The home care workforce some 2.5 million strong is one of the nation's fastest growing yet also worst paid. Turnover is high, and with a potential labor shortage looming as the baby boomers age, there are efforts to attract more people to the job.
One such effort plays out in a large, sunny room in a Bronx high-rise, where Cooperative Home Care Associates holds an extensive, monthlong training program. On a recent day, two dozen women paired off at rows of hospital beds. As instructors coached them, they took turns lifting each other in a mechanical sling, or gently stretching each other's limbs, as is commonly done for stroke patients.
Such training distinguishes Cooperative Home Care Associates, along with the vision of the agency's president, Michael Elsas.
"We think that our workers are ready to use some of the newer technology," he says, "the smartphone type of technology."
Elsas says home aides could monitor and record things, such as changes in a patient's skin color. This could cut down on doctor's visits, perhaps even hospitalizations, "which would lower the cost of health care, have a dramatic effect on the cost of health care," he says.
And Elsas hopes that would have a dramatic effect on how much society values home health workers.
Right now, many get no training at all. There's little path to advancement. And with a median wage less than $10 an hour, it's hard to call this a career. Trainee Mary Miranda came to Cooperative Home Care Associates after a year's unemployment and will earn even less than she did in retail.
"It's not much," she shrugs on her lunch break. "But it's a stepping stone. Sometimes you gotta just take it as it goes and make the best out of everything."
Advocates say one big problem is a decades-old law that exempts home care workers from federal minimum wage and overtime, likening them to babysitters. Elsas believes this drags down wages across the field.
A year ago, President Obama proposed a rule to end that exemption, but it's yet to be finalized, so the lobbying goes on.
A few weeks ago, several dozen home aides from across the country came to Washington, D.C., for an advocacy day put on by the Direct Care Alliance. In matching royal blue T-shirts, they fanned out across Capitol Hill to make their case for better pay.
"When I'm in home care, I'm a doctor, I'm a nurse, I'm a cook, I'm a dietician," says Tracy Dudzinski, who traveled from Wisconsin. "You name it, we do it."
Over 16 years, Dudzinski says she's seen her duties grow more complex, as people live longer and hospitals release patients sooner after surgery.
"We have to watch for if they're having a reaction to medication," she says. "Sometimes we're doing basic wound care. I took care of a gentleman who was a quadriplegic."
Wisconsin, like 20 other states, overrides the federal exemption on minimum wage. Even so, Dudzinski says the highest wage at her agency is less than $11 an hour, and starting pay has gone down in recent years.
"In a typical supply-demand situation, if demand is greater than supply, then wage rates would rise to clear the market," says Dorie Seavey of the Paraprofessional Healthcare Institute. But she says supply and demand don't really work when it comes to home care aides.
"One of the biggest things that their wage rates are tied to are public reimbursement rates," she says. Namely, Medicaid, and a number of states have been cutting that to balance budgets. But Seavey says paying less to home aides doesn't necessarily save public money. About half of home care workers are in households so poor that they themselves rely on public benefits, like food stamps and Medicaid.
Even in privately paid home care, there is pressure to keep wages low.
"There's a fine line between what seniors are willing to pay for our services before they opt for other alternatives," says Paul Hogan, who heads Home Instead, one of the largest national home-care agencies. The company starts workers at $9 an hour, though charges clients at least twice that. Hogan says a higher rate could push seniors to hire someone outside an agency.
"It leaves the senior much more exposed to risk, such as fraud and abuse," he says. Worker advocates contend such fears are overblown.
Home Instead has lobbied especially hard to keep the labor exemption on overtime. Hogan says many aides log long shifts spending the night with clients.
"If the overtime would apply to these situations it would drive clients' bills up 20 or 30 percent," he says, "and this just makes it out of reach for them."
Advocates counter that, though it might be more more complicated, clients can avoid overtime by using extra aides to trade off night shifts. A recent study also finds that home health care is one of the most profitable franchises in the country, and growing fast.
Demand is set to soar, with polls showing that baby boomers overwhelmingly want to age in their own home. The hope is that enough people will want the job of caring for them there.
This story was produced for broadcast by Marisa Penaloza.