The growing concern about safety for home-bound patients comes at a time when payers, providers and patients all agree substantial growth in the industry would be a good thing. All three stakeholder groups have reasons to prefer care delivered in the home.
And that's fueling growth.
For insurers and providers, home care is much cheaper than time spent in the hospital. It also has the potential to improve continuity of care and avoid Medicare financial penalties for preventable readmissions.
“It's exploding,” says Michael Elsas, CEO of Cooperative Home Care Associates, a medium-sized home-care agency in New York with $60 million in annual revenue. “From a demographic vantage point, the demand will continue to increase as baby boomers hit the system. The boomers represent a whole new type of population. They are going to want to stay in their homes.”
Given the exploding opportunities, most new entrants into the home-based care business are for-profit businesses, not hospitals. The Medicare Payment Advisory Commission reported to Congress last March that home healthcare providers averaged 18% profit margins on Medicare business during the 2000s. Payment changes in the reform law are expected to hit average Medicare margins for home care, but they are still expected to remain at 14% in 2012, according to MedPAC.
The industry employs a wide variety of technical workers, many of whom already require licenses. Home-visiting clinicians include nurse practitioners, registered nurses and licensed practical nurses providing medical services for chronic conditions requiring post-acute or primary care services such as heart disease and diabetes. The home is a common site for physical, occupational and speech therapy, as well as hospice and palliative care.
However, scores of nonmedical direct-care staffers work in the field as personal-care aides and home health aides, cleaning homes, providing bathing and cooking services, and transporting patients. They are not just employed by hospitals or for-profit agencies reimbursed by Medicare, Medicaid and private insurers, but are often employed by families as “private duty” caregivers without insurance reimbursement.
Phyllis Stadtlander, CEO of Iowa Health Home Care, disputed a popular notion that nonmedical personnel are more prone to commit crimes against patients. “Is one more troublesome than the other? Not in my experience. Not if I've invested in them appropriately,” she says.
The various jobs are subject to a dizzying array professional standards, with the less-medical roles generally requiring less licensing and certification. In some states, nonmedical home-care workers are not regulated at all.
The strictest regulation comes from the CMS, but it only applies to agencies that receive Medicare payments. Such agencies are bound by Medicare conditions of participation that require home-care workers to treat patients' property with respect and notify home-health recipients that each state has a toll-free hotline for complaints and questions. However, Medicare covers only medical needs, not home-health aides' services. And the requirements do not apply to state-based Medicaid programs.
Professionally, some healthcare-related disciplines are regulated by particular license-granting boards, such as those for nurses and therapists. Likewise, organizations such as the Joint Commission, the Accreditation Commission for Health Care and the Community Health Accreditation Program provide voluntary certifications, which home-care companies can use as they promote themselves in competitive markets.
But much of the work of regulating the expanding home-visiting healthcare workforce falls to state governments. While the Social Security Act requires home-health agencies to follow state laws, state standards vary greatly. A national examination of those standards was last conducted in 2008, when the National Conference of State Legislatures received funding from the AARP Public Policy Institute to study the variation among states' home healthcare laws. At that time, several states had no requirements, while others had manifold rules governing which workers were exempt from background-check requirements and which crimes bar entry into the field.
A federal pilot program, which conducted background checks on direct patient-care workers in seven states in 2006 and 2007, found that nearly 7,500 people were excluded for past crimes among the more than 204,000 total applicants. Another 38,400 people withdrew their background check applications before they could be completed, according to an August 2008 report on the program.
But not everyone sees such measures as a panacea. “Obviously a criminal background check is important, and drug screening is important,” Elsas says. “But I would suggest that the interviewing and training process that we do does more to affect patient safety.”
Cisse Kane, the home-care worker convicted of a sex crime against a patient in Ohio, was prohibited from mentioning during his trial that his employer performed a criminal background check on him before he was hired, according to court records. Nevertheless, proponents of background checks such as AARP applaud their wider use. The organization lobbied for their inclusion in the reform law.
“Criminal background checks are one step that can be used to screen home-care workers and other workers and help prevent possible abuse and neglect of individuals who need long-term care services and support,” says Rhonda Richards, senior legislative representative for AARP. “I think every so often you hear problems, in the media or anecdotally. Certainly abuse or neglect of older adults is an issue, and this is one step that can be taken.”