When friendsand family are unavailable or unable to care for homebound loved ones, primary care often deploys Home and Community Based Services, including home health aides. For these homebound older adults, home health aides are essential to help preserve an independent life at home and avoid nursing home care.1 With the onset of the COVID-19 pandemic, the limits of the role of home health aides were tested, as is reported in the piece by Franzosa et al. As the increased fears of the virus’ spread led to diminished informal social support and care systems for many older adults, home health aides served as both lifelines to the outside world and as “boots on the ground” in providing essential medical care.

Despite their essential role, home health aides are vastly undervalued by the US healthcare system. Considered “unskilled” laborers, these professional caregivers assist adults at home with activities of daily living and instrumental activities of daily living. According to the Bureau of Labor Statistics, the median salary of a home health aide is $13.02 per hour, and this is often without benefits.2 Low wages, in combination with the risks of illness during the COVID-19 pandemic, contributed to a serious dearth of workers. This care gap is only likely to increase, given the projected 33% increase in the older adult population over the next decade.2,3,4

As healthcare professionals, we must recognize the importance of home health aides in supporting older adults at home. Home health aides’ consistent and longitudinal presence and care of patients uniquely positions them to identify subtle changes in patients’ health and wellness, potentially preventing disease exacerbations and hospitalizations. However, despite possessing this vital information, communication of clinical changes to medical teams is frequently difficult as most home health aides work for agencies unaffiliated with the patients’ primary care providers.

Current health care practices need to overhaul routine protocols so that identification and communication of the valuable information that home health aides possess will be enabled. Franzosa et al. advocate for increased integration of home health aides into the primary care team, and the VA Home Based Primary Care (HBPC) model may very well provide this opportunity and setting. The Home Based Primary Care interdisciplinary team model could serve as a testing ground for integration of home health aides into team care.5 It is not clear how the authors envision this structure—whether home health aides would be hired into the team itself or permitted specific VA access for communication purposes.

Other methods to increase communication between home health aides and primary team members might emphasize technology. Although the pandemic has ushered in an expanded role for telehealth, barriers to its implementation can be substantial. Lack of available technological equipment and internet access, as well as physical impediments (e.g., dementia, low vision, hearing loss), can make virtual communication challenging. In Franzosa et al.’s study, they found that home health aides’ assistance in telehealth visits provided the needed human link between the patient in their home and their providers in the medical setting. Digitizing communication tools such as the “Stop and Watch”6 could enable home health aides to convey real time information about important changes in the patient’s condition to healthcare professionals who can then decide how to intervene.

The aides interviewed by Franzosa’s team indicated that COVID-19 pushed their skills and scope of practice to the limit and sometimes beyond. Unfortunately, during the early COVID-19 pandemic, as essential as home health aides were to the individuals they serve, their role was largely forgotten as national focus turned to discussions surrounding care rationing and supplying personal protective equipment to hospitals. Home health agencies struggled, especially early in the pandemic, to even obtain suitable protective and testing equipment.3

This focus must be changed. Supporting and investing in these essential health care workers will reap benefits for us all. Home health aides will benefit from investment in the professional development of their role, via training programs, as well as meaningful incentives to continue in their profession. Support of the professionalization and fair reimbursement of home health aides is also an issue of equity. Most home health aides identify as female, reinforcing the tired trope of “feminine” jobs receiving reduced compensation.7 The majority of home care workers, including home health aides, are people of color with 28% Black or African American, 23% Hispanic or Latino, and 8% Asian or Pacific Islander.8

In addition to disparities faced by home health aides, older adults also experience difficulty in accessing Home and Community Based Services, with disparities found along racial and rural lines.9,10,11 Furthermore, even when able to access these services, outcomes reflect persistent health disparities.10,12 Older adults who self-fund home support are more likely to go into debt, struggle to pay bills, fail to procure adequate food and medicine, and be more likely to become long-term nursing home residents.13 Certain health and social conditions, such as a diagnosis of dementia, and being a dual eligible beneficiary, further increase risk of eventual nursing home residency and of increased out of pocket expenses.14,15 Without a strong community support system, we can expect inadequately supported older adults to continue to cycle through illness, repeated unnecessary hospitalizations, and potentially unwanted nursing home admissions.

Moving against this tide, expansion of Home and Community Based Services would ideally allow for increased numbers of at-risk older adults to age in place and evade nursing home admission. Eighty-eight percent of older Americans say they prefer to continue to live in their homes or friends’ or families’ homes rather than move into a nursing home.16 While already a priority prior to the pandemic, we anticipate that the devastating losses of nursing home residents to COVID-19 are an added motivator to prevent nursing home admissions and increase interest in home health aides’ role in prevention of instituitonalization.17

State and national legislation is needed to bring this essential need to the forefront. Unfortunately, Home and Community Based Services, which includes home health aides, was removed from the final infrastructure bill of 2021. One potential impediment to including Home and Community Based Services in a national bill is that these services are typically allotted at the state Medicaid level, limiting the reach of a national mandate. Regardless, there has been both a federal and state-level rebalancing effort over the past several years in an effort to reduce institutionalization and increase community living, even for adults who may require help at home with activities of daily living.18 States vary greatly in how they choose to allocate home and community-based service benefits to Medicaid beneficiaries but increased federal support tied to specific coverage requirements could increase availability of these services.

The initial inclusion of Home and Community Based Services in the 2021 infrastructure bill has helped to spark discussion about the importance of “human infrastructure.” The COVID pandemic provides the perfect opportunity to reflect upon, expand, and solidify the care provided to our vulnerable, homebound older adults. The value of the work of home health aides reflects the value we place on helping our elders to age in their communities and avoid institutionalization. Recognizing, supporting, and appropriately compensating the individuals working as home health aides will have a positive ripple effect through older adults and their families, the health care system, and communities as a whole. Let’s choose to move forward in support.