Who's caring for our loved-ones?

Qualifications often overlooked, says survey By Brian Goslow BOSTON - Lisa Gravel faced a dilemma when the registered nurse who had cared for her father during his stay at an assisted living facility left. Since her dad was experiencing the early stages of Alzheimer's disease, Gravel was told she'd have to hire someone to look after his daily needs or he'd be moved into a nursing home. "He doesn't need skilled nursing at this time," Gravel said. "He just needs a CNA (certified nursing assistant) to assist him in taking a shower, cleaning up, making sure his housework is done or to help tidy things up in the apartment and select clean clothes for the day." At the departing nurse's recommendation, Gravel hired Framingham-based Homewatch CareGivers after checking out the company with the Better Business Bureau in Boston and the Massachusetts Department of Public Health. "It took no more than a couple of hours," Gravel said. "If you have access to the Internet, you can do a lot of research on a company." Not everyone is as thorough as Gravel in researching the qualifications of those they hire to look after their loved ones. According to a recent Harris Interactive Survey on in-home caregiving, when family members hire home care for a sick loved-one, most - 78 percent - assume the professional caregiver has undergone formal training. The survey was conducted on behalf of the Caregiving Project for Older Americans (CPOA), a collaboration of the International Longevity Center-USA and the Schmieding Center for Senior Health & Education. The organization seeks to improve the country's caregiving work force through training, establishment of national standards and the creation of a career ladder. The large percent of people believing in-home caregivers receive formal training didn't surprise project coordinator Dr. Kenneth Knapp. "There's lot of evidence that the prevalence of training is not that high," he said. If a person's home care is covered through Medicare, Medicaid or another health insurance policy, some professional training is required. But, Knapp said, if you engage a home care agency to hire a caregiver on your own, the agency may farm out its caregivers' contracts to companies that could provide workers with little, if any, professional instruction. The CPOA isn't suggesting the majority of paid caregivers aren't caring and hardworking, Knapp said. It does seek to point out that differences in expectations can sometime lead to conflict. "The person receiving the care and his or her family members have certain expectations about what that caregiver is supposed to do, while the paid caregiver might have different expectations," he said. Lee Catineau, 74, had to find a new caregiver to look after his wife when the company employed to care for her stopped providing rides to her doctor's visits. "All of a sudden, they didn't have the manpower," said Catineau, a full-time stockbroker. His wife, Rose, 68, suffers from numerous health issues, including asthma, which requires her to be on oxygen 24 hours a day, stomach problems and a broken back. "And those are just the big things," Catineau said. He hired Homewatch CareGivers to look after Rose after the company satisfactorily addressed his two main areas of concern: always delivering the services for which it was contracted and replacing a worker if the couple was not satisfied. Catineau said he spends his work hours with the peaceful feeling that his wife is in good hands. "This is my sanity," he said. Now that her father's care is under control, Gravel is now looking for a caregiver to assist in caring for her in-laws. She said she is rejecting home care companies if they don't have "qualified medical staff," or are not insured and bonded. People who require home care and don't get their services through a state agency can't always be sure the person who comes into their home is qualified to provide the services they're hired for, said Elder Services of Worcester Area Inc. Executive Director Lou Swan. "There's a lot of groups out there that do private pay care work," he said. "They have to do criminal records checks but there are no standards. There's no guarantee of what you're getting." Swan said "fly-by-night operations" that want to get into the private care business sometimes target people in the state with higher incomes. Since they have to pay for their own home care, they don't have the same protection as those getting it through a state-related health insurance program. "They can be the ones with the least oversight," he said. "They think they're getting better service than they actually may be getting." There's a general perception that home care is part of health care. "It's a reasonable expectation," said Leeann Reynolds, president of Homewatch International, which has seven franchises in Massachusetts. "You're helping maintain a life. Because of that medical connection, people perceive these people have some certified education." Most of the clients of Homewatch CareGivers, the company's franchise for the MetroWest and Boston areas, require advanced care. Many of owner Patty Servaes' 80 employees are nursing assistants and home health aides supplementing their full-time jobs and have the proper qualifications - a home health aide or CNA certificate and state registration - to work with state agency clients. When necessary, Homewatch provides home health aide certificate training, a two- to three-month, 75-hour process that includes studying an 18-chapter home health manual, passing a test and completing a practical with a licensed nurse. All Homewatch caregivers attend monthly classes on health-related issues. "The ongoing training and education is a huge part of our system of retaining caregivers," Reynolds said. While the national annual turnover of caregivers is 26.4 percent, according to the National Private Duty Association Insider, Reynolds estimates her company's rate is half that. Milton Salazar, 45, has been a nurse's assistant at various nursing homes and hospitals since coming here from his native El Salvador more than 10 years ago. He supplements that income assisting Homewatch CareGivers' MetroWest clients with body washes, nail cutting, mouth care and, in one instance, moving the client from wheelchair to bed. A special training session taught him how to use the special lift. "We get really good training," said Salazar, who underwent CNA training at the American Red Cross in Worcester. "We have special information for what to do in emergencies, if someone is choking in their dining room or they're a diabetic, for instance." There are no national requirements for in-home caregiver training - and even advocates admit there are potential pluses and minuses to their establishment. While CPOA would like to see home care regulations and a nationwide certification program put into place, it's concerned about the cost of establishing them and the effect on caregiving costs. However, Knapp said, by giving caregivers proper training and skills they could potentially use in acquiring higher paying jobs in the nursing and other related industries, it would make the profession more attractive to potential employees. Aiming to bring an influx of employees into the nursing and caregiving industries, CPOA has initiated a Caregiving Training RFP (Request for Proposals) program. Several $25,000 grants, to be announced in June, will be awarded to up to 12 community colleges to enrich existing programs or establish new ones. "Community colleges are well-positioned to provide that training," Knapp said. "They are community-oriented and have networks and partnerships with hospitals, nursing programs and employment and work-force development agencies." The Caregiving Project wants those programs' curricula to include literacy and cultural sensitivity. If caregivers are immigrants or English is not their native language, differences in cultural or social economic status can affect communications vital to care. "They often don't speak the same language," Knapp said. "But it doesn't mean they don't care." While calling the survey and CPOA's goals an admirable attempt, Swan said, "If everyone's required to have an associate's degree, there would be an 80 to 90 percent loss of workers." In most long-term care circumstances, he noted, caregivers already are required to have some form of medical certification. Also, different levels of care are required and so the skill level a caregiver needs would vary. Each state has its own home care standards - if they have them at all. Companies looking to expand from their original location can have trouble entering new markets because of differing standards. Similarly, an individual who's worked as a caregiver in one state might not meet the requirements of another. This is another instance where a nationwide computerized registry would benefit the industry, Servaes said. Servaes doesn't believe added government regulation would help the profession. "I see it as raising the price of home care," she said. However, she thought a nationwide criminal and professional background check registry would be a good thing. She cited an example of a person who had stolen from a client while employed at one company and had negotiated an apology and made restitution in lieu of a criminal conviction. While that would make them an undesirable employee, the act wouldn't show up in a criminal background check, putting clients potentially at risk. Nationwide regulations or not, there's already a shortage of professional caregivers. Only 4 percent of the CPOA survey's respondents had worked as a paid home care worker in the past year, 43 percent in a full-time capacity. "It's not traditionally a well-paid profession with a career path," Reynolds said. "People get involved later in life or want to be altruistic by caregiving. We're exploring ways to educate and train family caregivers, perhaps by having them sit in on some of our staff classes, with the hope some of them might come into the profession."