Houston home health caregiver Rachel Fuentes is struggling between her need to stay employed and her fear of the COVID-19 vaccine.
Fuentes, 43, worries that her employer will make vaccinations mandatory, or that she won't find clients who will let her care for them if she's unvaccinated.
One of her co-workers, a 33-year-old, is already facing that reality: The assisted living facility where her client lives has said that if she's not vaccinated by May 1, she won't be allowed in.
Both women say they are more afraid of the injection than of catching COVID-19, which both say they have staved off by following safety protocols for a year.
"I don't know what's going to happen to me. Health care is all I've known," said the 33-year-old, who asked to remain anonymous because she fears backlash from people who know her and because she hasn't told the older man she cares for that she will probably have to stop caring for him.
Like other home health agencies across the state, the women's employers at Encore Caregivers in Houston are trying to navigate a growing dilemma: Their clients want home-based caregivers to be vaccinated against COVID-19, but they fear that they soon won't have enough workers who are vaccinated to meet the demand.
"It's starting to rear its head," said Marilou Schopper, owner of Encore, which has more than 100 caregivers on staff. She said 10% of her staff has been vaccinated, and others have plans to be.
Home health and personal care aides help seniors and Texans with disabilities or debilitating illnesses to remain in their homes rather than move into a facility — which most prefer to avoid, according to government studies.
The caregivers are in the state's 1A priority group for front-line health workers but are struggling to get access to vaccines because most aren't affiliated with a state-approved vaccine provider like a hospital or nursing home.
In addition to lack of access, national surveys indicate that at least one-third are hesitant to take the vaccine, though those numbers appear to be decreasing, agency owners say. Researchers say that the main issues are distrust in the level of research on the vaccine and fear of side effects, among others.
Health experts and public officials widely agree that the vaccine is safe. Pfizer and Moderna reported their vaccines are 95% and 94% effective, respectively, at protecting people from serious illness, and while no vaccine is without side effects, clinical trials for both Pfizer and Moderna show serious reactions are rare.
As of May 2019, the U.S. Bureau of Labor Statistics reported some 300,820 personal care and home health attendants are working in Texas, not including those who are self-employed.
Patient demand, however, may push more caregivers like Fuentes to overcome their vaccine fears if they have a hard time finding clients.
More than 300,000 Texans are getting care at home or in community-based settings through nearly 6,000 home health companies or through private pay or similar avenues, according to a November 2020 report by the Texas Health and Human Services Commission.
If home health agencies start losing clients because they don't have enough vaccinated health workers, they'll have to lay off workers, said Darby Anderson, vice chair of the Partnership for Medicaid Home-Based Care, a national advocacy group.
"How will you keep my family safe?"
The only thing fending off a crisis, operators say, is that most clients know there aren't enough shots to go around, so many aren't demanding that their caregivers be vaccinated. For now.
"The market is very quickly pushing me towards having COVID-vaccinated staff that I'm going to need to get out to [clients]," said Travis Boldt, director of operations for At Your Side Home Care in Houston, which has about 100 employees. "People are already asking me if I can guarantee that the staff is vaccinated."
That is certainly true at Atria Senior Living in Houston, which offers assisted living, independent living, memory care and short-term stays for seniors. Its parent company, which operates facilities across the U.S. and runs vaccination clinics for residents in partnership with CVS, set a May 1 deadline for employees and private duty aides to be vaccinated.
"The No. 1 thing residents and family members want to know is, 'How will you keep my family safe?'" said Kathleen Dixon, vice president at Atria Senior Living. "We believe our residents deserve to live in a vaccinated environment and our employees deserve to work in a vaccinated environment. It's the responsible thing to do for as many people as possible to be vaccinated, and this includes private and home health aides who serve our residents."
Lora Roberts' 84-year-old mother, who has advanced Parkinson's disease, has been getting hospice care in her Plano home for more than two years and is unable to leave the house to get the vaccine. Roberts is shopping for a new agency that can guarantee her the staff will be vaccinated.
"They come in and out of the home, they go from home to home and they also go from home to nursing home, where we've had a horrible pandemic," Roberts said. "They have not vaccinated their staff. They know I'm mad about it, and I'm looking at taking her out of there."
If the problem goes unchecked, agencies could lose money and be forced to either scale back their operations or close altogether, which would reduce options for home-based care and potentially push more older Texans into costly residential facilities, Anderson said.
The 33-year-old with the client in the assisted living facility knows that refusing the shot likely means scuttling a career she's been building since she was a teenager.
"I think it's cruel to make people choose between keeping their job and getting a vaccine I don't want to get," she said.
Hesitancy and demand
In a recent national survey of more than 100 home health providers by the Home Health Care News group, only 10% said there was "universal acceptance" of the vaccine by staff.
The problem is so troubling to the industry that Anderson's group recently launched a national education campaign called "Be Wise, Immunize" to bring public awareness to home care workers, including testimonials and a website.
Home health workers are mostly women of color, at least half of them live in low-income households, and most have high school diplomas or general equivalency degrees. Research has shown that vaccine hesitancy is higher among people in those demographics.
At Griswold Home Care in San Antonio, administrators surveyed the agency's 130 field staffers in December to find out how many of them planned to be vaccinated. Fewer than 50 said yes, said spokesperson Ryan McGuire, who said the agency is working to educate and encourage staffers to get the vaccine.
Their efforts, combined with a national trend toward increasing acceptance of the vaccine, seem to be working, he said. At the end of January, he said, more than 100 said they wanted to be vaccinated.
"More people they know are getting it, and they're getting a little bit more information," he said. "I think more people are coming around to it."
At Encore Caregivers, Schopper is collecting testimonials from her staffers who have gotten the vaccine in order to help sell acceptance to her staff. In other outreach, she is actively helping them get vaccination appointments through Houston and Harris County-based programs.
Some of her employees, like Rashidat Falore, didn't have to be told twice.
"I wanted to do it, at all costs, because I don't want to catch COVID," said Falore, 60, a Nigerian immigrant who takes care of an 87-year-old client. "You don't want to get infected and infect your client. That's no good. She is vulnerable."
The next challenge
Most home health workers do not have the same access to the vaccine as their counterparts in hospitals, which are authorized to get vaccine allocations and can vaccinate their own staff on site.
Instead, home health workers frequently must get their shots from public vaccination hubs or through scarce public health programs, an arduous process as demand for vaccines in Texas still far outpaces supply, said Rachel Hammon, executive director for the Texas Association of Home Care and Hospice.
"It's been unnecessarily challenging, and agencies have been fighting tooth and nail, in every way, trying to piece together places for their employees to go get vaccinated," Hammon said.
Boldt, the operations director for At Your Side Home Care, said his agency is trying to find a way to help workers get vaccinated, including potentially offering bonuses for time spent getting the shot.
"Getting them the vaccine is really going to be the ultimate solution," he said.
A simple solution, Hammon said, would be if qualified home health agencies were allowed to administer the shot to their employees and clients — like they already are allowed to do with flu and pneumonia vaccines.
A recent change in federal law appeared to open the door to authorizing home health agencies to administer the COVID-19 vaccine in Texas, where they currently aren't allowed to do so, Hammon said. But agencies were notified last week by state health officials that they don't believe it preempts state law.
"It is unconscionable not to look for any possible way to allow for the mobilization of over 30,000 nurses to put shots in the arms of our most vulnerable Texans and the front-line workers who care for them every day," Hammon said.
A bill in the Texas Legislature would allow this, but it could take months to pass. The bill's author, state Rep. Donna Howard, D-Austin, said Gov. Greg Abbott should use his emergency powers and allow it temporarily through an executive order.
"Since the state's political leaders and medical experts are all in agreement that we must vaccinate all willing Texans against COVID-19 as swiftly and efficiently as possible, it should follow that we must do everything possible to make that happen — especially cutting away at red tape preventing health care providers from doing their jobs," Howard said. "An executive order from the governor is necessary to provide this temporary relief while the Legislature works to provide a permanent solution."
Meanwhile, home care workers like Fuentes and their employers are waiting to see what will happen in the next few months.
She has some time because her client, a frail 91-year-old, hasn't asked her to get vaccinated. But she knows that her choice to avoid the shot will, at some point, become a matter of deciding whether to stick to her guns or keep her job.
"I'll just work with the ones that are willing to work with me," she said. "I think eventually I will have to get it, but as long as I can push it off, I am."