Barnstable County is facing twin demographic emergencies. First, as rents and the cost of living rise ever higher, the year-round workforce is evaporating. Second, the population — already far older than the rest of Massachusetts — includes a growing number of the infirm aged.
At the intersection of these statistical trends sits a deeply human crisis: who is left to care for the elderly?
Home care, which includes homemaking and personal services like cleaning, food prep, and shower assistance that can allow people to age in place, is hard to line up. There are 380 people on the waiting list for home care from Elder Services of Cape Cod, the state-designated area agency on aging.
“It kills me,” Elder Services Executive Director Maryanne Ryan said.
The shortage of home care workers is not new on the Outer Cape. But it used to be workable, said Provincetown Council on Aging Director Chris Hottle. Now, she said, “It’s at a critical state.”
In the past, “There may have been a month’s wait,” Hottle said. “Now it can be up to a year.”
Elder Services has over 2,400 people receiving home care, with 395 living in Eastham, Wellfleet, Truro, or Provincetown.
To carry out its programs, Elder Services contracts with 60 different agencies; 13 of those provide homemaking and personal care services. There are plenty of agencies, but, according to Ryan, staffing is the problem. And, relatedly, pay: “The rate of pay hasn’t kept up with the times, the pandemic has done a number, and housing is affecting everything,” Ryan said.
The median hourly wage for home health and personal care aides in Massachusetts was $16.40 in 2022, according to the Bureau of Labor Statistics — $1.40 over the state’s minimum wage.
Kevin Smith, the CEO of Quincy-based Best of Care, said his company’s retention rates are strong. They currently have 400 employees serving 1,500 clients. “But if I could hire another 200 people today, I would, and I still would not have enough people to meet the overall demand of the region,” he said.
“People at that low end of the wage scale are not going to go into homes and give showers when they can do something else and make 30 percent more,” Wellfleet COA Director Suzanne Grout Thomas said. The convergence of housing and cost-of-living pressures and the aging population, she said, constitutes a “maelstrom.”
Elder Services connects agency vendors and MassHealth recipients who are income-eligible, on a sliding scale, for a certain amount of state-funded home care. But while state reimbursement rates for agencies have risen in recent years, they haven’t kept up with minimum-wage increases. And that limits what home care companies are able to pay their workers.
Transportation is a major obstacle for home care workers on the Cape. “It’s not like Boston, where you can jump on the T and see 10 clients in a day,” Smith said.
Private Care, to a Point
The Outer Cape’s home care staffing crisis, driven by a lack of aides and long commutes for workers living closer to the bridges, has increasingly crept up Cape. But it’s perhaps most acute here, where many of the aides who do serve clients are commuting from as far away as Mashpee.
Private pay has historically been a sure bet for accessing home care services quickly. But Hottle and Ryan both said that’s changed since Covid, as demand has heavily outpaced supply.
Dan Schreiner of Truro operates a private-pay ComForCare franchise in Orleans. He said that, with some maneuvering, he’s been able to provide care for every client who contacts him. “If I know about a particular client in a particular area, I can recruit for a specific need,” said Schreiner, who is also chair of the Truro Council on Aging.
But a lot of companies “don’t even deal with Orleans to Provincetown,” Schreiner said. Sometimes they refer Outer Cape clients to him, he said.
“What I’ve found is that the agencies that say they provide care here will not provide services past the ‘Entering Wellfleet’ sign,” Sarah Ireland said. Ireland is a certified RN who has transitioned her small company, Outer Cape Healthcare Solutions, to more of a case-management business because she can’t find enough qualified workers.
“There are no aides in town,” Ireland said. “I’m constantly finding aides and saying to them, if I have a need, can I call you? But they’re all working at Stop & Shop or somewhere else as a second job. They’re more worried about finding a place to live right now. It’s a never-ending crisis.”
Best of Care currently has 5 clients in Orleans, 12 in Eastham, 8 in Wellfleet, and none in Truro or Provincetown. It has four staff covering the region, according to Best of Care Cape office manager Maryanne Drysdale.
Neighbor to Neighbor
From Wellfleet to Provincetown, local connections fill many of the gaps for people who are willing to pay directly for services.
Terre DeLuisa, a former nursing home aide who moved from New Jersey to Provincetown eight years ago to work as a live-in caregiver, now provides private home care to Outer Cape residents after a stint at Seashore Point. “I tell them, listen, make believe I’m another daughter and tell me what you want me to do,” she says. Right now, DeLuisa has two clients, both in Provincetown’s West End.
The work ebbs and flows, she said. She finds clients by word of mouth and sometimes turns people away because she’s too busy. Other times, “I have nobody,” she says.
In the winter, she’ll make a big pot roast and mashed potatoes and deliver it to all the “old ladies here that don’t cook.
“There are a lot of seniors who need help,” DeLuisa said. “It’s just a quiet little ripple under the water that nobody knows about.”
Jane Paradise, a photographer who lives and works in Provincetown, started looking for home care five years ago when her husband’s Alzheimer’s symptoms worsened. Through word of mouth, she found a caregiver who stayed for nearly four years before moving from Eastham to Maine. Now, Paradise has someone who works from 4 p.m. to 10 p.m. five days a week. But she’s still looking for weekend caregivers.
“My husband wants me sitting next to him all the time, so it’s hard for me to get any work done,” Paradise said. “I’ll sit at the dining room table while he’s sitting on the couch with the caregiver so I can work.”
Going through an agency would be a “last resort,” Paradise said. She likes being in direct communication with the caregivers, and she’s also heard from friends that agencies often send different people to cover shifts. “My husband is used to the same person, and different people showing up wouldn’t be good for him,” she said.
In late 2019, Wellfleet resident Martha Smith’s husband began experiencing severe cognitive decline and needed round-the-clock care. At first, Smith contracted with private agencies and paid for services out of pocket. But she was draining the couple’s finances, spending over $200,000 a year.
With help from Elder Services, she investigated a dizzying array of state programs and was eventually able to obtain a Frail Elder Waiver (FEW), a MassHealth program that covers comprehensive home-based services for participants who would otherwise move to a nursing facility.
Smith now receives caregivers from Bayada, a national franchise and one of the major home-care providers on the Cape. Smith has found the team of five people who rotate schedules to be more consistent than the private agencies she previously hired.
“It’s a very confusing system,” Smith said. “It’s hard to know from the consumer’s point of view what the best thing to do is. Imagine if my husband didn’t have me to do all this,” she added. “He probably would have been placed in a nursing home during Covid, and — I’m not going to say the rest of it.
“If someone doesn’t have a strong advocate, they’re in trouble.”