They really are the heavy lifters. That's why the people who do the caregiving in America's nursing homes reportedly have the highest rates of workplace injuries and illnesses in the country.

Certified nursing assistants are eight times more likely than a roofer to suffer a back injury and twice as likely as a sheet metal worker to be bruised, according to the Public Health Institute.

For all this hard work, and the kindnesses they provide for families who can't or won't take care of an elderly relative, CNAs are paid about $10 an hour. Nationally, nearly 30 percent of direct-care workers (who include CNAs and the noncertified personal aides who do home care) live in households at or near the poverty level, and more than half have no health insurance.

"We pay them such paltry wages and expect them to take care of the people who should be our most revered," says Marilyn Luptak, assistant professor in the University of Utah School of Social Work.

No wonder, then, that there is a high turnover rate and a shortage. And it's only going to get worse, predicts Carrie Blakeway, senior manager with The Lewin Group, whose emphasis is long-term-care policy. "It's going to be a crisis pretty soon," she says. The increase in the "traditional" caregiving work force — generally women 24 to 45 — will lag far behind the number of elderly who will need them.

At Wasatch Valley Care Center, half of the residents don't have any outside contact at all, says former administrator Alec Stephenson, and another 25 percent have a visitor maybe once a month. CNAs become surrogate family.

At the funeral of one Wasatch Valley resident a few years ago, the woman's grandchild told CNA Pam Peterson that when his grandmother died "your name was the last one she called out."

"Verging on saints," is the way Salt Lake geriatrician Dr. Fred Gottlieb describes CNAs.

Occasionally a CNA abuses a resident. Even though the state Department of Health requires criminal background checks, if a CNA has previously assaulted someone the crime may still be wending its way through the court system, unbeknownst to the care center or home health agency that does the hiring. Or the abuse may have gone unnoticed or ignored. And sometimes the abuse goes the other way, because when people are old, sick and confused they might punch and slap and cuss the people trying to change their briefs or wake them for breakfast.

Juanita Albor has dodged the fist of the occasional confused or angry resident during her 28 years at Christus St. Joseph's Villa. Not long ago, she was helping a man in the bathroom when he took a swing at her.

But "anybody who took stuff like that personally couldn't ever work in a place like this," says Peterson, who has been a CNA at Wasatch Valley Healthcare Center for years. "Not everybody can do this type of work," she says, then adds, "Anybody who can come in and take care of them and not get attached to them shouldn't be here."

Albor says she thrives on the love she gives and receives back from residents at the nursing home. "I love coming into work, just to see these dear elderly people. If you go on vacation, you can hardly wait to see them again. And I have my favorites, but I treat everybody the same. A little hug, a little touch on the hands picks them up. To me, that is very, very important."

When she herself is old, she says, "I expect someone to take care of me the way I've taken care of them. I would not mind a nursing home, if that happens."

CNAs in Utah are listed on a registry maintained by the Davis Applied Technology Center, through a contract with Medicaid, and must by federal law complete a minimum of 75 hours of training. Personal-care workers, who do the bulk of the hired nonhealth home care in Utah, are usually not CNAs. Personal-care workers are not licensed by the state, so there is no training requirement — a situation that At Home Personal Care owner Randy Swartwood expects to change as the industry grows. Swartwood requires his personal-care aides to attend monthly in-service training, and says his goal is to hire people who want careers as caregivers. His best workers, he says, are middle-aged women whose children are grown and who haven't previously had another occupation.

Fifty percent of his work force, he says, are Polynesian, a figure that echoes a finding of the AARP Public Policy Institute: "The most intimate care to frail older persons in developed countries is increasingly provided by young women whose native language, race and culture are different from those they serve."

Receiving intimate care from a stranger is often one of the realities of old-old age, and many of the recipients discover to their surprise that this stranger has become, at the end of their lives, a dear friend.

Nidia McCray, a native of Uruguay and former CNA in nursing homes, was retired and "sitting in my house like this" — she slumps down in her chair — watching TV when she decided in her late 60s to sign on as a personal-care worker. A Bountiful woman named Pat explained her new friendship with the affable McCray this way: "We talk about our families. And we joke a lot."

One Salt Lake woman describes what happens every Monday morning when her mother's favorite home-care worker shows up at the door, after a weekend substitute: "Each weekend she seems to be dying, but when the lively caregiver comes, Mom perks up."

The anticipated shortage of health-care workers for the elderly also extends to physicians.

"It's a big dead moose on the table," says the Utah Medical Association's Val Bateman about the trend of physicians nationwide to limit the number of Medicare patients in their practices. "Those patients whose physician retired or left the area were having problems getting a new physician," says Bateman, quoting a survey from several years ago. "And the doctors who are baby boomers will be retiring." Nationwide, the number of geriatricians is down 4,500 from a decade ago.

It's hard to run a private geriatric medical practice and make any money, explains Salt Lake geriatrician Carol Baraldi. That's because of inadequate Medicare reimbursements and the extra time it takes to treat the old-old, who may have more medical problems, take multiple medications, be hard of hearing and forget appointments.

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