'Not enough of me to go around': Caregiver shortage creates strain as more seniors age at home

LAS VEGAS, N.M. — She’s known around San Miguel County as “the homemaker.”

Debbie Romero travels throughout the county doing nonmedical tasks that seniors can’t do for themselves.

She changes linens. She sweeps, vacuums, mops and dusts. She drives clients to doctor’s appointments, shops with them at Walmart and keeps them company.

Romero enjoys her job — “I love caring for the elderly,” she said — but she faces a major challenge: There’s too much work to do.

Romero’s three-page roster of clients includes more than two dozen names, most of whom qualify for four hours of care each week. That adds up to about 100 hours of work — and only one homemaker.

“There’s not enough of me to go around,” Romero said.

It’s a common refrain in the caregiving industry. To meet the true needs of San Miguel County’s seniors, the area could use two or three homemakers, estimated Phyllis Urioste, an assessment specialist for senior centers in Las Vegas, Pecos and Ribera.

The same is true in more-urban Santa Fe, said Ellen London, executive director of Coming Home Connection, a local not-for-profit organization dedicated to providing seniors with in-home care, service navigation and equipment loans.

Caregiving is an essential element to allow seniors to age in place — something most people want to do, London said — but caregivers and administrators agree the industry needs big changes to become a viable, long-term career for most who enter it.

“It’s so important that people value this work and encourage [it] and pay appropriately for these really critical skills,” London said.

‘Where did all the workers go?’

Romero’s journey to becoming a homemaker started with a lost job. Laid off after nearly two decades from her position as the office manager in a health clinic, Romero said she turned to caregiving out of a desire to find a job with that same personal touch.

“What I really missed was the patients,” she recalled. “I’m a people person; I tried other jobs … and it just didn’t work.”

Some people are cut out for professional caregiving. “When people love it, they really love it, and they’re good at it,” London said.

Caregivers perform essential tasks. While trained personnel take care of medical tasks like medication management, professional caregivers are typically responsible for assisting with what are known as “activities of daily living.” Those can include tasks such as toileting, bathing, dressing and getting in and out of bed or a chair, as well as more complex duties, like providing transportation or preparing a meal.

Dr. Ann Garcia, who specializes in geriatric medicine through Christus St. Vincent Regional Medical Center’s Center for Healthy Aging in Santa Fe, usually sees some kind of caregiver — whether it’s a family member or a paid professional — with each of her patients.

“We have to engage with these folks,” Garcia said. “I tell all my patients, ‘You’re coming in with someone. You have to have someone next to you when we have this appointment.’ ”

The trouble is, the ratio of caregivers to people in need of care is out of balance: There aren’t enough caregivers to meet the true need in the city.

During the coronavirus pandemic, many caregivers walked away from the profession, London said. Not everyone came back.

“Like everyone says, ‘Where did all the workers go?’ We don’t know,” she said.

Christus’ Community Health Implementation Plan for 2023 to 2025 identifies older adult health as a “super priority” for Santa Fe. Alleviating “caregiver burden” is part of that.

In practice, the dearth of caregivers strains those who remain in the industry. Each week, Romero has to make tough choices to prioritize who needs care the most — a client with dementia, another on hospice, a third who is blind.

Her clients ask why she can only visit them once a week or call asking her to make an extra visit to Rociada and other outlying communities in San Miguel County.

“People are calling me, and I’m like, ‘I’m sorry; I can’t.’ My month gets filled up,” Romero said.

Cost of care creates barriers

There is no typical day at work for Margaret Rigatti.

The Santa Fe-based caregiver, who offers her services through her own company, arrives at her clients’ homes with no set agenda in mind. Instead, she devotes herself to helping with housework and other activities of daily living, or just keeping her clients company.

“I see them, and they know it,” Rigatti said of her clients. “They know they’re being seen; they know they’re being heard. They’re allowed to say whatever they want, be whoever they want to be without any judgment.”

Coming Home Connection connects clients with independent caregivers, including Rigatti. On any given day, about 60 of the organization’s clients are paying for their own caregiving, with wages starting at $25 per hour, London said.

The organization also offers a limited no-cost caregiving program, primarily funded by the city of Santa Fe and Santa Fe County and based on clients’ income.

For some of Coming Home Connection’s clients, the cost of caregiving isn’t an issue, London said; for others, it’s a major financial hardship.

London described Coming Home Connection’s no-cost caregiving program as the “tip of the iceberg.” It highlights the gaps in the system for seniors who can hardly afford housing, much less the cost of assisted living or skilled nursing care.

Medicaid can cover either home-based care or care in skilled nursing facilities — but London said the lack of skilled nursing beds in Santa Fe tends to leave low-income seniors without the latter option.

“It does get to the issue of people who probably shouldn’t be living alone anymore — but we don’t have options in Santa Fe,” she said.

Garcia said she sees that same dynamic play out among her patients, many of whom just can’t afford to pay for care. The cost of professional caregiving is an “obvious” barrier, she added, leaving seniors “teeter-tottering” on the edge of being able to adequately care for themselves.

As a result, the Center for Healthy Aging’s on-staff social worker maintains a running list of seniors to check on, Garcia said.

There is another cost to caregiving.

Rigatti said the personal connections she forges with clients is “the biggest part” of her job, and it’s intensely intimate work. It also can take a toll on the caregiver.

Rigatti works within what she calls the “emotional soup” of her clients’ lives. Often, she appears when they’re already weathering some kind of change — reeling from a bad diagnosis, recovering from an injury or doing battle with insurance companies.

“If I’m going to care for someone, I don’t look at it any differently than showing up to care for my own mother and father. ... I’ll be as vulnerable as you are and meet you where you’re at,” Rigatti said.

That mindset can lead to a disparity between the emotional heft of the work and the caregiver’s hourly wage, she added.

“You give and give and give, and then when the paycheck came at the end, it was out of balance,” Rigatti said. “So how long do you want to do that? How long can you show up that way?”

Stark wage gap for caregivers

Rigatti’s second caregiving job — before she started her own company — offered an hourly wage of $12 per hour, she said.

That’s not unusual. Inadequate pay is among the industry’s major stressors.

A 2023 analysis by the U.S. Department of Health and Human Service’s Assistant Secretary for Planning and Evaluation found wages for home health aides and personal care assistants trail those of other entry-level positions by an average of more than $3 per hour, despite rising demand for their services.

In New Mexico, the analysis found home health and personal care aides made about 75% of what other entry-level workers did in 2019, with wages averaging less than $11 per hour.

The wage gap becomes even more stark when considering the demographics of direct care workers like nursing assistants, home health aides and personal care assistants. The majority are women and people of color, according to Health and Human Services. More than a quarter are immigrants.

In addition to appropriate pay, London said caregivers should have the kind of career ladder customary in other industries. They can start with basic caregiving, before becoming nurse’s assistants, registered nurses or specialists in a particular type of care, such as memory care.

Professional development opportunities to help caregivers manage the emotional toll of their work would be helpful, too, Rigatti added.

Rigatti argued fixing the system will require a fundamental shift: “Value human life. Value our elders. … Value me as the caregiver, and I value you as the recipient of my care,” she said.

She recalled one instance in which she was cleaning up a client who had just used the toilet.

“This must be the most humiliating part of your job,” the client said.

Rigatti responded: “There is absolutely nothing humiliating about my job.”

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