Home Health & Hospice Week

More areas may be without service than you realize.

Home health and hospice agencies have known it for years, but the problem is finally getting more widespread notice — a critical shortage of nurses and aides to provide care in the home.

COVID-19 has brought a multitude of workforce problems into focus, ranging from pay to benefits to working conditions. Publicly traded companies addressed the issue in their latest earnings calls (see story, p. 69). And take a look at a sampling of recent mainstream press stories on the topic:

In Colorado: Grand County, a 15,700-person rural county, had no home health or hospice provider for eight months until for-profit Namaste Home Health was persuaded to cover the county last year, reports The Colorado Sun newspaper. One of the reasons agencies stay out of such counties is the large amount of billing, certification and payment processing work that can be a “huge lift for rural communities,” Jennifer Fanning, executive director of the Grand County Rural Health Network, told the Sun. Long commutes between patients, potential staff commuting to urban areas for higher wages, and a high cost of living in the communities are also factors.

Competition from other types of work is also a challenge. “It’s hard to recruit people into a field where you’re like,

‘I can go work at Amazon and make $20 an hour,’ versus this backbreaking work where you probably don’t have a lot of benefits,” said Chrissy Esposito, policy analyst at the Colorado Health Institute.

“Drastic changes to the payment model” are needed, Stephanie Einfeld, CEO of Northwest Colorado Health — the home health and hospice provider that left Grand County in 2020 — told the newspaper.

But even with a pay boost, staff are hard to find. Colorado implemented a Medicaid home health pay raise in December to ensure aides receive at least $15 per hour, reports The Denver Post. “We’re competing with Starbucks at $17 an hour and McDonalds at $15,” one Colorado Medical Services Board member said of the change. “It doesn’t go far enough, but it is so much better than where we were before.”

It’s a good next step, said one advocate. “Hopefully, it means an easier step to $17 an hour and $20 an hour,” Cody Jakubowski told the Post. “There’s caregivers on Medicaid taking care of clients on Medicaid.” In fact, 47 percent of aides are on some form of public assistance, the newspaper reports.

“There’s a pretty good chunk of care workers that have been homeless,” Jakubowski added.

State official Candace Bailey said the state will study whether $15 accomplishes the goal of increasing the home care workforce, but she expects more increases will be needed, according to the Post.

In Pennsylvania: The lack of caregivers is hitting parents of children with disabilities particularly hard, reports TV station KDKA in Pittsburgh. “It’s just not feasible to stay in this field with the pay rate,” one parent told the station.

“We are in a direct care worker, home health aide crisis,” Pennsylvania Homecare Association’s Teri Henning said. With Medicaid reimbursement at about $18 to $20 per hour, aides make $10 to $11 per hour, she noted. “In today’s marketplace when you can go down the street and do a lot simpler, easier, less demanding job for $15, $18, $20 an hour … there’s no contest,” Henning told KDKA.

In Massachusetts: “The ability to meet the needs of all the requests has been very limited, because we don’t have enough home health aides,” Elaine Fluet, CEO at Care Central VNA and Hospice in Gardner, told The Recorder newspaper. Many home care staff decided they didn’t feel safe working in patients’ homes during COVID, and they haven’t returned, Fluet related.

Elizabeth Davis, an aide with South Hadley-based O’Connell Care at Home, said the rise in demand for home care is unprecedented over the course of her 37-year career. “The reason we can’t get aides is because they are not paying enough,” Davis told the Recorder. “They are in competition with Dunkin’ Donuts or McDonald’s, because they are paying much more than home health care agencies,” she said.

“I’ve been in his work for 35 years, and it’s the most challenging time I’ve experienced because of the workforce shortage, and at a time when informal caregivers are not around,” said LifePath Executive Director Barbara Bodzin, according to the newspaper.

More challenges to filling both aide and nursing positions are the increased acuity of patients at home and vaccination requirements, multiple publications report. Vaccination rates are lower for direct care workers than for those in hospitals and nursing homes, reports The Atlantic.

In 2019, 41 states had a wait list for state-funded home care, with 820,000 waiting an average of 39 months for the service, according to The Atlantic. That was before the pandemic,” said Nicole Jorwic with advocacy organization Caring Across Generations. “That number has certainly gone up,” Jorwic told the magazine.

“The implications for older adults are dire,” says Kaiser Health News columnist Judith Graham about the shortage. “Some seniors who are ready for discharge are waiting in hospitals or rehabilitation centers for several days before home care services can be arranged. Some are returning home with less help than would be optimal. Some are experiencing cutbacks in services. And some simply can’t find care,” Graham highlights.

Worker availability does vary across states. America’s Health Rankings names New York as the state with the most aides at 442 per 1,000 adults aged 65 with a disability. On the other end of the spectrum is Florida, with just 53 aides per 1,000 such adults. (See your state’s ranking at https://www.americashealthrankings.org/explore/senior/measure/home_health_care_sr.)

Even the Medicare Payment Advisory Commission has raised the problem of home health and hospice access, particularly in rural areas (see HCW, Vol. XXXI, No. 2).

What Needs To Change?

While there are many accounts of the problem, solutions are harder to come by.

Salaries have been rising. For example, the national average hourly rate for hospice aides (CNAs) increased 4.52 percent in 2021, reports the Hospital & Healthcare Compen­sation Service in cooperation with the National Association for Home Care & Hospice, in its 2021-2022 Hospice Salary & Benefits Report released last November.

And the average hourly rate for Registered Nurses in home health agencies increased 2.98 percent in 2021, HCS says in its 2021-2022 Home Care Salary & Benefits Report released at the same time.

For RNs in all settings, pay rose about 4 percent in 2021, reports The Wall Street Journal. And that’s not including overtime and other “bonus” pay, the newspaper says.

Other states are also working on getting Medicaid pay raises through their legislatures.

“There is little doubt that nursing costs, like other healthcare costs, incurred by healthcare providers will never return to pre-COVID-19 [Public Health Emergency] levels,” maintains consulting and accounting firm The Health Group in Morgantown, West Virginia.

But nurses and aides need more. So say the authors of a study published recently in the American Nurses Association Online Journal of Issues in Nursing.

“Employees today seek more personal time versus financial compensation,” says the study by RNs Brenda Nevidjon with the Duke University School of Nursing and Jeanette Ives Erickson with Massachusetts General Hospital in Boston. And “employees want to be active both at work and at home, not choosing between the two,” they say in the study, The Nursing Shortage: Solutions for the Short and Long Term.

Nurses also want some control at work. “People who can create environments of teamwork and creativity are the definition of strong managers,” the study suggests. “No longer is top-down control seen as desirable.”

For aides, creating career ladders and offering education is attractive, Lorin Chevalier, founder of People Care Health Services and a board member of the Home Care and Hospice Association of Colorado, told the Denver Post.

Public recognition of aides’ professionalism and value is also appreciated, multiple sources emphasize.

Whatever efforts policymakers and providers undertake, “the shortage of healthcare professionals will not be eliminated soon,” The Health Group posits in its electronic newsletter. And the resulting rise in personnel costs will make its way into higher Medicare and Medicaid spending and higher health insurance premiums, the firm forecasts.

Note: See the OIJN study  at  https://ojin.nursingworld.org/MainMenuCategories/ThePracticeofProfessionalNursing/workforce/NursingShortage/Resources/NursingShortageSolutions.html.