The hardest part of Culix Wibonele’s first job in long-term care was not getting injured.

Originally from Kenya, Wibonele worked as a certified nursing assistant in Atlanta in 2014. She went to the homes of mostly older clients, helping them with everything from bathing to cooking. Wibonele worked alone and sometimes had to lift clients much bigger than her.

It was demanding work and paid only $9 per hour with no benefits. If not for Wibonele’s second job as a babysitter and her husband’s income, they would not have made ends meet while supporting their four children.

“My paycheck, you know, was literally just nothing,” Wibonele said. “I was kind of shocked, like, the amount of work we (were) expected to do and the pay you get at the end.”

Wibonele’s experience reflects broader trends in the long-term care workforce. Those who tend to older adults in settings like private homes and assisted living facilities across the U.S. face low wages and risk of injury while the industry struggles with staff shortages, CNHI News and The Associated Press found as part of an examination of the state of America’s long-term care.

Meanwhile, demand for these workers is rising as the population ages. By 2030, roughly 20% of the U.S. population will be 65 or older, and that share will continue to grow, according to the U.S. Census Bureau.

‘NO WORKFORCE COMING IN’

The industry has dealt with labor shortages and high turnover for years, problems that were made more acute during the COVID-19 pandemic.

Nursing care facilities shed employees after the pandemic’s onset, and the workforce has not fully recovered, federal data shows. A March survey of hundreds of nursing home providers by the American Health Care Association found almost all have open jobs and difficulty recruiting. And a recent nursing home staffing mandate from the Biden administration has panicked facility administrators who say they’re already scraping to fill vacancies.

Turnover is so bad at nursing homes that some see all of their employees leave within a year, said Alice Bonner, director of strategic partnerships for the Center for Innovative Care in Aging at Brown University.

Noelle Kovaleski, administrator of the Carbondale Nursing and Rehabilitation Center in Pennsylvania, said the biggest challenge in hiring is the lack of candidates. One nurse supervisor position at her facility went unanswered after being posted on a leading job site for two years.

Experts see looming potential shortages as the industry grows. Overall demand for full-time workers in long-term services and support settings is projected to increase by 42% between 2021 and 2036, according to the federal Health Resources and Services Administration. Demand for direct care workers, who make up the bulk of the workforce, is expected to grow 41%.

LOW WAGES

Direct care workers play vital roles in their clients’ lives — a certified nursing assistant bathing an incontinent dementia patient, a home health aide assisting an older widower with his medication, a personal care aide helping residents of a group home eat lunch. These workers are mostly women and people of color, and many are immigrants.

The industry added about 1.5 million new direct care workers between 2012 and 2022, an AP-CNHI analysis of Bureau of Labor Statistics data found. It’s expected to add close to 800,000 new direct care jobs through 2032 — which experts say will be hard to fill.

Pay is a big factor.

The average annual salary for home health and personal care aides was $33,380 in May 2023, according to the bureau. These earnings were similar to cafeteria attendants and retail sales workers.

Direct care workers are typically on the low end of pay scale. Roughly half of them rely on public assistance, according to a January Department of Health and Human Services report.

Experts point to funding as a reason wages are low. Medicaid is the primary payer of long-term care services, but many stakeholders argue Medicaid reimbursement rates are insufficient to properly compensate workers.

Some states have made efforts to bolster the workforce, such as requiring a percentage of providers’ Medicaid reimbursements go to direct care worker wages. Others have used funding from the 2021 American Rescue Plan Act to boost wages and recruitment efforts. Meanwhile, the Biden administration finalized a rule in April requiring 80% of Medicaid payments for homecare services be used to pay workers.

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The Associated Press Health and Science Department receives support from the Howard Hughes Medical Institute’s Science and Educational Media Group and the Robert Wood Johnson Foundation.