The downward trend in wages doesn't bode well for the future, considering the increasing demand for services. An HHS study in 2006 found that at a consistent rate of 50% turnover, the direct-care industry would have to find around 900,000 new hires in 2020 because of the country's aging population, both "baby boomers" and people with disabilities whose life expectancies are increasing.
And turnover comes with its own cost. In 1998, researchers at the University of Minnesota found the price of replacing 50% to 70% of the national direct support workforce, at a rate of nearly $1,400 for training each new employee, cost the healthcare system between $200 million and $300 million per year. Last year, LifeDesigns hired and trained 85 new direct support professionals at a cost of $136,000.
Those costs only will go up if predictions hold true and funding continues to drop.
"You have people who are legislators who set the rates," Hewitt said. "It's not people who are looking at demand or quality of services. It's fickle, because it's at the whim of the government's spending priorities."
A muffled scream answers Lauren Harding's knock. From outside the home, the sound is disturbing. But inside, it's understood as something sweet.
Harding, pleased, knocks one more time.
"Stephanie, she loves answering the door," Harding says.
Footsteps draw closer. The door swings open. A middle-aged woman in a red apron stares back with her mouth wide open. The greeting continues like a siren, a happy "hello" from someone who can't use words.
The client is in the caregiver's hands. An employee such as Harding, who knows the difference between excitement and a cry for help, is invaluable in a profession where lives are literally at stake.
One incident more than a year ago showed how important oversight is in this industry. Caregiver Ken Aker had contracted for LifeDesigns, and before that, Options for Better Living, for about a decade. State law mandated the company should have been sending employees to check on Aker and his client, Tammy West, twice a month. But no one had visited the home in three months when West, a woman with cerebral palsy, was rushed to the hospital in January with severe bedsores.
West died, and Aker is awaiting trial on a felony charge of neglect.
After that incident, LifeDesigns initiated an internal review of its oversight procedures last spring, and made changes. But not everything was caught, and residents would later lose Medicaid coverage because the agency had failed to adequately monitor clients' finances.
No one lost medical care during the lapse, and certainly no one suffered physical harm. But it showed what can go wrong in a system where every aspect of a life is in someone else's hands.
Keeping the best people to watch over clients is imperative. But there are no easy solutions. Wages matter, but raises by themselves would bring their own problems. The political push now is for a minimum wage of $10.10 per hour. Stone Belt's Green would love to see it for her employees, but it would destroy her agency.
"Financially speaking," Green said, "that would close our doors."
Erin Meyers isn't waiting for answers. As a house manager for Stone Belt, she has to work until the job is done. That means giving direction to Betsy Higgins, a client, who is working to form salmon mush into a loaf for tonight's dinner.
It can also mean a 13- to 14-hour shift, if another employee has to call out sick. She makes the same money she did years ago as a teaching assistant in Indianapolis. Later in the evening, she'll be responsible for sorting through a client's medication for the proper dose.
"What we are paid, for what we do, it just doesn't match up," she says.
She takes a napkin and wipes down the speckled wooden countertop and says, "I thought I was messy."
There are rewards for what can seem like a thankless job. Harding is currently developing a plan for a client to get their driver's license. For others, the goal might be to learn how to wash their hands.
First, they might learn the parts of the car. First, they might learn how to turn the faucet on. It could take them both five years to find independence, but it's worth it.
Meyers, who has been at Stone Belt for more than four years, is attached to her clients. After the deaths of a couple of the home's residents, she was there to provide a sympathetic shoulder.
Hewitt and researchers at Indiana University, including Teresa Grossi, had devised a plan to give people like Meyers and Harding more reason to stay.
In 2005, Hewitt, Grossi and others received funding from Indiana's Family and Social Services Administration to work out a credentialing program that would give direct support professionals a pay raise if they completed three levels of training. Ivy Tech Community College agreed to administer the classes during the trial period.
Studies have shown that giving employees a career ladder and opportunities for ongoing training lead to better employee retention. Indiana, Hewitt said, could have been a leader — could have been. New leadership at the Division of Disability and Rehabilitative Services stopped the project in midstream in 2009.
"They just crossed it all out," Hewitt said. "They were about cutting money, not new program development."
Politicians rarely speak ill about the need for programs, but problems continue with few solutions. Harding continues to scrape by, paycheck to paycheck. Meyers continues to sort through clients' medications, looking to the gas station down the street and wondering if she could work there and support two kids without going into debt.
"The vast majority of people say we want individuals with disabilities to have the care they deserve and in the political spectrum, there is no party division on that," Stone Belt's Green said. "But when it comes down to the brass tacks of what it takes to support people, things don't go as far as they should."