Characteristics of Home Care Workers

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Characteristics of Home Care Workers

Who Leave Their Jobs: A Cross-Sectional
Study of Job Satisfaction and Turnover in
Washington State
a b
Sahar Banijamali MPH, JD , Daniel Jacoby PhD & Amy Hagopian
c
PhD
a
Service Employees International Union Healthcare, Seattle,
Washington, USA
b
University of Washington-Bothell, Bothell, Washington, USA
c
University of Washington-Seattle, Seattle, Washington, USA
Click for updates Accepted author version posted online: 12 Jun 2014.Published
online: 19 Aug 2014.
To cite this article: Sahar Banijamali MPH, JD, Daniel Jacoby PhD & Amy Hagopian PhD (2014)
Characteristics of Home Care Workers Who Leave Their Jobs: A Cross-Sectional Study of Job
Satisfaction and Turnover in Washington State, Home Health Care Services Quarterly, 33:3, 137-158,
DOI: 10.1080/01621424.2014.929068
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Home Health Care Services Quarterly, 33:137–158, 2014
Copyright © Taylor & Francis Group, LLC
ISSN: 0162-1424 print/1545-0856 online
DOI: 10.1080/01621424.2014.929068
Characteristics of Home Care Workers Who

Leave Their Jobs: A Cross-Sectional Study of Job
Satisfaction and Turnover in Washington State
SAHAR BANIJAMALI, MPH, JD

Service Employees International Union Healthcare, Seattle, Washington, USA
DANIEL JACOBY, PhD

University of Washington-Bothell, Bothell, Washington, USA
AMY HAGOPIAN, PhD

University of Washington-Seattle, Seattle, Washington, USA
Attracting and retaining a stable and motivated home care

workforce has become a top policy priority. We surveyed 402 for-
mer home care workers in Washington State. We compared these
“leavers” to current home care workers recently surveyed. Those
who left the profession were more highly educated, had higher
household income, and were more likely to be White. Those newly
employed have better benefits, wages, hours, and career mobility
than in their home care jobs. The low status and poor pay of home
care workers may result in the inability of the profession to retain
those who face better prospects.
KEYWORDS home care workers, human resources for health, job

satisfaction, retention, turnover, workforce
INTRODUCTION
Health policy makers are facing a predicted shortfall in the number of formal
home care workers needed to provide care in the coming decade (Bercovitz
et al., 2011; Hayashi, DeCherrie, Ratner, & Boling, 2009). High turnover and
vacancy rates are becoming a serious concern in community-based long-term
care, as the work is characterized by low pay, limited benefits, little respect,
Address correspondence to Amy Hagopian, PhD, Department of Global Health,

University of Washington, Box 357660, Seattle, WA 98195, USA. E-mail: hagopian@uw.edu
137
138 S. Banijamali et al.
and stressful working conditions (Ashley, Butler, & Fishwick, 2010; Delp &
Muntaner, 2010; Stone & Dawson, 2008; Stone & Wiener, 2001). Home care
workers’ average hourly wage is lower than that of all other jobs in health
care (U. S. Bureau of Labor Statistics, 2009).
A 2005 national survey reported 76% of states named home care worker
recruitment and retention as major policy issues (National Clearinghouse
on the Direct Care Workforce, 2005). Washington State’s Office of Financial
Management forecasts the state’s population aged 65 and older will con-
tinue to grow as it has, 22% since the 2000 census. By 2030, the number
of individuals aged 65 and older will represent one-fifth of the state’s
population—about 1.7 million (Aging and Disability Services Administration
[ADSA], 2010). The population of individuals with developmental disabili-
ties has also grown, at 8% during the decade (ADSA, 2009). These trends are
expected to hold through 2028. If the number of Medicaid consumers receiv-
ing home- and community-based services from home care workers increases
at the same rate as the general population, 56% more Medicaid consumers
will live in Washington in 2030 than did in 2010 (Skillman, 2011). Increased
eligibility for Medicaid under the Affordable Care Act only exacerbates this
shortage.
It’s been estimated at least one in three home care workers leave
the workforce each year, with some researchers claiming the rate is three
or four times that high (Matthias & Benjamin, 2005). In Washington State,
annual home care worker turnover has been estimated at 37% for individual
providers (McDonald & Davis, 2007), while one home care agency esti-
mated its annual turnover of agency home care workers to be 67% (Catholic
Community Services [CCS], 2004). However, turnover rate calculations are
controversial, because the methods used to define and measure turnover
among home care workers have been inconsistent (U.S. Government
Accountability Office [GAO], 2001).
Other researchers have investigated home care worker job satisfaction
and intent to stay on the job (Center on Wisconsin Strategy, 2003; Dawson
& Surpin, 2000; Ejaz, Noelker, Menne, & Bagaka’s, 2008; Ellenbecker, 2004;
Matthias & Benjamin, 2005; Tett & Meyer, 1993). Our goal was to gather
information from home care workers who didn’t just intend to leave, but had
actually recently left their jobs, to determine actual precipitants of turnover.
Our research question was, “What reasons do former home care workers in
Washington State give for voluntarily leaving the profession between August
1, 2007 and October 31, 2010?” Because we also had data from home care
workers who were still in the workforce, we were able to make comparisons
between “leavers” and “stayers.” We sought to identify factors associated with
turnover that could be most readily be addressed by policy makers or the
union that represents home care workers in the state.
Home Care Workers Who Leave Their Jobs 139
Washington’s Home Care Program

Home care workers provide support services to disabled people who are
unable to live safely at home without help. Washington’s home care pro-
grams channel state and federal funds to low-income consumers of home
care so they can hire an individual provider of their own choosing. The
provider can be a friend, a family member, or a person unknown to the con-
sumer. Alternatively, some contract with an agency to supervise and manage
their home care services. Without home care services, many people with
disabilities and older adult consumers would be cared for in more expensive
and less desirable institutional settings.
Washington spends about $2 billion per year on long-term care older
adult and developmentally disabled consumers, or 5.3% of the state’s biennial
budget, with about half of that for home care (Washington State Department
of Social and Health Services [Wa DSHS], 2011). Approximately 74% of
45,000 home care workers are individual providers paid by the State’s
Department of Social and Human Services—this includes both individual
providers paid directly by the state of Washington and home care work-
ers employed by private home care agencies that receive funds through
the Medicaid program. Estimates are based on Washington’s Aging Disability
Services Administration’s agency provider projection provided at the Long-
term Care subcommittee meeting on July 3, 2010 and the Service Employees
International Union (SEIU) Healthcare 775NW Unionware records for July
2011. Washington’s individual providers are unionized (with the SEIU
Healthcare 775NW), and their wages are set through a collective bargain-
ing agreement with the state. The hourly wage scale for individual providers
ranged from $10.03 (for individuals with 2,000 or less cumulative career
hours) to $11.07 (for individuals with 14,001 or more cumulative career
hours) at the time of the survey and had been the same since July 1, 2008
(WA & SEIU, 2011). Agency providers employ about 26% of the home care
workforce in Washington State, about two-thirds of whom are unionized,
with wages ranging from $9.67 to $11.12. (Wage range estimate is based on
wage rates provided in the 2011-13 collective bargaining agreements for eight
Washington home care agencies represented by SEIU Healthcare 775NW.)
The long-term care workforce is diverse, with a higher proportion of
women, people of color, and immigrant workers than the general population.
More than 30% of home care workers and their families—about 13,000—earn
incomes below the official federal poverty threshold. Many more struggle to
meet basic daily needs and have to make difficult choices between caring for
themselves and caring for others. The current starting wage in Washington,
$10.03 an hour, is well below what a worker needs to support a family in
a state with the 14th highest cost of living in the nation (Foundation for
Health Coverage Education [FHCE], 2010), as well as the most regressive tax
structure (according to a 2009 report by the DC-based Institute on Taxation
and Economic Policy). While health insurance is available for Washington
State home care workers, no benefits for family members or dependents

are required by the employment contract, nor is paid time off or retirement
benefits.
METHODS
A number of conceptual models have been proposed to examine job sat-

isfaction, intent to stay, and turnover among home care workers (Barak,
Nissly, & Levin, 2001; Delp & Muntaner, 2010; Dill, Keefe, & McGrath,
2012; Ellenbecker, 2004; Iecovich, 2011; Tett & Meyer, 1993; Wiener, 2010).
Building on their work, we hypothesized that the central policy-relevant job
turnover factor among Washington State home care workers was job sat-
isfaction, which is influenced by extrinsic rewards (wages, fringe benefits,
etc.), training and career development (e.g., basic training, continuing edu-
cation, mentoring, and opportunities for advancement), reasons for being a
home care worker (motivation), and the political and market environment
(Figure 1). Because home care workers in our study were primarily working
for clients alone in their homes, we did not include traditional measures of
supervision and management as factors in our model. Our analysis focuses
on the policy-relevant factors in our model.
FIGURE 1 Factors Affecting Job Turnover of Home Care Workers in Washington State.
We drew a sample of former Washington State home care workers and

interviewed them about their work experiences and career choices. Our sam-
pling frame comprised the SEIU Healthcare 775NW “Unionware” database,
which included information on 31,205 former home care workers who had
ever been union members. Eligible survey participants were aged 18 years
or older, were able to complete the survey in English, and had voluntarily
left the profession between August 1, 2007 and October 31, 2010. Individuals
who were terminated; laid off; or who left the profession as a result of retire-
ment, death, or illness were excluded. Our goal was 400 respondents. The
Feldman Group, Inc., conducted interviews on April 4 and 5, 2011. Calls
were made until we completed 402 interviews. In addition to no answer,
we encountered 360 individuals who did not speak English, 4,156 bad
or disconnected numbers, and 84 business numbers. We made a total of

75,113 attempted calls, with the assistance of automated dialing machines.
To enhance comparability with ongoing survey work on turnover and
retention in the home care field, our 56-item survey drew heavily from instru-
ments developed by three previous studies in this field (Howes, 2008; Kiefer
et al., 2005; Morris, 2009).
To see how the characteristics of current home care workers compared
to the “leaver” population of interest, we examined demographic data per-
taining to currently employed workers (in 2010) from two prior surveys
conducted for SEIU Healthcare 775NW and the SEIU Healthcare NW Training
Partnership. The first was a telephone survey of 501 qualified respondents
and the second was a survey of 400 qualified respondents, both conducted in
October of 2010. Both of these surveys were also conducted by the Feldman
Group with similar parameters as our survey of former workers (in English,
evening calling hours).
Using cross-tabs with chi squares calculated in SPSS 18 (SPSS Inc.,
Chicago, IL, USA), we analyzed the relative importance of a variety of
factors influencing the decision to leave the home care profession in our
respondents—including wages, benefits, work hours, reasons for working,
attitudes toward home care, reasons for leaving, attitudes toward future
employment, and relative satisfaction with current employment.
RESULTS
Home Care Workforce Demographics
Table 1 provides a demographic portrait comparing current and former
Washington State home care workers. Our sample of Washington State home
care “leavers” contained fewer minorities, compared to those still in the
workforce (“stayers”): 81% White compared to 73%, with more Latinos and
Asians in the current workforce. We found no differences between leavers
and stayers on gender or age, with 84% of both populations being female,
TABLE 1 Demographics of Former Washington Home Care Workers Surveyed, 2011
A: Our sample B: Total current

(home care home care
Variable leavers) workforce p
Race/Ethnicity of caregiver n = 394 n = 382 .07∗

White/Caucasian 319 81% 280 73%
Black/African American 18 5% 17 5%
Latino/Hispanic 13 3% 24 6%
Asian/Pacific Islander 13 3% 27 7%
American Indian/Native Alaskan 10 3% 12 3%
Other 21 5% 22 6%
Gender—Female 338 84% 337 84% 1.0
n = 402 n = 400
Relationship to client n = 400 n = 599 .0038
Family member or knew but not family 236 59% 433 72%
Did not know before working for this client 164 41% 166 28%
Marital status n = 394 No data NA
Married/cohabiting 240 61%
Widowed/separated/divorced 83 21%
Never married 71 18%
Educational attainment n = 391 n = 394 .026∗∗
Less than high school 29 7% 30 8%
High school 94 24% 136 34%
Some college/technical school 164 42% 160 40%
College graduate 73 19% 58 15%
Graduate school or more 31 8% 10 3%
Had another job while caregiving 136 34% No data NA
n = 400
Claiming earned income tax credit n = 402 No data NA
Yes 128 32%
No 195 49%
Not sure 79 20%
Current annual household income n = 351 n = 298 .0004∗∗∗
Less than $15k 67 19% 64 22%
$15 to <25k 73 21% 95 32%
$25 to <35k 66 19% 57 19%
$35 to <55k 58 17% 43 14%
$55k or more 87 25% 39 13%
Age, M (SD) 49.1 (15.4) 50.2 (15.6) .33
n = 384 n = 388
range = 19–83 range = 18–87
Washington State location n = 402 n = 390 .67
Eastern 138 34% 125 32%
Western 264 66% 265 68%
Home care worker was the primary wage earner 189 49% 333 57% .11
n = 389 n = 585
Dependents, M (SD) 1.62 (0.86) 0.86 (0.83) .76
n = 391 n = 390
range = 0–7 range = 0–7
∗
Comparing White to non-White.
∗∗
Comparing high school and below to more than a high school education.
∗∗∗
Comparing less than $55,000 to more than $55,000 in annual household income.
Sources of data: Column A is an April 2011 survey of 402 former Washington State home care workers
contacted by telephone; Column B is from two different surveys conducted in October 2010 of current
Washington State home care workers (N = 501 and N = 400). Both sampling frames came from Service
Employees International Union Healthcare 775 NW, the union that represents all individual home care
providers and approximately 75% of agency-employed home care providers in Washington State.
and leavers averaging 49 years of age compared to 50 years for stayers. The
geographic distribution of leavers was also very similar to stayers, with about
one-third of home care workers residing in the eastern (more rural) part of
the state.
Leavers and current workers are different in some important ways, how-
ever. Our sample of leavers was more educated and wealthier than current
home care workers. More than one in four (27%) leavers had a bachelor’s
degree or higher level of education, compared to fewer than one in five
(18%) of stayers. Further, one in four leavers had a current household income
at or above $55,000, compared to only 1 in 10 (13%) stayers, and leavers
were also less likely (than stayers) to be the primary wage earner for their
household when they were working in home care (49% versus 57%). About
40% of leavers were the only wage earner for their household (not tabled).
Further, leavers were less likely than remaining home care workers to
have been working for a client to whom they were related or acquainted
prior to establishing the caregiver-client relationship. About 41% of leavers
cared for consumers they did not know prior to becoming their caregiver,
compared to 28% of the stayers. Leavers also tended to have more depen-
dents, averaging 1.62 people who relied on them for support, compared to
0.86 dependents for stayers.
Finally, about a third of leavers were working multiple jobs (34%)
and/or claiming an earned income tax credit (32%) while in home care.
We do not know how current workers fair in comparison, as they were not
surveyed on either of these topics.
Reasons for Entering and Leaving the Home Care Profession

The most important reason our respondents gave for becoming home care
workers was their commitment to or feeling of obligation to care for their
particular clients. About 42% of our sample indicated this was the main rea-
son they became a home care worker. Overall, only 20% said home care was
an improvement over their previous work in terms of pay, benefits, or hours.
On the other hand, about the same proportion (21%) reported their primary
reason for entering home care was that it was rewarding work. Only 1% said
their reason for becoming home care workers included desperation, the lack
of other jobs at the time, or lack of skills to work in another profession (data
not tabled).
Table 2 details the problems people reported they had while working
in home care, as well as their reasons for leaving the job. Insufficient pay
and not receiving enough paid hours of work were the biggest problems our
respondents reported. The pursuit of better career opportunities and/or bet-
ter hours, wages, and/or benefits were the primary reasons cited for quitting.
One in four (28%) were going back to school or got a better job. The next
most important reason (at 23%) was the desire for a job with better hours. For
TABLE 2 Dissatisfaction With the Job and Reasons for Leaving Among Individuals Who Left
the Home Care Workforce
Issue Leavers n, %
Main reasons given for voluntarily leaving home care profession (n = 229)
Left to go back to school, get a better job, or a job that would advance 63 28%
their career and provide skills development opportunities
Wanted a job with better hours 53 23%
Wanted better wages and/or benefits 36 16%
Wanted a less physically and emotionally stressful job 29 13%
Tired of home care work, bored, or burned out 25 11%
Issues with the patient or the patient’s family 13 6%
Wanted a job that involved less travel or commute time 10 4%
Problems faced while working as home care worker (n)
Insufficient pay for the work done (396) 78 20%
Not getting enough hours of home care work (398) 81 20%

No health benefits or inadequate health benefits (396) 71 18%
No pension or retirement plan (386) 69 18%
Physical pain or discomfort (399) 54 14%
Finding a new client when you needed one (379) 48 13%
No paid sick time (390) 48 12%
Too little control over hours or days of work (398) 46 12%
Finding a replacement when sick or needed time off (395) 45 11%
Source of data: April 2011 survey of 402 former Washington State home care workers contacted by
telephone, where the sampling frame came from Service Employees International Union Healthcare
775NW, the union that represents all individual home care providers and approximately 75% of agency-
employed home care providers in Washington State.
these respondents, half (47%) reported home care provided too few hours
of work, 29% said the job required inconvenient hours of work, and 21%
felt the hours were too inconsistent or unreliable (not tabled). Only 3% of
respondents wanting better hours reported their home care job required too
many hours of work (not tabled). The third most predominant reason why
individuals left their home care jobs was for better wages and/or benefits;
18% of leavers cited the lack of or inadequate health benefits or the lack of
a pension or retirement plan as a major problem they faced while working
in home care.
Former Home Care Workers’ Prior and Current Work Conditions

Prior to entering the home care workforce, 38% of former home care workers
were employed in either another health care job (15%), office administration
(12%), or retail (11%). Additionally, 10% previously worked in food service;
6% worked in manufacturing; and 4% worked in housekeeping or janitorial
services. Those who left home care and were now working in another job
were typically doing office work (23%), retail (21%), another health care
position (18%), or as a teacher/teacher’s aide (15%) (data not tabled).
Data in Table 3 describe work characteristics of our sample of leavers.
While working in home care, 86% worked only part-time in home care
TABLE 3 Characteristics of the Home Care Job Versus Current Non–Home Care Job
Leavers
Variable Home care job Current job p Current home care workforce∗
Benefits
Health insurance for yourself 89 22% (n = 393) 97 25% (n = 393) .4884 Yesb
Health insurance for dependents 34 9% (n = 395) 68 17% (n = 395) .0312 N/A
Paid vacation time 158 39% (n = 396) 104 26% (n = 396) .003 1 hour per 40 hours workedc
Paid sick and personal days 67 17% (n = 383) 104 27% (n = 383) .0243 None
Paid holidays off or extra pay for 88 22% (n = 383) 113 30% (n = 383) .0809 None
holidays worked
Retirement benefits 23 6% (n = 390) 81 21% (n = 390) .0002 None
Reimbursement for transportation .0001 IRS rated
145
199 50% (n = 393) 46 12% (n = 393)
costs
Current/final hourly wages (principal $10.36 (1.6) $14.89 (7.1) <.0001 Range = $10.03–$11.07e
job), M (SD) n = 333 n = 136
range = $7.00– $22.00 range = $8.00– $50.00
Total paid hours per month in home n = 313 n = 165 <.0001 n = 377
care jobs
Part-timea (Less than 140 hours) 268 86% 85 52% 267 71%
Full-time (140 hours or more) 45 14% 80 49% 110 29%
Very satisfied with home care job 155 39% 97 56% <.0001 245 62% (n = 393)
when they worked in home care n = 396 n = 172
compared to current job satisfaction SD = .48868 SD = .49734)
(for those currently employed)
(Continued)
TABLE 3 (Continued)
Leavers
Variable Home care job Current job p Current home care workforce∗
Type of caregiver n = 358 n = 602

Individual provider, paid by DSHS 154 43% N/A N/A 458 76%
Agency provider, private home care 204 57% 144 24%
agency
Number of years paid in home care n = 392 N/A N/A n = 400
Less than 1 year 123 31% 113 28%
1 to < 5 years 203 52% 138 35%
5 years or more 66 17% 149 37%
Working multiple jobs 136 34% 14 8% <.0001
n = 400 n = 174
SD = .47430 SD = .273
Received public assistance or 33 8% 51 13% <.0001 110 19%
146
government benefits as added n = 400 n = 325 n = 588
source of income SD = .27547 SD = .36429
∗
The benefits description and wage range given for the current home care workforce is for Washington State individual providers per their 2011–13 collective
bargaining agreement with the state of Washington. Individual providers comprise 74% of the home care workforce in the state. Agency home care workers benefits
and wages may vary slightly from those listed here, but tend to be very similar because of a state parity law for this workforce.
a
Part-time defined as less than 35 hours per week.
b
Home care workers become eligible for health insurance if they work 86 hours per month for three consecutive months.
c
Individual providers earn an hour of paid time off for every 40 hours worked. Total paid time off is capped at 80 hours per year.
d
Individual providers receive the federal mileage reimbursement rate for transportation expenses for up to 60 miles per month per client.
e
The minimum hourly pay rate is $10.03/hour. An additional pay increase is provided for each 2,000 hours worked. Wage scale steps range from $10.17 at
2,001 hours of work to $11.07 at 14,001 or more hours of work.
Sources of data: “Leaver” data come from an April 2011 survey of 402 former Washington State home care workers contacted by telephone; current workforce
data are from two different surveys conducted in October 2010 of current Washington State home care workers (N = 501 and N = 400). Both sampling frames
came from Service Employees International Union Healthcare 775NW, the union that represents all individual home care providers and approximately 75% of
agency-employed home care providers in Washington State.
(less than 35 hours per week) and more than one-third were also employed
in other non–home care jobs. Leavers had an average final hourly wage
of $10.36 per hour. The majority of leavers worked for private home care
agencies, while 43% worked as individual providers paid by the state’s
Department of Social and Human Services.
On average, currently employed leavers were now significantly less
likely to still be working multiple jobs, compared to their time as home
care workers. Only 8% of currently employed leavers indicated they were
currently working multiple jobs, compared to 34% when they were home
care workers. On average, currently employed leavers enjoyed a $4.53 per
hour spike in wages after leaving home care, and 35% more reported they
now had full-time employment. Additionally, the proportion of currently
employed leavers who indicated they were “very satisfied” with their new
jobs increased from 39% (while in home care) to 56%.
Currently employed leavers also enjoyed gains in their benefits levels
in their new jobs compared with their home care jobs. On average, 3%
more reported an increase in health insurance for themselves, and 8% more
reported having health insurance for their dependents. There was also a 10%
increase in the number of currently employed respondents who newly had
paid sick and personal days, and an 8% increase in the number who received
paid holidays off or extra pay for holidays worked. Further, the proportion of
currently employed former home care workers enjoying retirement benefits
increased from 6% (while in home care) to 21% in their new jobs. Currently
employed leavers did, however, report a reduction in transportation reim-
bursement and paid vacation time. While in home care, 39% of leavers had
paid vacation time, compared to 26% in their new jobs. This decrease in paid
vacation time may be offset by the increase in paid sick or personal days and
paid holidays.
Variation by Satisfaction
A little more than one-third of former home care workers reported having
been very satisfied with their work when they were home care workers.
Those who claimed to be very satisfied with their home care job tended on
average to be older (by 5.5 years), less well-educated, with fewer depen-
dents, and were more likely to be individual providers than those who were
less than very satisfied. (See Table 4.) The very satisfied were also slightly
more likely to be earning more than $10 per hour (p = .105) in home care,
and to be working full-time. The very satisfied worked in home care an
average of 1.7 years longer than those less than very satisfied. Additionally,
the proportion of very satisfied respondents whose client was their family
member was about 9% higher than those less than very satisfied.
The very satisfied were more likely to say they became home care work-
ers because they viewed home care work as rewarding or because they felt
TABLE 4 Satisfied and Unsatisfied Former Home Care Workers
Less than very

Variable Description Very satisfied N (%) satisfied N (%) P
Overall 155 (39.1%) 241 (60.9%) .0001

Age, M (SD), Range Mean age 52.43 years 46.97 years .001
Educational attainment High school or less 54 (36%) 67 (28%) .067
More than high school 95 (64%) 169 (72%)
Dependents None 110 (72%) 133 (57%) .001
One or more dependents 42 (28%) 101 (43%)
Structure of employment Private agency providers 51 (36%) 101 (48%) .015
Individual providers (paid 91 (64%) 109 (52%)
directly by state)
Client relationship Client is family member 64 (42%) 79 (33%) .044
Not a family member 89 (58%) 162 (67%)
Length of employment in home care 2 years or less 80 (53%) 162 (69%) .002
148
More than 2 years 70 (47%) 74 (31%)
Hours of paid home care work per month Part-time (139 hours or less) 97 (82%) 168 (89%) .051
Full-time (140 hours or more) 22 (18%) 21 (11%)
Main reason for becoming a home care Felt obligation to care for 72 (48%) 91 (38%) .017
worker particular client
Opportunity 19 (13%) 61 (26%)
Rewarding work 34 (23%) 45 (19%)
Desperation 26 (17%) 42 (18%)
Final hourly wage at time of leaving home Average hourly wage when in $10.49 $10.23 .105
care profession home care job (SD = 1.59) (SD = 1.29)
Hours per month Mean hours per month 75.6 74.6 .899
Years in home care Mean years 4.5 years 2.8 years .008
Source of data: April 2011 survey of 402 former Washington State home care workers contacted by telephone; sampling frame came from Service Employees
International Union Healthcare 775NW, the union that represents all individual home care providers and approximately 75% of agency-employed home care
providers in Washington State.
an obligation to care for their particular client. In contrast, the less than very
satisfied were more likely to have entered the profession out of desperation
(i.e., the lack of other jobs at the time, or lack of skills to work in another
profession) or because they viewed it as a good career opportunity (i.e.,
better pay, benefits, or hours than their prior job).
Variation Between Currently Employed and Unemployed Former

Home Care Workers
Table 5 illustrates differences between currently employed former home care
workers and those currently unemployed. Just less than half (46%) of leavers
were employed in new jobs when we phoned them. The unemployed,
however, included students and those who considered themselves to be

retired. More than one in five (21%) of respondents were retired, 15% were
looking for a job, and 8% were students (not tabled). Compared to those
TABLE 5 Former Home Care Workers Who Are Currently Employed Versus Those Not
Currently Employed
Currently
employed full Currently
Variable Description or part-time unemployed∗ p
Overall 174 (46%) 202 (54%) .1487

Age 19–40 53 (32%) 38 (20%) .000
41–55 73 (44%) 60 (31%)
55 and older 41 (25%) 96 (50%)
Dependents None 85 (51%) 147 (74%) .000
One or more 83 (49%) 51 (26%)
Education High school or less 46 (27%) 73 (37%) .044
More than high 125 (73%) 123 (63%)
school
Current annual $30,000 or less 69 (43%) 99 (58%) .006
household income More than $30,000 90 (57%) 72 (42%)
Ease in finding new Easy 112 (74%) 74 (57%) .002
non–home care job Difficult 39 (26%) 55 (43%)
with same/better
benefits and pay
Received public No, just wages 140 (94%) 113 (73%) .000
assistance or from own job or
government benefits as family member’s
added source of job
income Yes, received 9 (6%) 42 (27%)
public assistance
or government
benefits
∗
Includes retired people, but not students.
telephone; sampling frame came from Service Employees International Union Healthcare 775 NW, the
union that represents all individual home care providers and approximately 75% of agency-employed
home care providers in Washington State.
currently employed, the unemployed have fewer dependents, were less well-
educated, and were more likely to be older (and significantly more likely to
be over the age of 55). Not surprisingly, the currently unemployed found it
more difficult to find another job with the same or better wages and benefits
than their prior home care job. The currently unemployed were also more
likely to have a lower annual household income and to be receiving pub-
lic assistance or government benefits as an added source of income. About
27% of the currently unemployed respondents reported receiving some type
of public assistance or government benefits, compared to 6% of currently
employed respondents.
Variation by Ethnicity
Table 6 illustrates the differences between minority former home care work-
ers and White, non-Hispanic former home care workers. As a group, minority
respondents tended to be younger, had more dependents, and were less
well-educated than their White counterparts. They also tended to have lower
annual household incomes and had more difficulty finding another non–
home care job with the same or better pay and benefits after leaving the
home care workforce. Also, while working in home care, many more minor-
ity former home care workers were both the primary wage earner for their
household while also caring for a client who was a family member. Finally,
compared to White former home care workers, minority former home care
workers were less likely to have an additional supplemental source of
income and were more likely to claim an earned income tax credit.
Leavers’ Views of Home Care and Recommendations for Improving

Worker Retention
When asked what wage rate they would need to consider working in home
care again, 72% of former home care workers named higher wages. Half of
these respondents indicated they would need an hourly wage of $15 or more
to consider working in home care again.
When asked to choose from a list of options to best to recruit more
people to work in home care, respondents overwhelmingly (51%) indi-
cated higher wages would be the best way of incentivizing more workers
to enter the home care workforce. Another one in four (23%) said providing
more support and better training and opportunities for skill development and
career advancement was the best way of incentivizing individuals to enter
the home care workforce. Additionally, 12% listed improved benefits (e.g.,
paid vacation, health insurance coverage for spouse/dependents, sick pay,
etc.); 9% said providing more hours of paid home care work; and 6% indi-
cated improved communication or advertising of home care jobs. Tellingly,
TABLE 6 Minority Versus Nonminority Former Home Care Workers
White,
Variable Description non-Hispanic Minority race p-value
Overall (n = 394) 319 (81%) 75 (19%) .0001

Age 19–40 81 (26%) 28 (39%) .048
41–55 111 (36%) 25 (35%)
55 and older 117 (38%) 18 (25%)
Current annual Less than or equal 136 (49%) 42 (63%) .026
household income to $30,000
Over $30,000 144 (51%) 25 (37%)
Education High school or less 46 (27%) 76 (35%) .058
More than high 125 (73%) 142 (65%)
school
Relationship to client Client is family 107 (34%) 36 (48%) .016
Client is not family 210 (66%) 39 (52%)

Ease in finding another Easy 161 (71%) 31 (49%) .001
non-home care job Difficult 67 (29%) 32 (51%)
with same or better
pay and benefits
Dependents None 204 (65%) 38 (53%) .054
One dependent 34 (11%) 10 (14%)
Two or more 75 (24%) 24 (33%)
dependents
Earned income tax credit Claimed 92 (36%) 34 (54%) .008
Did not claim 162 (64%) 29 (46%)
Supplemental income Have additional 206 (65%) 40 (53%) .042
source of income
No, just home care 111 (35%) 35 (47%)
wages
Primary wage earner Home care was the 136 (44%) 48 (65%) .001
primary wage
earner for their
household
No, not the 171 (56%) 26 (35%)
primary wage
earner
telephone; sampling frame came from Service Employees International Union Healthcare 775 NW, the
union that represents all individual home care providers and approximately 75% of agency-employed
home care providers in Washington State.
no respondents said providing fewer hours of paid home care work or pro-
viding job placement and help in finding clients would help best improve
home care workforce recruitment.
DISCUSSION
We sought to understand why Washington State home care workers had

voluntarily left those jobs, and what they were doing now, in hopes of
learning what might motivate home care workers to remain in their positions
longer. Faced with an impending unprecedented demand for home care
workers, understanding turnover rate associated with this occupation and the
variety of factors relating to job satisfaction has important policy relevance
(Health Resources and Services Administration [HRSA], 2004). The Institute
of Medicine report, Retooling for an Aging America, identified an unstable
home care workforce as a primary challenge for aging Americans (Committee
on the Future Health Care Workforce for Older Americans & Institute of
Medicine, 2008).
We conclude that home care work is so poorly paid and working con-
ditions are so difficult that the personnel who left the workforce were those
better-off individuals (better educated, were more likely to be White, and
had higher household incomes) who faced better alternatives than home
care work. Previous studies support this conclusion (Benjamin, Matthias,
Kietzman, & Furman, 2008; Morris, 2009). Like Morris, our newly employed
leavers were more likely to be working full time, and to be making more
money. About half of former home care workers in our study were currently
employed in new jobs, and these jobs typically paid significantly more, had
better benefits, and were more likely to be full time (and less likely to be
one of multiple jobs) than their home care work.
Similarly, Benjamin et al. (2008) found the job leavers who were cur-
rently employed (about half, like in our study) had far better hourly pay and
more benefits than stayers. Morris (2009) found health care coverage was an
important consideration for leavers, and while we found newly employed
workers in our study were just as likely to have health insurance in their
new jobs as their old ones, we found the new jobs were more likely to pro-
vide coverage for dependents. Since leavers in our study were more likely
to have dependents than those remaining in home care, this was likely an
important variable.
Other studies of home care worker turnover identified low wages as
the primary reason for people leaving or intending to leave the profession.
Wages and benefits have been stubbornly poor for home care workers for
decades. An early study of home care workers identified stressful working
conditions, low pay, few fringe benefits, lack of opportunity for promotion,
and powerlessness (Donovan, 1989). A study of New York City home health
care workers in 1992 found the profession attracted primarily middle-aged
minority and immigrant women, half of them without high school diplomas
(Chichin, 1992). A 1994 study remarked that home health care is relegated to
second-class status, although workers toiled alone as a guest in the client’s
home, resulting in an interpersonal dynamic that makes it unlike any other
patient-caregiver relationship in the health care system (Surpin, Haslanger, &
Dawson, 1994).
A study from Washington State conducted 20 years ago (1990) found
the modal wage among home care workers to be $5.15 per hour (Hayashi,
Gibson, & Weatherley, 1994). Ten years later, the national average hourly
wage was still only $8.46 (Stone, 2004); and in 2007, the mean national
wage had grown to only $10.88 (Bercovitz et al., 2011). The wage in our
study was not even that high—when they left their jobs, Washington former
home care workers were earning a mean hourly wage of only $10.36. Three
in four of the former workers in our study reported their household incomes
were under $55,000, while 87% of those still in the workforce reported their
incomes were that low.
As in our study, others have found those who were directly employed
by consumers (rather than by agencies) were more satisfied and better off.
The authors of a three-state study speculated that in addition to offering
better wages, friends and relatives often provide nonagency workers with
benefits such as housing, food, transportation, or other incentives (Simon-

Rusinowitz et al., 2010). The former home care workers in our study who
were re-employed were more likely to have been working for strangers
in their home care jobs, rather than relatives or people they knew before
taking the job. The other half of home care workers who were not currently
employed are mostly retired, still looking for work, or have gone back to
school.
A large proportion (just over one third) of home care workers in our
study said they were “very satisfied” doing home care work when they had
the job, while just fewer than half said they were “somewhat satisfied.” Even
for those who reported they were “very satisfied,” however, the mean hourly
wage was only $10.49, compared to $10.23 for those who said they were
less than very satisfied. These wage comparison results, though not statis-
tically significant (p =.105), suggest the pay range for home care workers
is just too narrow to incentivize tenure in home care or to reward good
performance. The lack of a counterfactual higher wage and fringe benefit
experience makes it difficult to show its role in the turnover or retention
of home care workers. However, evidence from studies in Ohio (Ejaz et al.,
2008) and Maine (Morris, 2009) suggests compensation is highly correlated
with job satisfaction and actual job turnover. The Maine study found an
estimated reduction in intent to leave and actual turnover of a 20% wage
increase ($9.23 to $11.08) is 7% and 28%, respectively. Similarly, the Ohio
study found that feeling fairly compensated for the home care job and receiv-
ing key benefits (i.e., health insurance and a retirement/pension plan) are
significantly related to home care worker job satisfaction, which in turn is
related to turnover. The role of improved wages and benefits in the recruit-
ment and retention of home care workers was supported by our survey
respondents’ overwhelming indication (72%) that they would not work in
home care again unless offered a higher wage, at least $15 or more.
Home care workers in our study, both leavers and stayers, are not young
(about 50 years old). The profession is unlikely to attract young people, who
face better wages and working conditions in office or retail work. A minority
reported they were drawn to the work because it was rewarding, although
leavers were more likely than stayers to have been working for a client
previously known to them. We are not the first to suggest that if wages were
better, workers originally drawn to the profession to serve someone they
know might consider staying to serve clients unknown to them (Benjamin
et al., 2008).
Because home care jobs offer such low wages and benefits, many work-
ers take multiple jobs. One third of leavers in our study had another job, as
did 20% of the home care workers in the 1990 Washington State study and
more than 90% of the stayers in a California study (Benjamin et al., 2008;
Hayashi et al., 1994). Any unexpected expense, temporary loss of a client,
or reduction in hours can be a financial calamity for the home care worker
and her family (Delp & Muntaner, 2010). Chronic low wages also lead home
care workers to rely on public safety net programs, such as food stamps and
Medicaid, as did close to 1 in 5 of the “stayers” in our study and 1 in 10 home
health aides in a national study (Bercovitz et al., 2011). From the point of
view of the employer, the precarious financial status of home care workers
makes it more difficult to quickly resolve problems that may interrupt their
work. Every crisis for the home care worker becomes a potential crisis for
the home care consumer or agency employer.
The job market for those who have worked in home care includes other
low-paid positions in health care, office work, classroom support, retail, and
even (to a lesser extent) housekeeping, food service, or manufacturing. It is
remarkable that home care workers earn less than hospital aides or nursing
home aides, though their work is more autonomous, less closely supervised,
and likely requires more judgment. Further, the home care worker average
age is 10 years older (46) than the average hospital or nursing home aide
(age 36; Montgomery, Holley, Deichert, & Kosloski, 2005).
The art and science of caring for older adults at home must become rec-
ognized as challenging, rewarding, and socially valuable to attract and retain
qualified professionals and aides (Hayashi et al., 2009). The lack of respect
and low status given to home care workers will continue to inhibit entry
to the profession and hasten departures (Ashley et al., 2010). Home care
work is physically taxing and requires ongoing responsibility and judgment
as well as emotional commitment and flexibility. Further, home health aides
face double the incidence rate of injuries and illnesses for all occupations
taken together, placing this job among the country’s 30 riskiest occupations
(Seavey, 2010). Typical personal assistance workers had worked continu-
ously for their current employer for 2.5 years or less, and because other
low-wage occupations with fewer demands and better benefits are available,
attracting and retaining skilled workers could become significantly more diffi-
cult if conditions do not improve (Kaye, Chapman, Newcomer, & Harrington,
2006).
The main limitation of this study was ensuring a representative ran-

dom sample, because we conducted interviews exclusively during evening
hours and in English-only, using phone numbers provided when workers
were previously employed. This likely skewed our sample toward better-off
respondents. Home care workers in Washington may also be different than
those in other states; for example, California’s workforce is more dominated
by minority and Hispanic workers (Delp & Muntaner, 2010).
All of our respondents had also been union workers, but this con-
tributes to the representativeness of the sample as most home care workers
in Washington State are unionized (McDonald & Davis, 2007). As in
Washington, the states of New Jersey, Wisconsin, Illinois, Massachusetts,
Montana, Oregon, California, Ohio, Michigan, Nevada, Virginia, Kansas, and
Missouri also have widespread unionization of their home care workforce.

The ability to generalize our findings nonunionized states, however, may be
limited. One of the strengths of our study lies in the use of a conceptual
model that focused on the factors available to policy makers and employers.
We were also able to sample actual former home care workers, rather than
current workers who simply “intended” to leave the profession.
Ours was the first study, since 1990, to look at job satisfaction and
turnover among home care workers in Washington State. Home care
workers assist consumers in many activities of daily living—including med-
ication management, transfer, transportation to and from medical appoint-
ments, bathing, dressing, meal preparation, shopping, and house cleaning
(Washington Administrative Code [WAC], 2005a, 2005b). The job can be dif-
ficult, strenuous, and even dangerous, and pays poverty wages (Stone &
Wiener, 2001). The organized voices of consumers and workers, however,
have the political power to demand adequate resources and effective deliv-
ery of long-term care services (Dawson & Surpin, 2000). Given the unique
and important relationship between home care workers and consumers, job
retention is related to quality of care. Policy makers are in a position to
improve recruitment and retention of motivated and skilled worker in this
profession.
ACKNOWLEDGMENTS AND FUNDING
Service Employees International Union (Healthcare 775NW) provided access

to membership lists, previous surveys, and other relevant data, and also
provided funding to support the survey for this study, conducted by the
Feldman Group, Inc. Lisa Morris and Candace Howes shared their research
tools from a study in Maine, which we adapted for our study. Finally, we
thank the 1,303 home care workers who responded to the three telephone
surveys that provided the majority of the data for this study. Selected results
were presented to policy makers in Washington state during the legislative
session in Olympia, Washington, in February 2012.
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Home Health Care Services Quarterly

Characteristics of Home Care Workers

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Characteristics of Home Care Workers Who

SAHAR BANIJAMALI, MPH, JD

DANIEL JACOBY, PhD

AMY HAGOPIAN, PhD

Attracting and retaining a stable and motivated home care

KEYWORDS home care workers, human resources for health, job

Address correspondence to Amy Hagopian, PhD, Department of Global Health,

Washington’s Home Care Program

State home care workers, no benefits for family members or dependents

A number of conceptual models have been proposed to examine job sat-

We drew a sample of former Washington State home care workers and

or disconnected numbers, and 84 business numbers. We made a total of

TABLE 1 Demographics of Former Washington Home Care Workers Surveyed, 2011

A: Our sample B: Total current

Race/Ethnicity of caregiver n = 394 n = 382 .07∗

Reasons for Entering and Leaving the Home Care Profession

Not getting enough hours of home care work (398) 81 20%

Former Home Care Workers’ Prior and Current Work Conditions

Type of caregiver n = 358 n = 602

TABLE 4 Satisfied and Unsatisfied Former Home Care Workers

Less than very

Overall 155 (39.1%) 241 (60.9%) .0001

Variation Between Currently Employed and Unemployed Former

however, included students and those who considered themselves to be

Overall 174 (46%) 202 (54%) .1487

Leavers’ Views of Home Care and Recommendations for Improving

TABLE 6 Minority Versus Nonminority Former Home Care Workers

Overall (n = 394) 319 (81%) 75 (19%) .0001

Client is not family 210 (66%) 39 (52%)

We sought to understand why Washington State home care workers had

benefits such as housing, food, transportation, or other incentives (Simon-

The main limitation of this study was ensuring a representative ran-

Missouri also have widespread unionization of their home care workforce.

ACKNOWLEDGMENTS AND FUNDING

Service Employees International Union (Healthcare 775NW) provided access

Ellenbecker, C. H. (2004). A theoretical model of job retention for home health

workforce shortages and associated data needs. Washington, DC: National

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