The New Old Age: A Better Way to Find Home Care Aides

 

Because a phrase like “matching service registry” can cause readers’ eyelids to droop, let me tell you instead about three women in Oregon.

Marcia Watson and her mother, Ethel Green, live in Jefferson, Ore., in a small house with a ramp for Ms. Watson’s wheelchair. She’s disabled, at 51, in the aftermath of myasthenia gravis, and needs help with bathing, dressing and organizing medications. Her mother, 77, is frail and sometimes finds it difficult to rise from a chair. Neither can manage laundry or grocery shopping on her own.

They qualified for part-time home care through the state Medicaid program, but were unhappy with the workers dispatched through an agency. “I called my case manager and said, ‘What else can we do?’” Ms. Watson told me. “She said, ‘We have a database of providers who’ve been screened and trained and had criminal background checks.’”

If the women had owned a computer, they could have logged onto this database, the Oregon Home Care Commission Registry and Referral System, themselves. Because they didn’t, commission staff members ran the search for them. The registry allows both workers and employers to search for one another after specifying their preferences and requirements: Do you want someone to come mornings or afternoons, or to live with you? Do you need an aide who speaks Russian or Somali? Or drives? Do you need someone with special training in dementia care?

Ms. Watson and Ms. Green requested a nonsmoking English speaker who wouldn’t be fearful of a large dog and two parrots. Among those listed: Beverly Haynie, now 65, a veteran caregiver and dog lover who lived five minutes away. When she came for her interview, Ms. Watson said, “We were sitting here yakking about stuff for half an hour.”

When Ms. Haynie said she’d call in a few days to learn their decision, Ms. Watson recalled, “I looked at my mom and she looked at me, and we said, ‘That won’t be necessary.’”

Three years later, Ms. Haynie comes to their home 81 hours a month at $10.20 an hour, a rate negotiated by the union representing public home care workers in Oregon and a huge bargain for state taxpayers, compared with any kind of institutional care. Clients who pay privately for home care can also use the registry, free of charge. Workers generally charge them more because private employers rarely pay benefits. Yet the clients still will wind up paying less than agencies charge.

More than 17,000 approved workers, about two-thirds of whom are currently working, are listed with the registry, said Cheryl Miller, the commission’s executive director. Almost 1,100 Oregonians looking to hire help consult the service each month.

These are three happy women. “It was so much better being able to choose for ourselves,” Ms. Watson said.

“I don’t have to advertise in a newspaper anymore,” Ms. Haynie said. “The registry provides you with employers who need you.”

Sixteen states have such matching registries, according to a recent report by the SCAN Foundation; five more registries function in regions within states.

(A map from P.H.I., an advocacy group working to support direct caregivers, indicates which states maintain registries and contains links to the organizations that sponsor them, including state governments, public authorities, nonprofit corporations and centers for independent living.)

Some registries serve only clients receiving Medicaid services, but most, like Oregon’s, are also available to people paying privately. Some charge modest fees; most are free. All report on workers’ qualifications and availability; most include criminal background checks. When I poked around these Web sites, it seemed clear that some were more useful than others, but generally the idea makes sense.

“They gather information on both sides of the equation: consumers’ needs and preferences and workers’ requirements,” said Dorie Seavey, director of policy research at P.H.I. and a co-author of the SCAN Foundation report. “Then they help workers and consumers find each other.”

More people hire home care independently (through what’s been called the “gray market”) than through agencies, Dr. Seavey pointed out, because non-agency workers charge less (since an agency isn’t taking a major chunk of their wages) and are often more flexible about hours and duties.

But families worry about how to find candidates and evaluate their abilities and integrity. With luck, they find aides through trusted friends; otherwise, they post notices on supermarket bulletin boards or trawl through Craigslist and cross their fingers. “Registries have great potential to overcome the difficulties of a very decentralized, atomized system,” said Dr. Seavey, a labor economist by training.

The need for home care aides will certainly grow, not only because the population is aging but because the Class Act’s cash benefit for long-term care (if its opponents don’t kill it off) will allow more people to hire them. The Class statute requires “adequate infrastructure” to create a sufficient supply of trained caregivers. These registries could help. But for now, Dr. Seavey acknowledged, they’re in their infancy — and in some places, notably Michigan and Wisconsin, they are already on the chopping block as states slash budgets.

The registries must be among the better-kept secrets in elder care, perhaps because most are less than five years old. Ideally, hospital discharge planners, doctors, social workers and local aging agencies would be spreading the word. But that doesn’t seem to happen much outside Medicaid programs. “People don’t know about them,” Dr. Seavey said. “There’s a lot more public education needed.”

Paula Span is the author of “When the Time Comes: Families With Aging Parents Share Their Struggles and Solutions.”

 

Well: A Better Medical School Admissions Test

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Recently the college-age daughter of a friend talked to me about her dream of becoming a doctor. She was doing well as a psychology major and in her pre-medical courses, was working as a research assistant for a pediatrician at a nearby medical school and volunteered on the cancer ward at a children’s hospital.

I was impressed.

But her enthusiasm dipped sharply when she told me she was preparing for the MCATs, the Medical College Admission Test, the required standardized test that measures mastery of the pre-medical curriculum. She was putting all her extracurricular work on hold so she could focus on reviewing biology, physics, chemistry and organic chemistry for the exam. “Does my ability to memorize the Krebs cycle and Bernoulli’s equation really have anything to do with what kind of doctor I’ll be?” she asked.

The answer, it turns out, is yes — and no.

The first MCAT, then referred to as the Scholastic Aptitude Test for Medical Schools, was administered in 1928 and represented an effort to address the significant medical school dropout rates of the time. Up until that point, medical school applicants had been evaluated, and accepted, on the basis of stray bits of biographical information, random letters of endorsement, a few prior grades or the existence of a high school diploma. As many as half of those accepted eventually quit, resulting in huge losses of time, energy, educational resources and money. But thanks in part to the MCAT, by the mid-1940s the medical school attrition rate had plummeted to less than 10 percent, even as the standardized exam was becoming a much-maligned rite of passage for aspiring young doctors.

Over the years, the MCAT has gone through four major revisions and has only strengthened its ability to predict success in medical school, particularly when evaluated in combination with grades. Each year more than 70,000 students take the exam, vying for a little more than 19,500 medical school slots. These days, fewer than 4 percent of those finally accepted drop out.

But the MCAT has had one major failing in its otherwise brilliant performance: It has been unable to consistently predict personal and professional characteristics. As early as 1946, medical educators were trying to design the MCAT in a way that might tease out such information, but they, and those who followed, were unable to succeed.

Now the MCAT is about to undergo its fifth revision, the first in nearly 25 years. Last month, the Association of American Medical Colleges, the national organization that administers the MCAT, released the preliminary recommendations of a 22-member advisory committee that has been studying the issue for the last three years. They recommend, among other things, lengthening the four-and-a-half hour exam by 90 minutes and adding questions on disciplines like sociology and psychology. The new exam would also test analytical and reasoning skills in areas like ethics, philosophy and cross-cultural studies, which could include questions about how someone living in a particular demographic situation, for example, might perceive and interact with others.

Despite what some view as a long overdue re-examination of this linchpin of medical school admissions, many medical educators, including members of the advisory committee, remain cautious about tampering with a test that has proved successful so far.

“It’s like trying to improve a Honda,” said Dr. Ronald D. Franks, vice chairman of the committee and vice president of health sciences at the University of South Alabama College of Medicine in Mobile. “When you’ve got something that’s working extremely well, you can make improvements, but you’ve got to be mindful of the services it has rendered.”

Those services can be gargantuan. Jefferson Medical College in Philadelphia, for example, receives almost 10,000 applications each year and must whittle those numbers down to 800 for interviews for the 260 available slots in each class. In combination with grades, the MCAT can help admissions officers eliminate a quarter of the applications.

“But we and other medical schools have so many great applications from the standpoint of just numbers that we usually also need to go through other parts of the application as well,” said Dr. Clara A. Callahan, dean of student affairs and admissions at Jefferson and the lead author of one of the largest longitudinal studies on the predictive validity of the MCAT. “You want to make sure someone isn’t just saying that he or she wants to help people.”

It’s likely that Dr. Callahan and other medical school admissions officers will have to continue to look beyond the MCAT to learn more about their applicants’ personal qualities. The science of personality testing has advanced tremendously over the last 25 years, but the committee felt it was still unclear how accurately a test could predict traits like integrity, altruism and the ability to collaborate. Some members were uncomfortable, too, with the long-term implications. “Will we end up labeling someone forever with a 9.2 for their personality?” Dr. Franks asked.

Only time will tell whether this newest version succeeds where earlier ones have not. But one thing is certain: Taking the MCAT is likely to remain a rite of passage for doctors-to-be for years to come.

“The reality is that we doctors are taking standardized tests – in-service exams, board exams, recertification exams – all our life,” Dr. Callahan said. “It’s something people have to master in medical school and beyond, so it’s nice to be able to accurately predict at the outset how someone will do with them in medical school and beyond.”

The MCAT advisory committee is continuing to solicit opinions through its Web site until February. The new exam will be administered beginning in 2015.