A ‘pivotal moment’ for home healthcare

Home healthcare is an industry poised for huge growth. Yet even as demand for care increases, the industry is hamstrung by obstacles to attracting and retaining workers.

It’s the best of times and the worst of times for home healthcare, as David Totaro, chief government affairs officer at Bayada Home Health Care and chairman of the Partnership for Medicaid Home-Based Care, puts it.

Home care is expanding, buoyed by advances in telehealth, an aging population with a desire to age in place and pandemic-inspired trepidation over congregate living facilities. But aides are underpaid, companies are limited by Medicaid funding and providers struggle to compete for workers with less demanding industries.

Laura Bradley, a caregiver with Home Helpers in Martinsburg, West Virginia, for the past three years, entered the industry after a career in the Coast Guard and at the Veterans Affairs Department. 

“The biggest reward is when you get a smile from someone you don’t often get a smile from,” Bradley said.

She loves the work and finds it rewarding—but doesn’t plan to stay in the profession. Bradley is nearly finished with a degree in therapeutic recreation and is considering pursuing a job in long-
term care, an elementary school or in veterans’ affairs.

Bradley’s story is one echoed across the industry, as home care aides wrestle with their love of the field and the realities of low pay, difficult work and few opportunities for promotion.

Workforce challenges

Bayada Home Health Care  has lost 23% of its home care aides since the first quarter, and 28% of shifts are open, meaning 28% of clients go unserved, Totaro said. The Moorestown, New Jersey-based company would need to hire 1,000+ additional aides to meet the demand in its home state alone, where it already employs 3,000, he said.

Recruiting personal care aides is a hard sell. The median annual wage for home health and personal care aides in May 2020 was $27,080, according to the U.S. Bureau of Labor Statistics.

Meanwhile, other fields with similar pay, such as retail and fast food, are raising wages and offering benefits such as childcare and tuition assistance. McDonald’s increased hourly pay an average of 10% in May and plans for average hourly wages to reach $15 by 2024 at company-owned restaurants. Target and Walmart both started fully covering college tuition for their employees.

Home Helpers Home Care, an in-home care agency based in Blue Ash, Ohio, aims to have a conditional hire within 72 hours after an inquiry for employment comes in, said President and CEO Emma Dickison.

“If they’re looking for employment, they’re not just looking at us. It’s a very competitive space,” Dickison said. “I used to say we were in an employment environment where we could go fish. Now we have to go hunt. Time is of the essence.”

Home care operators say their ability to increase wages and improve benefits is limited because of low Medicaid reimbursements. If Medicaid pays $15 to $18 for an hour of service, providers have to pay workers less to cover administrative and infrastructure costs, said Bill Dombi, president of the National Association for Home Care & Hospice.

The home care workforce more than doubled from 973,000 in 2009 to nearly 2.4 million in 2019, said Stephen McCall, a data and policy analyst at consulting firm PHI.

“There’s an extraordinary demand for this workforce,” McCall said. “The main factor contributing to growth in this space is the rapidly growing population of older adults.”

The number of people in the U.S. who are 65 and older is expected to increase from 54 million in 2019 to 81 million in 2040. Over that time, older people will go from constituting 16% of the population to 22%, according to the data from the Health and Human Services Department.

And many of those older adults want to age in place, rather than go to a residential care community or nursing home, McCall said. “That was probably always the case. The difference is, our policies and programs are now catching up to that,” he said. “We have demonstrated that services can be delivered safely at home, at lower cost than in institutions.”

Home care companies expect to add more than 1 million jobs from 2019 to 2029, McCall said. But the industry will have to address turnover and find ways to make the jobs desirable, he said. “Even for workers who love their jobs and love working with clients, in many cases they can’t afford to stay,” he said.

“There’s so much opportunity to innovate in the caregiving space,” McCall said. “I feel like there’s so much more that needs to be done. To stabilize this workforce and meet the demand, it’s going to require a pretty dramatic rethinking of these jobs.”

Higher wages are needed, which would require higher government reimbursement, McCall said. More than that, these workers must be made to feel like valued professionals and offered better training and paths to career advancement, he said.

Efforts by the Biden administration to invest in home care and its designation of caregiving as infrastructure makes this “a pivotal moment in our field,” McCall said.

Expansion of the home health universe

As it grows, the home health industry is also redefining what it means to receive care at home.

“You’re seeing the universe we call healthcare at home expanding in its nature but also its size,” Dombi said.

Higher-acuity care is being provided at home as technology advances and as restrictions on telehealth services eased during the COVID-19 pandemic, Dombi said. And care is being offered by a wider range of providers, including hospitals and health systems.

Telehealth was in its infancy just five years ago, said Dr. Angel Mena, an adult medicine doctor at Cincinnati-based TriHealth and chief medical information officer of Halo Health, a clinician collaboration platform. “In one year, it all exploded,” he said.

“You’re seeing a lot of collaboration and coming together of community organizations, providers and policymakers at the state and federal level to be able to integrate and deliver as much of the healthcare as possible at home,” said Dickison of Home Helpers, who also is president of the Home Care Association of America. “There are all kinds of services that now come into the home for healthcare, even dialysis.”

Ohio State Wexner Medical Center went from having 50 telehealth visits a month two years ago to nearly 3,000 per day now, said CEO Dr. Harold Paz. And the system is continuously looking at new ways to deliver care at home.

This year alone, Ohio State Wexner in Columbus has formed two new home care partnerships.

In July, the hospital teamed up with DispatchHealth, an in-home medical care provider, to offer acute-care services at home. Under the partnership, Ohio State Wexner patients and providers can request same-day at-home care for viral infections, chronic obstructive pulmonary disease complications, congestive heart failure and other ailments. Those services are coordinated with patients’ care teams.

The health system also launched a home health joint venture with Alternate Solutions Health Network to provide home health services in central Ohio. Patients are offered home care from a multidisciplinary team after surgery, for chronic or acute conditions like cancer, for nursing care, or for rehabilitation services.

The biggest challenge in the expansion of the home health continuum of care is coordination between different teams of caregivers, Halo Health’s Mena said.

“If today, coordinating care is a challenge within the walls of the hospital, just imagine how much of a challenge it would be to do it outside the walls of the hospital,” Mena said. “I think we’re still in the beginning.”