Demand for home health aides is soaring. So why are they still so undervalued?

On most days around 2 p.m., home health aide Duane Crichlow can be found in an apartment in Sunset Park, Brooklyn, playing catch with his client — a man in his 30s with a developmental disability who is quick to give Crichlow hugs and kisses. If it’s nice outside, Crichlow will walk his client, who is nonverbal and in a wheelchair half the time, down three flights of stairs, hauling the wheelchair back and forth separately.

A 49-year-old Trinidadian who lives in Bed-Stuy, Brooklyn, Crichlow works for St. Nicholas Alliance Home Care, where he earns between $17-$18 per hour. His client likes it when Crichlow imitates Mojo Jojo, a character from the TV series “The Powerpuff Girls,” or tries out Cardi B’s signature catchphrase, “Okurr.” “I do different characters that make him laugh. As long as he’s happy, I’m happy,” Crichlow said.

But while Crichlow loves his client, he’s faced a number of hardships over more than two decades working as a home health aide. There are the untenable hours, long commutes, and constant stress: He frequently works 12-hour shifts, from 10 a.m. to 10 p.m., along with a one-hour commute each way involving two trains and sometimes a bus.

Then there are the humiliations, insults, and verbal attacks. On a past fill-in shift, while waiting on the street outside a packed bus, Crichlow’s client, who is white and in a wheelchair, told the bus driver that Crichlow, who is Black, wasn’t his home attendant after Crichlow suggested they wait for the next bus. “He was mean and bullying me,” said Crichlow. Over a decade ago, shortly after Crichlow’s parents passed away, a regular client of eight years told him, “F— your dead parents” on two separate occasions. That same client, on Crichlow’s last day of work, told him to “scram!”

The stress of the job often follows Crichlow home, where he struggles to sleep. In the past, Crichlow tried psychotherapy for multiple sessions. It helped, and he thought he didn’t need it anymore. But as time went on, he said, “I started to kind of mentally fall apart a little bit.” At the same time, talking about his experiences can be hard. “I don’t want to keep thinking about it, because it’s going to make me more miserable.”

At a time where 75% of adults want to age in place, home health aides are likely to play a key role in the future of U.S. health care. The number of home health aide jobs is expected to increase 25% between 2021 and 2031 — much faster than average, according to the U.S. Bureau of Labor Statistics.

But it’s a job that can take a toll on workers. Roughly 21% of home health care workers report poor mental health, according to a survey of close to 3,000 workers published in the American Journal of Public Health in 2021. Low household income, a history of depression, and trouble accessing health care because of costs all contribute to their health issues, according to the survey by lead author Madeline Sterling, an internist and assistant professor at Weill Cornell Medicine, and her team. The survey also found that home health care workers had worse general, physical, and mental health compared with low-wage workers in other industries.

A 2019 paper, meanwhile, found that most home health aides reported feeling isolated and alone on the job. And a 2019 study found that verbal abuse, which has been linked to negative health outcomes ranging from sleep problems to depression and heightened stress, is commonly experienced by home health aides.

Experts say that improving the mental health and working conditions of home health aides isn’t just important for the workers themselves — it will also go a long way toward ensuring that patients get the best possible care.

“Home care workers work long hours and pick up extra shifts because a lot of companies are short-staffed,” said Victoria Higgins, who worked as a home health aide for four years. “That can make some caregivers miserable that aren’t normally. If they’re tired, overworked, and underpaid, they may not do the best they can. It’s the clients that ultimately suffer.”

While working as a home health aide for two private companies, Higgins, 36, a single mother of five who stands 5-foot-2, often felt nervous before overnight shifts. She’d confronted plenty of potentially dangerous and high-pressure moments, from encountering unexpected strangers in her clients’ homes to getting tasked with moving a patient twice her size or facing a medical emergency for which she hadn’t been trained.

“I felt like crying every time,” Higgins said. “But of course, I did my best, because I want to make sure that I’m taking care of this person — not only because the family is paying top dollar, but because this is a human being who deserves nothing but the best.”

The work of professional caregiving, Higgins explained, involved prioritizing another person’s needs and, often, burying her own — all while working 10- to 12-hour shifts for $10 per hour.

Not once did the companies Higgins worked for acknowledge her safety concerns or the exhausting demands of the job. She once asked for a $2 raise to bring her wages to $12 an hour — a request her company balked at, opting for a raise of 25 cents per hour instead.

Peer support programs could help alleviate at least some of the pressures that home health aides face. In 2020, a team of Cornell researchers tested a six-week virtual peer coaching program for almost 20 home health workers to address their mental health needs. The researchers found the programs to be a boon for supporting home care workers, in large part because they enabled aides to meet one another and give voice to the despair and abuse they often experience. One participant told researchers how much they appreciated talking to someone “to have a second opinion, to give you support, to make you feel like what you’re doing is valid. Evidence from a 2023 paper also shows that peer support programs are particularly effective at reducing depressive symptoms among home health aides. 

Institutions ranging from labor union SEIU’s 119 Training and Employment Fund to the Oregon Institute of Occupational Health Sciences have also piloted and tested the efficacy of peer support programs to support the health of the home health aide workforce. And Sterling’s team will start recruitment in late 2023 or early 2024 for a clinical trial to test the use of peer support to improve depressive symptoms, stress, and loneliness among home health aides.

But the benefits of peer support programs only go so far. In order to support aides’ overall mental and emotional well-being, extensive policy changes must address everything from their pay, benefits, and job security to their need for greater support from employers and unions, according to Emma Tsui, an associate professor at the CUNY School of Public Health and lead author of a study testing the benefits of emotional support calls to home health aides during the Covid-19 pandemic.

For too long, Tsui said, aides have been literally and figuratively devalued. “One of the real pain points of this job is having a felt experiential day-to-day sense of why this work is so important,” she said. “And then feeling societally that it is invisible and not recognized.”

Improving the working conditions of home health aides is paramount in a system that’s decided that “allowing for care to be done in the comfort of someone’s home is the more effective, better way to go,” said Ariel Avgar, a professor at the School of Industrial and Labor Relations at Cornell University who frequently collaborates with Sterling. “That’s a great approach. The only thing is it relies on an entire workforce [that’s] ignored and invisible.”

“Many of my studies have demonstrated where workers are treated better, where workers have better working conditions, where the practices that guide their work are more progressive, the outcomes for patients are better,” said Avgar. “Investments in workers and investments in working conditions are tools to drive better care.”

Without these changes, it’s inevitable that home health aides will keep burning out and leaving their jobs. The median caregiver turnover rate was 64% in 2021, according to data shared by home care training agency Home Care Pulse, compared to a median 22% turnover rate among registered nurses as of last year, according to a survey by the recruitment company NSI Nursing Solutions.

Higgins eventually returned to working as a teacher’s aide where she earns more money, though she still works as a home health aide one afternoon per week for a 90-year-old man she considers a friend in Riegelsville, Pa., who has heart issues and peripheral neuropathy in his legs, offering him companionship, shuttling to appointments, and taking care of light housework. Higgins said she continues to take pride in “helping people in their most vulnerable times.”

Crichlow, meanwhile, cares for an elderly client once a week in Harlem, and continues to travel to Sunset Park four days a week. From breakfast to bedtime, he tends to the client who he says is like a brother to him: Showering him in the shower chair, putting him on the toilet, pureeing breakfast, lunch, and dinner. Still, Crichlow says, family members of his client sometimes tell him, “You’re not doing a good job. Hurry up. Hurry up.”

“That can be very stressful,” Crichlow said. “I’m trying to do the best I can.”

This reporting was supported by the International Women’s Media Foundation’s Howard G. Buffett Fund for Women Journalists.