Trina Tonorezos’ 71-year-old sister, bedridden from stage 4 cancer, recently wound up in a nursing home when she could not get approved for round-the-clock home care.

She’d wanted to remain in her Glen Cove home, where home health aides and hospice workers attended to her during the day. Yet the months before entering the nursing home hadn’t always run smoothly. When aides couldn’t come for whatever reason, the agencies that employed them “never sent anyone else,” said Tonorezos, 74, of Port Washington. “They said especially on a weekend they didn’t have replacements and I should take care of her.”

“I’m older than my sister and I can’t take care of her,” she said. “It was horrible. I wound up hurting myself trying to lift her one day … The aides from that agency were lovely, but I guess there weren’t enough of them.”

She is right. While the category of home care worker is one of the fastest-growing sectors in the United States, the need is growing even faster. The home care industry will have to grow by millions of workers to meet the needs of an aging population over the next decade, experts said, even as it struggles to recruit and retain enough workers to meet the need.

On Long Island, home health care agencies said they are sometimes unable to accept new cases or fully staff existing ones, especially on weekends and holidays, and in areas with poor access by public transportation such as Nassau’s North Shore and Suffolk’s East End. Some aides prefer cases in the city over ones in Nassau due to higher minimum wages and better transportation, agency leaders said.

Over the decades, shortages — which affect not only the elderly but also the disabled, including children, and people with dementia and disabling illness, at home and in residential facilities — have eased in economic downturns when other jobs aren’t readily available, and tightened when, as now, unemployment is low. Beyond the cycles, however, is the aging of the baby-boom generation.

Rick Schaefer, chief operating officer for Better Home Health Agency in Rockville Centre, estimated his workforce was down by 25 percent compared with the same time last year. Perhaps half the shortfall came from retirements, he said. “With more people aging out of the workforce and more people requiring services, it doesn’t seem sustainable as our workforce becomes our clients.”

Rising minimum wages in jobs outside home care also are contributing to the current shortage, said Kathy Febraio, president and CEO of the New York State Association of Healthcare Providers. “In the past, when there was a larger disparity between what home health workers were being paid versus [what] fast food and retail workers were being paid, we had an advantage,” she said. “Now that they are becoming more competitive, it’s more challenging for recruitment and retention of home health aides.”

Agencies are going the extra mile to try to attract, train and retain their workers. Star MultiCare Services, with offices on Long Island, Queens, Ohio, Pennsylvania and Florida, uses social media recruitment, email, texting platforms and referral bonuses to attract applicants, “anything we can do to try to make it easy for them to apply,” said Lauren Scalcione, the agency’s RN administrator.

“Years ago, we’d have people in our office coming in applying all the time. We don’t see that any longer,” she said, noting that the agency is sometimes unable to staff its cases on the weekends. The agency is certified to train new aides but can’t fill its classes “even for free,” she said.

She added, “It’s harder to attract young people to work as aides. What are they doing? I wish I knew.”

Sandy Myers, a spokeswoman for nonprofit Selfhelp Community Services on Long Island and New York City, said the agency sends its team of recruiters to community fairs, job fairs, laundromats and libraries, and uses partnerships with government agencies and “every medium that is out there to recruit these individuals … it brings alarm that we’re continuing to experience shortages.”

“There are many agencies on Long Island in a similar boat,” she said. “There are cases we cannot fill because of the shortage.”

Any changes to the nation’s immigration laws to favor wealthy and highly educated immigrants, as proposed by the Trump administration, also would have a chilling impact on the home care workforce. In New York State, significant numbers of home care workers come from other countries. Myers said more than a third of its trainees and new hires over the last year have been documented immigrants. A recent report by health care policy group PHI, based in the Bronx, found that New York “has one of the highest percentages of home care workers that are immigrants. They’re over half,” said Allison Cook, PHI’s New York policy manager. “So we really rely on immigrants to fill these jobs.”

And there are other issues squeezing agencies, and their workers, on Long Island and elsewhere. Agencies complain they are not fully compensated by Medicaid for state-mandated wages and overtime pay. In some cases, they’ve responded by cutting home health and personal care aides’ hours to avoid paying benefits, and ending or curtailing overtime, requiring more aides to staff a case.

Even facilities that care for the elderly and disabled must juggle to cover their shifts. At the assisted living residence The Regency of Glen Cove, executive director Beth Evans said the situation in the last year or two was “unbelievable, it’s like an epidemic.”

“We call home health agencies; even if we want to do an hourly rate to use their staff and even to hire our own staff, we’re finding it very difficult,” she said. Applicants “come here to fill out the paperwork and then don’t show up to work after we’ve done the physical and fingerprinting. I believe there are so many opportunities for them, and if there are no trains or buses when the shift is over at 11 at night, it’s very difficult.”

Shital Patel, labor market analyst on Long Island for the New York State Department of Labor, said home health agency demand for tables at the labor department’s job fairs far outpaces availability for their industry. And for the agencies who do get a recruiting table at the fairs, the job offers far outnumber the number of jobseekers who apply for them, she said.

But she projects a 53 percent increase in the number of home health aides working on Long Island in the coming decade. “It has been growing, and that is our assumption that there will be 53 percent growth.”

Nationally, the Bureau of Labor Statistics foresees home health aides and personal care aides as the third- and fourth-fastest-growing job categories between 2016 and 2026. That means that 7.8 million more people would have to take jobs in those categories to meet expanding demand as well as replace workers who retire or leave the industry for other kinds of jobs, experts said. According to the bureau’s projections, the decade from 2016 to 2026 will see the direct care workforce overall adding the greatest number of new jobs compared with other occupations in 38 states and become the largest workforce in 21 states.

From 2016 to 2026, New York State will need another 892,500 workers to fill new jobs and replace exiting workers in direct care. Of that, 744,700 workers would be needed in home care as aides by 2026, said Stephen Campbell, an analyst for PHI, which also coaches long-term-care providers on ways to better recruit, train and retain workers.

“I think that reports from the field already show employers are struggling to fill their openings,” he said, adding that the situation is “just going to continue to worsen. I think it just underlines the importance we address these problems now.”

Maria Alvarez, director of Statewide Senior Action Council in Albany and the coordinator for its Home Care Crisis Campaign, applauded the addition of $15 million to the New York State budget to help counties keep seniors at home, but said that because funds went out to counties based on their reported need, and counties don’t keep records of unmet need in the same way, “We’re not sure the need was truly met.”

In Nassau County, officials for the Office for the Aging said it would receive $348,000, but that the county was appealing to the state for more to bring down a waitlist that ranges from 100 up to 150, and waits that range from a day or two to several weeks. Deputy Commissioner Jorge Martinez said, “We work on this every single day … we’re hoping to give [agency partners] more resources so they can add more hours, a transportation package to enable seniors and aides to get to their locations.”

Carol Waldman is executive director of the Glen Cove Senior Center, serving up to 2,000 people in the community with services ranging from a day program for frail elderly to lectures, referral services, social events, home visits and a program where volunteers take local seniors to local medical appointments. Increasingly, the center is being asked to fill gaps in care caused by the shortage of home care workers, she said.

“We’re getting more and more people approaching us to try to meet the needs of people who really need a home health aide,” she said. “… Can we shop for them and take them to doctors, shovel snow and assist them in their homes in various ways. Lift them out of bed and help them get dressed.”

As demand rises, she said, she foresees more pressure on senior centers for services, “But we can’t provide the one-on-one support needed in many situations.”

For some aides, the work itself is rewarding despite the low pay or lack of benefits. Alma Gonzalez, 31, of Glen Cove, works part time as an aide, while her husband pays her family’s household expenses. Her experience, she said, came from helping her mother care for her grandmother in her home country of El Salvador. “I love my job, what I do for a living. I get to know the patients, how they feel, what’s bothering them. I spend a lot of time with them.”

Rick White of Astoria, Queens, said Gonzalez was his 88-year-old mother-in-law’s mainstay, but with the elderly woman’s frequent hospitalization, her home care was irregular. He and his wife went back and forth to fill in the gaps. Now that she has been approved for long-term home care, he said, they would do whatever they needed to do to make sure Gonzalez could work on the case. “Finding somebody that works well in the circumstances they are put into isn’t always the easiest thing in the world,” he said.

Roger Noyes, communications director for the Home Care Association of New York state, said that starting in 2011-12, the state required higher wages for its Medicaid home care cases, with a $3-an-hour higher minimum wage in New York City compared to Long Island and Westchester, plus an extra $1 in benefits. The resulting wage differential made it harder to recruit for Nassau County, he said, in particular for home health aides, nurses and physical therapists.

Noyes said his group recently surveyed its membership of home care providers and found that more than 17 percent of home health and personal care aide cases went unfilled. It also found a 20 percent shortfall in nurses, and another 20 percent shortfall in therapists.

Many agencies complain bitterly that while they are required to pay higher wages, their contracts with the managed long-term care plans — through which the state funnels Medicaid funding — don’t fully reimburse them for the costs.

Moreover, those managed care plans have been pruning the number of agencies they can contract with, and smaller agencies said they fear they’ll be forced out of Medicaid-funded long-term care while big corporate agencies take a bigger share of the market.

Ed Scher recently sold one of the two home care agencies he owned to a larger company owned by a private equity firm, as he grew frustrated with constraints and challenges in staffing and funding. He said that more agencies will lose their contracts to staff Medicaid cases in the fall, forcing many patients to find new agencies to send them aides, or to switch managed long-term care plans.

“Patients … may not get the same number of services or hours,” he said, adding he has observed that the plans “are being less generous with benefits.”

He said his own mother was forced to switch plans after her home care agency lost its contract, and was told she would only get an aide for eight hours a day instead of a live-in. He said he was eventually able to convince them to change their decision. “It’s a major dilemma.”

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