencies, they hold onto clients twice as long, and they’re paying $2 more an hour” to their owner-employees.
When Gusoff and his co-authors interviewed co-op members for a qualitative study in JAMA Network Open, “we were expecting to hear more about compensation,” he said. “But the biggest single response was, ‘I have more say’” over working conditions, patient care, and the administration of the co-op itself.
“Workers say they feel more respected,” 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, Carina, serves workers and clients in Oregon and Washington. Established through agreements with the Service Employees International Union, the nation’s largest health care union, it serves 40,000 providers and 25,000 clients. (About 10% of home care workers are unionized, according to PHI’s analysis.)
Carina functions as a free, “digital hiring hall,” 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’ wages start at $20, and they receive health insurance, paid time off, and, in some cases, retirement benefits.
Other registries may be operated by states, as in Massachusetts and Wisconsin, or by platforms like Direct Care Careers, available in four states. “People are seeking a fit in who’s coming into their homes,” Mirani said. “And individual providers can choose their clients. It’s a two-way street.”
Finally, recent studies indicate ways that additional training for home care workers can pay off.
“These patients have complex conditions,” 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’s recent clinical trial of home health aides caring for patients with heart failure — “the No. 1 cause of hospitalization among Medicare beneficiaries,” Sterling pointed out — measured the effects of a 90-minute virtual training module about its symptoms and management.
“Leg swelling. Shortness of breath. They’re the first signs that the disease is not being controlled,” 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’s most central problem: cost.
Medicaid underwrites home care for low-income older adults who have few assets, though the Trump administration’s new budget will slash Medicaid by more than $900 billion over the next decade. The well-off theoretically can pay out-of-pocket.
But “middle-class retired families either spend all their resources and essentially bankrupt themselves to become eligible for Medicaid, or they go without,” 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 “have a lot of insight into patients’ conditions,” Sterling said. “Training them and giving them technological tools shows that if we’re trying to keep patients at home, here’s a way to do that with the workforce that’s already there.”
The New Old Age is produced through a partnership with The New York Times.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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