Top Home Health, Home Care Legal Concerns for 2021

Wage-and-hour litigation, confusing state-level regulations and an increase in federal audits were among the biggest legal trends of 2020. While many of these issues will remain in the year ahead, 2021 will also bring several more legal hurdles for home-based care providers.

The decision of whether to mandate COVID-19 vaccinations for home health and home care workers is toward the top of that list. Other emerging legal battles that will shape 2021 include telehealth dos and don’ts.

To keep in-home care operators in the legal loop, Home Health Care News reached out to four attorneys who specialize in the field. The group of legal experts offered their take on the biggest focus areas of 2021.

Their responses are below, edited for length and clarity.

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An enormous challenge home care and home health providers face is remaining compliant with the myriad of federal, state, and local laws and regulations that continue to change at a record pace. It is critically important that providers have a comprehensive legislative tracking process and adopt proactive compliance strategies to both identify changes and modify their policies and procedures to conform appropriately. Providers that operate in multiple jurisdictions or states are especially confronted with this challenge.

One of the most straightforward examples is ensuring compliance with the payment of varying minimum-wage rates. The federal minimum wage is currently $7.25 per hour. However, the Biden administration will likely seek a $15 federal minimum wage. Many states already require a higher minimum wage, such as Colorado’s $12.32 requirement. Some states — such as California — have local jurisdictions, each with its own unique minimum wage requirements that often depend on the number of employees within a given business.

Another major trend to watch out for is the enactment of Domestic Workers Bills of Rights (DWBRs) across the nation. These laws provide specific requirements that employers within a given jurisdiction must adhere to with regard to minimum wages, overtime wages, discrimination and harassment complaints, training requirements and much more. Last year, Philadelphia became the 10th jurisdiction to enact employment legislation to protect domestic workers — and some may recall the federal DWBR legislation sponsored by Kamala Harris in 2019.

We can anticipate a revival of that effort under the Biden administration.

Angelo Spinola, co-chair of the home health and home care industry group at Littler Mendelson

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If I had to pick one legal issue to watch in 2021, it would be health care payment and coverage reform. While the Affordable Care Act was enacted over a decade ago, its wake continues to make waves in the health care sector. Legal challenges remain unresolved in the courts. Twelve states have not expanded Medicaid. Over 10% of Americans remain uninsured. Federal agencies continue to use their broad regulatory authority to push providers toward value-based reimbursement.

With the inauguration of Joe Biden, I anticipate seeing significant efforts to build on the ACA and, potentially, legislative attempts to expand coverage. While Democrats will control the White House and both chambers of Congress, their razor-thin margin in the Senate makes “Medicare for All” proposals unlikely.

Although the regulatory proposals have been overshadowed by recent events, the Trump administration has proposed or finalized rules that could have a significant impact on provider payment and oversight. A significant theme in 2021 will be the extent to which the Biden administration alters or replaces those rulemaking efforts

As we emerge from the pandemic — hopefully soon — federal and state governments and private payers will examine the many regulatory waivers and flexibilities granted during the public health emergency. Which ones will stay? Which will go? Only time will tell.

— Matt Wolfe, partner at Parker Poe

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2020 shined a spotlight on the importance of home health care, as in-person doctor visits were no longer accessible to seniors and facility-based providers dealt with depleted resources and fewer available beds. As access to services dwindled and remote care began to flourish, a massive inequity affecting home health care was revealed.

Remote care services are frequently not reimbursable in a home health setting — and any home health visits delivered via telehealth do not count toward LUPA thresholds during an episode of care. That policy essentially punishes these home health providers that use telehealth to supplement in-person care. In an environment swiftly moving toward value-based outcomes and technology-driven efficiencies, this disparity became evident to policymakers, who are now working toward a remedy.

For those companies who rely on fee-for-service income, the motivation to transform businesses using new technologies will continue to lag unless we figure out a way to increase financial incentives to enable such transformation. We should expect to see innovative home health companies form or participate in value-based enterprises under the newly published Anti-Kickback Statute safe harbors as a way to compensate for the current lack of reimbursement for virtual services.

— Rebecca Gwilt, partner at Nixon Gwilt Law

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The first half of 2021 will keep providers occupied with getting their employees and patients vaccinated. The pandemic has caused, in many respects, the reduction of home care hours as patients are concerned about aides bringing COVID-19 into the home.

The vaccine offers providers the opportunity to reassure their patients that the aides are not bringing the virus into the home. In turn, it’s a way to increase hours. Therefore, we anticipate that providers will launch wide-scale efforts to get their workers vaccinated. This will involve helping the caregivers understand the importance of being vaccinated and, in some cases, conditioning future and continued employment on the employees’ agreement to become vaccinated.

— Emina Poricanin, managing attorney of Poricanin Law

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Wage Bumps, Training and Long-Term Care Financing: Recommendations for Improving Caregiver Job Quality

The demand for caregivers continues to grow significantly. But unless job quality improves, filling these roles will be an uphill battle.

That’s according to PHI, a New York-based advocacy organization for direct care workers. On Tuesday, the organization released a new report detailing recommendations to improve job quality for caregivers.

Overall, the direct care workforce includes 4.6 million workers. About 2.4 million of these caregivers are home care workers.

Between 2018 and 2028, there will be an estimated 8.2 million job openings in direct care. This includes 1.3 million new jobs to meet the growing demand for care and 6.9 million openings caused by workers leaving this line of work.

Currently, there are a number of factors that impact job quality for caregivers, including low compensation, inadequate training, limited career advancement opportunities, and gender and racial inequalities. Those challenges, in turn, make it more difficult for home-based care providers to recruit and retain workers on a long-term basis.

“For too long, direct care jobs have remained poor quality, impacting workers, employers, and consumers and their families,” Robert Espinoza, vice president of policy at PHI, said in a press release statement. “A positive transformation of this job sector will make life easier for all of these groups.”

On top of existing challenges, the COVID-19 emergency has further compounded working conditions for caregivers.

“The impact of COVID-19 and an under-resourced system continues today as providers struggle to not only provide quality care but to adequately protect and support their workforce,” the PHI report stated.

In order to address workforce challenges, PHI made eight recommendations.

For starters, PHI is calling for reforms to long-term care financing. This includes increasing Medicaid reimbursement rates and strengthening public financing for long-term care.

PHI also is suggesting an increase in wages for caregivers. This includes paying workers a living wage, improving access to full-time schedules and enhancing workplace benefits.

Additionally, PHI recommends improving training standards, funding direct care workforce interventions, creating robust workforce data collection systems, and integrating caregivers into important advisory roles and leadership positions. It also says providers need to address systemic racial and gender barriers.

“This country is at a critical and promising moment in history when we can finally move forward a range of strong policy measures that improve direct care jobs and enhance care for older adults and people with disabilities — we need to act now,” Kezia Scales, director of policy research at PHI, said in a statement.

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59% of Health Care CFOs See Home Care as Key Investment Area

The majority of health care financial leaders view home care as a key area of investment.

That’s according to a recent survey from BDO, a Chicago-based accounting, tax, financial advisory and consulting organization. Released Monday, the survey includes the responses of 100 CFOs at U.S. health care organizations, including home health providers, with revenues ranging from $250 million to $3 billion.

Specifically, 12% of the CFOs surveyed were leaders at home health or hospice organizations.

The COVID-19 virus is among the drivers making home care a priority. One of the impacts of the public health emergency is that it forced many health care organizations to reevaluate their areas of focus and specialties in order to address patient needs.

When looking toward 2021, 59% of surveyed CFOs identified home care as a priority investment.

This finding further suggests that home-based care providers demonstrated their value in delivering care during the past several months. As the U.S. still faces ongoing COVID-19 surges, the demand for home-based care will likely continue to grow.

“The home health setting has seen many significant contributions to the value-based care supply chain,” Steven Shill, partner and national leader of the BDO Center for Healthcare Excellence & Innovation, told Home Health Care News in an email. “I think the pandemic has just served to confirm an already valuable process.”

Aside from home care, 56% of surveyed financial executives identified elder care as a priority investment.

Another 77% of CFOs said they’re looking to fund primary care.

“A significant number of in-home primary care users are the elder population,” Shill said. “As there is a transition to Medicare Advantage, you will see an acceleration of in-home primary care. The reason is that, when a physician, nurse or [physician’s assistant] visits higher-risk patients in their homes, patients are less likely to need emergency room visits, acute care hospitalizations or institutionalization in a [skilled nursing facility] for example. This will likely reduce the overall costs.”

In addition to identifying key investment areas, the survey also touched on emerging trends. From an M&A perspective, for example, 42% of surveyed CFOs said they believe the COVID-19 emergency will cause increased consolidation throughout health care.

In fact, many health care organizations went into the public health emergency with already weakened balance sheets, according to Shill.

Many have been able to stay afloat thanks to the Paycheck Protection Program (PPP) and CARES Act funding, but eventually, those wells will run dry.

“The focus on consumerism, the move towards value-based care and a major drive toward digitization in health care — trends that existed prior to the pandemic — all contributed to consolidation,” Shill said. “Many health care organizations pre-pandemic did not have the resources to address these trends, which in turn caused them to have weakened positions in the marketplace, increasingly inefficient operations and significant losses to patient volumes, all ultimately resulting in them becoming financially weakened and forcing them to either merge, be acquired or shut down.”

Additionally, BDO’s survey found that partnerships will likely take center stage in 2021.

About 31% of surveyed CFOs said they had plans to acquire physician practices. Another 28% said they planned on merging with another organization, with 24% planning to form a joint venture.

In the home-based care space, this move toward partnerships could be a business opportunity for providers.

“The home health sector has historically been heavily fragmented, often lacking professional leadership and appropriate levels of capital investment,” Shill said. “That is why, in the few years prior to the pandemic, it was getting a lot of attention from private equity. As institutional health care continues focusing on value-based care and overlaying it with the impact of the pandemic, it would seem that this type of partnership will likely see an acceleration.”

BDO’s survey was conducted by Rabin Research Company, an independent marketing research firm.

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Right at Home Sets Sights on ‘Boomer Consumers’ with Custom Aging-in-Place Approach

For reasons beyond the coronavirus alone, 2020 was an unprecedented, action-packed year for home care operators. This year is guaranteed to bring more disruption as well, particularly as U.S. demographics continue to skew older and as the overall health care system looks to decentralize traditional models.

Omaha, Nebraska-based Right at Home — an international home care franchise system with roughly 500 domestic locations — is working to stay ahead of the curve.

In part, that means launching new service offerings to better target “boomer consumers,” a population that prefers to take charge of their aging-in-place strategy. It also means accelerating market development with a mix of de novos locations, new franchise openings and acquisitions.

To learn more about Right at Home’s 2020 and plans for 2021, Home Health Care News recently caught up with CEO and President Brian Petranick. Highlights from that conversation are below, edited for length and clarity.

HHCN: Can you start by briefly recapping Right at Home’s 2020, if that’s even possible after all the challenges you had to face?

Petranick: It was an interesting year. And this is a good time for this conversation, because I’ve been doing a bunch of reflection on 2020 over the last few weeks. I always get very reflective this time of year.

Let me start off by saying that I am incredibly proud of our team, including both our franchise system and our corporate-owned locations. I’m so proud of everybody, top to bottom in our network, in addition to our international partners. With COVID-19, we saw the real concern surface toward the end of February. Then all sudden, by March, it was like, “Oh my god! Here we are. We’ve got a potential pandemic on our hands.”

I’m sure every organization out there did some level of projecting, thinking about worst-case scenarios. We certainly did. And you know what? We never came close to that. We had about a six-week period of time where our business faced pretty significant losses. That was from March 1 to the middle of April. From that point on, we’ve been building back up and growing very steadily. We actually had a record level of volume across our system during the last week in February, right before the pandemic became “official.” We had our highest amount of volume in the domestic U.S. system — ever.

Well, we got back to that volume. We even exceeded those record numbers by September. We’ve been hanging around that all-time high, breaking records week after week. We’re on a pretty good trajectory here. But with that being said, we know infection rates shot up right after Thanksgiving and may rise again due to the winter holidays.

Again, I would say, in summation, that I’m incredibly proud of our year and our people. I’m proud of the way people responded. I know they’re tired. They’re fatigued. But they’re resilient. We’ve learned a lot about our team here at Right at Home, in terms of how we can respond to a crisis and how quickly we can make decisions. There are so many positives that have come out of this really awful year, at least from that standpoint.

How did Right at Home grow in terms of number of new territories or new locations?

We probably had a little bit lesser growth in that area than we’ve had in the past. Some of that is obviously due to the pandemic. But looking back on 2020, we are finishing up with a handful of — maybe about 10 — new operating territories. Some of those are corporate-owned, while some are new franchises that have opened.

What were the biggest challenges you had to navigate in 2020? I know you already mentioned fatigue, for example. There’s, of course, personal protective equipment (PPE) procurement.

I think it was broadly managing the volume and the speed of change in an efficient and effective manner. Early on, there was so much information flowing from different sources — PPE policies, infection protocols and more. We had to figure out, at the corporate level, how to get all of that information and filter it in a meaningful way to the people who are operating the local offices.

Our goal was to take that information and give our team the tools to act on it without having to think a whole lot. Instead of operators having to do their own extensive research, we wanted to say, “Hey, we’re here. This is what we know. This is what we’re learning. Here’s how you need to apply this in your business.”

There was a lot to decipher. But out of everything, I think we got the most questions about dealing with the Paycheck Protection Program (PPP) loan and PPE protocols. Understandably, there was also confusion about cities being shut down, with caregivers sometimes being in this murky area of “essential” or “non-essential.”

So much changed on a daily, even hourly basis. Ultimately, I think our biggest success was our ability to take all of that information and rapidly distribute it in a meaningful way, allowing our partners to focus on their caregivers and clients.

The debate around home care staff being “essential” from a regulation standpoint surprised me. Was that somewhat revealing to you? Seems like there’s a ton of advocacy left to do.

Exactly. I think, to some degree, it was eye-opening. But we’ve always known that some people, policymakers and insurance companies don’t truly understand what it is that we do. When policies are rushed out the door during a pandemic and you see that you’re not included in something important, it crystalizes that idea.

It’s good and bad. The bad is that it highlights how others view our industry at the moment. And the good is that we can more clearly see where there are opportunities to start open discussions about home care.

Listen, policymakers have been trying to figure it all out. They also need help. Right at Home — independently, as well as a part of the bigger coalition of the Home Care Association of America (HCAOA) and other advocacy groups — continues to get in front of policymakers to have those key conversations. That will benefit us, long term.

It’s going to be interesting to watch as policymakers and others start writing new policies and reimbursement schedules around shifting more care into the home. Do they really understand the dynamics of the home environment and all the different types of care delivery models?

How about two or three predictions for the new year. What do you expect for home care in 2021, maybe even looking beyond COVID-19?

None of this is probably going to be a surprise for you. But I would start by saying that we’re clearly on a path where there is just more change, more disruption coming. I’m talking about changes in the health care system, changes in U.S. demographics, changes to reimbursement models — all of those things. As we think about home care in 2021, we need to expect more change.

This acceleration to the pace of disruption is partly due to the pandemic. That isn’t doing anything to slow the changes down. But we’re also coming off of a presidential election. There could be some big philosophical changes coming into the White House. For as much as people want 2021 to be calm and a year where we get back to normal, there will be a lot to navigate. I think it’s going to be a lot like 2020, just in different ways.

With all that disruption will likewise come an increase to the level of sophistication within home care. Operators — independent home care providers and individuals who are part of a franchise system — will have to become more sophisticated in their approach to business. Wage pressures are increasing. Service costs are increasing costs. The traditional structures of health care are evolving, with more Medicare Advantage opportunities and new initiatives, including hospital-at-home programs. Operators will need to be overall more sophisticated to succeed.

What else? I would say — again, not shocking — there will be more collaboration between home health, home care and the broader health care sector. There’s just so much focus right now on bringing down the cost of care. The best way to do that is with stronger collaboration across the board.

A final prediction for 2021 is that the “boomer consumer” will take centerstage. We’re starting to deal a lot more with baby boomers — and they just have very, very different demands in regard to the care they want. They want to control that care and how they interact with their care providers. We should see a lot more focus on the boomer consumer outside of health care, too.

What’s an example of that? How is your “boomer consumer” different than the traditional home care consumer from a generation before?

It’s a great question. Some of this will probably be overly broad, but I think the generation before — the post-depression era, let’s say — was a generation that didn’t question their doctors. If a doctor said, “Here, this is what you need,” then they just did it. They were raised to listen to their doctors. That’s not the boomer generation or any other generation. They’re the WebMD generation, the Google generation. They’re used to going in and searching for answers on their own. And they’re used to getting what they want.

Boomers have had a lot of resources. They’re typically wealthy, as a group. They’re used to BMWs, Starbucks and those types of things. I think they’re going to expect more from their home care providers, more from all of their health care providers.

We’ve already seen some of that, right? If you look at the way hospitals were in the 80s and, to some degree, the 90s, you had to pay all kinds of money for a private room. Now, some of these hospitals are like hotels. You get a single room. You’re ordering off of menus. We’ve all got different expectations now.

We’ve already operationalized some of those changes, but there’s definitely more coming because we’re still on the leading edge of the baby boom generation. At the end of the day, they want more communication, more choice and a better experience.

How about two or three predictions for Right at Home? What specific goals or strategies did you have in mind for 2021?

You’ll definitely see from us more accelerated market development. I don’t think that’s a secret. At this point, everybody knows we’re opening up more corporate-owned locations, where we’re doing de novos. That means going into markets where we don’t have offices now and opening from scratch. We’re also growing through acquisition of independents in some of the markets where we’re interested in going. We’re still franchising. We’re just kind of agnostic to how we grow. But we want more market development. That’s No. 1.

No. 2, we’re thinking about all these changes that are happening in health care. We want to make sure we’re moving in the right direction. We want to make sure that we’re buttoned up on our data and thinking strategically about how we’re leveraging our data. We’re going to continue to put a lot of focus on our, like I talked about earlier, sophistication level. We know that we need to position ourselves best for working with the broader health care system and home health partners.

Lastly, we’re looking at all kinds of different ways to broaden our value proposition to our clients. That partly means hitting on what the boomer consumer wants. We’re not thinking about ourselves as just a home care company. How do we think broader? Where are there other opportunities to add to our own value proposition? There are some really interesting models out there that we’re looking at.

What do you mean by that?

Care coordination is an example. To use one analogy: Most people, when they build a custom home, they don’t do it themselves. You could hire a plumber. You could hire an electrician. You could hire a framer. You can hire all of those people individually. You can have somebody come in and put your foundation in and do your grading and all of that stuff. You don’t need the contractor.

But what the contractor does is make it easy. The contractor becomes the middleman and coordinates all of those other things. All you have to do, as the homeowner, is decide on design, your choice of your tile, your carpet, your paint. I think there’s going to be more of a demand for that type of service in home care.

If you think about it, there’s probably 5,000 different pieces of technology that somebody can bring into the home to help with the aging process. Well, who in their right mind has time to research 5,000 pieces of technology, from a consumer perspective? Or 50 home care companies? Or 20 transportation companies? I think there is an opportunity for somebody that can come in and help people manage the broader aging process, not just one aspect of it.

What else is important to touch on?

One of the things we have to be very, very cognizant of is the impact of COVID fatigue. I can’t stress that enough. We’ve had a strong year at Right at Home. I’m incredibly proud of our team. But we’re tired. People are just tired after operating at really, really high levels for nine or 10 months. COVID fatigue is real. It’s a challenge, but people are going to have to fight that off as best as they possibly can in 2021.

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New York Moves Up COVID-19 Vaccination Eligibility for Home Care, Hospice Workers

Home care and hospice workers are now part of the pool of New Yorkers eligible to receive the COVID-19 vaccine.

The New York State Department of Health originally announced that home care and hospice workers would be eligible to receive the first dose of the vaccine starting on Jan. 11. This placed these individuals in the Week 5 group of the state vaccination program.

The department updated that plan last Monday, moving home care and hospice workers to the Week 4 group receiving the vaccine starting on Jan. 4. 

This development didn’t just happen overnight. In fact, it was the result of a significant push from New York home-based care associations, Roger Noyes, director of communications at the Home Care Association of New York State (HCA-NYS), told Home Health Care News.

“I would say that is a huge development, and it’s something that we’ve been pushing for several weeks to ensure that there was a prioritization in Phase 1A for home care and hospice workers,” he said. “It took a lot of conversations with the state department of health and the city department of health.”

HCA-NYS is a state trade organization that represents nearly 400 home- and community-based care providers and organizations.

Noyes noted that — because of the infrastructure currently in place, which involves the 10 regional hubs of New York overseeing the vaccination system — the distribution-planning process involved multiple conversations with various agencies and players. 

Home Healthcare Workers of America was also part of the overall advocacy push. The organization, which represents over 26,000 in-home care workers, saw firsthand the need for urgency when it comes to vaccination.

“During this time, tragically, we have lost 12 aides from the start of this to the present,” Joe Pecora Jr., the organization’s vice president, told HHCN. “Our members were desperately asking for access to the vaccine. We’re happy that the governor’s office and the department of health have agreed to move up their eligibility. This is a lifeline.”

New York state employs more than 210,000 home care aides, labor statistics show.

Home Healthcare Workers of America is a part of the International Union of Journeymen and Allied Trades (IUJAT). The organization represents workers primarily located in the five boroughs of New York City.

Throughout the COVID-19 emergency, visibility has been a major challenge for home-based care organizations. At times, this resulted in these organizations being overlooked.

Being prioritized for vaccine eligibility represents a shift, according to Noyes.

“Whether it was [personal protective equipment] status or authorization to visit patients in their own homes when there were travel restrictions in place, this has been an issue,” he said. “To now have, at this pivotal stage of the vaccination rollout, home care and hospice workers in early, that is an important accomplishment.”

For now, HCA-NYS has been keeping its members updated on the logistics and procedures for actually getting the vaccine.

It’s a process that has run the gamut, according to Noyes.

“For instance, some agencies, I understand, have ordered the vaccine, and I don’t know whether they’ve received it yet, but they have plans to vaccinate their own staff — to actually have their own agency be the point of dispensing a vaccine for their workers,” he said.

Meanwhile, other agencies have opted to instruct their staff to essentially make their own appointments with the various dispensing hubs that are being set up across the state.

In these cases, HCA-NYS has provided instructions around what information workers need to bring to these appointments in order to prove they’re Phase 1A. Similarly, it has helped its members understand what documentation they need to retrieve from the vaccination site.

So far, New York City’s mass vaccination efforts have gotten off to a rough start.

Despite a surge of new COVID-19 cases, few people have been vaccinated. This has left public health experts concerned, according to reports from The New York Times.

Overall, only 167,949 of 489,325 doses of the vaccine — roughly 34% — have been administered as of Friday. The rate for New York state overall is over 40%, according to The New York Times.

The vaccination rollout potentially creating hiccups that would impact home care and hospice workers is a concern, according to Noyes.

“Home care and hospice workers are now in priority 1A,” he said. “But if there’s concern that the vaccine is not being administered to health care workers at the rate it should be because of hesitancy, … then there’s going to be a big impetus to push through to the other phases. Certainly, there are other priority groups that need the vaccine quickly, but my concern is whether or not this push could squeeze out access for home care and hospice workers.”

Elsewhere, early last week Los Angeles County’s home care companies received confirmation that non-medical caregivers are part of the first group eligible for vaccination.

Prior to this confirmation, home care companies weren’t clear on whether their employees were part of this group, which includes their home health counterparts.

Home health leaders and clinicians in various parts of the country have also begun to highlight their vaccine experiences on social media. That group includes Dr. Steve Landers, president and CEO of the Visiting Nurse Association Health Group Inc.

Senior living operators have ramped up their vaccination efforts as well.

On Dec. 21, for example, Brookdale Senior Living Inc. (NYSE: BKD) announced it had held its first community vaccine clinics, with plans to schedule more across the company’s 726 communities.

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Senior Housing Occupancy Hits Record Low, Suggesting More Tailwinds for ‘Aging-in-Place’ Providers

Senior housing occupancy in the U.S. hit a record low in the fourth quarter of 2020, according to the National Investment Center for Housing & Care (NIC).

The record downturn is further proof that seniors and their families are looking for alternative long-term care options, at least until a vaccine is widely distributed and concerns about congregate living are lifted. The numbers out of NIC similarly suggest that tailwinds for home-based care providers are likely to persist — and maybe even grow stronger.

The final quarter of 2020 brought another decrease in senior housing occupancy, from 82% in Q3 to 80.7% in Q4. The 1.3% drop brought the total loss in occupancy up to 6.8% since Q1 of 2020.

Declining occupancy in senior housing was the story for nearly all of 2020, with no month standing as the main culprit. Occupancy fell steadily each month after March, according to NIC data.

While the drop in Q4 wasn’t as drastic as Q2 and Q3, it’s likely that the trend isn’t yet over.

“Senior housing occupancy declines were less pronounced in the fourth quarter than the previous two quarters, though the fourth quarter decline is still quite large from a historic perspective,” NIC’s chief economist, Beth Burnham Mace, said in a press release. “The surge in COVID-19 cases following Thanksgiving and Christmas suggests further disruption lies ahead. That said, the recent distribution of the vaccines should soon provide some relief.”

NIC conducts intra-quarterly occupancy rate updates, covering 31 major metropolitan markets. Within those markets, there is some degree of disparity, NIC notes.

For instance, in California, San Jose and San Francisco all remained right around or above 85% occupancy — as did Seattle in neighboring Washington. On the other hand, Houston, Cleveland and Miami all checked in below 77% in terms of occupancy rates, with Houston falling all the way to 73.5%.

That is the lowest out of all markets reviewed by NIC.

“The COVID-19 pandemic has impacted move-ins and move-outs across senior living properties,” Chuck Harry, chief operating officer of NIC, said in the release. “Move-ins slowed as operators enacted moratoriums to keep residents safe and as safety protocols limited new leasing activity, while move-outs have been affected as residents moved to higher-acuity care settings.”

Assisted living occupancy also fell another 1.3%, to 77.7% in Q4. Independent living occupancy dropped to 83.5%, falling by 1.4%. Those occupancy numbers have fallen at a similar rate to senior housing, around 6% to 7%.

There are home-based care operators involved in senior housing, such as BrightStar Care.

But BrightStar’s senior living segment hasn’t experienced the same headwinds

In September, BrightStar CEO Shelly Sun told Home Health Care News that she had seen significant growth in the company’s communities in 2020. She credited that to the more personal space that BrightStar had created in its brick-and-mortar locations.

“The concept of a lot of personal space has really resonated in the community,” Sun said. “There’s very strong interest in [them]. And I think a lot of that is because a lot of the choices around assisted living or memory care tend to be hundred 200- to 300-room formats.”

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Interim’s New Recruitment Campaign Targets Job Candidates Looking to Make a Career Transition

Finding enough workers has been a longstanding pain point for in-home care providers. With the launch of a new national recruitment campaign, Interim HealthCare wants to take a proactive approach to address those persistent challenges.

Interim is a Sunrise, Florida-based in-home care franchise with more than 530 locations across the U.S.

The company recently launched “Made for This,” a recruitment campaign that focuses on placing job candidates in careers in the home-based care industry.

“We are innovating again,” Jennifer Sheets, president and CEO of Interim, told Home Health Care News. “We’re at the table realizing that the health care industry is facing critical shortages. We’re all focused on recruiting — and we always have been.”

In part, in-home care providers have struggled with recruiting enough workers simply because consumer demand is so high. The overall employment of home health and personal care aides, in fact, is projected to grow 34% from 2019 to 2029, much faster than the average for all other occupations, according to the U.S. Bureau of Labor Statistics (BLS).

But being an in-home care worker is also a difficult job, one that’s sometimes overshadowed by similar caregiver roles in other settings.

As part of its new recruiting efforts, Interim’s campaign includes opportunities for professional expansion, professional development and specialized training, Sheets said. All of those points are critical for cultivating a new candidate pool.

“What we’re trying to do here is create a new pool of candidates who are different from anybody we’ve recruited in the past,” Sheets added.

In some ways, the current climate has laid out the groundwork for Interim’s recruiting campaign.

For starters, the COVID-19 emergency has resulted in a surge in unemployment. About 25% of adults in the U.S. report that they or someone in their household have lost their job, according to the Pew Research Center.

Job loss was especially prevalent among individuals working in service industries in the months following the onset of the pandemic.

Roughly 1.9 million store-based retail workers were unemployed as of June, according to BLS. The leisure and hospitality industry had lost 7.7 million jobs as of May.

Additionally, 5.5 million food service workers experienced job loss.

People working in these service-oriented industries often already possess the qualities that providers are looking for when it comes to job candidates, home care experts believe.

This creates the opportunity for a career change for these workers and gives the in-home care industry a recruitment boon, according to Sheets.

“We really wanted to highlight the open door for a professional career change,” she said. “There are a lot of people out of work. There are a lot of people who are already in a customer service-facing industry. These people already have a heart for servant leadership and may not even realize that they’re actually perfect for — or made for — health care. That was the idea behind it.”

Aside from trying to reach individuals who have a background in other service-related industries, Made for This also targets individuals who are looking for “purpose-driven” work. A desire to transition into a mission-driven job is a common goal for individuals following economic recessions.

Interim’s campaign is also setting its sights on individuals who are already working in health care and interested in transitioning into the home-based care side.

“If somebody wants to go from a restaurant employee to a CNA, or from a CNA to an LPN or therapist, we can support them along the way,” Sheets said. “It’s about pathways to help them go from that setting to a health care setting, or to go from a hospital setting to a home care setting.”

In order to help someone transition into home-based care, the campaign tailors training and education based on an individual’s background and experience.

“You can’t just go from one setting to the other, so this program is about helping people fill those gaps through education, through mentoring, through a very defined onboarding and orientation process,” Sheets said. The biggest thing to keep in mind, from my perspective, is what Interim brings to the table.”

Sheets is referencing Interim’s 54-year history of training people to be successful in the health care space.

Carolina Lobo, the company’s chief people officer, calls this ability the organization’s “lifeline.”

Amid the public health emergency, Sheets points out that there are a number of reasons the home setting may have a new appeal for those currently working in hospitals.

“We find that nurses and therapists are getting burned out in the hospital setting — especially in the midst of the pandemic,” she said. “They want more control in their lives. They’re looking for flexibility. A lot of them are also heads of household. They’re looking for ways to work around their kids’ virtual learning environment, and they want autonomy to make a long-term impact.”

For Sheets, helping clinicians who want to switch lanes career-wise comes from personal experience. She is a former ICU nurse who would go on to hold a leadership position running several hospitals, before ultimately landing in her current position.

“I realized I wanted to be a part of home care after I had my own story,” she said. “I had my father and my grandmother on home care, home health and hospice services at the same time, and I wanted to be a part of that setting. I realized that [this setting] was driving the real quality of life that people want and deserve.”

Although it’s still early in the new year, looking ahead, Sheets believes the industry will continue to see critical shortages as it relates to the 2021 labor landscape.

“Hopefully, a lot of health care workers will get the vaccine, but we’re still going to deal with people who are out because of an exposure,” she said. “This environment is extremely hard for the health care worker, … so we’re going to see a higher burnout — even more than we are seeing now.”

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Amedisys Adds New Board Member; UVMHN Tabs New President

Samuels joins the Amedisys board

Amedisys Inc. (Nasdaq: AMED) has named Ivanetta Davis Samuels to its board of directors. She became officially active in her role on Dec. 15.

“I am excited to welcome Ivanetta and her vast leadership experience to our Board of Directors,” Amedisys CEO and President Paul Kusserow said in a statement. “Her unique legal and public policy experience will provide our leadership team with a new and broader perspective as we continue our journey to becoming the solution for those who want to age in place.”

Baton Rouge, Louisiana-based Amedisys is a provider of home health, hospice and personal care services. It operates in 39 states and Washington, D.C.

On Samuels end, she has a vast law background and is excited about the opportunity to operate on a board with various forms of voices on it.

“I am honored to join the Amedisys Board of Directors,” Samuels said in a statement. “As a woman of color who understands the importance of diverse perspectives, I am especially thrilled to be a part of a leading healthcare organization with a board composed in its majority by women, that is intentionally providing equitable and inclusive quality care to all of its patients.”

Currently, Samuels is the senior VP, general counsel and corporate secretary for Meharry Medical College. She oversees legal affairs and transactions, including litigation management, policy management, immigration services, compliance, risk management and environmental health and safety, according to the Amedisys release.

UVMHN announces new president

The University of Vermont Health Network (UVMHN) announced that Adrianne Johnson Ross had been named the next president of Home Health & Hospice as well as COO. Johnson Ross will take over for Judy Peterson, who is retiring from her post after eight years.

“For decades and throughout this pandemic, home health and hospice professionals have played a crucial role in the delivery of essential care,” Johnson Ross said. “I believe home health is central to the future of health care delivery and will continue to expand and reach more families, ensuring patients will remain as comfortable as possible while receiving care.”

UVMHN Home Health & Hospice previously operated under the name The Visiting Nurse Association of Chittenden and Grand Isle Counties. The brand changed when it joined UVMHN in January 2018. It’s the first affiliate of the network to provide post-acute, community-based care.

The nonprofit organization delivers home health and hospice care to individuals of all ages across two dozen towns in Vermont.

“Adrianne brings an innovative mindset to help us think about our services and care delivery to our community,” Tara Pacy, chair of the home health and hospice arm’s board of directors, said in a statement. “I am excited about her energy and passion for our organization.”

Griswold Home Care’s names director of marketing

Griswold Home Care has created a new position — the director of marketing — and has hired Shelly Kanther to serve in the role.

The Blue Bell, Pennsylvania-based company offers home care, personal care and respite care services as well as companion care to patients. Its network consists of 200 locations spanning 30 states.

Kanther has wide-ranging knowledge of digital marketing, most recently serving as a marketing and digital strategy consultant at the New England Appliance & Electronics Groups (NEAEG).

“Our goal to elevate and modernize the Griswold Home Care brand requires fresh eyes and a digital-first mindset,” CEO Michael Slupecki said in a statement. “Shelley’s familiarity in online strategy for local small businesses provides experience similar to working with a franchise network, while bringing innovative ideas and the shift in perspective we’ve been looking for.”

Axxess adds home care expert to senior leadership team

Axxess, the Dallas-based home health technology company, has bolstered its leadership team by hiring a non-medical, private-pay home care expert.

Patricia Drea joins the Axxess team after serving as COO of home care company Visiting Angels for 12 years. Drea also served as chair of the organization’s board of directors during that time.

“Pat will be an invaluable resource for our home care clients,” John Olajide, founder and CEO of Axxess, said in a statement. “She has more than 30 years of experience in private duty and skilled nursing, including owning and managing home care organizations and working with franchises.”

In addition to her background at Visiting Angels, Drea was the former chair of the National Association for Home Care & Hospice’s (NAHC) Private Duty Home Care Association and the CEO of At Home Total Care.

Home Care Alliance elects VP for trade group

The Home Care Alliance of Massachusetts recently elected Home Health Foundation President and CEO Karen Gomes as vice president of the board of directors.

Boston-based Home Care Alliance is a nonprofit trade association of home care agencies.

“Karen’s experience and expertise will be most welcome around our board table as we navigate these most challenging times in home care,” Pat Kelleher, executive director of the Home Care Alliance of Massachusetts, said in a statement.

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Home Care Workers Get Vaccine Prioritization in LA County, Setting Off Potential Domino Effect

Los Angeles County’s home care companies woke up to some welcomed news right before the new year.

Non-medical home care workers are now officially a part of the first tranche of individuals who can make an appointment for a vaccination, according to the Los Angeles County Department of Public Health.

Previously, home health care workers were clearly included in the county’s prioritization list. Home care providers, however, were unsure whether their employees made the cut.

Confusing and unclear guidance for non-medical home care operators has been a familiar problem across the country during the COVID-19 pandemic.

Los Angeles-based 24 Hour Home Care was among the organizations searching for answers to vaccine questions before Christmas. Its leadership was elated to learn that its caregivers could now begin scheduling vaccination appointments for themselves.

“This news was just fantastic for us, because we were kind of waiting to see what would happen when we saw that home health services were being considered,” Andy Matthews, vice president of business development at 24 Hour Home Care, told Home Health Care News. “But with the non-medical sector, there’s always confusion if we’re going to be included when [something] says ‘home health services.’ So to see that the non-medical side was included in that was such a breath of fresh air.”

Founded more than a decade ago, 24 Hour Home Care is an independent, non-medical home care provider with 20 locations across California, Arizona and Texas. It has over 10,000 caregivers in its network.

In LA County’s announcement, “home care organizations” are explicitly listed alongside “home health agencies.”

The clarity is especially helpful for agencies in the Los Angeles area, given that COVID-19 cases are currently spiking to unprecedented levels in the region. Nearly 820,000 cases have been reported out of the county, which accounts for more than a third of all of the cases in California.

The state reported its highest daily new case count — nearly 65,000 — the day after Christmas.

“This is impactful because it protects our caregivers and our field staff, which obviously indirectly affects our clients,” Ryan Iwamoto, the president and co-founder of 24 Hour Home Care, told HHCN. “At least from my team, too, there’s a fear that home care would be overlooked in this process, because we’re usually in the shadows of other post-acute care services. I think it was a great sign to see home care in the spotlight and elevated as an essential service in this pandemic.”

Los Angeles County is a large enough actor to sway other counties as well, which could go a long way to help home care advocacy efforts across California and the entire country. If home health employees are being prioritized in other regions, home care organizations should ask for clarification on whether that includes all home-based care workers, as 24 Hour Home Care did.

“You can use that as an example to say, ‘Hey, this [priority group] also should include home care as well,’” Iwamoto said. “Hopefully, we have set the precedent for other counties and states to include home care as a part of [that group].”

Los Angeles Mayor Eric Garcetti has complained about the amount of federal help the city has received for vaccine rollout. Far fewer doses have been administered at this point than what was expected, a trend playing out across the country.

“We have not been delivered what was promised at the national level,” Garcetti said on CBS’ “Face the Nation.” “We are at a pace right now to deliver vaccines in Los Angeles in over five years instead of over half a year.”

For home-based care organizations, available vaccinations are especially helpful because they are an invaluable resource to regions dealing with ongoing COVID-19 surges and in-patient capacity challenges.

As of Monday, nearly one-third of all in-patient beds in California were occupied by COVID-19 patients, according to the U.S. Department of Health & Human Services. Almost 90% of all ICU beds are occupied in the state.

Too much demand for home care

24 Hour Home Care is seeing 20% more inquiries than it did in November. Due to skyrocketing demand, it has been forced to turn down 26% of those inquiries after reaching operational capacity.

From a staffing perspective, more unemployment claims have hurt the agency as well during COVID-19. That’s likely to continue, with a new unemployment add-on provided by the recent government spending bill.

Before the public health emergency, the company usually experienced 250 to 300 unemployment claims per year. In 2020, at times, it saw that amount in just a week.

“I’ve never seen this type of supply and demand discrepancy in my 15 years of being in home care,” Iwamoto said. “We are being hit pretty hard.”

The company has established an affiliate network in the area to try to find care for the seniors that it has to turn away. That network has helped it turn inquiries over to other agencies when it cannot handle new cases, Iwamoto said.

It is also working with its assisted living partners to place patients there when they may fit better in that kind of setting.

In addition, 24 Hour Home Care is helping hospitals improve their home-based COVID-19 transition protocols and programs.

Hospitals, more than ever, are having to find ways to accommodate seniors who don’t want to stay inside their walls or go there in the first place.

“The good thing that has come from this is being able to work with our competitors and other home care companies,” Iwamoto said. “It’s actually been really, really cool to see our industry step up in this fashion.”

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Inside Care To Stay Home’s Person-Focused Retention Strategy

The COVID-19 emergency has further compounded the difficulties home-based care providers face when it comes to retention.

Still, many organizations have used this time to solidify their efforts around company culture. Care To Stay Home is one example.

The company recently topped Fortune’s annual Best Workplaces in Aging Services list for the second year in a row.

Headquartered in Orange County, California, Care To Stay Home is a private-pay home care company that provides personal care services throughout Southern California, Utah, Washington and Idaho. The company also has an affiliate office in Arizona.

Parker Wells — Care To Stay Home’s vice president — believes that the key to the company’s success has been building a company culture that is people-focused, above all.

“We are only as good as the people that we have,” Wells told Home Health Care News. “I think that’s really evident in the way we built Care To Stay Home from the ground up. We built it on a company culture that’s focused on supporting our clients and our employees. Our mission statement kind of goes into that — we really focus on enhancing the dignity, independence and quality of life of those two populations.”

To this end, Care To Stay Home has continually sought creative ways to retain its workers.

When it comes to interacting with caregivers, Care To Stay Home has found that taking a personalized approach, especially in regards to celebrating or thanking them, has been effective, according to Care To Stay Home President Kraig Nakano.

“We still send handwritten personalized thank you cards and notes out to our caregivers,” Nakano told HHCN. “Our staff is just amazed when they get a handwritten note. Those kinds of interactions really speak to what we do. We’re in a very personalized business.”

Another way Care To Stay Home has bolstered its retention efforts throughout the years is with employee raffles and giveaways.

However, the company’s annual employee appreciation week is typically the main event.

“We’ve designed a week-long event where we open up our office to our clients and employees,” Nakano said. “We have lunch that’s catered for everyone. Each year has different themes.”

This year the company was unable to host the event in-person, but Nakano views this time as an opportunity to switch roles with Care To Stay Home’s caregivers.

“I think that so often caregivers carry such a heavy burden of caring for somebody else, and we forget about caring for the caregiver,” he said.

For Care To Stay Home, it’s also been important to stay ahead of the industry and be a “wage leader,” even if it’s been challenging at times, according to Nakano.

“We have continued to push forward things such as a 401(k) with company match,” he said. “Oftentimes, you hear about companies having a 401(k), but you don’t hear the important part, which is that the company matches — and that’s something we really take pride in.”

Employees are eligible for this benefit 30 days after their start date. Care To Stay Home provides a 4% match if caregivers do a 5% contribution. It’s the company’s way of helping employees keep an eye toward the future, Nakano noted.

Thanks to these and similar initiatives, the company has seen a significant improvement in its employee turnover over the course of four years. Care To Stay Home went from a turnover rate of 78% to 40%.

It has roughly 500 employees in total.

“If we look at some of the things we’ve implemented over the last three or four years, they’ve all been focused on the employee, not only recognition but also the retention element,” Wells said. “I think that those fundamental changes we’ve made have really led to that significant drop across the board.

Ultimately, one area Nakano believes home care leaders often struggle with — and Care To Stay Home has really honed in on — is taking employee needs into consideration.

“Caregivers in the field will say companies didn’t tell me about that information,” he said. “They didn’t give me a call. They just put me into an assignment. I think one of the things that we’ve always been conscientious of has been to engage our team, as to what’s important to them and not just what we’re offering.”

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$1.4 Trillion Spending Package Extends Sequestration Holiday, Grants Home Health OTs More Authority

As different health care stakeholders combed through the new $1.4 trillion spending package approved by Congress on Monday, many likely felt a mix of excitement and disappointment.

Included in the nearly 6,000-page spending package was a $900 billion COVID-19 relief bill, changes to home health therapy rules, certain hospice provisions and more. That’s really just the tip of the iceberg, too, as it’s unlikely that even the lawmakers who voted on the package read it in its entirety.

Home-based care insiders are in the process of doing so. So far, there’s reason to be happy about the relief package, which now awaits President Donald Trump’s signature.

“We are grateful that Congress recognized the need to support home care and hospice during the pandemic,” William A. Dombi, the president of the National Association for Home Care & Hospice (NAHC), told Home Health Care News in an email.

In addition to the previously noted items, Dombi called attention to the package extending the Medicare sequestration holiday, which was initially set to expire at the end of this month. More CARES Act grants, an extension of the Medicaid Follows the Person (MFP) program and extra spousal impoverishment relief are likewise victories for home health and hospice operators, NAHC’s president said.

“[There is also] the expanded SBA Paycheck Protection Program (PPP) and more that will help keep [home health] and hospice operational,” Dombi added.

Specifically, $284.5 billion more has been added for a second round of PPP loans for businesses with less than 300 employees and a demonstrated revenue loss greater than 25%.

The extended sequestration suspension is a major win for all Medicare-reimbursed health care providers, which have faced a 2% cut since 2014. Providers across the country continue to deal with new, previously unexpected expenses and erratic revenue patterns.

The new pause on sequestration runs through March 31.

Additionally, the spending package and COVID-19 relief includes nearly $70 billion to purchase and distribute vaccines, plus funds to help states conduct testing. About $20 billion of that funding will be dedicated to making the vaccine available at no cost for certain individuals.

Other COVID-19 specifics include $22.4 billion for testing, contact tracing and other prevention practices necessary for combatting the virus. Another $3 billion was included for additional grants for health care providers to be reimbursed for expenses or lost revenues tied to COVID-19.

For Medicare-funded home health businesses, $175 billion more has been put into the Provider Relief Fund, which could grant them a lifeline until the pandemic subsides.

Therapy changes

Similar to NAHC, the American Occupational Therapy Association (AOTA) celebrated certain provisions on the $1.4 trillion spending package.

In what AOTA called a “historic home health victory,” the package includes language from the Medicare Home Health Flexibility Act that enables occupational therapists (OTs) to open home health therapy cases. The U.S. Centers for Medicare & Medicaid Services (CMS) will have one year to implement a rule allowing for that change.

“Today we celebrate hard-fought victories for occupational therapy scope of practice and payment, following extensive AOTA-led advocacy initiatives,” the advocacy organization wrote in a statement.

OTs were granted the flexibility to open up home health cases during the public health emergency, but this bill will allow them to do so moving forward. AOTA said it has worked for “decades” on this measure.

The bill also made COVID-19-related telehealth flexibilities permanent.

Funding for hospice providers, small businesses

The “Rural Access to Hospice Act” and the “Helping our Senior Populations in Comfort Environments (HOSPICE) Act” were also included in the spending package.

Rural health clinics and federally qualified health centers cannot currently bill under Medicare Part B for hospice, which often becomes a barrier to caring for remote populations. With the Rural Access to Hospice Act in place, providers will be able to receive payment for services to patients in hospice, which will help those populations.

The National Hospice and Palliative Care Organization’s (NHPCO) was happy with the hospice provisions.

“NHPCO appreciates this bi-partisan, bi-cameral agreement,” NHPCO President and CEO Edo Banach said in a statement. “Hospice patients and families will benefit from improved access in rural and underserved communities as well as needed relief during this public health emergency. This legislation will enable hospice providers to continue providing uninterrupted care during this unprecedented time.”

Adult day providers weren’t as lucky. There were no specific provisions aimed at helping those operators during the public health emergency.

Katie Smith Sloan, the president and CEO of the aging-focused organization LeadingAge, previously discussed how Congress has fallen short in its efforts when it comes to helping adult day centers around the country.

What may help these providers, as well as other home care organizations, is the new round of PPP money that’s included in the package. If they are able to qualify, which most should be able to, that will at least ease some of the payroll burden that they’ve faced amid the public health emergency.

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Beyond the Pandemic: 9 Overlooked Stories from 2020

The ongoing COVID-19 pandemic dominated headlines in 2020 — and rightfully so.

But there were plenty of other storylines that defined the year, including the launch of the Patient-Driven Groupings Model (PDGM), the conclusion of a hotly contested presidential election and the execution of multiple industry-shaping transactions.

These are nine of the most overlooked stories from 2020, as determined by Home Health Care News. All of these stories were popular amongst our readers, but HHCN considers these stories “overlooked” because they didn’t capture quite the same attention they would have in any other year.

1. “NAHC’s Dombi: Agencies Aren’t Panicking in the Streets Over PDGM”

It was relatively early into PDGM’s first year, but it nonetheless became clear in March that the overhaul wasn’t as devastating as many initially predicted. “We’ve not heard anything about large closures of agencies or any kind of panic in the streets,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told HHCN at the time. “And strangely enough, the one thing we’re surprised we haven’t heard so far is the cash flow impact.”

Yes, PDGM presented numerous challenges — and the model certainly still has its flaws. For the most part, though, home health providers large and small met those difficulties with a combination of creativity and perseverance.

2. “Late RAPs Could Trigger Immediate 20% Payment Reduction in 2021”

Related to PDGM is the plan by the U.S. Centers for Medicare & Medicaid Services (CMS) to phase out Requests for Anticipated Payment (RAPs) entirely in 2021. While home health operators knew about this plan way back in 2019, new details emerged about stiff financial penalties for late no-pay RAPs moving forward. If an agency submits a no-pay RAP one day late next year, the result could be a 20% reduction to its 30-day payment amount.

3. “Aging-in-Place Company Amedisys to Acquire AseraCare Hospice for $235 Million”

The pandemic may have delayed some home health, hospice and home care M&A activity, but it didn’t stop it entirely. In fact, there were multiple industry-shaping deals that took place in 2020, including Amedisys Inc.’s (Nasdaq: AMED) $235 million deal for Compassionate Care Hospice, announced in April. This was a huge acquisition for Amedisys, which now ranks as a top-five home health and hospice provider in terms of market share. “AseraCare is a great hospice company,” Amedisys CEO and President Paul Kusserow told HHCN. “When we decided that hospice was a business line we wanted to move forward in back in 2016, we actually approached AseraCare. But they weren’t for sale.”

4. “AccentCare, Seasons Hospice to Merge”

Another M&A blockbuster from 2020: the planned merger between AccentCare Inc. and Seasons Hospice & Palliative Care. After joining forces, the combined AccentCare-Seasons enterprise will be among the five largest home health and hospice providers in the nation. “This is incredibly complimentary to our own approach toward strategic markets and being very focused on working with large health systems,” AccentCare CEO Steve Rodgers told HHCN in November.

5. “LHC Group CEO Keith Myers: Change in Washington Won’t Derail ‘Incredible’ Home Health Opportunity”

Over the past four years, the home health industry has steadily advanced its position in Washington, D.C., and within the administration of President Donald Trump. Come January, there will be a new team in the White House that’s led by President-elect Joe Biden. While his administration will bring plenty of new perspectives on health care policy, home health providers will likely maintain their standing.

6. “Caregiver Turnover Rate Falls to 64% as Home Care Agencies ‘Flatten the Curve’”

Turnover remained a trouble spot for most home care agencies, though the overall turnover rate actually improved year over year, according to Home Care Pulse. Better pay and benefits, plus stronger training programs that enable career advancement, are just some of the reasons caregivers are staying in their positions for longer.

7. “Medicare Advantage Startup Clover Health Slated to Go Public in a $3.7 Billion SPAC Deal”

There could be multiple headlines here at No. 7. The main takeaway? This year was the year of the special purpose acquisition company (SPAC), or blank-check company. In October, Clover Health announced it was going public through a SPAC. Most recently, Deerfield Healthcare Technology Acquisitions Corp. (Nasdaq: DFHT) announced it was acquiring CareMax Medical Group and IMC Medical Group Holdings, then combining them in a blank-check company of their own. There were other SPAC plays, too, with 2021 certain to bring several more.

8. “Senior Helpers, BrightStar Are Venturing Out of the Home to Serve Seniors. Here’s Why.”

Home care operators continued to take bold steps in 2020, thinking outside the box and expanding into new services lines. Senior Helpers and BrightStar Care were two good examples of that trend, with each making progress on its home care-adjacent businesses. For Seniors Helpers, that is its Town Square franchising model. For BrightStar care, it’s the company’s senior living franchise strategy. “We saw that many of our clients, as they progressed and had a change in condition, had higher-acuity needs,” BrightStar Care CEO Shelly Sun said during an HHCN event. “The family wanted to be able to move them out of the home to something with more socialization. They were looking for recommendations from us for assisted living facilities or, in many cases, dementia and memory care communities in their area.”

9. “In-Home Care Agencies May Look to Cut Costs by Scrapping Brick-and-Mortar Offices”

To be fair, this one definitely has to do with COVID-19. But it’s somewhat of an overlooked and indirect aspect of the pandemic. In 2020, businesses across industries shifted operations from physical offices to remote setups, typically without any major problems. Moving forward, it will be interesting to see if cash-strapped home care agencies decide to cut costs and jettison the traditional office.

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Providers Scramble to Figure Out EVV as Implementation Date Inches Closer

When it comes to clinical and operational efforts, COVID-19 has been at the forefront for most home-based care providers.

With the public health emergency top of mind, it may be easy to forget that new federal technology requirements — electronic visit verification (EVV), in particular — are right around the corner.

Starting on Jan. 1 of next year, Medicaid-reimbursed home care providers are required to electronically verify the services that they deliver in the field. Caregivers must record data points, including date, time, location, type of service and other information.

Medicare-certified home health providers won’t have to do so until Jan. 1, 2023.

EVV originally became law in 2016 under the 21st Century Cures Act, with the goal of curbing fraud and abuse in the delivery of home-based care. The law sets the federal guidelines for EVV, but the mandate is administered at the state level.

States that aren’t compliant with EVV guidelines by the Jan. 1 deadline will be subject to a reduction in Federal Medical Assistance Percentage funding, which in turn impacts resources for state programs.

In some ways, it makes sense that the implementation of EVV has been placed on the backburner for some providers.

Originally, EVV adoption was supposed to take effect on Jan. 1 of 2020 — this year. Instead, most states — New York, for example — applied for and received exemptions, which pushed implementation back a year.

“New York state had several requests to postpone the implementation, given the difficulties in rolling this out in the personal care industry,” Emina Poricanin, managing attorney of New York-based Poricanin Law, told Home Health Care News. “Those were granted. New York state didn’t have the ability to just unilaterally postpone it.”

Now, roughly two weeks before providers are meant to be in compliance with the law, some providers feel less than prepared, according to Poricanin.

“There are way too many providers out there who are still calling to this day, asking what is EVV and what do I have to do about it,” she said. “Those are very late questions to be asking at this point in the game.”

States also have a hand in overall preparedness industry-wide, Courtney Martin, EVV expert of technology solutions provider CellTrak, told HHCN.

“That very much depends on the local state implementation plan. … Some states have been early with their implementation and are already to the point where they’ve given a lot of guidance to their providers around expectations and how they’ll be measured against them,” Martin said. “About half the states have done that. Then there are some states that are taking a little bit longer to implement.”

CellTrak is a Schaumburg, Illinois-based provider of home-based care solutions, including EVV, for more than 4,000 home care agencies internationally.

Providers have two responsibilities when it comes to the mandate. They have to collect correct, compliant EVV information in the field, at the point of care. Additionally, providers have to relay that information to the state or to the managed care organization that requires this data for compliance.

This means that whatever technology solutions a provider has in place must help them accomplish this, according to Martin.

To this end, providers have the option of implementing either a state-procured EVV solution or a commercially available solution.

“Those decisions are obviously very unique to the providers,” Martin said. “Generally speaking, the state system will include a very straightforward check the box compliance. Some providers that are trying to meet the minimum requirement, may choose to adopt the free solution.”

However, for providers that operate on a multi-state level, this may create challenges, according to Martin.

“The downside to a free solution is that if you are operating in multiple states, and those states all have different free solutions, this can be complicated for an agency,” she said. “Now, the agency is trying to support training and monitoring their caregivers on these different state solutions.”

When it comes to deciding on a technology solution, providers should consider their company’s operational workflow, as well as state compliance requirements.

As the EVV implementation date inches closer, Martin stressed the importance of providers beginning the data collection and documentation process as soon as possible.

“We encourage providers to do that, rather than waiting for state guidance,” she said. “The reason being that it’s time for their caregivers to get used to the technology solution. It gives them time to think through how their workflow, internal to the agency, is after their EVV processes are in place. It also gives them time to be prepared for when that state guidance comes.”

Providers should also follow state stakeholder meetings in order to stay up to date with the new information.

The state of New York, for example, has held weekly calls over the past several months. The aim of the calls was to help providers get prepared and address some of the technical issues associated with EVV, according to Poricanin.

As providers continue to operate amid the public health emergency, Martin believes that EVV adoption will help improve care delivery.

“You’re going to have way more information about that patient — and about the care that they need,” she said. “This can help you do a better job in the visit and also alert you to any specific circumstances that you need to know, including that patient’s potential sensitivity to being exposed to COVID-19.”

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NAHC, NHPCO, Others Release Vaccine Guidance for In-Home Care Providers

The dichotomy in the U.S. right now is evident, especially for those in health care: While vaccines and coinciding hope are being injected into Americans, the number of new COVID-19 cases each day continues to climb.

And while every home-based care provider and worker keeps reading that the vaccines — both Pfizer’s (NYSE: PFE) and now Moderna’s (Nasdaq: MRNA) — are here, they’re wondering where.

Vice President Mike Pence and his wife, Karen Pence, were both vaccinated on video Friday. Senate Majority Leader Mitch McConnell (R-Ky.) tweeted out a picture of himself post-vaccination as well. Hospital workers have danced on TikTok celebrating the Pfizer-BioNTech vaccine’s arrival at the Boston Medical Center.

But for the home-based care world, key information regarding the vaccines is still hard to find.

“We don’t know not only when but where,” David Totaro, the chairman of the Partnership for Medicaid Home-Based Care (PMHC), told The Philadelphia Inquirer last week. “We don’t even know how we’re going to be notified.”

Over the last week, most of the major home-based care trade organizations have released guidance for providers on how to handle vaccinations in the workplace.

Home-based care workers have been labeled 1a — or highest priority — to receive the vaccine in most states.

The National Association of Home Care & Hospice (NAHC), for instance, is telling providers to “encourage all home care and hospice staff to receive a COVID-19 vaccination at the earliest possible time consistent with vaccine guidance.”

The national association suggests providing the support necessary to help workers gain access to the vaccine as soon as possible as well as access to comprehensive and fact-based information regarding immunization. It also reiterated the importance in following safe protocols throughout the pandemic in the meantime.

The Home Care Association of New York State released similar guidance, and the National Hospice and Palliative Care Organization (NHPCO) released a statement of its own.

“Hospice and palliative care professionals are on the front lines of health care delivery in this country. Not only are they serving the most vulnerable population with complex medical needs, but they are caring for people in their homes, interacting with family caregivers, and traveling throughout the communities they serve,” NHPCO President and CEO Edo Banach said. “For their own protection, the safety of those under their care, and the welfare of their families and communities, NHPCO encourages these dedicated professionals to receive the COVID-19 vaccine.”

Each state’s plan to roll out the vaccine is different, so organizations that work in multiple states will have to do their due diligence in each region to ensure that their workers have access to one of the two vaccines as soon as possible.

Still, the home-based care organizations stopped short of encouraging mandatory vaccinations for workers, despite their assurance that immunization will be safe and effective in stopping the spread of COVID-19.

“The next thing that we’re trying to address right now is whether or not vaccines should be mandatory among our staff,” Totaro said during Home Health Care News’ Capital+Strategy event earlier this month. “And that’s a very, very complex issue. We’re taking it very seriously.”

San Francisco-based law firm Littler Mendelson released a client alert to home-based care organizations this week regarding that issue.

For many reasons, Littler is urging providers to wait before taking a firm position on mandatory vaccinations for workers.

“Employers really cannot make vaccinations completely mandatory,” Angelo Spinola, a shareholder at Littler Mendelson, wrote. “They must always allow exceptions based on health and religious beliefs.”

Spinola urged home-based care clients to consider a handful of questions: Firstly, are there exclusions regarding who should receive the vaccination, from a medical perspective?; Will there be side effects to the vaccine that could hurt employees?; Are your employees reticent or or enthusiastic about the vaccine?; And how are others in the industry responding?

Those questions all suggest that providers should wait before making the call. In some states, health care workers are required by the government to receive flu shots, for instance. If the government could make vaccines mandatory, Spinola urges providers to let lamakers do it first.

Plus, there are other things to consider.

“Mandatory vaccinations may lead to potential workers’ compensation claims from employees who suffer an adverse reaction to a potential vaccine,” he wrote.

In any case, encouraging vaccination, but stopping short of mandating them, seems to be the resounding guidance right now from industry insiders.

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Turnover, Tiny Homes and New Technology: 2021 Predictions from 14 Home Care Executives

The U.S. home care industry is at an inflection point.

Prior to the COVID-19 pandemic, an increasing number of payers and health care providers began to recognize the value of non-medical home care, particularly when it comes to chronic disease management and preventative care. That recognition has grown even stronger in 2020, with home care often playing a leading role in emerging care delivery models, including hospital-at-home and SNF-at-home programs.

That momentum will continue in 2021, most home care executives believe. To stay relevant, though, agencies will need to embrace new technologies, invest in staffing and boldly go where no home care operator has gone before.

For a clearer picture of home care’s future, Home Health Care News asked 14 executives to look into their crystal balls and describe what lies ahead. You can read their predictions below, edited for length and clarity.

HHCN previously shared our executive forecast for the home health industry on Dec. 14.

* * *

We all know that 2020 was unarguably one of the most difficult years in recent history. One aspect of the pandemic that influenced senior care is that aging in place as well as the demand for home care accelerated. And it will continue to accelerate in 2021. We predict that there will be a significant change in the mindset of seniors to favor aging at home instead of in congregate residences such as long-term care facilities, plus assisted living and independent living communities.

This influx of demand for home care will come with its own challenges, mainly the need for additional qualified staffing. As home care industry leaders, we need to ask ourselves, “How can we make caregiving a profession that will attract the ‘best’ talent in the coming years?” Regardless of the hardships that the pandemic caused, we need to view these challenges as potential opportunities in both business and in life.

— Mario D’Aquila, COO at Assisted Living Services Inc.

* * *

Demand is running high for caregivers and senior homes. We believe we’ll see a wave of ingenuity and innovation in senior living solutions. We’ve seen the tiny home movement model on TV that’s popular with millennials; we think we might also see that with seniors as well to help combat the loneliness epidemic. The idea is that older adults have their own bedroom, bathroom and living space, but they’ll walk down a short path to join others for meals and engagement.

The tiny home park allows caregivers to operate more easily because the seniors are aggregated more so than they are in a traditional neighborhood home. This model allows seniors to maintain their independence but also offers much higher engagement with others.

Companies will try to bust that loneliness and isolation bubble we’re seeing so much of, which has only been escalated in 2020.

— J.J. Sorrenti, CEO of Best Life Brands

* * *

Heading into 2021, the need for home care will drastically increase as a result of the COVID-19 crisis. Over the past year, it has become evident that in-home care is a much more attractive option for families looking to care for their aging relatives, without needing to place them in a restrictive or possibly unsafe nursing home or long-term care facility. They’ve learned that there is a huge difference between aging at home while being in your own community and aging in a facility where you have little to no control.

Individuals don’t want to put themselves or family members into a situation where they are restricted from their family. This lesson has been burned into the minds and psyches of people who are aging — and their search for non-medical home care and assistance with daily living activities is going to strengthen the home care industry in the coming years.

— David Savitsky, CEO of CareBuilders at Home

* * *

Personal Care benefited from amazing positive awareness in 2020. I predict that there will be a divergence in 2021 — of agencies who stay the course, and those who capitalize on this awareness and press the advantage for greater utilization within the health care continuum and attention from payers.

I foresee this divergence also spreading to include agencies that innovate on how they recruit, retain, train and incentivize their caregivers, and those that continue to struggle with enough staff. I feel we will look back on this time as a watershed moment in home care, where we truly saw advancement in the industry. 2021 is the year to truly make that a reality.

— Jeff Wiberg, CEO of Family Resource Home Care

* * *

While we can’t wait for 2020 to end, 2021 probably won’t be much different for the first half of the year. We are looking at 2021 being a bifurcated year. More of the same for at least the first quarter and probably most of the second quarter, but we should start to see some significant relief from the virus by late spring of next year as the vaccine hits our communities broadly. Nonetheless, we have to prepare ourselves for potential glitches in the role-out of the vaccine and that helping hospitals discharge COVID-positive patients may consume more of the year than we hope. We are continuing to stock up on PPE and hire and train aides for COVID cases, but it would be great to get to a point where we are throwing away PPE in 2021!

— John Bradshaw, CEO of Georgetown Home Care

* * *

After a year like this one, where every business and employee has had to adapt, I expect 2021 to continue to drive innovations that bring care to the consumer, leverage new technology and increase our talent pools.

From hospital-at-home programs to home care agencies innovating their offerings, each will bring solutions that increase independence and the ability to live at home longer. Integrated solutions bringing care and support to the home will enable consumers to be more compliant with care plans and will enhance revenues.

I predict this innovation will come from two approaches. One, strategic partnerships will help optimize the consumer experience and reduce redundancies. Second, technological solutions that help manage a consumer’s ongoing care and anticipate changes in health proactively.

My final prediction: We will experience new candidate pools for positions across the health care continuum. Those companies with strong training programs will be able to differentiate themselves and will see faster growth. By retooling workers from other service industries into meaningful, needed roles in health care, home care especially may see dramatic improvements in staffing and quality.

— Emma Dickison, CEO of Home Helpers

* * *

In 2021, providing home care is going to be harder but the quality of care will be much better. It’ll be harder since COVID-19 isn’t going away, but it’ll also drive improvement in care quality through better infection control, faster restaffing when a caregiver reports flu-like symptoms and other innovations that pay dividends into the future. This means the bar to operate becomes higher. Home care companies will have to invest more in technology and tools to deliver the new level of expectation — likely leading towards further consolidation in the industry

— Seth Sternberg, co-founder and CEO of Honor

* * *

2021 will be all about people and technology. Every industry webinar talks about the need to create an engaged and empowered workforce. It’s no longer a talking point — industry survival depends on it. Every company without a specialized caregiver engagement focus will lose. Business models that address caregiver wages will win.

This year has demonstrated more than ever the need for “touchless” strategies to serve the customer and the employees. Virtual onboarding and virtual visits will become the baseline. Stakeholders will expect real-time interventions.

— Andrea Cohen, co-founder and CEO of HouseWorkers

* * *

COVID has been a catalyst for a major shift in how we serve seniors. 2021’s opportunity lies in more data, analytics and partnerships. Isolation is fatal! Providers need to start moving their models away from high-touch-only, to high-touch and high-tech. There is tremendous opportunity to connect to value-based opportunities, which require more analytics to provide better care across integrated delivery systems and prove efficacy. High-tech augments high-touch and intelligently and thoughtfully supports our ability to address workforce demands, cost, and meet the growing need for effective whole-person community-based options.

— Joel Theisen, CEO of Lifesprk

* * *

In 2021, as we transition out of the COVID-19 pandemic into a normal way of life, we will begin to see the marriage between the “old way” of how traditional home care was done with the “new way,” including technology-process integration. As home care agencies are looking to stay ahead, we will see a major shift toward telehealth services over traditional aide services while we look to continue placing an emphasis on keeping patients both healthy and happy in the comfort of their own homes. 2020 has taught home care clients the necessity of including a tech component within their homes. As patients have become more comfortable with this change, we will continue to see an increasing number of seniors seek out home care technology alongside an aide as part of their home care solution.

— Josh Klein, CEO of Royal Care and Emerest

* * *

After an unprecedented year in 2020, home care needs to stay the course on its momentum prior to the pandemic and the tailwinds after. The desire for seniors to age in their home has increased even more since the pandemic, and the best news is that the health care system is supporting that as well. Home care agencies must look to data-driven outcome strategies to help families understand their loved one’s ability to age safely in their home. Agencies who embrace partnerships and technology solutions will enable this to happen. 2021 offers a bright future for those agencies that adapt to a value-based care environment.

— Peter Ross, CEO and co-founder of Senior Helpers

* * *

In 2020, we asked, “Who or what is essential?” Our caregivers were heroes before 2020, but the year brought their heroics into the spotlight. The goal in 2021 and beyond is to never forget this fact. As more and more baby boomers become senior citizens, they will require companionship and assistance at home or at a facility, not just clinical care. We must focus on recruiting and retaining by attracting new caregivers and welcoming back the heroes sidelined due to the pandemic. We will also need all in the non-medical care industry to embrace existing and emerging technological services, such as those designed to connect receivers with loved ones or doctors. We saw tremendous success among our own receivers and expect the efficiency and quality of these systems to improve and grow in popularity in 2021.

— Howard Algeo, director of business development and training at Seniors Helping Seniors

* * *

In 2021, I think the home care industry will see proof that the private equity groups that are consolidating the industry are creating huge competitive advantages over smaller independently-owned businesses and franchisees. Any home care agency that operates in a top-20 market and is under $15 million in revenue in their local market will continue to struggle in caregiver recruiting, online marketing and operational efficiency. Our industry is just starting to see what can happen when you scale a business nationally, with geographic concentration of caregivers, clients and referral sources in local markets.

— Jim Kimzey, CEO and founder of Tender Rose Dementia Care Specialists

* * *

Home care has long been an underappreciated element of health care. The vital role it has played during COVID-19 reminded the industry — and society — of the value of providing quality in-home care to keep vulnerable populations safe. In 2021, I predict that home care will ride this momentum by supporting managed care organizations to reduce overcrowding in hospitals and extend their ambulatory care management bandwidth while lowering costs. I predict an increase in Medicare Advantage plans that offer home care as a supplemental benefit. Because of the compelling data and positive outcomes that demonstrate the holistic benefits that home care provides to its members and the plans, it’s a no-brainer to meet this demand similar to what we witnessed in the past with outpatient physical therapy (PT) and hospice care.

— Ryan Iwamoto, president of 24 Hour Home Care

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Backed by Harpeth Capital, Industry Veteran Launches HomeFirst Home Healthcare

Backed by investment bank Harpeth Capital, a home-based care veteran recently threw his weight behind a new home health venture. The new company is called HomeFirst Home Healthcare, led by James Happ, who serves as president and CEO.

If Happ’s name sounds familiar, it’s because he spent some time at the leadership level of SunCrest Home Health, which is now an LHC Group Inc. (Nasdaq: LHCG) joint venture. Happ brings all of his past experiences to this next chapter, he told Home Health Care News.

“While at SunCrest, I was involved in business development,” Happ said. “We had made several acquisitions during my time there. I basically implemented a strategic planning process at SunCrest and [the company] grew very quickly and successfully. It was really all because of very effective executive leadership and operational leadership.”

As far as HomeFirst, the company was formed to buy certificates of need and state licenses of two home health agencies that served 24 counties in Tennessee. HomeFirst’s services lines include skilled nursing, private-duty care, physical therapy, occupational therapy, speech-language pathology and medical social work.

The road to HomeFirst has been a long one for Happ.

He first met with Harpeth Capital in 2007 when he was coming off of a successful run at Tender Loving Care, a home health company that would later be acquired by Amedisys Inc. (Nasdaq: AMED). At the time, he was looking to acquire a home health agency.

“We weren’t actually successful there, but [Harpeth Capital] continued on and got themselves involved in following the industry and became really impressed with the success that Suncrest had,” Happ said.

By the time Happ approached Harpeth Capital again, the investment bank was very keen on entering the home health space.

“When this opportunity presented itself here in Nashville, I approached the folks at Harpeth and they were very interested in getting involved through their Harpeth Ventures Opportunity Fund,” he said. “This is a relatively new fund that’s going to invest in health care opportunities. This is their first investment. Had they not been very comfortable with the senior leadership and their experience in the home health industry, they may have not been as excited.”

When Happ first eyed what would eventually become HomeFirst, the industry was on the verge of a major reimbursement shakeup with the upcoming Patient-Driven Groupings Model (PDGM).

“Last October, we were made aware that these two licenses were for sale,” Happ said. “We kind of slowed the acquisition process because PDGM was on the horizon. We wanted to get a feel for how that was going to be received and how that would play out within the industry.”

Five months later, the industry began seeing the impacts of the COVID-19 emergency. This only further slowed down the acquisition, according to Happ.

But then two months later, acquisition talks picked up again.

“It became clear that it was still a great opportunity for us,” Happ said. “The assets that we acquired were distressed assets. It provided an opportunity for us to acquire — at what we felt was a very attractive price. After quite a bit of due diligence, we closed on the transaction on Sept. 15.”

As HomeFirst moves forward as a company, private-duty home care is an area where Happ sees a lot of opportunities.

“Tennessee has a program called TennCare, which is a state Medicaid program, which has been popular for many years,” Happ said. “The Tennessee Medicaid program just continues to renew and improve. There are lots of other opportunities in private-duty as well, whether it’s long-term care insurance providers, or even out-of-pocket private-pay-type services. We see those opportunities expanding across the country on a daily basis.”

As a veteran in the home-based care arena, Happ’s years of experience have given him an interesting perspective.

One key change he’s seen over the years is the way the federal government both views and reimburses home health.

“The government, in the past, never really recognized efficiency,” Happ said. “They paid based upon the cost that you incurred, as long as you were under certain caps. Over the last 20 years, they’ve very slowly moved towards outcome-based reimbursement.”

Happ has also seen more overall awareness of the benefits that care in the home setting can provide.

“The home is now viewed as a place where you have to be serious about focusing on delivering care,” he said. “We’ve been in this industry now, all these years, we’re in a great position to be able to assist the government and all other health care providers that are seeing their patients at home.”

Now 90 days in, Happ is already looking to the future and thinking about expansion opportunities.

“As we get our foundation and our structure completely built down, which we’re in the midst of, then we’ll be looking for opportunities to expand in neighboring territories and states,” Happ said.

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‘I Don’t Know When It Will Slow Down’: Homewatch CareGivers Nearing 40 New Locations in 2020

Homewatch CareGivers has grown its business during the COVID-19 crisis, so much so that it has even been surprising to its own executive team.

The Denver, Colorado-based home care franchise company has awarded 37 new territories in 2020, 21 of which will have new franchisees at the helm. The new offices opened in a variety of areas in the U.S., including Arizona, Connecticut, Illinois, Nevada, New Jersey, Texas and Utah.

“The kind of growth that we’ve had so far this year is not what we had expected,” Jennifer Tucker, the COO of Homewatch CareGivers, told Home Health Care News. “I thought maybe we would do 25 new territories this year, and we’re at 37 right now.”

Tucker, who is the top executive at the Homewatch CareGivers, is also confident the company will close on another five or so territories this year, bringing the total amount of new territories to over 40 in 2020.

The franchiser added 17 locations last year. When Tucker spoke to HHCN in early March, she was hoping it would add “at least 22” this year. Now, it’s likely that number will be nearly doubled.

As of June 2020, the Homewatch CareGivers system serves 33 states and seven countries. The franchiser employs over 4,500 caregivers across its network.

Because 2020 exceeded expectations from a growth standpoint, it has completely changed the company’s outlook over the next few years.

“Because we’ve added so many new territories this year, it means that we’ll have bigger numbers next year, because our franchise owners will be able to care for more and more clients and we’ll be able to hire more caregivers,” Tucker said.

The demand for home care, which has been accelerated by COVID-19, has played the largest part in the outsized growth. And that’s a trend that the company does not expect to slow down anytime soon.

It’s expecting more franchisee interest, more clients and more potential leads and partnerships.

“I expect it to continue into 2021, and I don’t know when it’s going to slow down,” Tucker said. “It’s definitely changing our outlook. It’s great, because growth has always been part of our plan. We do have a lot of whitespace in the United States, and we’ve really been wanting to grow domestically. So this is just kind of accelerating things for us, which is fabulous.”

Even when a vaccine is widely available and has been distributed in mass, Tucker — and a lot of other health care executives and insiders — don’t believe that the tailwinds for home-based care will subside.

There will always be a place for other types of senior care outside of home care, but now that some of the proverbial cracks have been shown in other community- or facility-based settings, there could be no going back.

“[Those other providers], they’re still really important and they fill an important need,” Tucker said. “We’re very friendly with folks in those other spaces, and we partner with them all the time. But I definitely think COVID-19 has highlighted the fact that care can be provided at home. So many people didn’t understand that home care was even an option before. And I do think it’s put a spotlight on our business.”

Its relationships with referral sources — such as home health, hospice, primary care and rehab providers, as well as hospitals — have strengthened since March.

“Our classic referral sources in markets where we were already established, those relationships have gotten even stronger,” Tucker said. “Because we’ve had to find ways to continue to connect with those folks, even though we can’t necessarily be face to face.”

Outside of the new locations, the specifics of Homewatch CareGivers’ growth have also been a bit surprising to the company. Generally a private-pay home care provider, the company’s Medicaid business is up 35%, year over year.

That’s true for all of its claims-based business, whereas private pay has been mostly flat. That is beginning to pick up as well, however, Tucker said.

The recession and new franchisees

When recessions hit, as one is now, franchisee interest ticks up. A lot of home-based care providers have seen this trend resurface during the public health emergency.

“This whole trend around the downturn in the economy, it usually drives people to being interested in small business opportunities,” Tucker said. “I just think with the pandemic, people are realizing the setting is going to be the home, and they want in on the business.”

A lot of individuals within corporate America, which is usually the demographic that is most likely to venture into franchising, are concerned about their own companies instituting layoffs or salary cuts.

Franchising gives them the opportunity to take their fate into their own hands.

“They want to be in charge of their own future and want to build something,” Tucker said. “I think that’s just the time for those more entrepreneurial corporate folks to go, ‘Yeah, I want to do something else.’ And it kind of gives them that extra boost to make a different decision.”

On Homewatch CareGivers’ end, it saw the same thing happen in the last recession around 2008 and 2009.

That trend is another that the company is not expecting to slow down. Especially as the company invests in new virtual strategies for its entire network, it believes that it will continue to be an attractive option for potential entrepreneurs.

It’s gotten to the point where Homewatch CareGivers is worried about having too many interested franchisees.

“I almost don’t know if we can handle much more interest,” Tucker said. “It’ll be a good problem to have. … Of course, we would want new clients, but the big limiter in home care for us is the lack of access to caregivers that are fabulous.”

Tucker is not worried about finding new clients, but instead, she’s worried about staffing new locations, if the growth trends continue. That’s where the company will aim a lot of its focus moving forward — finding a lot of good caregivers, and making sure to retain them.

That’s another reason the company is instituting a virtual care strategy, one that it believes will help out workers, first and foremost.

“The virtual care space [can be] really attractive to caregivers and something they really want to work with, and it drives caregiver satisfaction,” Tucker said. “So we’re looking at things that can kind of drive that efficiency, and then use caregivers in person when we absolutely have to… so those are some of the things we’re looking at for next year.”

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Papa Steps into the Virtual Care Arena with Launch of ‘Papa Health’

Papa Inc. — the rapidly growing company that originally launched as a “grandkids-on-demand” platform to help curb senior isolation and loneliness — announced Tuesday it is rolling out a new virtual care platform known as “Papa Health.” The news marks the latest development for the Comcast Ventures-backed startup.

Currently, Miami-based Papa is a membership-based platform that mostly connects college students — or “Papa Pals” — and older adults. The goal of that connection is to provide companionship and general assistance, including transportation services and similar task-based help, in turn lowering the odds of hospitalizations and other negative health events.

With the launch of Papa Health, the company expands its services to include health management. This means virtual primary care, urgent care and chronic care management through the Papa platform.

The new services are building on and enhancing the company’s current capabilities, Papa founder and CEO Andrew Parker told Home Health Care News. Thanks to the rollout, Papa will now be a mix or social and clinical services to address the holistic needs of its members.

“Papa historically has provided — and still very much so does, as our core products — companionship and support to older adults and families through health plans,” Parker said. “With Papa Health, we’re now able to continue our mission of supporting older adults and families throughout the aging journey, by not only providing them curated companionship but also curated care.”

“Curated care” is something many aging services operators are trying to advance. Despite progress in breaking down care silos across the continuum, senior care is often still too fragmented.

Through Papa Health, members will be able to connect virtually with “Papa Docs” for appointments. Papa Docs are part of a network of board-certified and licensed clinicians that include MDs, nurse practitioners and behavioral health providers, put together by Papa’s chief medical officer, Dr. Ford Brewer.

Papa Docs can, for example, provide care plans or prescribe medicine. Papa Pals are also in the mix, to do things like help navigate appointments, provide transportation or help with care facilitation.

“If [members] need a lab test, for example, a Papa Pal will go and pick the member and take them to get the lab tests,” Parker said. “When the test is uploaded to the internet and onto our platform, the member will be able to have a review of that lab with the doctor. We’re launching Papa Health as a foundation of our products so that we support members socially and clinically.”

This isn’t Papa’s first time supplementing its core services.

Amid the COVID-19 emergency, Papa launched “Assistance from a Distance,” a virtual platform that enables Papa Pals and seniors to connect during quarantines and stay-at-home periods. Papa Health is a natural progression of Assistance from a Distance, according to Parker.

“Our platform, which has always been HIPAA-compliant and secure, can effectively provide virtual and in-person services, whether it be companionship or Papa Docs,” he said. “We see virtual as a very important component, but we also see in person as an important component. Through our platform, we’re able to support members with all of those modalities. Sometimes they need to go to the doctor, sometimes their blood needs to be drawn, so it’s a really flexible configurable experience for the varying needs of the members.”

Papa’s latest move shouldn’t come as a surprise to those who have been paying close attention to the company, financially backed by Magnify Ventures, Canaan Partners, Initialized Capital and several others in addition to Comcast.

At the beginning of the year, Papa threw its efforts behind revamping the company’s brand. The aim was to move away from its “grandkids-on-demand” branding to the more all-encompassing “family-on-demand” label. This was a move that Parker made with an eye toward future opportunities.

Over the past few years, the company has also raised more than $31 million in funding while forming partnerships with health sector giants, such as Humana Inc. (NYSE: HUM) and Aetna, a CVS Health company (NYSE: CVS).

For now, the company remains focused on the launch of Papa Health and what it means going forward.

“A big focus of mine right now is that we’re launching this particular product,” Parker said. “It’s a significant undertaking and incorporates capturing data from the health plans improving the lives of their members. It’s a pretty big initiative.”

Papa is planning to be in all 50 states by January 2021, according to the company.

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Mission Healthcare Hires Two New Executives; Lifesprk Names New President

Mission Healthcare adds to executive team

Mission Healthcare has made new additions to its executive leadership team.

The company named JoAnn Mack its chief operating officer and Damien Weston its chief growth officer.

Mission Healthcare — which has more than 600 employees — is a San Diego-based home health and hospice services provider with 10 locations serving the Southern California region.

The hiring of Mack and Weston is part of Mission Healthcare’s broader growth strategy. Both executives were brought on to guide the organization with its overall expansion plans.

Prior to her appointment, Mack held leadership positions at VNA Health of Santa Barbara, Vitas and Interim Healthcare. She is also a member of the National Hospice & Palliative Care Organization (NHPCO), California Hospice & Palliative Care Association (CHAPCA) and California Association for Health Services at Home (CAHSAH).

“JoAnn’s deep involvement in the industry and years of experience will prove invaluable to the Mission Healthcare team as we continue our 10-year track record of growth and success,” Paul VerHoeve, CEO of Mission Healthcare, said in a statement. “Her leadership will be instrumental in ensuring we consistently deliver high-quality care and strengthen our company culture as we expand into new markets. We feel very fortunate to attract great talent that will be instrumental as we continue to expand into more western states.”

Before joining Mission Healthcare, Weston held leadership roles at Compassus, Gentiva and Kindred Healthcare.

“We are thrilled to put Damien at the helm of our expansion efforts. His experience will be integral to helping us scale strategically and expand our quality care offerings,” Verhoeve said.

Lifesprk appoints new president

Lifesprk has announced that Elmer Baldwin has been named company president. Baldwin has a history with Lifesprk — having served as the company’s long-time advisor.

Lifesprk is a Minnesota-based health care provider with a suite of home-focused services.

Baldwin steps in for former president Tom Schmitt, who will now serve as executive director of value-based payment strategy and growth at Lifesprk.

In his new role, Baldwin will oversee the development of Lifesprk’s business model, as part of the company’s overall growth strategy.

“We are growing in all our lines of business, including community-based in-home services, Medicare skilled home care, property management, primary care, acute care at home and hospice, while investing in our value-based, tech-enabled alternative delivery system designed to help seniors age magnificently,” Baldwin said in a press release.

Baldwin has been a Lifesprk advisory board member for the past decade. Prior to his latest appointment, he served as senior executive director of technology investment banking with Minneapolis-based Cherry Tree & Associates.

Caring People names brand ambassador

Caring People has added Jo Alch as a brand ambassador to its team.

A portfolio company of private equity firm Silver Oaks Services Partners, home care company Caring People currently operates in New York, New Jersey, Connecticut, Florida and Texas, serving an average of 1,700 clients per day.

Alch has joined Caring People to support its plans in relation to leveraging new opportunities, partners and PR efforts.

“Establishing and fostering relationships with industry leaders in a variety of spaces will ultimately benefit our seniors tremendously,” Alch said in a press release. “I, and Caring People, truly have a heart for the elderly. This role will provide fresh opportunities for new organizational partnerships with a unified goal: compassionate and highest-quality senior care.”

Before joining Caring People, Alch founded Acappella — a Texas-based home care agency — in 2006.

Caring People also noted that Alch is a thought leader and prominent figure in the Texas health care community.

Additionally, she has served on the board of directors of the Texas Association for Home Care and Hospice and was the committee chair for the Dallas Area Agency on Aging Advisory Council.

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The Care Team Expands Footprint with InTeliCare Purchase; CareFinders Buys Union Home Care

The Care Team acquires InTeliCare

Private equity-backed The Care Team has acquired InTeliCare Home Health & Hospice. The financial terms of the deal were not disclosed.

Farmington Hills, Michigan-based The Care Team is a home-based care provider that delivers a variety of services including nursing, therapy and hospice services across central and eastern Michigan. The Care Team is a portfolio company of the Denver-based PE firm Revelstoke Capital Partners.

InTeliCare Home Health & Hospice is a Michigan-based care provider that operates in Standish, Gaylord and Traverse City.

For The Care Team, the deal was an opportunity to join forces a company that closely aligns with its goals in terms of care delivery, Jason Laing, CEO and founder of The Care Team, said in a statement.

“The Care Team and InTeliCare share similar cultures and a strong commitment to patient care, clinical excellence and compliance,” Laing said. “We see a tremendous opportunity to combine the strengths and capabilities of both companies.”

The deal expands The Care Team’s footprint and places the company in a stronger position to negotiate with payers and referral partners moving forward.

“With the acquisition of InTeliCare, The Care Team will have the ability to treat patients across the entire lower peninsula of Michigan, which will allow us to be better partners to our payer and referral relationships,” Jonny Miller, vice president at Revelstoke, said in a statement.

CareFinders Total Care purchases Union Home Care

CareFinders Total Care has purchased Union Home Care, a Pennsylvania-based home care services provider.

Founded in 1995, Hackensack, New Jersey-based CareFinders provides in-home care services to more than 8,500 patients throughout New Jersey, Pennsylvania and Connecticut. It has 26 offices in total.

For CareFinders, the deal is another opportunity to expand its Pennsylvania footprint. Currently, the company has six offices in the state.

“Union Home Care is a high-growth, premier home health agency in the Philly market offering Medicaid personal care services,” CareFinders CEO Jim Robinson said in a press release. “This newest member of the CareFinders family of companies has an impeccable reputation for high-quality personalized care. With our expanded footprint in Philadelphia, this acquisition takes us one step closer to our goal of becoming the No. 1 home care services company in the Northeast.”

Both organizations align when it comes to values and an overall mission, Mila Mendel, the founder of Union Home Care, said in a statement.

“This is an exciting change that will benefit our clients, our caregivers and our health care partners, and I am excited to help lead this charge,” Mendel said.

Moving forward, Mendel will serve as the executive director of CareFinders’ Philadelphia division. She will also oversee growth plans in that market.

Home-focused health care organizations receive approval to merge

Florida health systems Empath Health and Stratum Health System have been granted formal approval to merge from their board of directors. The organizations’ originally announced plans to merge back in February.

Both organizations provide care in the home setting through their networks. Stratum Health System oversees and supports both Approved Home Health and Avidity Home Health, two agencies with multiple locations in southwest Florida.

Meanwhile, Empath Health offers home health care as a part of its wide-ranging services. The company also focuses on patients with advanced or chronic illnesses.

The merger will create the country’s largest not-for-profit health system, according to the two organizations. Combined, the enterprise will serve more than 6,000 patients daily.

In total, the organizations would have an estimated annual gross revenue of $300 million.

Empath Health and Stratum Health System will continue to operate under their current banners.

Additionally, Rafael Sciullo, president and CEO of Empath Health, will continue in this role. Jonathan Fleece, president and CEO of Stratum Health System, will serve as president.

“As the saying goes, bigger does not automatically make you better,” Sciullo said in a press release. “It is what we do with that opportunity that will allow us to create meaningful change while continuing to excel at doing what we do best, … providing compassionate care to our patients and their families.”

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Senior Helpers, Reliant at Home, Others Crack 2020’s Best Workplaces in Aging Services List

On Thursday, Fortune unveiled its annual Best Workplaces in Aging Services list. The list features several home-based care providers that made a mark when it comes to company culture.

Last year, Senior Helpers and 24 Hour Home Care cracked the list’s top five. These companies make a return appearance on 2020’s top workplaces list, compiled by analytics firm Great Place to Work. Other companies that earned a spot on the list include Reliant at Home, Assistance Home Care and Constellation Health Services.

To compile this year’s list, Great Place to Work analyzed survey results from 189,159 employees working in the U.S. senior care and aging services sector. Those surveyed were asked about their experiences working at their current company.

The questions stem from the Great Place to Work’s Trust Index, which measures a number of factors, including respect of management, fairness, credibility, camaraderie amongst colleagues and pride in the work.

The companies that make up the list meet the Great Place to Work-Certified standard, Activated Insights CEO Jacquelyn Kung told Home Health Care News.

Oakland, California-based Activated Insights is a Great Place to Work subsidiary focused on senior care.

Companies that have earned a spot on the list have a competitive edge over other home care agencies when it comes to recruiting caregivers. Even companies that didn’t make the list, but are Great Place to Work-certified have found success when it comes to these efforts, according to Kung.

“In our research, we found that just getting certified, which is the baseline, increases the number of applicants to your organization by an average of 19.7%,” she said. “That’s huge for our industry, especially this year when turnover has gone up for a variety of reasons. Recruiting has always been important. There’s always been a talent shortage coming into the sector.”

One noteworthy takeaway Great Place to Work identified was that in-home care employee engagement is higher in comparison to providers on the congregate settings side.

The COVID-19 emergency had a significant impact on companies this year. The way companies responded to the public health emergency influenced their performance on the list. During this time, many providers embraced “servant leadership,” according to Kung.

“They, No. 1, put their employees and their safety first,” she said. “They did everything they could to make sure their employees were protected. This meant sending packs of PPE out to homes, making grocery deliveries to their employee’s homes, if a grocery delivery service wasn’t available. Executives would actually drive groceries around and drop them off with employees.”

Kung also noted that quick response from leadership teams and transparency were greatly valued by employees.

One company that made the list, Reliant at Home, partnered with the North Texas Food Bank and Shiftsmart as part of its COVID-19 response. The company also implemented health care screenings for workers.

“Local community and employee-centered benevolence is a culture priority for Reliant at Home,”

Jana Lightfoot, the company’s CEO, said in a statement. “We made hundreds of meal kits for our employees who are front-line health care workers and for patients [and] families that had trouble getting food on their table due to long days caring for others and mitigated access to groceries.”

Allen, Texas-based Reliant at Home provides a number of services, including personal care, home health and hospice.

Another company on the list, Senior Helpers, leaned on training and education when it came to keeping workers safe.

“We continue to offer updated protocols in weekly communications to our system on COVID-19 so that all feel comfortable and prepared,” Peter Ross, CEO and co-founder of Senior Helpers, said in a statement. “Additionally, we offer extensive staff training with courses that include topics such as hand hygiene, infection control, influenza prevention and transmission-based precaution — all aimed so that our clients can age safely and gracefully in the comfort of their own home.”

Senior Helpers is an international home care franchise with more than 320 locations worldwide.

Overall, Care to Stay Home (No.1), Assistance Home Care (No. 2), Senior Helpers (No. 3), Sunland Home Care (No. 4), 24 Hour Home Care (No. 5), Constellation Health Services (No. 6), Compass Care (No. 7), Elite Home Health Care (No. 8), Sunshine Homecare (No. 9) and Reliant at Home (No. 10) rounded out the top 10 home-based care providers.

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No Funding, Closures and Limited Capacity: Adult Day Providers in Dire Need of Help

In late November, the aging-focused advocacy organization LeadingAge wrote a note to Congress, calling for relief on behalf of the 5,500 adult day service providers across the country and the vulnerable patients they serve.

“Adult day services providers across the country urgently need dedicated federal funding to ensure they are able to continue providing services during and after the COVID-19 pandemic ends,” the letter read.

It was signed by LeadingAge President and CEO Katie Smith Sloan and Donna Sizemore Hale, the executive director of the National Adult Day Services Association.

Unlike other health care providers across the care continuum, adult day providers haven’t been the benefactors of any major funding from the federal government. Meanwhile, state mandates have kept adult day operators completely closed, or opened at just 30% or 50% capacity.

A lack of government relief and a major loss in revenue due to limited capacity or complete closures has left the adult day world in deep trouble.

“I think we definitely do need to appreciate that operating at 30% to 50% capacity — or whatever the capacity limit is — is going to have a huge financial impact on any organization over a long period of time, whether they are adult day operators or a business in any other industry,” Brendan Flinn, the director of home- and community-based services at LeadingAge, told Home Health Care News.

Operators are prioritizing safety as they open. That frequently means reopening at reduced capacity, which means a reduced bottom line as well — and sometimes an unsustainable one.

It also means additional expenses, even with a greatly reduced number of members. For smaller adult day operators, those expenses consist of purchasing safety equipment such as PPE and plexiglass in lower quantities — and, thus, at higher prices.

LeadingAge’s letter to Congress included an asking price of $422.5 million to support providers and the over 260,000 individuals they serve.

Worst of all, a lack of support means that the vulnerable individuals that frequent adult day centers are left behind. Reduced capacity squeezes out members in need of care and socialization.

“I was on a call with some of my providers last week that had recently reopened, … and they were talking about their members, and how they had lost a ton of weight, how they’ve declined cognitively,” Flinn said. “Whatever health conditions they had, they had been exacerbated.”

Those providers had also reported that once they had reopened and welcomed members back, all of those aspects had begun improving.

But that’s for the ones lucky enough to return to adult day centers amid the ongoing public health crisis. For the ones that haven’t, those conditions are likely to continue worsening, bringing stress to them and their families.

Adult day centers are a great resource for lower- and middle-income families. They offer care and socialization to seniors at an often lower, more feasible price.

According to Genworth Financial, the 2020 national median cost of adult day services was $1,603 per month. Comparatively, the assisted living cost was over $4,300 per month, while nursing home care was about $7,750.

“It’s similar to anything else we’ve learned from data, research or anecdotal reporting … we’re seeing the effects to a greater degree for lower-income families and communities,” Flinn said. “We know that adult day services are a great way for [these] families and individuals to receive some type of services if they are not eligible for Medicaid and can’t afford something like a nursing home, but need some sort of care.”

The distribution of funds

It’s not that the Provider Relief Fund, for instance, cut out adult day providers. Instead, it’s that once those funds were released to the U.S. Department of Health and Human Services (HHS), the agency did not include them among the providers who would receive relief.

Phase Two of the Provider Relief Fund — for the most part — was the only phase that adult day providers were able to access. Even then, it was designated for providers that had billed Medicaid, and resources were extremely limited.

“These funds were turned over to HHS, and it made the decision about where those funds went,” Flinn said. “So [HHS] were the ones who decided that Phase One would include Medicare Part A, they were the one that decided what providers would get what type of relief.”

So, if there is another relief package coming down the pike, it’s likely to be distributed the same way. And that would still likely leave adult day providers behind. Some states have been better than others when it comes to adult day relief funding, but it has not been enough to make up for the lost ground from a federal standpoint.

To make matters worse, in the recent and initial federal recommendations for vaccines, adult day providers and their members were not included in the highest priority group.

Stunted growth

Elder-Well, a non-medical social model for adult day care, had high hopes in January of this year.

The Framingham, Massachusetts-based company was founded in 2014 by home health veterans Kara and Ken Harvey.

The Harveys were set to begin growing their business by franchising locations in Massachusetts and Florida, offering discounts for potential franchisees. The couple hoped to add 10 in 2020.

“Adult Day is — and is going to be — a very preferred long-term care option,” Kara Harvey told HHCN. “And so before the pandemic hit, we had many people throughout the country interested in joining the franchise system, and then that halted.”

The Harveys have noticed the recession sparking more interest from entrepreneurs of late, but have held back on opening up a slew of new locations given the uncertain regulatory climates in the two states. While they recently opened a new Elder-Well location, they’ve fallen short of their aspirations for obvious reasons.

Adult day centers were also labeled non-essential in both Florida and Massachusetts.

“That was painful,” Harvey said.

In Florida, however, they were allowed to open back up in May. In Massachusetts, adult days weren’t allowed to reopen through the summer.

Elder-Well wasn’t eligible for larger Paycheck Protection Program (PPP) loans. And because it is a social model that does not receive money from Medicare and Medicaid, the only way they were able to recoup some revenue during the public health emergency was to offer virtual solutions.

“It was difficult, I think, for all service providers in the senior care industry, but particularly for adult day,” Harvey said. “Those that weren’t able to pivot instantly and set up a virtual option really took a hit.”

Elder-Well has leveraged a partnership with the cognitive assistance company MapHabit, as well as Zoom and Facebook Portal, to stay in touch with its members.

After keeping its head above water virtually in 2020, the company has tempered its expectations. Now, it hopes to open six locations in 2021.

“Whether it be a social or a medical model, adult day centers are key in order for seniors to continue living at home in each community,” Harvey said. “There needs to be more insight provided for the lawmakers to understand that, and to appropriate funding and support for programs.”

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Care Finders, Lyft, LogistiCare Partner to Give Caregivers COVID-19 Transportation Support

Care Finders Total Care announced Wednesday it has teamed up with LogistiCare, a non-emergency medical transportation company, to provide transportation services to caregivers working in the home. Ride-hailing giant Lyft Inc. (Nasdaq: LYFT) is also involved with the partnership.

Founded in 1995, Hackensack, New Jersey-based Care Finders provides in-home care services to more than 8,500 patients throughout New Jersey, Pennsylvania and Connecticut. It has 26 offices in total.

Meanwhile, LogistiCare is one of the largest managers of non-emergency medical transportation programs for state government agencies and managed care organizations. The company’s service lines include call center management, transportation provider network development, ride management and credentialing.

Under the partnership, CareFinders’ caregivers can request Lyft rides through LogistiCare.

The services offered through the partnership are a response to the public transportation challenges that stem from the COVID-19 emergency. The aim is to make sure that caregivers have safe and reliable access to transportation, according to Care Finders leadership.

“As the largest home care services provider in the state of New Jersey, transportation is always top of mind for us,” Martha Stuart Williams, chief operating officer of Care Finders, told Home Health Care News in an email. “LogistiCare and Lyft brought a technology-centric and patient-centric solution for what is a persistent issue for many home care providers, particularly during a time as challenging as the pandemic.”

The partnership has its roots in a contract between LogistiCare and the New Jersey Department of Human Services.

“This partnership began when LogistiCare started delivering food to those in need during the pandemic,” Kenneth Wilson, chief operating officer at LogistiCare, told HHCN. “This was in addition to our New Jersey state contract to provide non-emergency transportation for Medicaid patients to their medical appointments.”

LogistiCare learned about CareFinders’ transportation needs via conversations with New Jersey’s Medicaid director, Wilson noted.

“We reached out to CareFinders, and they expressed an interest in working together, so we agreed to create and launch a pilot program, which has been very successful,” he said.

For CareFinders, LogistiCare’s willingness to work with front-line care teams in communities hardest hit by COVID-19 made the company an attractive partner, according to Williams.

“They stepped up as a willing partner, providing reliable transportation for some of our most vulnerable caregivers in the midst of the COVID-19 shutdown,” she said. “That’s super important to us, because Total Care at CareFinders is about supporting our caregivers first and foremost so they can care for our clients.”

Overall, Williams believes that the partnership between LogistiCare, Lyft and Care Finders has allowed them to provide consistent care services.

“At the end of the day, this partnership allows us to provide care to patients who otherwise might have been unable to receive care,” she said. “As a company dedicated to changing lives day in and day out, this partnership has become a tremendous asset for us.”

Additionally, LogistiCare is in talks with other home care providers about potential partnerships.

On its end, Lyft has increasingly gotten involved in the health care space, especially around home-based care. Many home-based care agencies use Lyft to coordinate transportation services for both caregivers and clients.

In total, Care Finders employs more than 7,.600 certified home health aides, plus more than 180 RNs and LPNs.

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Providers Attempt to Absorb COVID-19 Expenses, Keep In-Home Care Costs Down

Most in-home care operators and other aging services providers have tried to absorb costs related to the COVID-19 pandemic. But that hasn’t always been feasible, causing the cost of care to rise substantially for consumers.

That’s according to the latest annual Cost of Care Survey from Richmond, Virginia-based Genworth Financial Inc. (NYSE: GNW), a Fortune 500 insurance holding company. To compile this year’s survey, Genworth contacted nearly 60,000 in-home care agencies, assisted living facilities, adult day health providers and nursing homes.

“[Providers] told us that the same factors responsible for the continuing increase in long-term care costs in recent years — a shortage of workers in the face of increasing demand for care, higher mandated minimum wages, higher recruiting and retention costs, and an increase in the cost of doing business, including regulatory, licensing and employee certification costs — were made even worse by the pandemic,” Gordon Saunders, senior brand marketing manager at Genworth, said in a press release announcing the news.

Overall, the survey found that the cost of homemaker services increased 4.44% to an annual median cost of $53,7681 in 2020. Genworth defines “homemaker services” as assistance with tasks such as cooking, cleaning and running errands.

Meanwhile, the cost for home health aide services increased 4.35% to an annual median cost of $54,912, the survey found. “Home health aide services” includes assistance with activities of daily living (ADLs).

For both categories, the annual median cost is based on 44 hours of care per week for 52 weeks. In other words, those costs are linked to individuals who require mostly full-time home-based care.

Despite challenges and rising costs, home-based care operators have had plenty of tailwinds in 2020. More than ever, the U.S. health care system is recognizing the value that in-home care plays in keeping people healthy and happy — normally at a far lower cost than institutional care.

Additionally, many in-home care agencies have embraced various technologies this year, a fact that could help them become more efficient and lower costs for consumers down the road.

“The pandemic has shined a bright spotlight on the value of home care,” Jeff Huber, CEO of Home Instead Senior Care, said in the release. “We can increase the capacity of the health care delivery system. The hospital of the future looks a lot like your living room. As a part of a value-based care package, we can reduce costs, admissions, readmissions and overall usage of the health care system.”

Omaha, Nebraska-based Home Instead Senior Care is a home care franchise company with more than 1,200 independently owned and operated offices worldwide.

In the senior living space, assisted living facility rates in 2020 increased by 6.15% to an annual national median cost of $51,600 per year, according to Genworth.

The national median cost of a semi-private room in a skilled nursing facility (SNF) rose to $93,075, an increase of 3.24%. The cost of a private room increased 3.57% to $105,850.

Many of the aging services providers Genworth talked to said they were trying to absorb new COVID-19 costs, such as personal protective equipment (PPE), hazard pay and more. But over half predicted they would eventually be forced to raise rates in the next six months.

“Providers have been competing with higher-paying, less-demanding jobs for years, but with COVID-19, they told us it has become much more difficult to recruit and retain care professionals because of factors such as concerns about exposure to COVID-19 and parents needing to stay home with school-age children,” Saunders said.

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Business Is Booming, But Home Care Demand Is ‘Probably at a Midpoint’

The non-medical home care industry has slowly carved out an important position within the larger health care continuum over the past several years. It has done so thanks to the home care’s documented ability to improve health outcomes and cut costs.

The COVID-19 pandemic has only solidified home care’s role, especially as caregivers continue to provide critical care on the front lines of the public health emergency.

“COVID-19’s impact has really put us, as an industry, front and center. It has really solidified our place in that continuum of care, overall,” Jeff Bevis, CEO of FirstLight Home Care, said last month at the Home Health Care News Franchise Forum. “[There have been] evolutionary changes [in the past], but COVID-19 has actually helped us.”

Headquartered in Cincinnati, Ohio, FirstLight is a national home care franchise company that operates in more than 30 states. Among their services, FirstLight agencies offer companion care, personal care, dementia care services and more.

Michael Slupecki — CEO of Blue Bell, Pennsylvania-based Griswold Home Care — echoed that idea.

For the last 20 years, the home care industry has predicted that “the home” would serve as the future center of the health care continuum, Slupecki said at Franchise Forum. But before 2020, the industry was just taking “baby steps” toward making that reality.

“There was an opportunity there, but it looked like it was going to take about 50 years for that prediction to come true,” he said. “One pandemic later, and the prediction has become reality. People have been made aware of the value of care in the home — and not only the value but the possibility. I think all of us have learned so much.”

Griswold currently provides personal care services across 200 locations in 30 states. As part of its business mix, the franchiser also offers hospice care at some of its locations, plus an array of other services aimed at enabling aging in place.

While the demand for home care services is at an all-time high this year, the industry itself has yet to reach its full potential.

Yes, COVID-19 has accelerated the need for in-home care, but there’s still the “silver tsunami” to watch out for. In-home care providers have hardly felt the impact of America’s rapidly aging population at this point.

“We talk internally and see indications that demand is probably at a midpoint,” Bevis said. “We still have a good 10 to 15 years ahead of us, where demand is going to go higher.”

For FirstLight, the past five years have been a time of dramatic growth. The company has seen revenue growth of 318% during this time period, with new-unit growth of roughly 95%. Currently, the company is in over 260 markets.

Plus, the company has seen steady growth in its number of clients and caregivers, according to Bevis. Even after the current public health emergency subsides, FirstLight will continue to be bullish when it comes to expanding its footprint, he noted.

“We’re probably pretty aggressive minded,” Bevis said. “We really expect to have even a bigger and faster growth element to our national footprint. That’s for both opportunity markets and for growth in our national alliances and third-party payers.”

Similarly, Griswold has its sights set on expansion, but plans to take the slow-and-steady route.

“We do want to expand geographically, but we also want to be selective,” Slupecki said. “[We want to] be measured by the number of successful franchisees, not by the number of franchises sold. We want to be thoughtful around it.”

Recently, Griswold has seen an uptick in individuals looking to join a franchise system. This is potentially influenced by the current COVID-related recession and job uncertainty, according to Slupecki.

“There have been people impacted by the slowdown, economically, and people that have lost their jobs and are looking for something that they control their own destiny on,” he said.

Moving forward, Bevis and Slupecki believe that more and more will be expected of home care providers. Home care’s role as “the eyes and ears” in the home will serve as a vital tool for its counterparts working in skilled home-based care.

For example, that includes home health providers that are looking to set up SNF-at-home product lines. Such models need to have a strong home care component for constant monitoring and support with ADLs.

Additionally, with news that COVID-19 vaccine manufacturers Pfizer and Moderna filed for emergency use authorization with the Food and Drug Administration (FDA), Bevis hopes that caregivers will be recipients of the vaccine.

“We sure hope that home care is part of the health care worker component there … we do need to protect our employees, who then can make sure we protect our clients and their families too,” he said.

To this end, seven national home-based care advocacy organizations recently petitioned the CDC’s Advisory Committee on Immunization Practices to ensure that home care workers are included in the health care workers that the committee determined should be first to receive the vaccine.

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Hoping to Prevent Community Spread, Home-Based Care Advocates Vie for ‘Critical’ Vaccine Access

A number of national home-based care advocacy organizations have come together to address the CDC’s Advisory Committee on Immunization Practices (ACIP). In a new letter penned to ACIP Chairman Dr. José Romero, the group called for the inclusion of in-home caregivers when it comes to priority access to the COVID-19 vaccine.

The letter was born out of a collaboration between seven organizations, including the Home Care Association of America (HCAOA), the National Association for Home Care & Hospice (NAHC), the Partnership for Medicaid Home-Based Care (PMHC) and the Partnership for Quality Home Healthcare (PQHH).

“I’m really thrilled that all of the home care associations got together and are speaking in one voice on such an important issue as vaccines,” Vicki Hoak, executive director of HCAOA, told Home Health Care News.

Last week, ACIP specified which groups should be granted priority access for Phase 1 of vaccine distribution.

ACIP determined that health care workers and residents of nursing homes should be on the list. The CDC committee also said that essential workers, older adults and individuals with underlying medical conditions should also be granted priority access to a vaccine.

During a Tuesday meeting, ACIP voted 13 to 1 in favor of those recommendations.

Vaccine distribution has garnered national attention since last month’s news that COVID-19 vaccine manufacturers Pfizer and Moderna filed for emergency use authorization with the Food and Drug Administration (FDA). Oxford and AstraZeneca are also close to rolling out a vaccine.

In their letter, the national home-based care advocacy organizations commended ACIP’s recommendations but urged the committee to be specific in its definition of health care workers in order to ensure that all caregivers are included. That includes home health aides, hospice aides, personal care aides, home care workers, direct support professionals and others.

“Our concern is that under the most recent CDC COVID-19 Vaccination Program Interim Playbook for COVID-19 Vaccination Program Jurisdiction Operations, home care workers, specifically personal care aides and home health aides, are not explicitly mentioned as Phase 1 or Phase 1A critical populations for vaccinations,” PMHC Chairman David Totaro told HHCN in an email.

The distinction is important because caregivers working on the non-medical side of home-based care are sometimes overlooked when it comes to federal policy, according to Hoak.

“Sometimes when you think of COVID, you think ‘medical,’ and a personal care aide helping people with activities of daily living doesn’t always come to mind,” she said. “But they are just as critical, especially during this pandemic.”

In the letter, the group also stated that the home care population should be afforded high-priority status for access to the vaccine.

The letter also stressed the importance of the adoption of these recommendations at the state and local levels. ACIP recommendations will serve as a guideline, but ultimately the decisions happen at a state level.

In Massachusetts, for example, physicians and community leaders on the Massachusetts COVID-19 Vaccine Advisory Group have expressed that front-line workers such as caregivers should be early recipients of the vaccine.

Texas has also placed home health workers in its “Tier 1” prioritization category, along with hospice staff.

“What we’re doing next is encouraging all of our members to send letters to their various state officials who are developing these plans,” Hoak said. “Now that we have tried to encourage the federal agency to adopt our recommendations — making sure that they’re all-inclusive — the next step is to advocate at the state levels to make sure that same message is carried forward.”

In addition to the previously mentioned organizations, the American Network of Community Options and Resources; the Council of State Home Care & Hospice Associations; and the National Hospice and Palliative Care Organization also signed the letter.

Combined, the seven organizations represent in-home care providers caring for over 12 million individuals annually. Collectively, those home-based care providers have served “tens of thousands of patients with active COVID-19 infections,” according to the letter.

Over 60% of home care and hospice providers are currently reporting COVID-19-infected patients on service, with many of those patients often living in facility-based settings.

“We want to emphasize that the individuals we serve often have complex service needs and are

at high risk for COVID-19,” The letter reads. “While we recognize the need for vaccinations for those that live in long-term care facilities, it is important to remember that our workforce, on a daily basis, frequently goes to multiple homes. They also provide care in other health care settings, including nursing homes, assisted living facilities and in-patient hospice facilities. The greater protection that both the workforce and individuals receive, the less likely there will be a community spread of the virus.”

U.S. nursing homes are experiencing the worst outbreak of weekly new COVID-19 cases since last spring due to community spread among the general population, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL) announced on Tuesday.

Nursing home cases have officially surpassed the previous peaks since the Centers for Medicare & Medicaid Services (CMS) started tracking cases in nursing homes.

“Our worst fears have come true, as COVID runs rampant among the general population and long-term care facilities are powerless to fully prevent it from entering due to its asymptomatic and pre-symptomatic spread,” Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement.

Additional reporting by Tim Regan.

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Payer Credibility Helps Propel Home-Based Care Company Prospero Health into 16 New States

Home-based care company Prospero Health announced Tuesday it is expanding into 16 additional states to serve 8,000 new patients in 2021.

That vastly increases the company’s footprint. Previously just in 10 states, the move now puts Prospero into 26 states total, allowing it to serve 25,000 patients on behalf of its partners, namely the Medicare Advantage insurer UnitedHealthcare.

The Boston-based company offers both non-medical home care and home health care services through a team of doctors, nurses and social workers. It also provides telehealth support for its patients and helps mitigate environmental hazards for seniors, such as fall risks at home.

“The pandemic accelerated the need for the services we provide,” Prospero President Dr. Dave Moen told Home Health Care News. “And our ability to do work virtually, as well, allowed us to expand into geographies that were previously not reachable by an in-person model.”

Founded in 2019, Prospero’s original plan was not to move this fast. But as of July, the average age of the patients Prospero was serving was 83 years old.

COVID-19 brought with it extenuating circumstances that kept seniors in their homes and insurers scrambling to figure out ways to keep them healthy.

“UnitedHealthcare, our biggest customer, saw that our results were solid,” Moen said. “And they were very confident that we had a team in place to actually be able to deliver a high-quality product. It was really about building trust and credibility with our customers.”

“It was about them seeing results that met their goals of high member satisfaction, and decreases in unnecessary hospitalization and ER visits,” he added, noting there are ample tailwinds for all forms of home-based care.

Rapid expansion

Prospero is based in Boston, but a large chunk of its employees are based in Memphis, Tennessee. This past summer, it began expanding in southern states, including Alabama. The company does not open brick-and-mortar offices when it expands, but instead leverages scheduling software programs that match patients’ needs with the right clinicians in their area.

When it did begin serving Alabamans, the company was already working on its next move and surveying the landscape for what came next. Now, Prospero is set to be in nine more states by Jan. 1 — and the majority of states in the U.S. by the end of 2021.

When considering expansion, Prospero is “very informed” by UnitedHealthcare’s membership data, as well as its own algorithm identifying the types of patients that are best served by its offerings, Moen said. Its virtual capabilities have given the company the confidence to move into markets that have less dense populations, but still have seniors with qualifying needs.

“When we look at [strictly] in-person visits, there’s a certain density that allows us to reach a certain number of people that allows us to staff appropriately,” Moen said. “The virtual model allows us to reach a lower-density geographies.”

An example of lower-density geographies is rural areas, which have traditionally dealt with issues when it comes to access to health care.

Earlier in 2020, Prospero partnered with the technology company GrandPad, which provides tablets specifically built for people over the age of 75. GrandPad helps Prospero facilitate its live video chats with patients.

In Memphis, the company has also invested heavily in its Care Support Center.

Addressing staffing

In order to expand as quickly as it has, Prospero has had to build goodwill with staff across the country in a hurry.

As part of its care plan strategy, nurse practitioners do all the initial evaluations on patients, either virtually or in person. After that, an interdisciplinary team comprised of physicians, nurses and social workers meets to discuss the patients’ needs.

“We assign patients based on their needs, and then we risk stratify and segment them,” Moen said. “Some patients are followed by a nurse practitioner, some are followed by an RN. And those two roles are supported by a physician or social workers who were brought in as appropriate for those patients.”

The key to any company’s growth is to be able to build and sustain workers across the country.

Moen is bullish on the tailwinds for home-based care persisting, especially when it comes to staffing. It’s his belief that building a workforce will be easier moving forward due an increased interest for working in what he’d call “a purpose-built care delivery model” for the elder population.

“We’re big enough that workers can now talk to our team members who have worked with us long enough to give them a true report of what it’s like to work in a company like this,” Moen said. “And we’re fortunate that we are off to a good start.”

Prospero is still in a position where it’s fielding multiple applicants for its open positions, which is a welcoming sign for the company in terms of its future outlook.

“I think, professionally, lots of people are interested in finding a career that has a deeper meaning and a deeper connection to what they care about,” Moen said. “The mission is compelling because people see the need. I think as we continue to establish credibility and tenure in the space — and people see it not as an under-supported career, but a very intentional, purposeful career — I do think that it’ll create more momentum in attracting more workers into this part of care delivery.”

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How Home-Based Care Businesses Are Combating the Worsening ‘Senior Loneliness Epidemic’

Holidays will look a lot different this year. In fact, half of seniors over the age of 70 don’t even plan to see family for Thanksgiving, according to a recent survey conducted by Aloe Care Health.

With more families staying apart, home-based care providers are gearing up to make seniors feel as comfortable and connected as possible. And most of them bring years of companionship experience to the table, as senior isolation has long been a major problem in the U.S.

“This year with the pandemic, we’re more concerned than ever,” Charlie Young, the CEO of Synergy HomeCare Franchising, told Home Health Care News. “The holidays are typically a time where we see an uptick in inquiries into Synergy HomeCare. That’s because adult children usually spend more prolonged time with their loved ones during this time, and they notice things.”

Often, seniors may have problems with their health or activities of daily living (ADLs) that go unnoticed until the family comes around. With families opting to stay home this year, that concern won’t go away, but instead manifests from miles away.

Home care providers like Synergy are adapting to help.

“It stands to reason that we would get an uptick in inquiries coming out of the holidays,” Young said. “So we just thought we would do our best to arm people with some knowledge and information as they look at doing the holidays in a different way this year.”

Gilbert, Arizona-based Synergy HomeCare is a non-medical home care franchise that offers companionship, personal assistance, housekeeping and live-in care services across 365 locations nationwide.

Additional statistics reinforce just how isolated families are in 2020: Air travel is down about 60% this year compared to last, with car travel likewise expected to be down.

For the millions of Americans that will be unable to gather with their senior loved ones, Synergy is recommending what they call “benevolent probing,” a series of techniques used to observe and inquire about an individual’s well-being.

Synergy is also urging families’ to observe ADLs virtually, through a FaceTime or Zoom call, for instance.

“First and foremost, it’s checking in on physical appearance,” Young said. “Are they shaving? Is their hair combed and well kept? How’s their clothing? How is their hygiene from what you can see? How’s their weight — do they look like they are eating properly?”

For memory, Young recommends that family members talk about current events. If seniors are brushing off questions, that could be a sign things aren’t going well.

Miami-based Papa — the on-demand companionship startup that serves older adults and their families — built a business model around helping seniors socialize. Its “Papa Pals” are what it calls “family on-demand.”

Usually, the Pals visit seniors’ homes and independent living facilities to hang out with lonely seniors. During COVID-19, however, it has pushed virtual engagement to make sure its clients are still having meaningful conversations with others.

Papa has successfully converted most of its seniors from telephone calls to video visits since March, Andrew Parker, the founder and CEO of Papa, told HHCN.

“Seniors are learning how to use technology, and doing that with their Pal as the guide,” Parker said. “And we’re making sure that everyone has somewhere to be or something to do on Thanksgiving.”

Two-thirds of the seniors polled in the Aloe Care Health survey wished they had a simpler technological solution to speak with family members.

One of the biggest priorities of Papa Pals this year has been initiating useful technology into seniors’ lives so they can stay in touch with their Pals, as well as friends and family.

Stepping in to help

Checking in on seniors is the relatively easy part. The hard part is knowing what to do when a senior’s health or cognitive status appears to be in decline, Young said.

“I think that this is one of the most challenging parts, and it starts with a conversation,” Young said. “Where we step in is … a home assessment. A simple phone call to Synergy HomeCare to discuss what you’ve observed can go a long way to give you peace of mind.”

Despite the lack of in-person observation this year, Synergy is still expecting an uptick in business due to holiday engagements — or lack thereof. The company has already noticed an increased interest in home care services, and it thinks that will lead to more indefinite business down the line.

“We typically see a spike in inquiries in the week after Thanksgiving and then leading up into Christmas,” Young said. “And I think this year we might also see a little bit of a bump in business in the first quarter in January.”

Papa is expecting the same.

“I do expect usage to go up this holiday season,” Parker said. “Every holiday our usage goes up more than you would expect. I think this holiday, we’re definitely going to see — and we’re already seeing — trends of increased usage, because people aren’t able to gather as much as they were historically and people aren’t able to talk to family. Or in some cases, that family doesn’t exist.”

Papa is also acting as a conduit to local organizations in seniors’ neighborhoods that could assist with the type of things that Synergy’s “benevolent probing” is aimed at monitoring.

“If people need to get connected to local organizations to support them during this time, we want to help with that, and make sure they’re feeling really good, excited and happy,” Parker said. “It’s the holidays — it’s not time to feel lonely.”

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In-Home Care Workers Increasingly Prefer Virtual Training

Virtual tools have quickly turned into the preferred method of training for in-home caregivers since the start of the COVID-19 public health emergency. That trend will likely continue beyond 2020 as well.

That’s according to a new survey conducted by Medflyt, a HIPAA-compliant web-based workforce management platform for home care agencies. The Forest Hills, New York-based company works with more than 100 providers and 100,000 caregivers across the U.S.

As part of the survey, released Tuesday, Medflyt gathered data from roughly 11,000 in-home care workers across the U.S. Overall, the survey found that 60% of surveyed caregivers would rather be trained online instead of in person.

“This pandemic kind of flipped the way agencies were operating on their backs, with agencies saying, ‘We should think broader. We should think smarter,’” Levi Pavlovsky, COO and co-founder of Medflyt, told Home Health Care News.

In addition to caregivers’ preference for virtual training, a key finding of the survey was that 38% of respondents wanted to onboard remotely. This percentage is much higher than before the public health emergency began, Medflyt noted.

Throughout the COVID-19 emergency, technology has been a critical tool in facilitating the delivery of care, a point reflected in the rise in telehealth utilization among home-based care providers.

But technology has also played a significant role in the operations side of the in-home care business as well. Since spring, many providers have shifted existing training and onboarding processes into the virtual realm.

“It’s an ever-changing environment. We’re going more to tech,” Pavlovsky said. “Technology is bringing efficiency. Now agencies can really focus on improving the quality of care for their patients.”

Another important finding from the survey: When it comes to retention, accessibility of staffing and onboarding processes plays a huge role. In fact, 62% of caregivers said that easy and quick onboarding staffing functions are deciding factors when considering one agency versus another.

For providers that have historically struggled with retention, these findings should encourage them to throw their efforts behind streamlining the recruitment and onboarding process, according to Pavlovsky.

Agencies that aren’t moving fast enough may find themselves unable to keep up with their competition, he added.

“Agencies that are not able to quickly pivot, quickly adapt technologies, they’ll be out of the game,” Pavlovsky said. “They won’t be able to continue to fight with agencies that are pivoting and adapting into the new era of this unfortunate pandemic.”

In addition to the previously aforementioned findings, the survey also revealed that 44% of caregivers believe “better communication and flexibility” from agencies would improve training.

On top of that, 54% of respondents said they want to be educated on topics related to the public health emergency such as social distancing, regulations and sanitation, in relation to their work.

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24 Hour Home Care’s Ryan Iwamoto: ‘We Wanted to Be the Trader Joe’s of Home Care’

Ryan Iwamoto co-founded 24 Hour Home Care 12 years ago, right in the middle of the country’s last major recession. Now, Iwamoto and his company find themselves operating through another economic downturn, with this one caused by the COVID-19 crisis.

Los Angeles-based 24 Hour Home Care is an independent, non-medical home care provider with 20 locations spanning California, Arizona and Texas. It employs over 10,000 caregivers and has been one of the fastest-growing companies in the U.S. for the past several years, according to Inc. Magazine.

Despite a lengthy list of challenges over the years, the home care company has managed to thrive. It has mostly grown organically since launching, though these days, it’s becoming more of an M&A player as well.

Iwamoto, who serves as the president of the company, credits 24 Hour Home Care’s success to its people — which he calls its “secret sauce.”

To learn more about that secret sauce and how 24 Hour Home Care has thrived in forming partnerships with Medicare Advantage (MA) plans, hospitals and other health care providers, Home Health Care News sat down with Iwamoto for a recent episode of Disrupt.

Highlights from HHCN’s conversation with Iwamoto are below, edited for length and clarity. Subscribe to Disrupt via Apple Podcasts, Google Play Music, SoundCloud or your favorite podcast app.

HHCN: 24 Hour Home Care has been recognized as one of the fastest-growing home care companies for eight years in a row. How have you managed to do that, year over year?

Iwamoto: When we started 24 Hour Home Care, we wanted to combine the professionalism of a large company with the personalization of a mom-and-pop business. And when we were thinking about what company did this well, in any industry, there weren’t really many that came to mind. But there was one: Trader Joe’s.

Everyone loves Trader Joe’s. They did an amazing job of being your grocery store, even though there aren’t many Trader Joe’s across the country. The store in your neighborhood, you probably identify that one as “your Trader Joe’s.” And their motto was brilliant, too, right? They’re not the cheapest. They’re not your 99-cent grocery store. They’re also not your Whole Foods. But they did a really good job of offering quality products at competitive prices.

Most importantly, the people that you deal with are their secret sauce. The people are super engaged, helpful, motivated and seem to be happy to work at Trader Joe’s. That was something we really wanted to emulate at 24 Hour Home Care. We wanted to be the Trader Joe’s of home care.

Is that the magic bullet that you think made 24 Hour Home Care successful — its people?

Absolutely, just like Trader Joe’s. It’s our people.

We actually have a motto here at 24 Hour Home Care, which is “Care and Compete.” Every employee has to have a little bit of both to work here, a dedication to caring and a sense of competition.

On the care side, you have to care for what we call the four C’s: your clients, your caregivers, your colleagues and, of course, the community. On the competition side, to be frank, we are a mission-driven company, but we are for-profit. So, you have to be able to compete.

This is not just competing in the traditional sense of competing with your industry competitors, but also competing with yourself to be a better version of yourself every day. I like to say those two values are the two threads that are interwoven to make the fabric of our culture.

Do you think you’d be able to launch in the same way you did 12 years ago?

To be honest, probably not. As everyone knows, home care is not easy. When I started the company with David [Allerby], I was 26. It was during the heart of the recession.

The one thing we didn’t have on our side is experience. But the one thing that we did have on our side is just this blind ambition. We really didn’t know any better. But we kept pushing forward. We would fail a few times, but “fail forward” and keep adapting to our circumstances.

And I think that’s what’s helped create the mentality that we have today, that with any challenge comes an opportunity. With COVID-19, I think we’ve seen the same thing. You just have to find that opportunity to rise above it. Once you get more established and more experience, I think you get a little bit more set in your ways, maybe more resistant to change.

It would be a lot harder going into home care with a little bit more experience now.

Most of your business comes from private pay, but you’ve also invested heavily in Medicare Advantage (MA). Why did you see that as an opportunity for growth, and how is that effort going?

We’re extremely bullish on MA. And one of the things that I love to see is the needle starting to move for our health systems — people seeing the benefit and value of home care. Medicare Advantage adding home care as a supplemental benefit a couple years ago, I think, was a huge leap forward.

As a company, we were truly honored to be able to work with some of the plans like Anthem Inc. (NYSE: ANTM) to help create a home care benefit.

Right now, MA is not a significant portion of our revenue. But being a part of this mission to show the value of home care is why we do it. Five to 10 years down the line, to see this as your standard insurance and Medicare benefit — that’s what keeps me going every day.

If you think about it, Medicare was established in the 1960s. For a while, outpatient physical therapy (PT) wasn’t a Medicare benefit at all. Then programs were put together, pilots were made to show the benefit of outpatient PT. Then in the late 60s, it was added. Hospice didn’t become a Medicare benefit until the 1980s. It was several years down the line before people really saw the value in it.

But people put programs and pilots together to show the value of hospice. Now today, people think differently. It’s just assumed as a benefit. I’m very confident home care will follow suit. We’re already seeing it start to happen with MA. I’m excited to be able to help pioneer this for the industry.

In terms of the presidential election, how are you looking at it from a home care perspective?

We’ve gone through three presidents — George W. Bush, Barack Obama and Donald Trump.

I think that with every election, there’s going to be some change, of course. And there’s also going to be change that you’re just not going to have any control over.

For me, I try not to get so bogged down thinking of what may or may not [happen]. Where my mind goes with any of this, whether it’s the election, crisis or change, is ‘with change comes opportunity.” You just have to find it.

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Amazon Unveils ‘Care Hub,’ a New Alexa Tool Designed for Aging in Place

Amazon (Nasdaq: AMZN) has taken another step toward taking over the aging-in-place space. Earlier this week, the online retail and technology giant announced it is rolling out a new health care feature through its Alexa device aimed at helping informal caregivers monitor seniors inside the home.

The new feature — dubbed “Care Hub” — allows Alexa voice assistant users to link their account to the account of the senior they are taking care of. Once the senior accepts the invitation to link accounts, the caregiver can then view information on their daily activity and send alerts.

“Once that connection is established, the care recipient doesn’t need to do anything and can go about their day as normal,” Toni Reid, vice president of Alexa Experiences and Echo Devices at Amazon, told CNBC.

In a blog post, Amazon noted that users have praised “the simplicity of the voice service.”

In addition to supporting general connectivity, Care Hub also allows seniors to reach their caregivers by saying a command — “Alexa, call for help” — when emergency situations occur. In these instances, the caregiver will receive an immediate push notification, allowing them to respond to avoid a potential hospitalization.

While Care Hub is marketed towards informal caregivers — spouses, family, friends or neighbors supporting a senior — the offering could eventually make a difference in the professional home care world. Many home care companies have experimented with in-home monitoring through Alexa or similar voice-enabled devices, though actually leveraging those tools on a day-to-day basis is still relatively uncommon.

One example is Wilmington, Delaware-based ChristianaCare, which recently unveiled its “Home Care Coach,’ a HIPAA-eligible Alexa tool that was designed specifically for the company.

“Voice assistants are in millions of homes in the U.S.,” Randy Gaboriault, chief digital and information officer at ChristianaCare, told Delaware Business Now. “By leveraging this technology, we are creating a new model of care within patients’ homes to support the best health outcomes possible.”

ChristianaCare provides skilled nursing, rehab, after-hospital care and other services to more than 8,000 patients in Delaware.

It’s easy to see Care Hub quickly building momentum and attracting new users, considering both the nation’s aging population and Amazon’s position in the smart-speaker market. According to some estimates, nearly 70% of U.S. smart-speaker owners use an Amazon device, with rivals like Google and Apple lagging behind.

Care Hub isn’t Amazon’s first foray into the home. In September, the company announced plans to expand Amazon Care, a virtual care clinic that allows its employees to gain access to in-home care and telehealth services.

The company has also dipped its toes in the senior care space, with talks of a possible partnership with AARP back in 2018. The nature of a partnership was centered around designing technology for aging populations.

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‘Our Work Begins with Getting COVID Under Control’: What a Biden Administration Means for Home-Based Care

After one of the closest and most hotly contested campaigns in modern history, President-Elect Joe Biden addressed the nation on Saturday from an outdoor platform in Wilmington, Delaware.

While it’s far too early to say what the first 100 days of a Biden administration will look like from a detailed policy perspective, the president-elect has made one point abundantly clear. It’s time to get to work — and that work starts with the COVID-19 pandemic.

“Our work begins with getting COVID under control,” Biden said during his victory speech. “We cannot repair the economy, restore our vitality or relish life’s most precious moments — hugging a grandchild, birthdays, weddings, graduations, all the moments that matter most to us — until we get this virus under control.”

As the United States inches closer toward the macabre milestone of 10 million total coronavirus cases, the Biden administration’s response to the ongoing pandemic will need to be wide-ranging and thorough, touching on everything from vaccine development and distribution, to additional rounds of relief for health care providers. Long-term care and protecting America’s senior population will also need to be at the very center of its response.

“I will spare no effort — or commitment — to turn this pandemic around,” Biden continued.

In the weeks and months leading up to his victory this past weekend, Biden — a soon-to-be 78-year-old man himself — suggested a deep appreciation of home-based care.

In July, for example, the former vice president outlined a $775 billion plan to overhaul the nation’s caregiving infrastructure, which is mostly made up of women and people of color. As part of that plan, Biden said he hoped to create upwards of 3 million new caregiving and education jobs over the next decade, while likewise creating pathways for former caregivers to re-enter the workforce.

The plan additionally called for a $450 million boost for senior care, with some of those funds dedicated to improving wages and labor conditions for in-home care workers.

“Home health workers do God’s work, but aren’t paid much,” the then presidential candidate said on social media. “They have few benefits, and 40% are still on SNAP or Medicaid. It’s unacceptable. I’ll give caregivers and early childhood educators a much-needed raise.”

Biden hasn’t just highlighted his appreciation of home-based care in broad strokes and policy promises. In addition to his $775 billion plan, the president-elect has repeatedly brought attention to very specific, innovative programs that typically only industry insiders know about.

That includes making nuts-and-bolts references to CAPABLE, the increasingly popular program out of the Johns Hopkins School of Nursing designed to support aging in place by coordinating nursing, therapy and handyman services in the home.

“To hear him really describe [CAPABLE] was thrilling,” Sarah Szanton, the Johns Hopkins professor who helped create the program, recently told Home Health Care News.

Protecting America’s seniors

Moving forward, Biden and his staff will likely try to secure additional resources for home-based care providers and other long-term care operators. In its official policy plan for nursing home regulations, for instance, the Biden team stated it would invoke the Defense Production Act to increase the overall supply of PPE.

The campaign was highly critical of the Trump administration for failing to coordinate sufficient distribution of testing supplies and personal protective equipment (PPE) early on, so a lack of action on that front would only be viewed as hypocritical.

Currently, “protecting older Americans” is one of the main priorities featured on the Biden-Harris Transition website. That fact that hasn’t gone overlooked by those in the aging services space.

“We appreciate the Biden-Harris Transition team’s announcement regarding its COVID-19 response,” Argentum CEO James Balda said in a statement. “The specific emphasis on protecting at-risk populations, which includes older adults and those who serve them, as well as a focus on the efficacy of vaccine distribution, is critical to controlling the spread of this virus.”

Argentum is the country’s largest senior living association.

The Biden-Harris Transition team announced the formation of its 13-person Transition COVID-19 Advisory Board on Monday. The advisory board will be led by former FDA Commissioner Dr. David Kessler, former Surgeon General Dr. Vivek Murthy and Dr. Marcella Nunez-Smith, a Yale physician and researcher.

“Dealing with the coronavirus pandemic is one of the most important battles our administration will face, and I will be informed by science and by experts,” President-Elect Biden said Monday.

Notably, the advisory board also includes Dr. Atul Gawande, the surgeon and writer who founded Ariadne Labs, a joint center between Brigham and Women’s Hospital and the Harvard T.H. Chan School of Public Health.

Gawande — former CEO of Haven, the health care venture founded by Amazon, Berkshire Hathaway and JPMorgan Chase — has been a staunch supporter of palliative medicine and end-of-life care. His participation on the board could signal a focus on those areas during the duration of the public health emergency.

The Coalition to Transform Advanced Care (C-TAC) said it has been encouraged by a number of Biden campaign proposals that have the potential to improve the lives of the seriously ill, particularly in home- and community-based settings.

“C-TAC looks forward to forging new relationships with those in the incoming Biden administration and Congress,” C-TAC Executive Director Jon Broyles said in a statement. “As we work toward building a health care system that works for everyone, it is essential that we come together to find innovative solutions that meet the needs of the sickest and most vulnerable among us, with particular attention to low-income, traditionally underserved individuals.”

Beyond home care

The advisory board may include others in days to come.

Given the pandemic’s outsized impact on people age 65 and older, additional expertise in aging — whether via gerontologists, industry leaders or researchers — would bring much value, according to Ruth Katz, LeadingAge’s senior vice president of policy. LeadingAge is a diverse association of nonprofit providers of aging services.

“We expect to see a focus on in-home and community-based services through programs in their platform on caregiving, education and workforce,” Katz said in a statement. “That’s a positive.”

Beyond directly supporting home-based care, a Democratic president in the White House and a split Congress may also mean a heightened willingness to reach across the aisle to get things done, at least compared to the past four years.

Initially, there’s bound to be friction between both governing parties, a concept reflected in the largely unsubstantiated voter-fraud concerns voiced by Republican leadership. Over time, though, lawmakers will hopefully find common ground on no-brainer, common-sense issues.

That could mean newfound momentum behind legislation with bipartisan support, such as the Home Health Emergency Access to Telehealth (HEAT) Act, a bill to provide Medicare reimbursement for audio and video telehealth services delivered by home health agencies during a public emergency. Among the bill’s backers is Sen. Susan Collins of Maine, one of the few Republicans to officially congratulate Biden on his victory.

It could also mean continued support for Medicare Advantage (MA), which, in turn, means continued support for home care. Often cited as the future of health care by Republicans, MA was actually first enacted under the Clinton administration as “Medicare Plus Choice.”

Better Medicare Alliance President and CEO Allyson Y. Schwartz reminded people of that on Monday.

“The story of Medicare Advantage is one this new administration can be proud to continue,” Schwartz, a former member of the U.S. House of Representatives, said in a statement. “We stand ready to work with President-elect Biden, Vice President-elect Harris and their team to build on this bipartisan success.”

Out of a total Medicare-eligible population of more than 62.4 million individuals as of October 2020, nearly 25.4 million had signed up for MA, federal statistics show.

Biden, of course, has also voiced support for “Medicare at 60,” a plan to allow Americans between the ages of 60 and 64 the option of buying into Medicare slightly earlier. If ever enacted, that plan would dramatically expand the population of Medicare beneficiaries able to receive Medicare-certified home health services.

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Caring People Building Its Business by ‘Reinvigorating’ Home Care Owners

Sky-high equipment costs and staffing shortages tied to the COVID-19 virus have made it drastically more difficult to run a profitable home care business for many operators. That’s not true for Caring People, CEO Steven East told Home Health Care News.

Caring People has had to face its fair share of challenges over the past several months, but the West Palm Beach home care provider has been able to leverage its scale to stay in the black. A portfolio company of private equity firm Silver Oaks Services Partners, Caring People currently operates in New York, New Jersey, Connecticut, Florida and Texas, serving an average of 1,700 clients per day.

In addition to avoiding “going upside down financially,” Caring People has also had success recruiting caregivers and adding to its leadership team.

HHCN recently connected with East to learn more about COVID-19’s impact and the toll it takes on home care operators. During the interview, the CEO also touched on what Caring People looks for in its acquisition targets and how the company is tapping into new service lines.

Highlights from HHCN’s conversation with East are below, edited for length and clarity.

HHCN: Providers have incurred higher-than-normal operational costs in 2020 because of the COVID-19 pandemic. What has “the cost of COVID” been for Caring People?

East: If you want to break it down to a micro level, every visit that a provider performs, you have to protect your caregivers and clients with personal protective equipment (PPE). In the past, we didn’t have to do this. It’s definitely increased per visit costs by several dollars. If you’re going through multiple gloves and masks, then that increases costs exponentially. While it is a cost, we haven’t found it to be a very significant impact on the business.

One of the interesting things that evolved during the pandemic was the need to have safer transportation service for our caregivers, too. They were not comfortable going on public transportation. The clientele didn’t want someone who just rode the train to go in and take care of them. We had to become more reliant on Ubers and similar services.

We were also lucky because we had our own internal van service. We were able to start leveraging our fleet of vans, with about four or five vans driving all over New York, New Jersey and Connecticut during that initial wave of the pandemic. We were able to get our caregivers from Point A to Point B. Clients were more comfortable knowing caregivers were taking the van and not riding on the train with 50 or 60 other people. That was a cost we incurred, but it also helped us continue services for our clients.

With the added costs in mind, how do your financial margins compare to last year? Is it harder to run a profitable business?

At our scale, No. I remember the days when I started out, doing eight different jobs in the office. Margins were so tight back then that if my cost of care went up by 10%, I probably was upside down financially.

Now, we’ve been doing this for 20-plus years. We have significant back-office support. We’re able to really navigate the situation a little bit better than if I was still just a single-site provider. I could definitely see how PPE and other COVID-related costs can adversely impact someone, but we’ve been very fortunate.

Caring People is currently experiencing growth in administrative staff and caregivers. Can you provide some details and numbers around this?

We added two new executive positions: chief operations officer and the chief people officer. There is a need to have super-talented individuals in leadership positions as we continue to grow. We don’t ever want to sacrifice our delivery of care because of growth. We want to always make sure we have the right people in the right positions, at the right time.

As far as caregivers are concerned, we have a very comprehensive recruitment process. We have a completely centralized recruitment team, which has worked tirelessly since COVID-19 first hit. They were doing everything they could to source caregivers and onboard them. We went to a completely virtual onboarding process, so we’ve been able to keep our pipeline of caregivers going. We were very lucky that we weren’t seeing a dwindling workforce while demand continued to increase.

We saw a significant influx of folks coming from the service industry to work with our clients, individuals who could benefit from just the companion-type of service. For our companion business line, non-certified caregivers, we definitely saw more availability.

Your company has been active on the acquisition front, with its latest purchases being Acappella In Home Care, Aging Care LLC and AMR Care Group. Will acquisitions continue to play a major role in the company’s growth strategy moving forward?

It’s definitely part of our growth strategy, especially when we look at new potential markets and also adjacent markets to where we are now.

We have an approach that focuses on acquisitions, as well as organic growth, which includes new branches and also new service lines.

When it comes to acquisition targets, we definitely look for culturally aligned owners. It’s not our preference to do an acquisition where you go to closing, then the owners disappear right afterward. We like owners who want to stay on and be part of a larger company. We support the parts of the business they’re passionate about by removing all the stuff that kind of bogs you down, such as payroll, making deposits, etc. Once that’s off of an owner’s plate, they get reinvigorated with the business.

That’s the stuff that we really enjoy — sitting at a table with the owners. I’ll sit with 10 or 12 owners of companies that became part of the Caring People family. We’ll talk about different ideas, different growth strategies, different things they’ve always wanted to do but couldn’t. For me, having owners who want to be part of that vision is critical. Everything else will fall into place if you have that.

Do you have any specific goals when it comes to acquisitions? Are there new markets that Caring People is trying to enter? A specific amount of targets the company wants to purchase?

We’re very disciplined, so we’re not going to get out of our comfort lane when it comes to acquisitions. We’ll look for companies that, as I said, have that cultural alignment. It’ll probably be in a geographic location that’s desirable to us. We don’t ever go into the year saying, “Well, we want to get 10 or 20 done this year.” I don’t think it’s realistic to ever position it that way. It’s about finding the right opportunities. We have a great system and process for meeting owners and sourcing opportunities. So it’s just finding the right people, then we kind of see where the conversation goes. But we’ll focus primarily on markets that were attracted to.

What do you expect in-home care M&A activity to look like in 2021?

I don’t have a crystal ball for that.

I think you’re seeing a lot of activity now because people want to take some of the tax benefits of 2020, and there’s a lot of uncertainty about what 2021 looks like. I think there’s going to be a lull for a bit in 2021. It’s been such a volatile year, to say the least, I think things are going to slowly come down at some point. The election will be over, the vaccine will be out, kids will be back at school, and I think people will take a deep breath and evaluate where they are.

It’s a great time to be in home care and a great time for people who are thinking about getting out or joining a larger company. But I think once January comes, that first-quarter gets a little slow.

Aside from acquisitions, what else has helped your company see growth?

We are now getting more involved in understanding how to implement different service lines for our clients, such as telehealth, collaborating with physician practices that do video assessments. We’ve begun offering different geriatric care management services in most of our markets now, which we’re also doing virtually. I think there’s a lot of opportunities to grow organically, especially as people are embracing the digital space.

Last month, your company launched an Alzheimer’s and dementia care program. Can you provide an overview of the program and an update on how it’s going?

About 80% of our clients have a primary or secondary diagnosis of Alzheimer’s and dementia, so it behooves us to really start to dive into understanding the best way to deliver care for that client population. By advanced training with our staff members and hiring certified dementia specialists, we now are able to add that next layer of services to our clients.

Our caregivers go through a very rigorous continuing education program that is customized for our caregivers and our clients. We call it the Caring People University. We’re slowly continuing to evolve the way we can offer support services to our clients.

We have other ideas that we’re looking to further deploy over the next several months.

For me, the bottom line is really a byproduct of everything else that goes into the business. If you provide a high level of service, your turnover is going to be less, caregivers will stay longer, and clients will have a better experience.

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Addus Reignites M&A Engine, Targets Home Health and Hospice Acquisitions

The feeling around the recently expanded Addus HomeCare Corporation (Nasdaq: ADUS) headquarters in Frisco, Texas, is different from just three months ago.

Speaking on its Q2 earnings call in August, Addus leadership said the company was in “rebounding mode,” but also not as affected by COVID-19 uncertainties as they initially expected. Additionally, recruiting had become a pain point for the organization, Addus executives noted at the time.

Their tune was different Tuesday during the company’s Q3 earnings call, as Addus execs reflected on a strong quarter based on year-over-year growth despite harsh economic realities tied to the COVID-19 virus. Instead of more recruiting difficulties, company leaders suggested Addus is now in a successful hiring stretch.

“Our revenues continue to be adversely impacted by the COVID-19 pandemic, with a decline of approximately $6 million dollars from our pre-COVID 2020 run rate,” Addus CEO Dirk Allison said on the call.

Addus is a provider of home health, hospice and personal care services. It currently provides care to about 44,000 clients by way of 215 locations spanning 25 states in the U.S.

In Q3, its net service revenues were nearly $194 million, a 17% increase from about $169 million in Q3 2019. Its personal care services line accounted for $165 million of that figure.

The negative monetary impact tied to COVID-19 is mostly due to the company’s New York personal care market and its New Mexico hospice operations, where it’s having trouble gaining access to patients in facility-based settings.

“We estimate our fourth-quarter revenues will continue to be negatively affected by approximately 3% to 4% as compared to our pre-pandemic run rate,” Allison said. “The majority of this reduction is occurring in our New York market.”

New York state of flux

The state of New York has reduced its Medicaid payments uniformly, dealing a major blow to Addus, which has a large market share in the state and also deals heavily with Medicaid as a payer.

The New York State Department of Health announced that all non-exempt Medicaid payments would be reduced across the board by 1% beginning Jan. 1, with an additional 5% reduction taking place beginning April 1 of this year.

“Approximately one-third of our New York business is directly with the state and was immediately affected by this reduction,” Allison said. “We continue to work with our New York State associations to mitigate any future rate reductions and help educate the state leaders of the value of home- and community-based services.”

While headwinds have persisted out of New York, the state’s budget is not the only potential problem moving forward. States nationwide will have to navigate difficult budget challenges due to the ongoing COVID-19 crisis in the coming months and years, which could challenge a provider like Addus.

Addus would argue, however, that with federal relief to states and the general population, states should be able to survive budgetary constraints without undermining home- and community-based service providers.

“States are currently receiving an additional 6.2% federal Medicaid match as part of the CARES Act that will continue through the duration of the health emergency, which currently goes through the first quarter of 2021,” Allison said. “Our home-based care is cost effective and significantly safer than having patients in long-term care facilities in today’s challenging environments, which we believe the leadership of our states have recognized.”

Still, Addus’ New York market census is about 17% below what it was in Q1 of 2020.

But in two of Addus’ largest markets — Illinois and New Mexico — the company has seen a promising bounce-back in billable hours per week.

Those two states have shown promise heading into Q4 for the company.

“With the upcoming rate increase in Illinois on Jan. 1, we should continue to see solid same-store growth in our personal care segment,” Allison said.

M&A strategies

Addus recently acquired home care service providers in Pennsylvania, Montana and New Mexico, as well as VIP Health Care Services, a provider out of Richmond Hill, New York.

“Acquisitions have been and remain an important part of our growth strategy at Addus,” Allison said. “We have strategically maintained a strong capital structure, which allows us to take advantage of acquisition opportunities as they occur.”

Addus “took a short pause” from pursuing new acquisitions during the early phases of the COVID-19 pandemic, but it is now fully reengaged in the process of identifying and closing additional acquisition, he added.

One of the company’s chief M&A concerns remains building density in different geographic markets. Although personal care services dominate the greater portion of Addus’ business, it hopes in the future to build out its home health and hospice segments to complete the “three legs of the stool,” an expression commonly used within the home-based care space.

Addus feels as though it is working toward that goal in New Mexico, in particular.

“We will continue to look in the personal care market, which is obviously the biggest part of our business, trying to fill out states in which we currently have strong operations,” Allison said. “But at the same time, we want to continue to look at the clinical side of our business, adding home health and hospice in those markets.”

Recruiting during COVID-19

After initial bumps in recruiting at the beginning of the COVID-19 pandemic, Addus has rebounded on the recruiting and hiring front.

“On a company-wide basis, we continue to see an overall reduction in patients on hold and improvement in our caregivers hiring numbers, which contributed to a sequential 6.5% increase in our personal care same-store census,” Allison said.

New York still remains a challenge, as there are still enhanced unemployment benefits in place in the state, which can discourage caregivers from coming back to work.

From August forward, however, Addus says that it’s up 2% in terms of caregiver hires per business day.

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Verma: Older Adults Must Have a ‘More Robust’ Set of Home Care Options

The U.S. Centers for Medicare & Medicaid Services (CMS) on Monday touted several tools designed to help states rebalance their long-term care ecosystem toward home- and community-based services. 

The development is the latest in a series of CMS efforts aimed at strengthening home- and community-based services amid the COVID-19 pandemic, with the ultimate goal of decreasing America’s reliance on nursing home care.

“The COVID-19 crisis has shone a harsh light on the human costs of a long-term care system that relies too heavily on institutional services like nursing homes,” CMS Administrator Seema Verma said in a statement included in Monday’s announcement. “Too often, they are seen as the default option, even for those who may not require round-the-clock care.”

Broadly, Monday’s “toolkit” offers examples of innovative state models and best practices to rebalance long-term services and supports programs toward in-home care. Examples largely focus on Medicaid, the primary funder of long-term services and supports nationally.

One specific example highlighted in the toolkit is Pennsylvania’s managed care policy that requires plans to implement a home care workforce innovation component within their programs, utilizing person-centered planning principles to improve the recruitment, retention and skills of direct care workers.

Another is Vermont’s Medicaid section 1115 demonstration to increase access to home- and community-based services for adults at risk for nursing home admission who may not be eligible for Medicaid and who do not meet level-of-care criteria for a nursing home.

“While nursing homes will always be an important part of a complete care continuum, many elderly individuals and their families should have access to a more robust set of home care and community-based care options,” Verma’s statement continued.

In FY 2018, 79% of total Medicaid long-term care spending for individuals with intellectual and developmental disabilities (I/DD) was tied to home- and community-based services. Nearly half of long-term care spending for individuals with mental health and substance use disorders was tied to home-base care.

Meanwhile, just 33% of long-term care spending for older adults and individuals with physical disabilities was tied to home- and community-based services in FY 2018.

Contextually, CMS issued its toolkit on the same day The American Health Care Association (AHCA) and National Center for Assisted Living (NCAL) released a report revealing that new COVID-19 cases are increasing in nursing homes in the U.S., mostly due to the community spread among the general population.

Weekly new COVID-19 cases in the general population rose by 61% to 391,527 new cases the week of Oct. 18, according to data from Johns Hopkins University.

A correlating uptick in new cases in nursing homes occurred when cases in the surrounding community started rising back in mid-September.


“As we feared, the sheer volume of rising cases in communities across the U.S., combined with the asymptomatic and pre-symptomatic spread of this virus, has unfortunately led to an increase in new COVID cases in nursing homes.” Mark Parkinson, president and CEO of AHCA and NCAL, said in a press release. “It is incredibly frustrating as we had made tremendous progress to reduce COVID rates in nursing homes after the spike this summer in Sun Belt states. If everybody would wear a mask and social distance to reduce the level of COVID in the community, we know we would dramatically reduce these rates in long term care facilities.”

The full long-term services and supports rebalancing toolkit is available here.

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Centerbridge Partners, The Vistria Group Acquire Wellspring’s Help at Home

Help at Home — a Chicago-based home- and community-based services provider that operates across 13 states — has been acquired by a consortium of private equity buyers.

Specifically, Centerbridge Partners and The Vistria Group are teaming up to purchase Help at Home from Wellspring Capital Management, which will remain a minority investor in the company. The deal officially closed on Friday.

Founded in 1975, Help at Home provides a variety of medical and non-medical in-home care services across its footprint, caring for more than 60,000 clients across 155 locations. New York-based Wellspring — a PE firm that has raised more than $4 billion of initial capital commitments through six private equity funds — completed its acquisition of Help at Home in August 2015.

In the deal announcement, Help at Home CEO Paul Mastrapa thanked Wellspring for its five years of stewardship. The CEO likewise noted that the Help at Home team looks forward to working with both Vistria and Centerbridge in years to come, especially as the COVID-19 pandemic shines a brighter light on the value of home-based care.

“For more than four decades, Help at Home has enabled seniors and people with disabilities to continue to lead independent lives in the familiar settings of their homes and communities,” Mastrapa said. “Now, with the COVID-19 pandemic, the in-home care we provide is more critical than ever because it allows these often vulnerable populations to receive care and support in the safety of their own homes.”

Chicago-based PE firm Vistria is already a big player in the home care and hospice space. Its portfolio, for example, includes St. Croix Hospice, Hospice Care of South Carolina and Civitas Solutions.

Broadly, the firm’s purchase of Help at Home was an opportunity to further bolster the delivery of care in the home, according to David Schuppan, a senior partner at Vistria.

“Help at Home is a leader in what is an important trend in health care and one that’s consistent with a theme we’ve been exploring, which is the support of seniors and others with complex conditions in their preferred home- and community-based setting,” Schuppan told Home Health Care News in an email. “We think there’s tremendous societal and economic value creation here.”

With offices in New York and London, Centerbridge Partners is a private investment management firm that has $26 billion in capital under management. Centerbridge had previously worked with Vistria to acquire Civitas as part of a $1.4 billion deal that closed in March 2019.

“We are excited to have completed the acquisition of Help at Home, a trusted provider of care solutions that empowers individuals to live life on their own terms with support from highly trained, compassionate and dependable caregivers,” Jeremy Gelber, senior managing director at Centerbridge, said in a press release. “As we move forward, we will partner with Paul and the talented Help at Home team to expand access to the company’s services as the company continues to deploy its resources and expertise to deliver unsurpassed care.”

Help at Home and Centerbridge both declined to comment for this story.

While financial terms of the transaction were not publicly disclosed, PE Hub previously reported on a rumored deal between Help at Home, Vistria and Centerbridge in September. At the time, PE Hub reported the deal was for $1.4 billion.

Now officially in the books, Vistria and Centerbridge’s play for Help at Home adds to what has been an increasingly active M&A market.

The second quarter of 2020 saw the lowest number of home health, home care and hospice transactions since the end of 2017, according to data from M&A advisory firm Mertz Taggart. Q3, however, saw at least 25 total transactions.
“I’ve been selling home health agencies since 2006, and can’t recall a time when demand has been higher,” Mertz Taggart Managing Partner Cory Mertz told HHCN early in October. “Since July, we have received more calls from both strategic and financial buyers looking for home health than I can ever recall in a three- or four-month period.”

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24 Hour Home Care Acquires Grace Care Management, ‘Actively’ Searching for More M&A Opportunities

In an effort to bolster its at-home care offerings in the San Diego market, 24 Hour Home Care has acquired Grace Care Management, another home care agency located in the area.

Since its founding in 2008, Los Angeles-based 24 Hour Home Care has grown quickly and steadily. But that growth has been mostly organic — until now.

Grace Care Management will become a part of the 24 Hour Home Care brand later this month. The deal will mark 24 Hour Home Care’s fifth acquisition overall.

“[Grace Care Management] has been in the San Diego area for nearly 20 years, so they’re really a staple of the community,” Andy Matthews, the VP of business development for 24 Hour Home Care, told Home Health Care News. “It made a lot of sense for us from that standpoint.”

24 Hour Home Care is an independent, non-medical home care provider with 20 locations spanning California, Arizona and Texas. It employs over 10,000 caregivers and has been one of the fastest growing companies in the U.S. for the past eight years, according to Inc. Magazine.

The acquisition of Grace Care Management was seamless considering that the two agencies have been working together since 2018, when Grace Care Management needed help with staffing capacity. Since then, 24 Hour Home Care has helped with any overflow the agency has had.

“But what we saw while helping was that they really have a patient-centered focus, and they also have a geriatric case manager — and we love that aspect,” Matthews said. “That’s something that really adds a lot of value to our clients, that we can now provide. It really seemed like this was the obvious next step.”

Grace Care Management is based in Ramona — a part of San Diego county — and expands 24 Hour Home Care’s footprint nicely in that area, Matthews noted. In addition to home care services, the organization also offers 24/7, on-call care management capabilities, as its name implies.

Ryan Iwamoto, the president and co-founder of 24 Hour Home Care, explained how the first decade of the company’s expansion was mostly driven by internal, organic growth on the most recent HHCN Disrupt podcast.

Now, the company’s success has positioned it to become more aggressive in M&A, Matthews said.

“We were very fortunate that Grace Care Management fell right into our lap,” Matthews said. “But we are actively looking for acquisitions as well. This is an active part of our strategy that we’re looking for new partners, whether it be in new markets or in our current market share.”

24 Hour Home Care’s strategy now will combine that trust in organic growth and growth through M&A. Matthews sees M&A as a way to add value to its existing markets and also expand to new markets in California, Texas and Arizona, and perhaps across the U.S. moving forward.

Cindy Hasz — the founder and CEO of Grace Care Management, and the geriatric expert that 24 Hour Home Care was so eager to add to its network — believes that the move will be mutually beneficial. 

“We’ve been looking for a partner that could provide the tech infrastructure that will create greater efficiencies,” Hasz said in a press release. “This is a win-win for seniors and those with special needs throughout San Diego because they will get the best of both worlds – the same great caregivers they know and love along with access to a staff of experts that can provide counsel any time they need it.”

Broadly, an increasing number of home health and home care companies have been active in seeking care management assets.

In August, for example, Caring People completed a handful of deals driven by a focus on care management. Meanwhile, in January, Arosa+LivHome acquired Lifecare Innovations to expand its care management footprint.

The focus on care management is likely to continue heading into 2021, especially as providers build out their service lines and care for more clients or patients on a longitudinal basis.

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Griswold Continues Building Out Leadership Team; NAHC, HCAOA Announce Board Additions

Griswold adds to leadership team, board

Blue Bell, Pennsylvania-based Griswold Home Care has named Matt Ericksen director of sales and operations.

In his new role, Ericksen will bring expertise in business development, compliance and recruitment to the team, according to the company. He was most recently the director of operations at BrightStar Care Inc., one of the largest home care franchises in the country.

On its end, Griswold — also a franchise — has 200 locations spanning 30 states.

“Matt’s expertise will be invaluable in advancing the growth of our franchise system,” Griswold CEO Michael Slupecki said in a press release. The CEO, who joined Griswold in February, hinted at a leadership hire in a recent interview with Home Health Care News

The company also announced that Christobel Selecky has joined its board of directors. Griswold nabbed Selecky after searching for a potential board member with a background in population health and social determinants of health.

Selecky serves as the board chair of Satellite Healthcare — a provider of kidney dialysis services — and also serves as a board member for ImmunityBio and Teleperformance.

Axxess CEO elected to NAHC’s board

John Olajide, the founder and CEO of Axxess, has been elected to the National Association for Home Care & Hospice (NAHC) board of directors. His term begins in January and will last three years.

Axxess is a developer of cloud-based software solutions in home health, home care and hospice.

“Technology is so critical to the success of the industry,” Olajide told Home Health Care News. “Technology partners are integral to how things work. They can no longer be seen as just vendors. … Providers can’t deliver incredible service without good tech partnerships, so it was great [to be elected] to the board.”

Washington, D.C.-based NAHC is a nonprofit advocacy organization that represents over 33,000 home care and hospice providers across the U.S.

HouseWorks CEO named to HCAOA’s board

Andrea Cohen, the founder and CEO of at-home care company HouseWorks, has been elected to the board of directors for the Home Care Association of America (HCAOA). She will begin her term in January.

Washington, D.C.-based HCAOA represents thousands of home care agencies across the U.S.

On its end, Boston-based HouseWorks was founded in 2002 by Cohen herself. The agency — which offers both non-medical home care and home modification services — serves communities in Massachusetts, Pennsylvania, New Hampshire and Maine.

“I’m honored to have been elected by my peers in the home care industry to serve on the HCAOA board of directors,” Cohen said. “When I started my career and served on the National Private Duty Association board – the precursor to HCAOA — home care was in its infancy; today, the industry is recognized for its professionalism and for the valuable role it plays in allowing adults to age at home.”

A social entrepreneur, Cohen also serves on the board of The Commonwealth Institute, the Schwartz Center Leadership Council and the Caregiver Action Network. She is also an appointee to the Massachusetts Women Forum.

“HCAOA has been indispensable during COVID-19, connecting home care providers so we can share ideas for how to protect our caregivers and provide the safest and best care to our clients,” she said. “I look forward to working more closely with my colleagues to elevate our vital work.”

Montachusett Home Care names CMO

The Montachusett Home Care Corporation (MHCC) announced that David Ginisi has been named as the company’s chief marketing officer.

Leominster, Massachusetts-based MHCC offers personal care services to seniors, as well as homemaking, chore help and adult day health.

Ginisi will oversee the organization’s digital strategy and help increase messaging and outreach to the 21 communities in Massachusetts that the company works with.

“We are excited to welcome David to our leadership team,” MHCC CEO Lori Richardson said in a press release. “David will be a tremendous asset to our agency with his drive for community engagement and his extensive proven marketing and outreach experience.”

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Homethrive Raises $18M to Fuel its Expansion into Health Plans and the Self-Insured Employer Market

Homethrive, a tech-enabled provider of non-medical care management and personal assistance services, raised an $18 million funding round.

The funding round was led by venture capital firm 7wireVentures, and investment firm Pitango HealthTech.

Homethrive has earmarked the new funds to be used in a number of areas, Dave Jacobs, co-founder and co-CEO of Homethrive, told Home Health Care News.

“We’re going to accelerate our penetration into health plans, and also accelerate our penetration into the self-insured employer market,” Jacobs said. “Additionally, we are investing considerably to build out the technology stack that will power the service we provide to those different markets.”

Homethrive’s staff of social workers provides clients with a comprehensive care plan for older adults, as well as coaching, personal assistance and concierge services. The Chicago-based company — which has 50 employees — services the private-pay market, long-term care insurance companies and Medicare Advantage plans.

While Homethrive’s aim is to facilitate aging in place, Jacobs expressed that this goes hand-in-hand with addressing the social determinants of health.

“We think that they are very interrelated,” he said. “We think that by addressing the social determinants of health, whether that’s food insecurity, isolation, loneliness, transportation or home safety, we can make it much easier for people to age at home.”

Homethrive said its Series A round comes on the heels of the COVID-19-related spotlight that has been placed on home-based care.

Jacobs believes that people overwhelmingly prefer to be cared for in their own home — a preference that has become a necessity due to the public health emergency.

“People had different choices, they could be at home, or they could oftentimes go to a senior living community, and now because of COVID people are much more reluctant to move out of their home,” Jacobs said. “We have a number of members who were in senior living communities and their families have brought them back home.”

Many of the company’s clients are also people who are unable to provide in-person support to their aging family members.

“The challenge is families not being able to spend time with and do things to help their aging loved ones,” Jacobs said.“They’re not able to travel, they’re not able to go see them … so they need help in navigating those things. Also, the incidence of depression, isolation and loneliness have gone up because those older adults are more cut off from other services and organizations that they would otherwise engage with.”

Looking ahead, Homethrive is focused on further solidifying itself in the home-based care space.

“We have spent the last two years proving the model, making sure we can deliver results and that we can really affect caregivers and older adults in a very positive way,” Jacobs said. “Now, our focus is on really accelerating that and improving the efficiency through which we provide that service.”

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Lack of Stimulus Bill Could Lead to Rise in COVID-Related Lawsuits

Throughout 2020, there have been a number of new laws and legal trends that could have major impacts on the in-home care industry. In order for providers to be successful in the long run, it’s important to remain abreast of the latest developments.

That was the message delivered by Angelo Spinola, an attorney and shareholder at Littler Mendelson, during this year’s National Association for Home Care & Hospice (NAHC) annual conference.

Among key legal developments, Spinola touched on the Families First Coronavirus Response Act (FFCRA), which creates paid leave — both sick leave and family medical leave — for employees who satisfy certain conditions.

When it comes to the FFCRA, the status of the health care provider exemption should be an area of interest to providers, according to Spinola.

When the law originally went into effect in April, the U.S. Department of Labor (DOL) created a broad exemption for health care providers.

“It certainly covered home health providers … and arguably covered most of the non-medical home care providers as well,” Spinola said. “What the [DOL] allowed companies to do, if you did meet the exemption, is exempt everybody within the entity, meaning it wasn’t specific to the employee. It’s whether the employer would qualify as a health care provider.”

Under the law, providers who qualified for the exemption could elect to not offer coverage to any of their employees, or they could offer partial coverage, such as paid sick leave, but not paid family medical leave.

“There were many home care agencies that were doing just that; they were offering the paid sick leave, but not the paid family medical leave,” Spinola said. “The reason for that decision is that companies were really concerned about losing caregivers for an extended period, for 12 weeks of time, because their children were out of school. [They were concerned about] not having anyone available to care for their clients.”

Recent rumblings in New York have caused confusion around what companies qualify for the exemption, however.

The state of New York issued a legal challenge to DOL regulations, effectively saying that the department exceeded its authority in making the health care provider exemption so broad.

Generally, the state of New York challenged four elements of the FFCRA regulations including the work availability requirement, the definition of health care provider, intermittent leave and the documentation requirement.

The state won on all grounds.

“What does this mean for you?” he said. “It means that if you were relying on a health care provider exemption to exclude coverage under the FFCRA, … there’s some risk to you for having relied on that exemption. You were relying on a broader exemption that has now been struck down.”

The DOL has since revised regulations, and providers need to determine whether their agency is subject to the FFCRA.

As far as other steps providers should take, it’s crucial to determine whether it’s in the company’s best interest to provide full or partial FFCRA benefits to all employees. Providers should also communicate with employees, as well as implement an arbitration program, according to Spinola.

Stimulus package, qualified immunity

The next coronavirus-related stimulus package remains top of mind for providers.

When it comes to advocacy initiatives, most providers had five key areas of focus.

These areas include increased pay for front-line workers to discourage many from going on unemployment, child care support for caregivers, priority access to personal protective equipment (PPE), qualified immunity and the creation of an “HCBS Direct Care Worker Fund.”

In May, House Democrats unveiled the Health and Economic Recovery Omnibus Emergency Solutions (HEROES) Act, a COVID-19 stimulus bill. The bill included most of the five industry initiatives except for qualified immunity.

Ultimately, the bill passed out of the house, but couldn’t pass in the Senate.

Another stimulus package, the Health, Economic Assistance, Liability Protection and Schools (HEALS) Act, was introduced in July. Out of five industry initiatives, the bill only included paid child care and qualified immunity. The legislation failed to pass out of the Senate.

“The problem that we are seeing is there’s no movement right now,” Spinola said. “They’re $2.5 trillion apart. There are significant differences between the two acts.”

While it’s impossible to say what will happen, Spinola pointed to the state of the economy as an indicator of the future.

“I think that what might happen is directly tied to the state of the economy,” he said. “We saw the economy really tank. We saw record unemployment claims. …I think we are seeing now because the economy is starting to rebound, there’s less pressure on Congress to create this stimulus package.”

As the election draws closer, there will be less focus on the stimulus bill.

“That’s concerning because that means a lot of the things that we were hoping to accomplish, … we might not get,” Spinola added.

In particular, if qualified immunity doesn’t pass, it puts the industry in a very vulnerable spot for litigation.

Overall, there have been at least 792 COVID‐related labor and employment lawsuits filed against employers, and more than 2,000 general COVID‐related lawsuits. More than 10% of these cases include class-action claims.

“Not surprising that since COVID hit, we’ve seen an increase in related cases,” Spinola said. “Each month, the number gets higher and higher, and we’re going to continue to see this. Unfortunately, we are seeing it specifically in the health care space.”

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Right at Home Partners with Home Modification Company TruBlue to Expand Aging-in-Place Services

Home-based care companies are trying to become one-stop shops for seniors wishing to age in place.

That’s why, when Omaha, Nebraska-based Right at Home’s executives saw a Home Health Care News article highlighting home modification franchise TruBlue Total House Care, they dialed up its president and began working on a partnership.

Cincinnati, Ohio-based TruBlue and Right at Home now have a preferred provider agreement, meaning that TruBlue will recommend its clients in need of home care to Right at Home. Right at Home will, in turn, recommend TruBlue for clients who need house work to age in place comfortably.

Right at Home — a franchise with over 500 U.S. locations — and Right at Home International are wholly owned subsidiaries of RiseMark Brands.

The new partnership will likely increase each company’s client base, executives from both told HHCN. For Right at Home, it will also advance its quest to become a home care organization that does far more than basic home care.

“In that aging journey, we want to be alongside that senior, helping them to navigate all the hurdles and the challenges that they face,” Kerin Zuger, the chief of strategic growth at Right at Home, told HHCN. “For us, that means providing them home care and doing everything that we can from a personal companion and skilled level, but also recognizing what community resources, tools, services and other providers need to come to the table to ensure they stay in the home as long as possible.”

TruBlue specializes in house care, home maintenance and safety modifications for seniors aging in place.

The partnership is launching at every franchise in TruBlue’s network that is within range of a Right at Home agency, so just under 50 locations as of mid-October. In June, TruBlue President Sean Fitzgerald expressed his desire to grow by 400% in the coming year.

The only roadblock to that was awareness. Now, after going into business with Right at Home, that shouldn’t be a problem.

“We feel that this is a key component that’s been missing in aging in place to provide complete peace of mind for families,” Fitzgerald told HHCN. “Combining home care with the maintenance of the home to make sure it is safe and comfortable, that can alleviate a lot of anxieties that families have over their loved ones aging in place.”

Many of TruBlue’s services are designed to cut down fall risk. Falls are the leading cause of both fatal and nonfatal injuries to older Americans, according to AARP.

The company also offers Age Safe America-certified home safety assessments, and its services span from general handyman work within the home to necessary yard work just outside of it.

Now that the program is in place, TruBlue’s expansion plans will be based largely on meeting Right at Home where they are around the country, Fitzgerald said.

Right at Home is excited about the partnership, particularly because it had been looking for one in the home modification arena before they found TruBlue.

“We were definitely seeking something like this out,” Zuger said. “This checks a box for us aswe continue to look forward into the future and think about our brand and how we really want to position ourselves relative to all things aging.”

TruBlue will also help Right at Home as it continues to explore Medicare Advantage (MA) and its franchisees pursue plan partnerships. For the franchisees that will benefit, their value proposition will grow due to the TruBlue partnership.

In 2020, at least 44 MA plans offered supplemental benefits focused on “structural home modifications,” according to an analysis from research and consulting firm ATI Advisory. Those plans covered more than 450,000 Medicare beneficiaries.

“It’s just an excellent extension of what Right at Home and our franchisees have been looking to accomplish in terms of that value proposition to our clients and to our families,” Zuger said. “It’s a great marriage of resources and service.”

The vast majority of Americans prefer to age in their own homes, a preference that existed prior to the COVID-19 crisis.

The mental hurdle for family members in the past, however, has been allowing their loved ones to stay at home without constant supervision, which is offered in more facility-based settings.

“One of the reasons why people put somebody into assisted living facilities or nursing homes is because they feel like they’re doing the right thing,” Fitzgerald said. “They’re getting the medical care, and they’re in an environment that is being monitored and is perceived to be safe. But aging in place, it’s healthier. It’s what seniors want, and it’s what they deserve. But I think the missing ingredient has been the home environment itself.”

One of the reasons Fitzgerald got into the home modification business in the first place was due to a family member falling and eventually dying from complications tied to that fall.

That fall risk, with TruBlue’s services and Right at Home’s coinciding care, would have been preventable, he said.

Bringing in new business

Right at Home is confident that it can access seniors earlier in their aging process due to the partnership.

Frequently, TruBlue will enter a client’s home and realize that they could also use home care services based on their condition.

“Let’s say our average senior is 80, but because of the partnership with TruBlue in shared markets, we were able to back that up to 79. That’s a big deal,” Zuger said. “Because we were able to get to that senior a year or two earlier because of this partnership, what does that do long term for that client, in terms of quality of life… as well as from a cost and outcomes standpoint?”

TruBlue, Zuger hopes, will help seniors get home care when they need it, as opposed to after a fall or similar tragedy, which is often the impetus for a home care inquiry. It’s all about getting into the home sooner.

On TruBlue’s end, interest in its services have “exploded” during COVID-19. With its new partnership, more tailwinds are likely ahead.

Helping seniors with their homes is a way to help them and their families while they’re being cared for there, but also after as well, Fitzgerald said.

“When a home is in such bad condition, as it often is, it becomes a big problem for families and the home can lose tremendous value because it wasn’t properly maintained,” Fitzgerald said. “So by doing this, we can create an environment where it’s cheaper for them to age in place, obviously, and then also just help maintain the property. Then when families do have to sell the home, it retains its value versus the opposite, which is what typically happens.”

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CareLinx, Doctor On Demand Team Up to Provide Virtual Care at Home

CareLinx is teaming up with virtual primary care provider Doctor On Demand to give high-risk seniors access to services in their homes. 

Burlingame, California-based CareLinx is a tech-enabled home care platform that connects seniors and their families to its nationwide network of 400,000 caregivers. The company was acquired by Generali Global Assistance in 2017.

Under terms of the partnership, CareLinx clients with high levels of functional needs will receive free initial visits with physicians through Doctor On Demand. In part, the move is a response to the COVID-19 emergency, Robin Glass, president of Doctor On Demand, told Home Health Care News in an email.

“As we all know by now, seniors are at highest risk of contracting and dying from COVID-19, given their age and likelihood of having at least one pre-existing chronic condition,” Glass said. “We believe that by offering high-quality, personal care in their homes, where they can remain safe, we can have a profound impact on their immediate well-being and longer-term health.”

Doctor On Demand is a San Francisco-based health care platform that gives users virtual access to physicians, psychiatrists, therapists and a care coordination team. In July, the company raised a funding round of $75 million, led by private equity firm General Atlantic.

Since the start of the public health emergency, Doctor On Demand has seen a sharp increase in its business.

In March, when the COVID-19 emergency began, Doctor on Demand recorded a 154% year-over-year increase in its new member registrations among the 65-and-older age group.

“COVID showed us all — providers and patients alike — that we can put much of the front-line, day-to-day traditional brick-and-mortar primary care online,” Glass said. “We’ve already seen that once patients try virtual care, they are likely to come back time and time again – even prefer the experience to in-person care.”

While some have predicted telehealth utilization to level off, Glass said she believes that virtual care can sustain its surge if companies focus on forging relationships with patients.

CareLinx’s desire to partner with Doctor On Demand stemmed from the company’s recent move to make its services available to Medicare Part B beneficiaries, Sherwin Sheik, CEO of CareLinx, told HHCN in an email.

“[Doctor On Demand] has done an amazing job building out their capabilities to address the needs of Medicare Part B beneficiaries,” Sheik said. “A large portion of CareLinx customers have Medicare Part B, and we have seen great interest from our clients to be able to access a doctor on demand safely at home amid COVID. We are continuing to explore additional ways our partnership can better serve geriatric and high-risk patients with functional needs at home.”

As a home care operator, Sheik believes the combined efforts with a primary care organization strengthens its services.

“CareLinx’s innovative approach amplifies the effectiveness of remote telehealth clinical teams by using tech-enabled caregivers who serve as their eyes, ears and arms in the homes of patients,” he said. “This partnership of telehealth coupled with tech-enabled home care, we believe, will become the future of health care, as it safely keeps patients at home, thereby reducing the cost of care and improving outcomes.”

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Private-Duty Home Care Providers Poised to Play Leading Role in Pop Health Models

As health care spending continues to rise, private-duty home care agencies will likely play increasingly important roles in population health management.

In total, U.S. health care spending is expected to reach $4.8 trillion by 2025.

Often, it’s chronic conditions, social determinants of health and functional limitations that drive that spending upward. The combined pervasiveness of those three factors creates a “high-cost trifecta,” according to Cindy Campbell, the director of operational consulting at WellSky.

WellSky is a rapidly growing international software and professional services company with clients that include home health providers, hospital systems, blood banks, labs, hospices, government agencies and human services organizations. The PE-backed company announced plans to acquire CarePort Health from Allscripts Healthcare Solutions (Nasdaq: MDRX) for $1.35 billion on Oct. 13.

Campbell made her comments during a presentation on Tuesday at the 2020 National Association for Home Care & Hospice (NAHC) annual conference.

When thinking about managing health care and expenses over time, the goal should be to deliver care in the least restrictive, least expensive and most satisfying place. This place is the home, according to Campbell.

Broadly, private-duty home care agencies already offer services that address social determinants and functional limitations.

“Home care providers have really been doing this in many ways for a long time,” Lucy Andrews, owner and CEO of At Your Service Nursing & Home Care, said during the presentation. “We know how to support functional needs for people. We know how to keep them home, as they progress through chronic comorbidities, diseases, new diagnoses. We know that incrementally the value of this expertise provides the market with an exceptional opportunity to innovate to be part of this process.”

At Your Service Nursing & Home Care is a Santa Rosa, California-based personal care provider. The company’s services include companionship, respite care, medication reminders, housekeeping and dementia care.

Home care generates considerable cost savings for complex and chronic patients with functional limitations while supporting a compelling business case for its value in population health management. As payers look for ways to reduce spending, the focus may shift to private duty, according to Campbell.

In other words, If population health management isn’t already on a provider’s radar — it should be.

“The first thing to do is really understand why this matters,” Andrews said. “We have the ideal platform because we have supply and demand.”

When it comes to population health management, having access to data and analytics that can reflect performance will be important for providers.

“How are you ultimately going to measure your success?” Campbell said. “What are those key performance indicators that you’re going to be looking for? These are the outcomes that you want to achieve. Think of the value proposition to a managed Medicare or managed Medicaid program, or to human beings in general, if we reduce hospitalization rates. That’s a good measure.”

Other potential performance indicators for private-duty home care agencies are emergent care rates, plus patient and family satisfaction scores. Any metrics related to a provider’s ability to keep patients in the home are also critical.

In population health models, it’s also important for providers to be able to identify when their high-risk patients are most at risk.

“Make sure that you’re looking within your organization at how you quantify risk for the people you serve,” Campbell said. “Who is in that top percentage of need out there that you want to focus on in your program?”

For providers, this could mean addressing transportation needs, risk of medication non-compliance, home-safety concerns and more.

Additionally, it’s important for providers to learn how technology can support their business.

In cases where a provider is caring for someone with chronic obstructive pulmonary disease (COPD), for example, having the right telehealth solutions in place can make a real difference, according to Campbell.

“We know that there’s a challenge within COPD, and solutions that employ and integrate telehealth really [can help] make it work,” she said. “If we can add messaging to that, really adjusting and fine-tuning the dial through this type of a virtual platform, then we can help people adjust in real-time to their needs, stabilize condition and reduce their readmissions.”

Overall, the COVID-19 emergency has placed home care in the spotlight. It’s the perfect time for providers looking to gain a “seat at the table,” Melanie Stover, owner of Home Care Sales, also said during the presentation.

“The time is now,” she said. “It is an urgent time to skill up and put metrics in place so that you can serve more clients, impact more families and increase your revenue. We have been incrementally moving the agenda of home care forward.”

Home Care Sales is a Fairhope, Alabama-based home health, hospice, and private-duty home care sales consulting firm.

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M&A Experts ‘Can’t Recall a Time When Demand Has Been Higher’ in Sizzling In-Home Care Market

M&A activity across home health, hospice and in-home care appeared to be “business as usual” at the start of 2020. COVID-19 froze the market in March, however, causing both buyers and sellers to bide their time.

But dealmaking action is finally starting to heat up again, multiple M&A experts confirmed to Home Health Care News.

In the past few weeks alone, for example, Charter Health Care Group announced its purchases of Vitality Home Healthcare and Heartwood Home Health & Hospice. Meanwhile, Bridges Health Services announced a series of mergers with various home health and hospice providers. Most recently, Chicago-based private equity firm the Vistria Group agreed to sell St. Croix Hospice to an affiliate of investment company HIG Capital.

To get a better understanding of the developing M&A market, HHCN asked several experts to provide insight into what they are currently seeing in the final months of 2020. They also touched on 2021 expectations.

* * *

I’ve been selling home health agencies since 2006, and can’t recall a time when demand has been higher. Since July, we have received more calls from both strategic and financial buyers looking for home health than I can ever recall in a three- or four-month period.

While hospice M&A has dominated the spotlight these past couple years, home health M&A has cooled off. The uncertainty of the Patient-Driven Groupings Model (PDGM) caused both the strategic and financial buyers to hold off on any significant home health investments until after dust settled on the overhaul. We expected buyers would be ready to engage in the second quarter of 2020, but COVID-19 delayed that by a couple months in April and May.

With the public companies, which are the ultimate consolidators, the long-term strategy remains the same. They want to have all three legs of the stool: home health, hospice and personal care. And they want that in each of the markets they serve. As a practical matter, most of these companies are really focused on filling out the skilled side first. As recently as three years ago, most of these strategic buyers had a significantly larger home health presence than hospice. That has changed.

As a result of the aforementioned hospice M&A activity and a lot of denovos, many of these strategic buyers are now shifting their attention back to penetrating new markets via home health acquisition, which they will then complement with hospice and at some point, plus personal care.

My crystal ball is clouded somewhat with an election less than a month away and a threat of another significant COVID outbreak, but I’m going to go out on a limb and speculate we will see near-record — if not record — home health M&A activity between Q4 2020 and Q1 2021.

— Cory Mertz, managing partner at Mertz Taggart

* * *

In order to provide an appropriate context to understand how 2021 is setting up, we must first look back to this time last year. There was a mixed level of excitement regarding the forecasted 2020 home health merger and hospice acquisition marketplace.

Home health owners were facing PDGM implementation with certain uncertainty. Hospice owners were enjoying uncounted unsolicited calls and emails from buyers asking for “just a few minutes of their time.” A tale of two cities!

Since mid-March, the COVID pandemic “tripped the breaker” on scheduled and intended home health and hospice deals — or did it? Data researched and compiled exclusively by The Braff Group may come as a surprise to some.

Home Health’s expectation for a “down” year appears to be on track as expected; 42 projected deals vs. 60 transactions in 2019. Similarly, during the past five years, we’ve documented 296 completed deals; averaging just under 60 per year.

Looking ahead to 2021, home health will start off slow but pick up greater deal activity as the year unfolds, especially for mid- and larger-size agencies.

There are several reasons for this. Sellers, as well as buyers, will be well past the initial shock of dealing with COVID-19 and have settled into new daily norms and routines. While we have not completely recovered, many agencies have returned to pre-COVID levels of activity. Once preoccupied within their own portfolio companies, private equity firms now are back aggressively looking to build up their pipelines and line-up deals to get done. By many indicators, home health, and especially hospice valuations remain at all-time highs.

— Mark Kulik, managing director at The Braff Group

* * *

I do believe we will continue to see in-home care M&A acquisitions pick up. I believe that dual-service-line providers will continue to get more traction in the market. Hospice continues to be a valuable target for both strategic and sponsor buyers. We believe that home health-only agencies will continue to be challenged with admissions and the PDGM RAP reductions in cash flow.

According to a survey by the National Association for Home Care & Hospice (NAHC), almost 80% of home health agencies have experienced a decline in admissions due to the pandemic, with a majority of agencies reporting a decline of greater than 15%. Although elective procedures and routine visits are beginning to open up across the U.S., we are still seeing agencies struggle with therapy-heavy episodes and facility-based patient admissions. With the decrease in admissions, timing for presenting the company to buyers may cause them some reservations until the agency has proven stabilization related to admissions and Low Utilization Payment Adjustments (LUPAs).

In regard to the future of dealmaking in this space, agencies with both home health care, private duty and hospice service lines will be more eye-catching to potential buyers. Diversification of service lines will remain attractive.

— Tom Maxwell, co-CEO at Maxwell Healthcare Associates

* * *

With the onslaught of the COVID-19 pandemic in early March, it quickly became pretty clear that M&A activity generally, as well as with in-home care, was going to slow down significantly through the balance of Q1 and likely until the middle part of Q2. We thought we would begin to see an uptick in deal activity around mid-June and after, and that assessment has more or less turned out to be accurate.

While business travel and group meetings have continued to be on-hold for many, sourcing deals, discussions among transactional parties, diligence and other deal-related activity has adapted to the new “normal” through virtual meetings, conference calls and increased use of outside support such as law firms like ourselves and other industry transactional advisors and consultants.

Since mid-June, we have seen a marked increase in “deal talk” among sellers, buyers, bankers, investors and lenders both in home care and hospice, and we are currently working on a number of home care and hospice transactions across the country.

As transaction parties have begun to understand better some of the COVID-19 related factors and issues and their impact on deals, valuations have stabilized and in some cases increased. We expect to see a continuing surge of deals as both PE and strategic players seek to add bolt-on transactions in their markets and additional platforms where available.

Capital remains generally available to acquirors, and both home care and hospice are being seen as more stable health care verticals with the ability to give patients an alternative environment to group settings like hospitals and nursing homes. That is an additional important consideration to patients and payers in this COVID-19 era.

In sum, all indications are that absent a systemic disruption, home care and hospice deal activity should continue to be active through 2020 and well into 2021.

— Les Levinson, co-chair of the national health care transactions practice at Robinson & Cole LLP

* * *

At the onset of the coronavirus pandemic, there was uncertainty of the impact of the virus across all sectors of the health care industry. The practicalities of country-wide lockdowns, coupled with high-risk patients who were reluctant to allow providers into their homes, led to weaker performance for in-home health care companies. For companies that qualified, government stimulus in the form of Paycheck Protection Program (PPP) loans alleviated cash flow concerns and allowed many providers to weather the storm. As a result, M&A activity slowed and deal activity was put on hold.

We are eight months into the pandemic, and M&A activity has accelerated. Transactions that were on hold are ramping up. Valuations are strong. Buyers are becoming more active as additional investment opportunities arise, and the upcoming U.S. presidential election seems to be motivating dealmakers to close deals before the end of the year.

In-home health as a “buy-and-build” strategy is attractive to investors as the sub-segment is highly fragmented. Buyers executing a consolidation strategy backed by a scalable platform for growth and supported by strong processes and systems, along with a well thought-out integration plan for acquisitions to achieve synergies, should experience robust investment returns.

— Claudine Cohen, managing principal, transactions and turnaround advisory at CohnReznick

* * *

It is a sobering truth that if you follow the money, you usually find the answer, or at least the motivation. Currently, investors are deploying massive amounts of capital to acquire home care agencies. The interest is at record levels. The money is telling us that we’re on the threshold of a golden age for home-based care. The growth of home care will be of great benefit to the patients. Let’s hope this growth trend continues.

— Andre Ulloa, principal at American Healthcare Capital

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NAHC Pushing for Palliative Care, SNF-at-Home Medicare Benefits

As home health and home care operators move toward the ninth month of the COVID-19 pandemic, it’s important to take stock of what has been accomplished from a policy perspective. Many of 2020’s regulatory changes will be fleeting, but others will shape the future of post-acute care for years to come.

That was the message delivered Monday by National Association for Home Care & Hospice (NAHC) President William A. Dombi during the nonprofit advocacy organization’s annual conference. In addition to providing a regulatory recap, Dombi hinted at new Medicare benefits on the horizon and explained how the value of home-based care is at an all-time high.

“There has been an increased awareness of the breadth and depth of care at home, and this will have a long-standing impact on policy and politics as well,” he said. “There has been an absolute, exponential increase in respect for what you do in the home care setting. We took the stresses of the pandemic head-on and proved that care in the home is not only essential but [the best option].”

During Monday’s Washington update, Dombi revealed that 67% of in-home care providers are serving COVID-19-positive patients.

To support them in delivering that care, providers have been able to lean on a variety of lifelines, including funds from the CARES Act Provider Relief Fund and the Paycheck Protection Program (PPP). Providers have also received essential-worker classification and greater telehealth flexibilities.

Additionally, the U.S. Centers for Medicare & Medicaid Services (CMS) has recognized that virtually the entire Medicare population meets homebound status requirements.

“When you’re Medicare eligible, over the age of 65 or on disability, and you need health care services, you have a compromised condition to put you at even greater risk of fatality,” Dombi said. “CMS agreed with our position on this and issued interpretive guidance indicating that individuals who need to leave the home for services, it is medically contraindicated, thereby meeting the homebound standard.”

During the public health emergency, CMS also paused claims audits and the Review Choice Demonstration (RCD), a regulatory initiative designed to reduce improper billing in home health care. That has since been restarted, with temporary administrative flexibilities.

COVID-19 testing, non-physician certification

At the end of September, the U.S. Department of Health & Human Services (HHS) announced that home health and hospice agencies would receive 10 million rapid COVID-19 tests from a federal inventory of about 150 million. Dombi likewise touted that as a win.

In the first week of distribution alone, he noted, about 160,000 tests were distributed to home health and hospice agencies.

“The fact that HHS recognized that home care was an essential part of health care services and made us part of that allocation in itself is a notable success,” Dombi said. “Just being recognized, not being considered some stepchild in health care.”

Among the other topics he touched on during his Washington update, NAHC’s president highlighted excitement around non-physician certification, something the home health industry had been working toward for years.

Senator Susan Collins (R-Maine) first introduced legislation that pushed for this change in 2007.

“We found ourselves in the middle of discussions, negotiations and advocacy with the CARES Act, and Senator Collins said, ‘I think this is our chance to get it done.’ [She] was able to convince the Senate that now is the time to allow non-physician practitioners to have equal status with physicians, to the extent that the state law allows it within the Medicare home health benefit,” Dombi said.

New Medicare benefits

Despite making major inroads across various fronts, there are still a number of measures that need to be taken.

For one, providers are still on the lookout for the next coronavirus-related stimulus package, which was originally expected before the July 4th Congressional recess, then again before the August recess.

“This is a back and forth that’s happening between the House and the Senate, between Republicans and Democrats,” Dombi said. “We’re still looking to see if we can have something before they go on recess in October, but we’re planning also for a lame-duck session on it.”

As far as what providers hoped to see in the next package, the list includes continued funding for the Provider Relief Fund, plus expanded funding for Medicaid home- and community-based services. The list also includes premium pay for front-line workers and litigation immunity.

Another area of focus for NAHC is palliative care. The organization is moving to get revisions in the Medicare coverage manual under home health care to fully recognize palliative care as one of the services provided as part of the existing benefit.

“We don’t think we need Congressional action to get there,” Dombi said. “Some of you — maybe many of you — are already doing things that would qualify as skilled palliative care under the benefit and getting Medicare to pay for it.”

Home health providers can also expect to see the 2021 payment rule finalized before the end of October or during the first few days of November. NAHC is calling on CMS to roll back the 4.36% behavioral adjustment in the Patient Driven Groupings Model (PDGM) ahead of the announcement of the final rule.

“It’s not just because we are in this unprecedented year of COVID-19,” Dombi said. “CMS projected a decrease in [Low Utilization Payment Adjustments], as they thought home health agencies would try to maximize 30-day episodic reimbursement. We have seen just the opposite of that, partially influenced, of course, by COVID-19.”

Additionally, NAHC is pushing for the creation of a new benefit that will allow for a skilled nursing facility (SNF) level of care at home.

“We have designed a [SNF-at-home] benefit to give individuals on the Medicare program the option of going home with expanded services,” Dombi said. “We think the design will work to be a win for the Medicare program as well. It’s been proven that you can provide less costly and high-quality care at home.”

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‘Without a System, You Can’t Win’: Data-Tracking Tips for Home Care Agencies

Despite the operational and financial challenges caused by the COVID-19 virus, hardly any private-duty home care agencies plan on going out of business. Instead, most agency leaders believe they’ll actually grow their business over the next five years, both in terms of census and new locations.

That’s according to recent statistics that Home Care Pulse shared this month during the Home Care Association of America (HCAOA) Virtual Leadership Conference.

“Running a business is tough, especially a home care business,” Home Care Pulse CEO Erik Madsen said during a presentation at the HCAOA event. “There are a lot of demands on your time as owners and executives.”

Each year, Home Care Pulse surveys thousands of home care agencies to uncover industry trends, challenges and business strategies. Of the 872 home care agencies surveyed in 2020, not a single one said it expects to go out of business within the next five years.

Typically, agencies are not pushed out of business by competition in their markets. In reality, operating difficulties usually stem from internal shortcomings, Madsen said.

“Rarely do you see a company go out of business because of external competition,” Madsen said. “It just doesn’t happen. There’s such a demand and a need, which is phenomenal. What does happen is they go out of business because they lack the right internal processes.”

‘You can’t win’

Idaho-based research and education firm Home Care Pulse works with thousands of home care agencies to help them decipher what they’re doing well and where they can improve.

Often, if home care agencies go out of business, it’s because they don’t have the appropriately trained workers or data-driven tools — or it’s because they’re missing both.

“Without a system, you can’t win,” Madsen said. “But those that have a system are absolutely winning right now.”

“Winning” means agencies are tracking key metrics like inquiry-to-admission rate, caregiver hiring ratios, caregiver turnover and revenue per non-caregiver employee. Other important benchmarks include client lifetime value, as well as the net promoter scores of both clients and employees.

When it comes to new business, about 33% of home care inquiries will turn into a new client, on average. If 37% of an agency’s inquiries turn into a new client, that puts them in the 75th percentile among home care providers in terms of inquiry-to-admission rate. If an agency is at 40%, that puts them in the 95th percentile.

While most agencies would like to improve their inquiry-to-admission rates, many don’t even have the systems in place for tracking that data.

“Here’s the key: As an agency owner, you have to track this data,” Madsen said. “I was shocked to see what percentage of agencies are not tracking every single one of their new inquiries.”

Tracking inquiries isn’t the only area where agencies are falling short. Home Care Pulse data has similarly found that only 25% of agencies track hospital readmission rates.

As for inquiry-to-admission rates, improving them by just a couple percentage points can mean thousands of more dollars in revenue per year — or month.

Caregiver data tracking

Hiring and maintaining caregivers has been among the most consistent issues for home care providers over the years. But agencies shouldn’t view themselves as helpless bystanders and victims of a sometimes brutal job market.

Tracking caregiver hiring ratios is a great way to balance quality vs. quantity in the recruiting process, Madsen said. In fact, it’s one of the keys to staying in business — and breaking through persistent revenue plateaus.

Too high of a ratio can mean that an agency needs to invest in higher-volume recruitment sources. Too low may mean that it needs to bring in more high-quality applicants.

According to industry averages, about half of all home care job applicants progress to an interview, with half of those individuals ultimately hired.

“You can go back and look at your business [with these numbers] and say, ‘How are we doing as an organization?’” Madsen said.

Tracking caregiver turnover is also critical. It normally costs $2,600, on average, to replace a caregiver when considering both direct and indirect costs, according to Home Care Pulse.

Just like increasing inquiry-to-admission rates by a few percentage points can increase revenue in a significant way, decreasing caregiver turnover can similarly have an impact on an agency’s bottom line.

The median home care turnover rate in 2019 was 64.3%, down from 81.6% the previous year.

Net Promoter scores

Net promoter score (NPS) may be the single greatest indicator of future growth for a home care agency, Madsen said. NPS is all based upon how likely a client or caregiver is to recommend an agency to someone else.

The client NPS average is 6.5 across the industry, while the employee NPS is 6.7.

“Ask yourself the question, ‘Are these the individuals that we need to refer to our competitors down the street?’” Madsen said. “Maybe it’s time to say, ‘You know what, it’s costing us a lot of time, energy and effort with these clients. We’re just not able to make them happy. Maybe they would be better served by going to another home care company.’”

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How Home Care Agencies Can Overcome Revenue Plateaus

When it comes to increasing revenue, home-based care agencies will always have an advantage in the markets they serve, because they will never be capped by a room or bed count like facility-based settings.

But revenue plateaus are still very common in the space and something that torments agencies nationwide, whether operators are looking to grow revenues by a few thousand dollars or upwards of $1 million.

When there’s a barrier stymying an agency’s growth, its leaders should step back and see where they may be handicapping themselves, Shelle Womble, the home care sales and operations coach for corecubed, said at the Home Care Association of America (HCAOA) Virtual Leadership Conference last week.

“What do we bottleneck in our business that’s creating this plateau?” Womble said. “What kinds of investments do we need to make, and what resources do we need to infuse into the business?”

The aging care marketing company corecubed specializes in assisting home care companies with content marketing, search engine optimization (SEO) and social media engagement, among other things.

Warning signs

Revenue plateaus generally come with warning signs. Recognizing those could be vital in curtailing an elongated period of stunted growth.

Those usually include sending office staff to cover a case, seeing hiring levels decline, not seeing net growth in the caregiver or clientele rosters and weekly inquiries drying up, according to Womble.

“[Another] red flag for me is key employees starting to get too comfortable and almost bored with their job,” Eric Pumfrey, the CEO and founder of Home Sweet Home In-Home Care, also said at the HCAOA conference. “Another indicator is when you notice that your hours are stagnating. … You’re stuck between 9,000 or 9,500 hours per week, for example, and you just cannot seem to make it over that 10,000-hour mark.”

Home Sweet Home In-Home Care operates out of four offices in southwest Michigan and offers customized in-home care, Alzheimer’s and dementia care, and home-safety assessments as part of its business.

Breaking through

Abiding by the mantra from “Fields of Dreams,” agencies should hire for the level of census they want to have, not what they have right now — “build it, and they will come.”

When looking to avoid a revenue plateau, providers should build their staff out for growth and not attrition, Womble said. Building a staff above an agency’s current need can create an influx of new clients.

“Any time an agency tells me its sales are stalling or plateauing, the first thing I look at is its last year’s worth of new hires and net hires — how many people it’s maintaining,” Womble said.

Without enough capable workers, expecting one’s business to grow is unrealistic. Hiring for where you want your business to be, as opposed to where it’s at, can push a company over that plateau.

“If you hire to maintain, that’s exactly what you’ll do — [maintain],” Pumfrey said. “Hire as many qualified candidates as you can.”

The next strategy is for an agency to bolster its marketing and sales efforts.

Developing and implementing a detailed sales plan, investing in SEO and pay-per-click (PPC) strategies and building strong relationships with referral sources are all good places to start.

Taking a look at an agency with a pair of fresh eyes is another strategy, but it also helps with the other ways to breakthrough. Sometimes when a company is plateauing, bringing in consultants to aid in the effort can go a long way.

Hiring an expert can validate the things a company is doing well and also expose issues that may be baked into workflow or the business plan that may be hard to recognize internally.

Finally, an agency needs to find out how it can expand its market. Acquiring competitors in other markets, reevaluating artificial barriers that an agency is putting on itself or simply hiring a salesperson in a new market without opening an office are all ways to begin exploring a larger market.

“One of the most simple things you can do as an owner of a company is to reevaluate any kind of restrictions you’re putting on your agency right now,” Womble said.

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Poor Job Quality, Low Wages Continue to Hurt Caregiver Recruitment in Home Care

Over the past decade, low compensation, inadequate training and limited career advancement opportunities have weakened job quality for caregivers. That, in turn, has limited the pool of hiring candidates for home care providers.

But in light of caregivers’ role amid the COVID-19 emergency, it’s more important than ever to take concrete measures that can improve the job for years to come.

“Home care providers should know that improving home care jobs can lead to various benefits, including increased job satisfaction, reduced turnover and better care with less costly health outcomes,” Robert Espinoza, vice president of policy at PHI, told Home Health Care News in an email.

PHI, a New York-based advocacy organization for direct care workers, released a new report highlighting the longstanding challenges caregivers face on Tuesday.

The home care market has been historically plagued with workforce issues, with providers in the space often struggling to recruit and retain caregivers. Between 2018 and 2028, there will be an estimated 8.2 million job openings in direct care.

Part of the reason recruitment can be a challenge in the industry is because caregiver wages cannot compete with other occupations, according to the PHI report.

Across the U.S., the median wage for caregivers is lower than that of other jobs with similar entry-level requirements, such as janitors, retail salespersons and customer service representatives.

In 2019, direct care workers earned a median hourly wage of $12.80, a meager improvement from $12.61 in 2009. As a result, 45% of direct care workers live in or near poverty, according to PHI data.

Another challenge for caregivers has been the training landscape.

“Direct care training requirements vary significantly by state, program and occupational role; personal care aides, for example, lack any federal requirements, and state laws for this segment of the workforce are thin and inconsistent,” the PHI report stated. “Furthermore, many training programs in this sector are topic-based and duration-based, instead of taking a competency-based approach that emphasizes workers’ acquisition of the right knowledge, skills and abilities.”

Additionally, there is a lack of career advancement opportunities for caregivers, according to PHI.

“The lack of career pathways within direct care jobs —and from direct care into other fields— prevents direct care workers from assuming new roles with elevated titles and higher compensation,” the report pointed out. “This scarcity of career paths also affects retention.”

In order to address these issues, there are five pillars PHI highlights for policymakers and industry leaders. These pillars include: quality training; fair compensation; quality supervision and support; respect and recognition; and real opportunity.

“This report makes clear that the workforce challenges we’re witnessing today in home care have been around for a long time and must be remedied by providing workers higher compensation, better training, increased career paths, and widespread recognition that they are essential to our care system and the economy,” Espinoza said.

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How BrightSpring Health Achieved a 48% Drop in Hospitalizations

Over the past few years, home care has gained more of a foothold in the larger health care continuum. One company, BrightSpring Health Services, exemplifies this evolution in the role of home care.

Based in Louisville, Kentucky, BrightSpring provides a diverse array of home and community-based services. It serves more than 350,000 patients across 50 states.

Last year, BrightSpring was acquired by global investment firm KKR — an affiliate of Walgreens Boots Alliance Inc. (Nasdaq: WBA). As part of the deal, the company merged with pharmacy giant PharMerica.

Above all, home care is primarily associated with helping seniors handle their activities of daily living.

While these services are largely non-medical, it’s important for providers to be strategic about the care they provide and take health conditions into consideration, Sherry Pemberton, vice president of sales for BrightSpring, said Thursday during a presentation at the HCAOA 2020 Virtual Leadership Conference.

“We have to think differently,” Pemberton said. “What is their health condition? How do I take care of a medically complex person from a non-medical approach? How does that look with the services that my agency provides? How do I make sure that they are not having issues from their medical condition based on the non-medical services that I’m providing?”

For BrightSpring, there are specific models of care that help the company keep seniors out of the hospital. This means managing for medical “red flags”, implementing frequent check-ins and building relationships with the clients and family.

“As an agency, the services we provide to those clients need to be more than just our caregivers going into that home and fulfilling a checklist of items that we tell them they need to have,” Pemberton said.

One way BrightSpring accomplishes this is by educating its caregivers on what signs and symptoms to look for.

When caring for someone with pneumonia, for example, a caregiver should take notice of things, such as shortness of breath, fever, chills, headaches and confusion, according to Pemberton.

“I go into the home as a caregiver to provide that homemaking or that bath visit and if these are things that I notice that’s when it’s important to make a call to a supervisor and say, ‘I noticed Miss Smith not feeling well today … we might want to call her family,’” she said. “By calling their family and providing that intervention as a supervisor … we’re getting that doctor involved earlier [rather] than waiting so far along into her pneumonia that she ends up in the hospital.”

Along with pneumonia, BrightSpring has also established care models for when a client has diabetes or chronic obstructive pulmonary disease (COPD). Medication reminders are also a part of the company’s care model.

This approach allows BrightSpring to gather data on the company’s outcomes, creating a value proposition that speaks to the impact of their strategy.

As a result of BrightSpring’s models of care, the company saw a 48% drop in hospitalizations in three of its branches. The company also had 107 extrapolated hospital diversions per year that were worth up to $1.14 million in payer cost avoidance.

Ultimately, these outcomes and data are appealing to payers, according to Pemberton.

“That’s non-medical, that wasn’t home health,” she said. “If I go to a payer with that kind of data, they’re going to think it’s a cheaper cost to have somebody in the home.”

On its end, BrightSpring has already begun to attract attention from payers.

“One of the payers that normally would not even look at us because we’re non-medical saw value in adding the non-medical piece based on the study that we had,” Pemberton said.

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For Home Care Agencies, Tracking ‘Total Cost of Care’ Is the Secret to Breaking into Narrow Networks

Home care agencies and their services have always been valuable to the patients they serve. But being able to demonstrate that value to payers requires more than just patient testimonials.

As the home care industry enters into an era filled with new tailwinds, including Medicare Advantage (MA) and managed care opportunities, providers need to create value propositions that make sense to payers.

Harvesting key data points is not just internally helpful for agencies. Being able to show what part a home care provider plays in keeping cost of care down is crucial in gaining new business.

“Tracking the number of patients that you’re serving and the total costs associated with those patients will allow you to show — in numbers — how [payer networks] may have those flaws or gaps in their existing network structure,” Effie Carlson, the chief growth officer at Healthcents, said at the Home Care Association of America (HCAOA) Virtual Leadership Conference Tuesday. “And that will be a way for you to push forward and get past that initial set of roadblocks.”

Founded in 1994, Austin, Texas-based Healthcents is an outsource solution company for managed care and general payer contracting. As part of its business, it provides analytical, contracting, negotiation and credentialing services to a wide range of health care providers.

In 2019, 75% of home care agencies did not track simple data points such as readmission rates, according to data from Idaho-based market research and education firm Home Care Pulse. For those that did, their means of recording that data was often elementary and conducted by Excel or just paper and pen.

“A lot of times people don’t think about that as value,” Carlson said. “And they’ll take the out-of-network from a referral and revenue perspective, but they don’t understand how that data can be used from a value proposition point of view.”

Narrow networks help payers from a clinical coordination perspective. Keeping a small group of providers as their go-to’s allows them to shed themselves of the burden of working with hundreds of agencies and systems across the country.

That means home care agencies looking to break into these networks need to clearly define what they are, what they do, and how they’d help if they were to become part of that smaller network.

Payers are looking for specific performance indicators. That’s why “value” is not just about the value of an agency, but rather the value they can provide to a particular payer.

“It’s not all about you,” Carlson said.

Gaining insight into how a home care organization can provide value to a payer can start with something as simple as conducting a SWOT analysis to gauge strengths, weaknesses, opportunities and threats. Additionally, an agency knowing more about how it fits in a market in regards to scale, geography and other factors can help it make more meaningful relationships with payers.

“In home care, it’s especially important because this space has so much potential to continue to reduce readmissions and keep people out of higher levels of care — and in their preferred place of care as well,” Carlson said.

Approaching payers without a value proposition or a sense of what value an agency can offer in each situation is futile.

Without the legwork and without a plan, looking for new business may just end up hurting business overall.

“All of this is saying that you need to understand what the health plan is trying to accomplish, and if they have any of these pre-existing network designs or desires in place,” Carlson said. “Because if you don’t, you’re going to waste a lot of time, and not be able to get past the first

potential barriers.”

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Recently Launched Alivia Care Plans to Enter ‘Saturated’ Home Health Market

Alivia Care Inc., a new operator in the senior care space, has plans to enter the home health market.

Launched at the end of September, Alivia currently provides hospice and palliative care throughout the Jacksonville, Florida, area. The company’s history is tied to Community Hospice & Palliative Care, which now provides care as Alivia’s subsidiary, serving 8,000 hospice patients and 9,000 palliative care patients annually.

Community Hospice & Palliative Care’s CEO, Susan Ponder Stansel, has joined Alivia as its president and CEO.

Aside from Alivia’s hospice and palliative care service lines, the company will provide home health care, private-duty nursing and personal care services moving forward. Alivia will additionally offer PACE programs and advanced care management in the future.

PACE — or Programs of All-Inclusive Care for the Elderly — is a comprehensive care model that often uses a combination of in-home care and center-based care to keep older individuals out of institutional settings.

“The goal was to create a care continuum as a whole, while paying attention to the individual products and give them the attention that they need to make sure that our quality and network keeps up with our goal to be innovative,” Ponder Stansel recently told Home Health Care New.

In creating a sort of one-stop-shop for aging services, Alivia has its eye on the future of how care will be delivered, according to Ponder Stansel. Increasingly, health system partners and payers are looking to team up with providers capable of caring for patients on a longitudinal basis.

“Part of it was to make sure that we are not just at the end of the waterfall, waiting for the fish to come over,” Ponder Stansel said, referring to Alivia’s roots in end-of-life care.

As far as home health care, Alivia’s interest was piqued when the company saw how more hospitals were beginning to move toward risk-based payments.

“We really want to be in the home health business, as well as have the home health capacities to allow us to do more of that advanced illness care, because we do see … a lot more interest in them moving to that risk-based payment,” Ponder Stansel said.

One of the biggest challenges Alivia has experienced in the home health space is figuring where its market opportunities are in an already saturated landscape.

From 2018 to 2019, the number of home health agencies dropped by about 3.6%, a decrease of 427 individual providers, according to the Medicare Payment Advisory Commission (MedPAC) 2020 data book. Since 2015, the home health subsector has contracted by more than 8%, with nearly 1,000 agencies exiting the market.

In light of this, Alivia has opted for acquisitions of existing entities over starting de novo locations, Ponder Stansel said.

“We figured that for us, the better way would be to go ahead and buy an existing book of business,” she said. “We weren’t starting cold.”

Looking ahead, Alivia is also paying close attention to how the Patient-Driven Groupings Model (PDGM) and other payment changes will shake out for the company’s home health business.

“It’s not just PDGM. There’s the pre-claim authorization,” Ponder Stansel said. “There’s a lot of pressure on home health care agencies. They have sort of a ‘death by 1000 cuts.’ For what we want to do with home health, PDGM is actually a good change because it incentivizes you to take those higher-acuity patients and not be so therapy-heavy, and that really that aligns with our serious-illness strategy very well.”

Additional reporting by Jim Parker, editor of Hospice News.

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Amedisys Expands Personal Care Network Through New Partnership with BrightStar Care

One of the largest home care franchises in the country is teaming up with one of the nation’s largest home health providers.

Chicago-based BrightStar Care signed a care coordination agreement with Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED), adding BrightStar’s agencies to Amedisys’ personal care network.

The personal care network’s goal is to facilitate care coordination between Amedisys’ home health and hospice centers and the personal care providers it partners with.

The agreement with BrightStar expands Amedisys’ personal care network to 1,211 partner agencies in 39 states. The network helps the company manage chronically ill patients’ activities of daily living, which, in turn, drives down hospital admissions and lowers cost of care.

The relationship will be piloted with care centers in Pennsylvania and Texas. If all goes well, the plan is to expand the footprint of the relationship.

“If COVID-19 has taught us anything, it’s that America’s seniors need quality care in the home more than ever before to stay safe and feel supported,” Amedisys CEO Paul Kusserow said in a press release announcing the news. “I’m delighted to welcome the incredible BrightStar Care caregivers as care coordination partners in expanding access to a much-needed continuum of care that improves patient outcomes and lowers costs.”

Amedisys has 480 care centers in 38 states and Washington, D.C. Its home health operating income for Q2 was nearly $50 million. It also provides personal care services, but that offering makes up a much smaller slice of its business.

Meanwhile, BrightStar Care has 340 personal care locations in 38 states, reaching about 75% of the U.S. population. The two company’s footprints overlap significantly, the release said.

Amedisys’ personal care network dates back to 2019, when the provider partnered with the home care software company ClearCare Inc. on the  project as a means to expand its reach and capabilities in the home. It was also a way to open the door for Medicare Advantage (MA) opportunities, Kusserow said at the 2019 Home Health Care News Summit in Chicago.

These partnerships allow Amedisys to enter the personal care arena without acquiring personal care companies. Those deals have presented challenges for the company in the past, Kusserow said.

The news comes on the heels of an already big year for BrightStar, which has expanded its personal care and senior living footprint, as well as built an effective and massive PPE pipeline for its franchisees during the height of COVID-19. 

“We’re excited to partner with Amedisys to bring to life our shared vision of re-imagining healthcare. Together, we strive to help Americans age in place safely, while improving the care experience and patient outcomes through the entirety of their home care journey,” BrightStar Care CEO and Founder Shelly Sun said in the press release. “We’re both passionate about delivering the highest standard of care, and BrightStar Care is uniquely positioned to provide Amedisys a personal care network that meets these high standards.”

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Decision to Care for COVID-19 Patients Pays Off for Home Care Agencies

In March, some home care agencies were gearing up for COVID-19 outbreaks in their areas, contemplating tough decisions like whether they’d accept positive cases — or do everything possible to avoid exposure. Since then, many have made the decision to take those patients.

And those that have are now wearing treated cases on their sleeves like badges of honor.

“When it first started hitting, we didn’t think we could handle COVID-19,” John Bradshaw, the CEO of Georgetown Home Care, told Home Health Care News. “There was just so much fear out there.”

Washington, D.C.-based Georgetown Home Care is a Mid-Atlantic home care provider that offers personal care, respite care, senior companionship services and senior transportation services to clients in the D.C. area, as well as northern Virginia.

Whether Bradshaw thought his agency could handle COVID-19 quickly became a non-factor. D.C. began to get hit hard by the virus in late March and early April, meaning it was time for Georgetown Home care to step up or shut down.

Bradshaw first realized his in-home caregivers needed personal protective equipment (PPE). Then, he knew his organization would have to come up with a new training plan. Most importantly, Bradshaw had to convince himself — and his staff — that caring for individuals battling the COVID-19 virus was something a non-medical home care company could manage.

To keep front-line workers motivated, Georgetown Home Care would also need to properly reward employees, the CEO recognized.

“I thought, ‘We’re going to pay our staff more, and we’re going to be able to protect them,’” Bradshaw said. “Really, the issue here is that we need to appeal to their sense of their willingness to help out in the Washington, D.C., region.”

To reinforce its caregiving operations, Bradshaw hired a nurse practitioner specializing in infectious diseases. With that expert insight, he and his leadership team then set up conference calls with small groups of Georgetown’s staff to explain the situation that was in front of them.

Georgetown is now proud of the progress it has made on treating the disease and the fact that it was, at one point, the only home care company taking COVID-19 patients out of the hospital in the D.C. area, according to Bradshaw.

It has now treated close to 50 COVID-19-positive clients. Those clients were also unexpectedly critical to Georgetown’s business and bottom line.

Specifically, they played a role in offsetting the 25% to 30% revenue loss the company experienced in April.

The home care industry has not fully turned the corner on COVID-19, in general. But the stigma that came with caring for COVID-19 patients has been erased and replaced with a new sense of distinction.

HouseWorks, a Boston-based in-home care company, went through a similar line of thinking, CEO Andrea Cohen told HHCN.

If home care agencies were willing and able, she urged them to get to work and start taking patients. She said as much during a COVID-19 panel discussion back in April, too.

Backed by health care investor RAB Ventures LLC, HouseWorks also offers home-modification services. It has locations in Massachusetts, Maine, New Hampshire and Pennsylvania.

HouseWorks’ operations were hit hard in May. In total, the organization ended up caring for around a dozen COVID-19-positive patients. It has been leading webinars for other operators on how to deal with patients, among other practices, for 12 weeks.

“I said, ‘Don’t judge the home care companies that don’t want to take positive patients.’ That’s fine, because some of them are smaller and can’t afford to pay up for PPE and other resources,” Cohen said. “But for those of us who were the larger companies and felt prepared or just wanted to do it, we as an industry have really come together to just help with [the situation].”

When it comes to PPE, many home care agencies have had to pay anywhere from 4 to 10 times typical market prices for gowns, masks, gloves and other supplies. To manage PPE, some have even created internal and external distribution centers, investing millions of dollars to help protect the home care workforce.

There’s undoubtedly been a change in home care’s perception of the COVID-19 crisis, Cohen noted.

“I did totally see a shift in that and I do see a lot more companies who are willing to take COVID-19 patients,” Cohen said. “And I think what’s been wonderful about that is that home care companies were sharing. I shared every single protocol that I did for COVID-19 with any home care company that wanted to see it. And it took my company a lot of time to write these protocols.”

The ability for non-medical home care companies to take on COVID-19 just like other segments of the health care continuum has furthered their common cause.

For providers like HouseWorks and Georgetown Home Care, they’re proud to say that they played a part.

“The future of home care is that home care companies are going to be asked to do more in the home than we’ve ever been asked to before,” Cohen said. “And we have to prepare for that.”

Home care operators aren’t the only ones wearing their COVID-19 experience as a badge of honor. In the home health space, for example, Amedisys Inc. (Nasdaq: AMED) touted its COVID-19 care response on a recent earnings call.

“We’ve been leveraging the fact that we’ve been good citizens and we have been open to taking COVID-19 patients since Day 1,” Amedisys President and CEO Paul Kusserow said on the call. “[That has resulted] In building up new referral sources and partners. This is paying off particularly well.”

Accentcare echoed a similar sentiment in July.

“We never stopped things like sourcing [PPE], or continuing to train our staff and ensuring that the majority of them are able to care for someone who is COVID-19-positive,” Dave Davis, AccentCare’s chief clinical innovation officer, previously told HHCN. “We’ve never slacked for a moment on any of that during the course of this.”

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Senator Kirsten Gillibrand Pushes for Increased PPE, Telehealth Payment for In-Home Care Providers

U.S. Senator Kirsten Gillibrand (D-NY) is asking the Department of Health and Human Services (HHS) and the Centers for Medicare and Medicaid Services (CMS) to ensure that in-home care providers have access to essential resources amid the coronavirus.

Throughout the public health emergency, home health and home care providers have been vocal about the challenges they’ve faced acquiring personal protective equipment (PPE), as well as the need for federal payment barriers to be lifted.

Gillibrand — alongside Senators Bob Casey (D.Pa), Tina Smith (D.Mn), Elizabeth Warren (D.Ma), and Richard Blumenthal (D.Ct) — penned a letter to HHS and CMS asking them to address those ongoing concerns and others.

Overall, the letter has drawn support from the industry, with Visiting Nurse Service of New York (VNSNY), American Network of Community Options and Resources (ANCOR) and Home Care Association of New York State (HCA-NYS) giving the authors praise.

“To keep our frontline staff safe and our homebound patients healthy, we must have appropriate policies and financial support,” VNSNY President and CEO Marki Flannery said in a statement. “That means reimbursing home health providers for vital services delivered through telehealth, sufficient Medicare and Medicaid funding for care in the home, and priority access to personal protective equipment.”

In the letter, Gillibrand details the struggles that providers continue to face when it comes to securing and maintaining adequate supplies of PPE. She urges HHS and CMS to grant in-home care providers priority access to PPE.

“In some jurisdictions, home care and hospice were not even recognized by emergency management and public health authorities as essential care settings where PPE was vital for care access, health safety and protection,” Gillibrand wrote in the letter. “HHS and CMS must establish home care and hospice essential personnel status for PPE and other prioritization in emergency response, and direct state and local public health jurisdictions to follow.”

The letter also addresses the need for additional flexibilities in telehealth waivers for Medicare home health providers, namely ones that allow home health providers to be paid for providing virtual visits. While CMS has been active when it comes to granting telehealth payment waivers to many Medicare providers, home health has been left out.

“Efforts have fallen short in regards to home health,” Gillibrand wrote. “Under current law, CMS allows [home health agencies] to provide telehealth to those under their care, but they will not reimburse HHAs for those services as ‘virtual visits.’”

Reimbursement for telehealth would allow home health providers to increase telehealth services while lowering the risk of spreading of COVID-19. An increased use of telehealth services would also help them preserve PPE.

Gillibrand acknowledged that the current payment model for home health may complicate telehealth reimbursement and that some services, such as wound or catheter care, should always be provided in person. Still, she argued it’s “imperative” for CMS and HHS to come up with some sort of payment solution to help home health agencies get home health reimbursement.

Additionally, the letter calls for support of Medicaid long-term care providers delivering services in home and community settings, which have become crucial when it comes to reducing the spread of infection and caring for vulnerable populations, according to Gillibrand.

“Some states have asked for and received waivers that enable states to stabilize [home- and community- based services (HCBS)] providers,” She wrote. “However, state Medicaid budgets are stretched thin, and the waivers only allow retainer payments to [home health agencies]/HCBS providers and employees for thirty days. The federal government must provide adequate resources for these service providers and the workers they employ.”

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‘We’re Not Providing a Luxury Service’: No-Nonsense Home Care Model Helps CareBuilders Grow Amid Economic Downturn

CareBuilders at Home — the non-medical home care division of ATC Healthcare — has announced a strategic growth plan across the U.S.

The Lake Success, New York-based franchise currently has 13 locations. It is targeting to add more in Michigan, Illinois, Texas, Pennsylvania, New Jersey and California, specifically in the Bay Area.

The vast majority of the company’s revenue comes from its private-pay home care line. Generally, its offerings include those related to activities of daily living (ADLs), such as errand support, light housekeeping, medication compliance and other services.

CareBuilders at Home decided to grow amid the ongoing public health crisis because of the increasing demand for home care. Additionally, the target locations are all places that have the demographics that will be in need of in-home care services moving forward, CEO David Savitsky told Home Health Care News.

“We think that those areas are particularly good areas for us to be in because we feel that there are a lot of cities that have large populations — and large populations of people who are aging in place,” Savitsky said.

The company is also looking forward to eventually expanding to Florida, Arizona and elsewhere in California in the future. First, though, the franchiser is looking for the right franchisees.

CareBuilders at Home takes care of the full back-office needs for each of its franchisees, which differentiates it from some of its competitors, according to the company. One of its main appeals is allowing the franchise owners to focus on growing their own businesses and meeting client needs.

Those back-office functions include client credit checks, invoicing, payroll for health care associates and receivables.

The company does business with a few payers, but the vast majority is private pay. That’s an intentional strategy due to the relatively straightforward relationship between provider and client, Savitsky noted.

Historically, the home care space as a whole has been mostly built on private-pay relationships.

In 2019, for example, 67.5% of home care agency revenue came from private pay, according to the 2020 Home Care Benchmarking Study by market research and education firm Home Care Pulse. The next closest revenue sources were long-term care insurance and veterans assistance, at 11.4% and 3.6%, respectively.

In 2018, 72.1% of home care agency revenue came from private-pay sources, according to Home Care Pulse.

“Our primary means of having our services paid for is through private pay, and we think that is a good place to be,” Savitsky said. “Because we think the majority of home care that’s going to be delivered will be through private pay because there are no gatekeepers. There are no restrictions.”

Private-pay home care restrictions and state licensure requirements vary by state, but it is true that they have less to abide by than, say, Medicaid or Medicare providers.

While out-of-pocket costs are less reliable during a recession, Savitsky isn’t worried.

Business has been good for CareBuilders at Home during the COVID-19 crisis, and its leaders don’t think that it’ll be affected much by the economic downturn.

“I think that there’s no such thing as a business that’s totally recession proof,” Savitsky said. “But I would say that we’re a very recession-resilient business. Our offices have continued to thrive during COVID-19. We’ve continued to bring new people into the business — and it’s larger today than it was six months ago.

Several other in-home care franchise companies have also achieved solid growth during the last few months.

Home Instead Senior Care, for instance, hit an organizational high-water mark in January in terms of revenue and hours of care provided, CEO Jeff Huber recently told HHCN. After initial COVID-19 disruption, it then saw even stronger business numbers in July.

That steady success is mostly due to the practicality and importance of in-home care, Savitsky added.

“We’re not providing a luxury service,” he said. “We’re providing services that allow someone to live at home.”

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Caring People Acquires Acappella In Home Care, Aging Care and AMR Care Group

Caring People is staying busy on the acquisition front.

In fact, the New York City-based Caring People has completed a handful of strategic deals — with a focus on care management organizations — in the last few months alone. The acquisitions consist of Acappella In Home Care, Aging Care LLC and AMR Care Group, all of which were purchased in separate transactions.

Financial terms of the deals were not disclosed.

Caring People is a portfolio company of private equity firm Silver Oaks Services Partners. The private-duty home care provider operates in New York, New Jersey, Connecticut, Florida and Texas, the latter state recently added to its geographic mix. Across its operations, Caring People serves an average of 1,700 clients per day.

Although Caring People CEO Steven East declined to disclose the financial terms of the deals, he told Home Health Care News that the transactions fell in-line with the current pricing parameters for private-duty home care assets.

“We feel very confident in the investment in those businesses,” East said.

Acappella In Home Care provides home health, hospice, private-duty home care and companionship services throughout 13 Texas counties.

“Texas is a terrific senior care market. It has very strong private-pay demographics,” East said. “At the beginning of 2020, I can’t say I could have predicted we’d be in Texas, but we’re not limited geographically.”

Meanwhile, Aging Care is a care management and non-medical home care company that operates throughout central Connecticut.

New York-based AMR Care Group is a care services company that enables seniors to age in place. The company is partly known for its Cultured Companions program — a service that connects older artists, musicians, professors and others with younger counterparts in their respective fields.

On its end, AMR Care Group had grown at a 97% clip from 2017 through last year. In 2018, the company’s annual revenue checked in at about $2.2 million.

“I don’t think there’s been a magic bullet to our growth,” the company’s founder and CEO Anne Markowitz Recht told HHCN last September. “There’s obviously a huge need for home care services, which everybody knows about. Beyond that, it’s just doing the right thing, expanding our business and giving clients what they want.”

Along with being a great cultural fit, all three companies were attractive acquisition targets because of their owners and infrastructure, according to East.

“We have a back-office support team that can scale and support new offices all over the country,” he said. “With these three acquisitions, what was attractive to us was that they had very like-minded owners, who all stayed on with the organization in different roles. We felt that we could continue working with them and growing what they built.”

Acappella In Home Care founder Jo Alch, for example, has moved into the role of ambassador of brand development for Caring People.

The acquisitions also allowed Caring People to expand the company’s service lines.

“[Aging Care and AMR Care Group] had a core competency in providing care management services,” East said. “That’s a revenue vertical and a service line that we’re very interested in adding to our existing platform. Those acquisitions were strategic in terms of getting that talent.”

In addition to the three acquisitions, Caring People recently opened a new branch in New Haven, Connecticut, last month.

“We set up that branch because we knew there was a great caregiver population in that area,” East said. “We felt that having an office in that location would give us some better positioning for recruitment.”

Looking ahead, East says Caring People will continue to take a multi-pronged approach to growth.

“Acquisitions are definitely part of [our growth strategy], especially as we look at new and existing markets,” he said. “Adding new service lines to our existing business is also part of it, as well as de novo branches to service clients. We see it as a mix, but acquisitions are definitely an important component [of our growth strategy] — at least 50% or 60%.”

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Home Instead Senior Care CEO: The Hospital of the Future Is Your Living Room

In the not-too-distant future, “the hospital” will turn into older adults’ living rooms. And non-medical home care providers will play a key role in that evolution away from brick-and-mortar facilities.

That’s according to Jeff Huber, CEO of Home Instead Senior Care, an Omaha, Nebraska-based home care franchise company with more than 1,200 independently owned and operated offices worldwide.

Huber recently sat down with Home Health Care News to share his thoughts on the future of in-home care, along with the workforce that’s needed to sustain its growth. During the conversation, the CEO also touched on the COVID-19 virus and the rollercoaster impact it has had on Home Instead Senior Care’s global business.

You can read the highlights from HHCN’s conversation with Huber below, edited for length and clarity.

HHCN: We last connected with Home Instead in March. Can you recap some of your organization’s highlights and challenges since then?

Huber: I’m really impressed with how our franchise owners, teams and overall network have risen to the challenges of the moment. They’ve been able to continue to provide services and care to our clients while maintaining their health and safety.

Here at our global headquarters, we set up a personal protective equipment (PPE) distribution center. We work with vendors and partners to source PPE, then send supplies out in a week’s time to our franchise owners. We have a partner pharmacy called Simple Meds, and they have really helped out in terms of producing hand sanitizer for our network. What we see at the local level is great creativity, resilience and problem-solving.

In terms of challenges, we want to continue to elevate the professionalism of personal caregiving and raise awareness.

Home Instead teamed up with Service Year Alliance to launch “Champions of Aging” — a service year program where young people spend a year working intensively on aging-related issues. How has that gone?

This is all about giving young people a deep understanding of the aging experience, so they can be transformative agents wherever their career might take them. We have a vision to change the face of aging; we recognize, to do that, we’re going to need to engage and create an entirely new generation of leaders. It’s probably never been more apparent how critically important that is.

We have a part-time opportunity for current undergraduate students. It’s a paid internship program. For graduates, there’s a one-year program where they will spend about 32 hours a week in service and another eight hours in formal education and leadership training.

In a recent op-ed, a New York state senator argued that investing in home care is a key way for reversing the nation’s overall economic downturn. Do you agree?

Home Care is certainly a growth industry. When I attend events like the World Economic Forum, a lot of the conversation is about the disruption of traditional job markets by innovation and automation. I think a great place for people whose jobs have been disrupted either by COVID-19 or by automation is home care.

One thing we know is that the traditional health care delivery system is really understaffed. Health systems and providers are under enormous pressure to produce outcomes. What we’ve proven in recent months is that the home is an effective place to care for vulnerable seniors. We can not only be an extension and increase the capacity of the health care delivery system, but we can be the centerpiece.

If you think about the future of the hospital, it looks a lot like your living room. I think home caregiving is definitely a growth opportunity for a future workforce. The home is really the only scalable place where we can care for people.

Business has been up and down for a lot of home care organizations. Overall, how has the Home Instead network fared over the past couple of quarters?

The year started off well. The 10th week of the year — I think, the first or second week of March — was a high-water mark for our North American operations, in terms of revenues and hours of care provided. Of course, in the second half of March, that quickly fell off and bottomed out. In June, we started seeing recovery.

July then replaced January as the best month in the company’s history. 

Internationally, exactly the same story has played out. Our U.K. operations, for example, also had a record month in July.

We’ve heard about some home care providers launching new service lines. Is that something Home Instead is doing? If so, what kind of bottom-line impact have you seen around that?

We began integrating tablets into operations long before COVID-19 began. It has allowed us to dial up remote capabilities and dial down in-person visits when appropriate. In some cases, it has allowed us to offer a pure remote offering. For example, we have the ability to offer check-in services and medication reminders — things that can supplement and enhance the amount of personal care that we’re able to offer.

We’re still working out the economics of it, but it’s allowing us to do more with less and increase productivity. It’s been a positive development for us.

Congress is going back and forth on another stimulus package. Is there anything in particular you’d like to see in that to help the home care industry?

We have a bill that’s sponsored. We’d like to see that become part of the next stimulus package. The bill would allow health savings accounts to help pay for our services. The other thing would be to offer liability protection for employers who are following CDC guidelines.

What have you done to recruit and retain workers during this time?

One thing that we have done across the board is make available a 24/7 support line for caregivers. Our caregivers can confidentiality call up a toll-free number and have immediate access to trained counselors to help cope with whatever physical, mental or emotional issues they might be experiencing. That has been a tremendous boost for our caregiver workforce, and it has helped to support them through such unprecedented times. In the three to four months that we’ve instituted that, we’ve had, on average, 600 unique users per month. It’s really been well-received.

We’ve also been able to quickly pivot our operations to do recruitment and training remotely.

Can you talk about the company’s growth plans moving forward?

It’s a growth industry, so we’re really looking to expand service offerings. We’re looking beyond just our hourly care to find new ways to serve a growing senior population with a variety of products and services.

We’re going to continue to expand our international operations. We’re going to give our local offices new tools to become more efficient … through the use of technology, integrated systems, data and analytics.

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The Secret to Setting Up Shop in the SNF-at-Home Space

For years, diversion between home health providers and skilled nursing facilities (SNFs) has been a big part of the industry narrative.

On their end, home health providers have reworked their operations to handle more acute patients and individuals traditionally served in SNFs. Now, home-based care providers are being even more intentional in their efforts by leaning into the SNF-at-home model.

While the idea of SNF-at-home has been gaining plenty of buzz as of late, the concept isn’t a new one, according to Leslie Palmer, administrator and clinical director at Josephine at Home.

“[In-home care providers] have known that keeping people at home typically results in better clinical outcomes,” Palmer told Home Health Care News. “It’s less expensive. And it keeps people out of the hospital. I think what’s different now is we have the opportunity to enhance that concept. Now, we’ve named it ‘SNF-at-home,’ and we’ve formalized operational aspects.”

Josephine at Home is a branch of Stanwood, Washington-based Josephine Caring Community, a cross-continuum organization that offers transitional rehabilitation, assisted living and other long-term care services, plus early learning and child care.

The nonprofit organization’s Josephine at Home business line currently offers home care services, though it’s in the process of expanding into home health care.

Additionally, Josephine at Home has upcoming plans to roll out an SNF-at-home services line.

Currently, roughly 25% of short-stay SNF episodes can be cared for in the home setting, creating an opportunity for in-home providers, according to statistics from Lincoln Healthcare Leadership.

Complex wound care and intensive therapy patients are examples of cases that can be treated within the SNF-at-home model, according to Jenn Ofelt, COO of UnityPoint at Home.

“Both of those are examples of patients that may have traditionally gone to an SNF because of an IV antibiotic or the need for daily therapy,” Ofelt told HHCN. “Both of those can easily be provided in the home if the additional layer of support that was needed by a 24-hour setting can be provided by a caregiver.”

UnityPoint at Home, a division of West Des Moines, Iowa-based health system UnityPoint, is a company that offers a range of home-based care services.

Similar to Josephine at Home, UnityPoint at Home is in the process of developing a SNF-at-home service line — and those two aren’t alone. LHC Group Inc. (Nasdaq: LHCG) and Johns Hopkins Home Care Group reportedly have SNF-at-home models in the works as well.

The fact that more and more in-home care providers are developing SNF-at-home service lines should come as no surprise. In general, more seniors and their families are looking for higher acuity care in the home setting, according to Dr. Cleamon Moorer Jr., president and CEO of American Advantage Home Care Inc.

“Families are looking for assistance with going through the logistics of, ‘How do I get a ramp installed? How do I go about getting a ventilator from a [durable medical equipment] company?’” Moorer told HHCN. “We’re finding that whole ecosystem of … [creating] a high-acuity nursing experience in a loved one’s home seems to be a gap that we’re able to step in and start filling.”

Dearborn, Michigan-based American Advantage Home Care Inc. is a provider of home health care, medical social work and other services.

The first steps

For home health providers looking to get a new SNF-at-home product line up and running, having a strong basis in home care — either organically or through partnerships — will be crucial.

“If you’re an expert in home health but not home care, then maybe look at partnering with an existing home care agency,” Palmer said. “It’s the same thing with home care — either look into forming a partnership with a home health provider or having someone who’s an expert help launch your own home health service lines.”

Having a home care component is especially important because in order to implement a successful SNF-at-home program, providers will need to replicate the 24-hour care component of traditional facilities.

Other potential partnerships aspiring SNF-at-home operators should strive for are ones with home medical equipment providers and infusion pharmacies.

“A SNF-at-home patient likely needs to be admitted the same day they leave the hospital,” Ofelt said. “Some of the elements of their plan of care include home medical equipment, such as assisted devices, a hospital bed, oxygen and IV infusion therapy needs. That infusion therapy pump and drugs all need to be delivered the same day. Having these partnerships in place will allow you to meet the clinical needs, immediately upon discharge from the hospital.”

On the staffing side, having a strong team of physical therapists, occupational therapists and speech-language pathologists is also key.

“You need to be able to staff these positions at a SNF-type level,” Ofelt said. “Prior to last October, patients went to SNFs and needed to receive a very high level of therapy to qualify for that day and for those SNFs to bill at their highest therapy rate. That needs to translate into the home. You need to be able to provide that level of therapy service.”

Providers that are looking to thrive within this space need to make sure that, on the clinical side, nursing competency is functioning at an acute level, according to Palmer.

One potential barrier for providers looking to implement this service line is that SNF-at-home doesn’t have a clear reimbursement model.

“Of course home health is reimbursed, and there’s chatter that Congress is talking about reimbursing some home care, but not the SNF-at-home program,” Palmer said. “As leaders in health care, we’re just going to proceed forward regardless of what the reimbursement looks like. We can maybe patch some of the reimbursement together.”

Broadly, SNF-at-home will need a reimbursement model that addresses the combination of care patients need.

“Traditional home health care payment will not be sufficient given these individuals will require a mix of both skilled home health care services and also home care assistance with activities of daily living,” David Grabowski, a professor in the department of health care policy at Harvard Medical School, told HHCN in an email. “The model will have to recognize these enhanced service needs.”

Looking ahead, Grabowski believes that the unified site-neutral payment model that the Medicare Payment Advisory Commission (MedPAC) has been working on might be the right catalyst for the SNF-at-home model.

“Rather than focusing on payment by setting, the unified payment model focuses on payment by condition,” he said. “For example, an individual recovering from a hospitalization for a stroke would be associated with the same reimbursement regardless of where they were discharged. Site-neutral payment would allow the care of patients in the home who previously would have been discharged to a SNF.”

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HCAOA Throws Support Behind CareAcademy Program to ‘Reskill’ 1M New Caregivers by 2023

Just one month after its original launch with venture capital company Kairos HQ, CareAcademy has expanded its caregiver job placement and training initiative.

CareAcademy is a Boston-based training platform for home care professionals. The company currently serves roughly 1,000 home care clients and locations. The company’s “Future of Work is Home Care” program aims to reskill 1 million new workers for the home care industry by 2023.

“The Future of Work is Home Care is really coming out of the necessity that we’re seeing born out of this moment and COVID-19,” Helen Adeosun, CareAcademy’s founder and CEO, told Home Health Care News. “We’re seeing the economy has left a lot of people unemployed and waiting for opportunities.”

Additionally, home care leaders are slowly seeing a rise in demand for their services, as seniors continue to shift away from nursing homes amid the public health emergency.

To meet that demand, providers are looking to dip into the pool of new job candidates — especially workers from the restaurant and hospitality industries — that has been created by the rise in unemployment in the U.S.

These circumstances have created an opportune time for “matchmaking” between home care companies and new caregivers, according to Adeosun.

As part of the program, potential caregivers will have the opportunity to enroll in a specialized, online “reskilling program” for caregivers. The program consists of four initial classes and the opportunity for additional training from home care companies.

Through the program, CareAcademy also matches caregivers with home care agencies, primarily through zip code.

“We wanted to make this as frictionless as possible,” Adeosun said. “We recognize that agencies have their own onboarding processes, … so [we] wanted to honor that by not making this too onerous. The idea is to provide a warm handshake to candidates who are interested in home care and to whet the appetite of folks who aren’t exactly sure what home care means — or what a career in health care means — via those four classes.”

This new iteration of the program plans to zero-in on millennials, she noted.

“Speaking as a millennial, we are the generation between the 2008 recession and this moment right now,” Adeosun said. “We’re meeting millennials exactly where they’re at, and that is by way of social media. As a result of our initial efforts to target millennials, we saw the ability to open up the aperture much wider.”

For this go-round, CareAcademy has brought on the Home Care Association of America (HCAOA) as a partner. Washington, D.C.-based HCAOA represents nearly 3,000 companies that employ more than 500,000 caregivers.

“HCAOA has sent out and is collaborating with CareAcademy to funnel in members who may be interested, have the capacity for this initiative and the desire to build their workforce,” Adeosun said. “Having that level of collaboration between Emma [Dickison] and Vicki [Hoak] has been absolutely tremendous. They are visionaries in their own right and see the opportunity.”

Emma Dickison is the president of HCAOA’s board of directors, as well as the CEO and president of Home Helpers. Vicki Hoak is HCAOA’s executive director.

When it comes to workforce challenges within the home care space, providers often find themselves playing the defensive. “Future of Work is Home Care” and similar programs are giving providers the chance to be proactive.

“There’s great energy behind home care,” Adeosun said. “This is a real opportunity to reshape what home care looks like and work in tandem with this type of energy. How do we best facilitate [opportunities]? How do we best help?”

Looking ahead, Adeosun is on the lookout for additional partnerships for the program. So far, CareAcademy has already received interest from job platforms that are interested in being part of the intuitive.

“Our main goal in this initiative is to elevate the value of home care, not just at this moment, but beyond,” she said. “We’ve been doing a lot of thought leadership, and now it’s just putting actions to those words. We’re looking for any partners — this is a call to action for folks to join us.”

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How Royal Care Improved Its Caregiver Retention Rate to Over 90%

Over the years, in-home care providers have been forced to become increasingly creative when it comes to retention. One company, Royal Care, has been able to accomplish this in the hyper-competitive New York market, thanks to a unique caregiver perks program.

Founded in 1995, Royal Care is an in-home care agency that provides professional nursing care, geriatric care, physical therapy, rehabilitation services, occupational therapy, personal care and housekeeping services. The company’s New York locations include Brooklyn, Flushing, Jamaica, Nassau and the Bronx.

The company employs over 5,000 people and serves approximately 5,000 patients per month — many of whom are Medicaid beneficiaries.

To reward and retain workers, Royal Care has built a robust perks program that gives caregivers access to top manicurists, hairstylists, makeup artists, salon specialists and more. All of the services are provided at Royal Care’s brick-and-mortar Brooklyn-based “perks facility.”

The program was first established in 2016. The goal is to not only retain caregivers more effectively, but also to emphasize “self-care” among its workforce, which is predominantly made up of women, people of color and individuals from immigrant communities.

“It’s not just a perks facility,” Josh Klein, founder and CEO of Royal Care, told Home Health Care News. “It’s about taking a workforce that is [primarily] women and elevating them — making them feel a certain way.”

For caregivers — who may not want to spend any additional income on services that are often viewed as luxuries — this became a way to still experience these aesthetic services through their work, according to Klein.

In addition to the aforementioned services, the facility also features snacks, beverages, a certified in-house nutritionist, ESL classes, advanced home care training and various technology classes.

A facility like the one Royal Care operates may be uncommon in the home-based care space, but as Klein points out, for years, startups and tech companies have been pushing the envelope when it comes to providing its workers perks that fall outside of traditional employee benefits.

For example, Google campuses offer its employees free gourmet food and the opportunity for free sessions with a masseuse, as well as access to fitness and tech classes.

Klein doesn’t believe that attractive benefits should only be limited to specific careers or people with an executive title.

“I tried to equate it to the big fancy tech companies — the Googles of the world,” he said. “Google has campuses that pamper every single tech executive … people that make a quarter of a million dollars and above. That company sees a need for pampering and caring for their employees … so imagine what it means for a caregiver that makes a lot less than a quarter of a million dollars.”

The company has seen success with the facility and has plans to roll out a second location in the Bronx — slated to open by December. The new facility will offer continuing education programs focused on career advancement, nutritional classes, meditation and yoga, and a wellness café.

In terms of return on investment, Royal Care is open about the fact that the company has put in millions to get these facilities up and running. For Royal Care, the return on investment comes in the form of retention, especially in a market as competitive as New York.

“Our turnover is less than anyone else in almost any industry,” Klein said. “Our retention rate is above 90%.”

As providers continue to combat the COVID-19 emergency, retaining caregivers will be more crucial than ever, according to Klein.

“Caregivers care about their work. They have big hearts. They wanted to do something as an essential employee,” he said. “As a company, you have to care for them, too.”

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Finding ‘Fresh Blood’: How COVID-Related Unemployment Has Created a New Class of Caregivers

The home care market has been long plagued with workforce issues, with providers in the space often struggling to recruit or retain caregivers. But as the U.S. continues to see a rise in unemployment, it’s creating a new pool of job candidates.

And providers are getting ready to jump in.

“[COVID-19] has created a very weak and sort of chaotic market,” Michael Carr, an associate professor in the department of economics at the University of Massachusetts Boston, told Home Health Care News. “A whole bunch of people were suddenly unemployed. Most of these people were in service jobs.”

As of the end of July, 16.3 million people were unemployed, largely due to the reduction in general business activity caused by shelter-in-place orders and operating restrictions. Roughly 963,000 more people filed for first-time unemployment benefits as recently as last week, according to the U.S. Bureau of Labor Statistics.

Overall, the surge in COVID-induced unemployment is more sizable than the increase during the Great Recession, which lasted from the end of 2007 to the beginning of 2010, according to data from the Pew Research Center.

Amid the job loss and uncertainty, home care is one of the industries that has often been referred to as “recession-proof.” While that sentiment has received pushback from experts, it’s safe to say that the demand for home-based care remains high.

“Home care is an industry where the need is still high, and we have clients that need to be served,” Charlie Young, CEO of Synergy HomeCare, told HHCN. “In some segments of home care, we’re seeing the demand growing, so there’s absolutely a healthy, robust job market.”

NexPhase Capital-backed Synergy is a Gilbert, Arizona-based non-medical home care franchise that offers companionship services, in addition to personal assistance, housekeeping, live-in care and 24-hour home care services. Currently, the franchise company operates throughout the U.S., serving roughly 25,000 clients and employing about 20,000 people.

Young is among the growing number of home care leaders that believe the rise in unemployment has created a new labor pool and an opportunity to reach a new crop of caregiver candidates.

“This brings us an opportunity in the home care industry,” he said. “At Synergy HomeCare, we’ve seen our franchisees have a renewed focus on new caregivers coming into the marketplace.”

Specifically, job loss in the retail and hospitality industries has been a recruitment source for the company, according to Young.

“Retail has been hit very hard,” he said. “There is the hospitality segment, hotel workers and restaurant workers. Service-minded people make great caregivers.”

About 1.9 million store-based retail workers were unemployed as of June, according to the U.S. Bureau of Labor Statistics. The leisure and hospitality industry had lost 7.7 million jobs as of May.

Meanwhile, 5.5 million food service workers — waiters, cashiers, chefs, bartenders and restaurant staff — have experienced job loss.

Young believes that the COVID-induced labor pool benefits the home care industry in two ways.

“It brings a fresh perspective and fresh blood,” he said. “I think there are some skills and some aspects of service in those industries that are just tailor-made for home care. If you are coming from hospitality, restaurants or certain retail environments, you’ve been trained in service. That is only an asset when you think about putting them into the home in a one-on-one environment with someone in need of care.”

While providers are aware that a new pool of candidates exists, they will need to be proactive in order to actually lean in and benefit.

“One thing that we’re doing very tangibly is working with our recruiting marketing efforts to tap into these new markets,” Young said. “An example of this is through Facebook advertising. It allows us to target a whole new segment that we believe would make great caregivers.”

The company also works closely with job site Indeed to create specialized marketing programs in order to tap into the new pool.

“Prior to COVID-19, that was one specific profile — people that were already in that market,” Young said. “We’ve now expanded and are able to vertically target other communities. Expanding your field of vision can only be helpful.”

Likewise, Boston-based training platform CareAcademy has also seen an opportunity in the current moment.

In July, the company launched a home care job training and placement program, in partnership with Kairos HQ, a New York-based venture capital company.

“[Anecdotally], we’re seeing everyone from gig economy workers, retail workers, and food service workers who are curious and accessing [our] platform,” Helen Adeosun, CareAcademy’s founder and CEO, told HHCN in an email. “The trendlines for those industries make this an opportune time to present our Future of Work opportunity to those prime candidates.”

CareAcademy has since expanded the program, teaming up with the Home Care Association of America (HCAOA).

Even with the opportunity for home care providers to recruit from a new pool of workers, home care providers will still need to step up when it comes to caregiver wages, according to Carr.

“The standard economist logic would be that the wages that people are paid ought to reflect the nature of the working conditions,” he said. “My suspicion is that the primary driver of recruiting and retention problems are the jobs just simply don’t pay enough.”

Moving forward, Young believes that this truly a unique time for home care providers that are looking to hire a specific kind of caregiver.

“There’s really an opportunity to be focused on really finding those people that have a connection to the vocation of caregiving, people that are empathetic, that are compassionate, that have life experiences in providing care and service to others,” he said. “I think there’s been no time like this in recent history for this industry.”

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Stuck in the Stone Age: 30% of Home-Based Care Providers Aren’t Using Technology Tools

The COVID-19 emergency has underscored how valuable technology can be when it comes to caring for seniors in their homes.

But while home-based care providers are increasingly upping their use of various technology solutions to aid in their virtual care efforts, there is still a number of providers uncertain about the value-add such tools offer. 

That’s according to the recently released 2020 Home-Based Care Technology Survey and Report, produced by Alayacare and Home Health Care News. The report highlights the views of over 300 individuals polled about the home-based care industry. 

Montreal-based AlayaCare is a software platform and secure cloud-based system that includes clinical documentation tools, client-and-family portals, remote patient monitoring and mobile caregiver functionality.

One of the key findings of the survey: While virtual care services are popular, their utilization among providers isn’t universal. More than 70% of providers currently use some form of technology to provide care, but almost 30% aren’t using anything at all, mostly relying on paperwork, phones and fax machines.

When taking a closer look at types of technology providers are utilizing to deliver care, telephone and live video received the most responses. Specifically, 82% of providers polled said they use telephonic services to provide care, with 66% using live video and 47% using online portals.

Another 14% used some other form of technology entirely.

On their end, the majority of providers that are utilizing technology are offering video conferencing and virtual visits in order to deliver care. About three-quarters of providers are offering video conferencing and virtual visits, while 51% are offering remote patient monitoring (RPM) and 42% online client-and-family portals.

In terms of the impact integrating virtual solutions has on their business operations, the majority of providers see a clear value. In fact, 61% of survey respondents agreed that technology is a value-add to their business.

Still, these opinions aren’t the consensus among all of the providers surveyed.

One-third of providers had “no opinion,” and 5% didn’t agree that integrating virtual solutions would improve their business.

Of the providers that aren’t using any type of technology, 50% responded that the reason for this is there isn’t enough demand from clients. Another 37% said virtual care services aren’t reimbursed in the state they operate in, presenting financial challenges.

Additionally, 27% of providers said technology is too costly; 16% said technology is too complicated.

While caregiver churn remains a top industry challenge, many providers are combating the topic with a number of solutions. More than 60% of providers polled said they offer their caregivers career development programs and 24/7 connectivity to the company’s office via app or website.

Additionally, 24% of providers offer community-development programs offline. Another 16% have implemented daily pay or advances, according to the HHCN-Alayacare survey.

Finally, many providers are looking at artificial intelligence (AI) and how it can potentially impact their business.

In total, 63% of survey participants said they believe that AI would benefit their organization. AI includes tools aimed at optimization or machine-learning.

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Addus COO: Recruiting Has Been ‘a Little Bit of a Struggle’ During COVID-19

Addus HomeCare Corporation (Nasdaq: ADUS) is rebounding from coronavirus-related disruption in its personal care and home health segments, company leadership noted Tuesday during a second-quarter earnings call.

But the Frisco, Texas-based company also acknowledged there are still significant challenges on the horizon.

“Addus had a very solid financial performance for the second quarter of 2020, with volume levels not as heavily impacted by the ongoing COVID-19 environment as we originally thought,” Addus CFO Brian Poff said on the call.

As an in-home care provider, Addus provides a mix of personal care, hospice and home health care services. It currently provides those services to about 42,000 individuals across 25 states and 185 locations.

Addus recently expanded that footprint. Last month, it announced it had closed on a deal to acquire A Plus Health Care Inc., a Kalispell, Montana-based home care provider.

Personal care services accounted for nearly 85% or Addus’s overall Q2 revenue, a total of about $156.3 million. Hospice accounted for about 13% of Q2 revenue, with home health accounting for the remainder.

Overall, net service revenues for Addus were up nearly 24% year-over-year in Q2, jumping to $184.6 million from $148.9 million in 2019.

The road to recovery

Patients shied away from care at the beginning of the public health emergency, Addus leadership noted.

That caused Addus to hit a low point in visit volume for all three of its segments in April, with personal care services contracting from about an average billable total of 39,000 in Q2 2019 to a little over 36,000 in Q2 2020.

But the damage was somewhat contained and volume is trending upward, Addus CEO Dirk Allison said on the call.

“As we see the return of these patients, when they become more comfortable with services provided in their homes, our personal care census should continue to recover,” Allison said.

Home health was actually the hardest hit, but also the quickest to rebound, according to the company. Since then, it has seen Medicare referrals for home health increase to the point of pre-COVID-19 levels.

Addus received $6.9 million related to its Medicare business from the Provider Relief Fund, but decided to return it.

For one, both Addus management and the board felt that the company had a strong capital structure — with little debt — that could sustain itself without the money provided. It also felt like it was the right thing to do.

“[We want to] let others who need these funds have access to the money,” Allison said.

Additionally, it felt uncomfortable not knowing what future federal reporting and audit requirements could come about after accepting money from the fund.

While it hasn’t impacted revenue, Addus is also actively taking COVID-19 patients in each of its segments.

“While the past five months have been challenging, I remain optimistic about the future of the home care industry and Addus, in particular,” Allison said. “We have a dedicated team of leaders and team members that have demonstrated their ability to continue to meet our mission — even if this virus has disrupted the way we have historically operated.”

Forthcoming challenges

Despite a strong quarter, the Addus leadership team was frank about the challenges that the company is currently facing and the ones it will continue to face.

It’s going to have to deal with a slew of state-by-state specific problems, such as minimum wage hikes in Chicago to $14 — and eventually $15. It will also have to consider and adjust to fluctuating state budgets after COVID-19, particularly as it pertains to its Medicaid side of the business.

“[Still], I think one thing to remember is our services are keeping folks in their home and isolated and are one of the best ways to try to protect them from this virus,” Allison said. “It also is an alternative to those folks potentially being in a nursing home setting, which we all know has been a problem during this particular virus. … So we feel that we have a great story to tell.”

Allison added that he believes that the states understand the severity of the situation and the benefits of the home-based care setting versus facility-based care.

Addus is also expecting its personal protective equipment (PPE) expenses, which have been a significant add-on, to be a part of the company’s budget for the foreseeable future.

“We believe this additional expense will be necessary for the next several quarters or until an effective vaccine or treatment is developed and widely available,” Allison said.

The company is also dealing with recruiting issues for the time being, but is hoping that lower unemployment benefits from the federal government and workers transferring to home-based care from other fields will help solve the problem.

“Recruiting has been a little bit of a struggle, I think, primarily due to the additional unemployment benefits that [have been out] there,” Addus COO Brad Bickham said on the call. “We’re getting a lot of inbounds, but frankly we’re also seeing a lot of folks that won’t show up for training or for interviews. So recruiting is honestly a little down, [but] I expect it to improve with the reduction of the $600 [per week in unemployment benefits].”

The company also plans to lure some unemployed workers back to work with some incentives in a few markets, but didn’t specify what those would be.

Historically, hiring has been better for Addus during economic downturns.

“That’s been a better time for us to be able to hire and bring folks on, and we believe that will occur over the next year or two as the unemployment benefits … come to an end,” Bickham said. “We do believe that the recruitment efforts will return to a more historical level and hopefully [get] somewhat better.”

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Home Care Companies Create New Revenue Streams by Helping Businesses Safely Reopen

After weeks — in some cases, months — of closures due to the coronavirus, businesses across the U.S. began reopening in early June. But by July, many of those same businesses were forced to go in the opposite direction, thanks to a national resurgence of COVID-19 cases.

As shops, manufacturing plants and warehouses again attempt reopening, many are turning to traditionally consumer-facing home care providers for backup. To help prevent the spread of the coronavirus, Senior Helpers, BrightStar Care, 24 Hour Home Care and several other organizations have expanded their service lines to offer screening services for unexpected business partners.

It’s a revenue-diversification opportunity that wasn’t on the home care industry’s radar, but it’s one likely to stick around for a while, according to Senior Helpers CEO Peter Ross.

“It’s a service that you and I would never have dreamed of months ago, but it’s come to fruition,” Ross told Home Health Care News. “I wouldn’t say our numbers are better than last year because of that, but certainly it has shown our flexibility and our ability to help the community.”

With a corporate headquarters in Maryland, Senior Helpers has more than 320 home care offices in its global franchise network, which covers parts of Canada and Australia in addition to the United States.

Many of Senior Helpers’ franchise owners have struck contracts to do temperature checks and related COVID-19 screenings for local businesses, Ross said. To support them in that mission, the franchiser sent forehead thermometers to owners and created an electronic brochure to help with marketing.

“We’ve noticed a bunch of opportunities across our system,” he said. “We’ve been finding a lot of manufacturing plants, warehouses, different types of factories … weren’t taking the proper precautions to do what they needed to do.”

Illinois-based BrightStar Care — another home care franchise giant with more than 340 locations in the U.S. — has taken similar steps to help businesses safely reopen. On top of doing temperature checks, the franchiser has also connected different businesses to its personal protective equipment (PPE) distribution center.

“Outside of securing PPE inventory for BrightStar Care franchisees to ensure the safety of their caregivers and clients, we’ve also shared access to our PPE distribution center with fellow business owners,” CEO Shelly Sun told HHCN. “We want to do our part in helping communities re-open safely, so that’s why we felt it was important to share access to our PPE supplies.”

Moving into B2B

In 2019, home care agencies typically sourced the bulk of their revenue from hourly in-home care, followed by live-in care, geriatric care and alert monitoring, according to the 2020 Home Care Benchmarking Study from market research and education firm Home Care Pulse.

But many of the home care professionals who participated in the benchmarking study said they expect to generate revenue from new avenues brought on by health screenings tied to the public health emergency in 2020.

Another Home Care Pulse report highlighting the impact of the COVID-19 virus on home care had similar findings.

“In our impact report that we [previously] released, a little over 50% of businesses said that their service lines were going to adapt and change based on learnings in the middle of the pandemic versus post pandemic,” Home Care Pulse COO Todd Austin told HHCN. “This is definitely one example — screening.”

Besides helping warehouses and manufacturing plants safely reopen, Austin said he’s also heard agencies are doing screenings at airports and various retail locations.

“Home care has had a little bit of B2B exposure through providing staffing and shipping to some facilities, but it’s never been a true B2B [industry],” he noted. ‘And that’s what 2021 will likely bring. home care agencies won’t just focus on B2C, but also more B2B service lines to where they can go out and network with other businesses.”

Per its screening contracts with non-health care businesses, Senior Helpers sends in rotating teams of certified nursing assistants (CNAs) or home health aides to cover different shifts of employees going into work. It typically does temperature checks, charging by the hour for those services.

“The last thing you want to do in a factory is let an employee who’s got COVID in with another couple hundred other people, with all of them working a few feet apart,” Ross said. “Look at what happened with all the different meatpacking plants in the country because of that issue.”

A July report from the U.S. Centers for Disease Control and Prevention reported that 23 states had COVID-19 outbreaks in meat and poultry processing facilities, with 16,233 cases in 239 facilities. Those outbreaks included 86 COVID-19-related deaths.

Senior Helpers has also used its screening contracts as an organic way of touting its caregiving services, Ross said.

“People say, ‘Oh, well, tell me more about Senior Helpers.’ They might need help in the home for their mother, their uncle, their grandfather,” he said. “From our perspective, it’s just a great investment in the community to keep people safe. And it certainly helps to drive the brand.”

That organic information campaign may also inspire some people to branch out into home care, perhaps even opening their own Senior Helpers franchise location one day, Ross said. It’s something that could factor into the strong growth the franchiser has seen lately.

“We’ve been growing really well, to the tune of 25 to 30 new owners a year,” Ross said. “We’ve been bringing more people on at a higher pace during COVID.”

On its end, BrightStar Care’s locally owned-and-operated agencies have provided screening services to 270 customers, including multiple Fortune 500 companies, as of mid-July, according to Sun.

BrightStar Care screening services are typically conducted by either a registered nurse (RN) or licensed practical nurse (LPN). Services range from taking vitals and conducting screenings, to interviewing employees and documenting answers for HR files.

Rates are based on the number of hours that the RNs and LPNs serve the needs of the customer.

“We’ll continue offering screening services as long as they are needed. We are proud to be able to support our communities and businesses to ensure safe reopenings,” Sun said. “We see staffing services as a long-term opportunity since each of our agencies have RNs, LPNs and CNAs on staff and have a 20-year history of providing staffing services in addition to home care. We are able to deliver on the skilled and non-skilled services, and [we’re] ready to provide future staffing services from screening to administering vaccines.”

Outside interest

California-based 24 Hour Home Care officially launched “SAFER at work by 24 Hour Home Care” to help with reopenings. The independent and fast-growing home care company has a team of 3,000 on-staff screeners to not only assist businesses, but also government buildings, schools and more, its website says.

But home care providers aren’t the only ones helping businesses reopen safely. Some of the technology companies that partner with home care agencies or post-acute care providers have gotten into the screening game as well.

Dina — an AI-powered care coordination platform that works with some of the largest home health providers and health systems around — is one example.

As of mid-July, Dina has two non-health care company screening customers: one municipality and one food manufacturer, President and CEO Ashish Shah told HHCN in an email. Those customers represent roughly 1,200 users, he noted.

Dina is helping home care agencies with screenings, too. Overall, Dina has helped facilitate more than 1 million employee screenings.

“We’re seeing more non-medical home-based care agencies start to step up and ask for help,” Shah said. ‘They’re finding very creative ways to use technology to check in on their patients and staff. And we’re seeing more non-healthcare businesses adopt our screening products to do exactly what hospitals and health care providers are doing to take care of their caregivers and patients.”

Home care agencies interested in launching new safe reopening business lines should keep two key things in mind, Home Care Pulse’s Austin said.

Caregivers screening dozens or even hundreds of workers need to have necessary PPE. Additionally, agencies should consider assigning one employee to one site to limit their exposure and possible virus spread.

“The first thing agencies need to do is make sure that the individual doing the screening is isolated to that [one location], whether it’s consumer screening or employment screening,” Austin said. “That’s step No. 1.”

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The Forgotten Field: ‘Invisible’ Home Care Workers Seek Agency Support

Despite being on the front lines of care during the COVID-19 emergency, New York City caregivers often felt “invisible” and faced a higher risk of contracting the virus.

That’s according to a study published Tuesday by JAMA Internal Medicine. As part of the study, researchers interviewed 33 caregivers who were employed by 24 different home care agencies across New York City.

“The findings are alarming but not surprising to those who are familiar with the work of home care workers,” wrote Dr. Theresa A. Allison in a corresponding JAMA op-ed. Allison is a professor of medicine in the division of geriatrics at the University of California San Francisco.

In many ways, New York was ground zero for the public health emergency in the U.S.

The first cases of the virus in New York City were reported at the start of March. In the following months, the U.S. would have more than 1 million confirmed cases of COVID-19, with one-third of these cases coming from New York City, according to the study.

Caregivers have been positioned as essential workers during this crisis, with many continuing to provide daily care to patients with complex and chronic conditions — or to individuals actually battling the COVID-19 virus.

But while serving in their essential roles, many caregivers felt like the “forgotten field” in relation to the larger health care community.

“You hear people clapping, thanking doctors and nurses, even the hospital cleaning staff,” one of the surveyed in-home care workers said. “I’m not doing this because I want praise; I love what I do. But it would be nice for people to show us gratitude.”

The COVID-19 emergency also placed caregivers at higher risk for transmission, as workers took on errands such as grocery and pharmacy runs in an effort to protect their patients. Many caregivers relied on public transportation, which they felt further increased the risk of contracting the virus.

The JAMA study also highlighted other themes that emerged from interviews with New York City caregivers. One theme was the differing levels of support from their in-home care agencies in terms of receiving information about COVID-19, personal protective equipment (PPE) and training.

While some agencies were able to respond quickly, some caregivers reported they barely received communication about the public health emergency.

Additionally, some caregivers reported that they received insufficient masks, gloves and other PPE from their agencies, in turn leaving them vulnerable. Some caregivers noted they did not receive COVID-19 training from their agencies, though some agencies had them perform self-assessments to screen for symptoms. 

“Although lack of sufficient PPE has been widespread throughout the first few months of the pandemic in the United States, inadequate PPE in the home increases transmission risks for not only the home health worker and care recipient but also other household members and visitors,” Allison wrote.

Without agency resources, caregivers relied on other sources of support, according to the JAMA study. Specifically, caregivers who didn’t receive information about COVID-19 from their agencies turned to the news, social media, government briefings and their worker unions.

In some cases, caregivers bought their own PPE, or turned to family and friends for help.

The study does suggest that some agencies were quick in their COVID-19 responses.

Based on her observations as the president and CEO of the New York State Association of Health Care Providers, agencies used several methods to support workers, Kathy Febraio told Home Health Care News in an email.

“Communication with staff became a daily event through as many channels as possible: social media, texting, email, web postings, phone calls and good old-fashioned snail mail,” Febraio said. “Agencies kept their employees informed about infection control procedures, proper donning and doffing of personal protective equipment, policy updates, as well as information on child care resources, government updates, school closings and wellness resources.”

The New York State Association of Health Care Providers is a trade association that represents 350 offices of home care providers, home health providers and other health-related organizations.

The study reported that caregivers often found themselves navigating difficult choices. For instance, caregivers had to decide whether to care for COVID-19 patients and risk contracting the virus, placing themselves in a financially unstable position.

Generally, caregivers felt it was their duty to provide care during this time.

Overall, the findings of the study are instructive for providers and policymakers as they continue to work on remedies, Roger Noyes, director of communications at the Home Care Association of New York State (HCA-NYS), told HHCN in an email. 

“Many of the key themes in this study echo what our organization has identified in our own survey of the home care field,” Noyes said. “This includes the need for a more coordinated effort at all levels of emergency management to overcome personal protective equipment supply challenges.”

HCA-NYS is a state trade organization that represents nearly 400 home- and community-based care providers and organizations.

Noyes points out that many home care leaders participated in grassroots efforts to establish voluntary PPE distribution sites in all boroughs of New York City to coordinate with city officials and partner organizations on this area of need.

In her op-ed, Allison said she hoped the pandemic will lead to future home care reform moving forward.

“Just as COVID-19 has accelerated other aspects of medical and social progress, it is time to use the pandemic as an opportunity to engage in social justice for home care workers, recognizing the value of their work by investing in their health and financial security,” Allison wrote.

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Humana’s Bruce Broussard: Consumer Demand for Home-Based Care Models Will Continue to Increase

Humana’s (NYSE: HUM) long-standing home- and community-based focus served the insurer well in Q2 2020 — a quarter dominated by the COVID-19 emergency. The coronavirus pushed more senior care into the home, boosting business for Louisville, Kentucky-based health insurance giant.

As a result, the insurer doubled down on home-based care initiatives in Q2 2020 and will continue to do so going forward.

“We believe consumer demand for high-quality home-based care models will continue to increase,” Humana CEO and President Bruce Broussard said on the company’s Wednesday earnings call. “And COVID has reinforced this belief as we see increased awareness and interest in home-based care models by consumers.”

Humana has long been bullish on home- and community-based care. In 2017, the company, along with two PE firms, announced the acquisition of Kindred at Home, the largest home health provider in the country.

The insurer ramped up its home-based care efforts even further amid the pandemic, announcing strategic partnerships with the in-home primary care company Heal and the home-based urgent care provider Dispatch Health.

“Heal will serve as our preferred home-based primary care model, which is inherently more capital efficient and scalable, allowing Humana to offer high-quality, value-based primary care to more members than a clinic-based strategy,” Broussard said on the call. “The ability to deliver emergency room and hospital-level care in the home through partners like Dispatched Health is highly complementary and allows patients to recover in the safety and comfort of their home. [It also] reduces caregiver burden and avoids the risk of secondary infections and further health declines often experienced at the result of inpatient hospital stay.”

Additionally, Humana has continued to invest in Kindred at Home, most recently by working on developing new clinical models and operational enhancements for the service line. Broussard did not elaborate on what those look like.

Humana also saw the fruits of its home-based care efforts partly in the form of increased Medicare Advantage enrollment in Q2.

Last quarter, Humana’s individual MA plan enrollment was up 11% year-over-year, growing to 3.8 million in Q2. That’s especially impressive considering the fact that Humana recorded its highest individual MA growth rate in a decade in 2019.

“Medicare Advantage plans were some of the first organizations to proactively identify and implement policy and benefit changes at the outset of the pandemic,” Broussard said. “These actions addressed testing and treatment costs associated with the coronavirus, identified and tackled social determinants needs such as food insecurity, and ensured continuity of care for our members.”

One reason for MA’s success amid the coronavirus is that supplemental benefits allow plans to offer members services such as home-based care, food delivery and more, lessening the risk of seniors’ virus transmission while also addressing some of the effects of loneliness and isolation.

Bolstered by the COVID-19 emergency, MA’s popularity at Humana is only expected to grow more in the months to come.

The insurer raised its expected MA growth projections as a result of the strong performance it’s posted so far this year. Humana increased its individual MA growth range for 2020 from 300,000 to 350,000 new members to 330,000 to 360,000 by the end of the year.

For the quarter ended June 30, Humana saw its profits soar to $1.8 billion, or $13.75 per share. That’s double the $940 million in profit the company posted a year earlier in Q2 2019, with a nationwide delay of elective procedures largely to thank for the spike.

Humana’s Q2 revenues totaled $19.1 billion, up from $16.2 billion year-over-year.

MA competition, synergies

When asked about competition in the MA market, Broussard acknowledged that a number of smaller plans grew substantially last year, orienting recruitment around member experience.

“They’re always a concern to us, but we continue to believe our brand is strong in the markets that we compete with them,” he said. “Our value proposition is strong both with our customers and with our providers.”

Humana has technology on its side, as well as potentially Walmart, which recently announced it would get in the MA game.

“They’re not really getting into the MA business; they’re getting into the MA distribution business, and they have been in that business for a long period of time,” Broussard said. “So they would distribute Humana products but also competitor products. … We frankly look at it as a great complement to us, as they can continue to be a distributor for us.”

Humana’s stock price was $403.91 at the end of the day Wednesday.

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New Franchise Helps Senior Living Providers Add Home Care, Creating Competition for Agencies

Congregate living providers and home care agencies are often at odds with each other, competing over clients and which care setting is best.

In recent years, the rising popularity of aging in place has often helped home care providers come out on top. But now, a new franchiser — the HomeCare Advocacy Network (HCAN) — is hoping to give senior living providers a leg up.

HCAN’s goal is to help senior living providers add home care services to make themselves more competitive with their home care rivals. If successful, that could mean less business for home care providers down the line and more clients for participating senior living providers.

“If you’re not out there providing services to your future residents, someone else already is,” HCAN co-Founder and President Mark Goetz told Home Health Care News. “The real opportunity is for senior living providers to be more in control of their own destiny and to strengthen their own long-term viability.”

Before bringing HCAN to life earlier this year, Goetz worked as an executive at Frederick, Maryland-based Asbury Communities, one of the nation’s largest not-for-profit senior living organizations. Prior to that, he spent 13 years at Omaha, Nebraska-based Home Instead Senior Care, an in-home care franchise company with more than 1,100 locations worldwide.

HCAN was born out of that combination of experiences.

“We saw that there was an opportunity to … help communities leverage the success that we saw on the home care side of things,” Goetz said.

It’s not that senior living providers haven’t tried to add their own home care services in the past; it’s just that their efforts haven’t always been worthwhile.

“It’s hard to be successful in home care if you’re not really focused on it,” Bob Kramer, founder and strategic advisor at the National Investment Center for Seniors Housing & Care (NIC), told HHCN. “It’s a different setting, and you really have to have expertise in doing home care. You can’t just add it as an ancillary line and assume because you’re experienced in senior care … that you’re automatically going to have success.”

Goetz agreed, noting that senior living providers often fail to specialize new home care lines appropriately.

He likened the mistake to a hospital adding a new labor and delivery wing, then staffing it with emergency room personnel. No hospital planner would do that, Goetz said, because the two disciplines are marked by a few important, specialized differences. As such, the wings should be separate but complementary.

The same is true for residential senior living and home care, Goetz said.

HCAN aims to help senior living providers get the specialty expertise and support they need to set up their own home care arms, separate from but complementary to their senior living offerings.

As a result, senior living providers will have a better shot of keeping clients, regardless of where they need their care, Goetz said.

“For years, in-home services businesses have been benefiting from partnerships with senior living, and I think that’s going to still continue,” he said. “But senior living being more empowered to serve and operate in the highly successful in-home services business … is going to just improve their overall long-term viability.”

In other words, senior living providers will be able to catch potential clients earlier in the care continuum, giving HCAN providers the option to eventually funnel those patients into congregate living settings later on or to continue caring for them in the home long-term — whichever is best for the client.

Such integrated, site-agnostic senior care is the way of the future, according to Kramer, who was unfamiliar with the HCAN model when he spoke with HHCN.

“An integrated approach … really looks at it from the point of view of the customer,” Kramer said. “What’s going to be best for them? Not for the business model, the payer, the environment or even the disease. … The integrated approach is one that I think is the way forward, but most companies, when they tried to do it themselves as a senior housing company, it hasn’t worked very well.”

How it works

Goetz described HCAN as a white-label franchise, meaning senior living providers that partner with the organization are able to retain their original name.

“White labeling is allowing the senior living provider’s name to be at the forefront — and for their brand to be the hero and our brand, the HomeCare Advocacy Network, to be secondary.”

For example, say “Mike’s Senior Living” decided to leverage HCAN’s home care help. It would become “Mike’s Senior Living, supported by the HomeCare Advocacy Network.”

From there, HCAN would provide Mike’s Senior Living with business training, brand development guidance and marketing instruction, all of which would come from leaders who know how to launch and run successful home care businesses.  

On top of that, HCAN will provide financial and human resources support, which includes an HR, recruiting and operational software for franchisers to use. 

“We’ve developed what we feel is a world-class caregiver training module that our franchise owners will have the opportunity to launch themselves, then built that with the understanding of the in-home services financial model,” Goetz said. “That’s often where some of the confusion comes [in] … between in-home services and senior living.”

In addition to that initial support, franchisees will also receive daily support to help them run their home care business, Goetz said.

“We guarantee that we’ll be on site three times the first year, two times the second and at least one time the third year to ensure the successful launch of their business,” he added.

HCAN has a royalty model, which means it succeeds only when franchisees do the same.

Growth goals

While HCAN has been in the works since August 2018, the HCAN pilot office in Omaha, Nebraska, just got up and running in April during the height of the coronavirus outbreak.

“We have two more deposits for franchises already in the Omaha metro area, so it’s growing faster than we expected,” Goetz said. “And we have a lot of meetings on the docket for people who are interested and want to get into this line of business.” 

While he couldn’t provide specific names or numbers, Goetz said the coronavirus has only helped drive up interest for HCAN. Amid the COVID-19 outbreak, home-based care has become the preferred setting for seniors, due in large part to the outbreaks that have occurred in congregate settings. 

“What COVID has done is allow us to have better conversations … with senior living executives and providers and for them to see the opportunity in a different light,” he said.

In the next 18 month, Goetz said HCAN’s goal is to be in 20 communities and have 30 locations. Within the next five years, the goal is to have 300 locations in the U.S. and three international partners.

“It’s very aggressive,” Goetz said. “But the market is really ripe with opportunity and really the time is now.”

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Court Ruling Could Prove Costly, Remove Home Care Agencies from FFCRA ‘Exemption List’

When the Families First Coronavirus Response Act (FFCRA) was signed into law in March, home-based care providers were exempt from granting their workers a handful of benefits related to the coronavirus, such as extensive paid sick leave and paid time off.

But on Monday, the federal court for the Southern District of New York ruled that the U.S. Department of Labor (DOL) was overbroad in how it defined the exemption for employees of “health care providers.” The U.S. DOL was responsible for defining what types of providers and caregivers were exempt from FFCRA’s coverage as employees of health care providers.

The ruling was in response to a lawsuit from the New York Attorney General after the regulations were set by the DOL.

A narrowing of the health care provider exemption could mean serious trouble for home-based care providers that were operating under the assumption they would be exempt from the FFCRA’s requirements. While that’s especially true for those in New York and Connecticut, the ruling could set a precedent with broader implications moving forward.

“This turns everything on its head, because the providers that I have worked with over the last few months have been relying on these regulations in structuring their leave policies and deciding who can take paid, job-protected leave and who cannot,” Emina Poricanin, the managing attorney of New York-based Poricanin Law, told Home Health Care News.

The FFCRA officially went into law on April 1.

Broadly, the ruling could mean that agencies with less than 500 employees will need to grant paid time off to any employee who is ordered to quarantine or isolate by a public official. The same holds true for employees who have been advised to self-quarantine by a health care provider or who have been experiencing COVID-19 symptoms.

It also could mean up to 12 weeks of paid time off for any employee caring for a child experiencing a school closure.

The ruling is effective immediately, according to Poricanin.

“The DOL regulations effectively said that employees of health care providers would be excluded — and also that any employee, no matter whether they perform health care duties or not, will be deemed exempt from the FFCRA,” Poricanin said.

That resulted in many employees from home-based care agencies — on the front lines or otherwise — not being granted paid time off under the FFCRA.

It is still not clear how the law will be interpreted, particularly for employees who were furloughed or not granted paid time off from April 1 until Monday.

“Based on this decision, home care providers will arguably have to provide their office employees who need child care accommodations with 12 weeks of paid time off, and that’s going to create a huge problem for providers,” Poricanin said. “Then there’s the question over what do we do about the retroactive period — that time from when the regulations took effect [until now].”

Providers will be operating in even murkier waters until they get further clarification.

“There’s a possibility that employees could claim that they’re owed paid time off for retroactive periods when they were ‘forced’ to take a furlough due to child care concerns that were caused by the coronavirus,” Poricanin said.

Poricanin said she would not be surprised if the DOL appealed the decision.

Until then, providers will have to make hard decisions over how they’re going to operate – and how they will address requests for time off that, arguably, qualify for paid time off under the FFCRA.

“There will have to be some strategic decisions made by providers who are bound by this court decision about how to apply this in their workplace, depending on their state, their size and what services they’re providing, whether that’s companion care, home care or skilled home care,” Poricanin said.

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Budgeting for the Future: Kindred at Home, Johns Hopkins Home Care and Always Best Care Look Ahead to 2022

As home health leaders look to the future, the lessons learned from the COVID-19 emergency will likely continue to shape their efforts for years to come.

In terms of business planning, it will likely be a long while before there’s a return to a world where the coronavirus isn’t the central driver of health care strategy, outcomes and cost.

“We realize the current situation is not really going away anytime soon,” Mary Gibbons Myers, president and CEO of Johns Hopkins Home Care Group Inc., said Wednesday. “We’ll continue to be flexible, creative and resilient.”

Myers made her comments at the National Association for Home Care & Hospice’s 2020 Financial Management Conference, which was held virtually due to the COVID-19 emergency.

For Baltimore, Maryland-based Johns Hopkins Home Care Group, utilizing lessons learned from the public health emergency and understanding how it fits into the company’s business model moving forward has been crucial.

“For example, prior to the pandemic, we were preparing for a huge expansion of our facilities,” Myers said. “What we realized is that we really did not need as much space as we thought. We moved that mindset from expansion to contraction and making sure our employees have the optimal experience for the non-patient-facing to be able to do that remotely.”

The COVID-19 emergency also served as a catalyst for innovation for Johns Hopkins Home Care Group, according to Myers.

“In a matter of weeks, we expanded our remote patient monitoring program exponentially to meet the needs of our health system by monitoring COVID-positive patients,” she said. “We are actively discussing strategies to further remote patient monitoring over the years to come with or without COVID.”

Johns Hopkins Home Care Group falls under the larger umbrella of Johns Hopkins Health System’s Home & Community-Based Services division, which includes four Medicare-certified home health agencies, two private-duty companies, a large home medical equipment company, 10 outpatient specialty pharmacies and three alternative care infusion sites.

Similar to Johns Hopkins Home Care Group, Always Best Care Inc. has also scaled back in terms of office space, in relation to the COVID-19 emergency.

Roseville, California-based Always Best Care is a home care franchise company that operates across 209 territories in 30 states.

As part of its COVID-19 strategy, Always Best Care has placed a greater emphasis on infection control — something that will play a larger role for all in-home care providers in 2020 and beyond, according to Sheila Davis, the company’s senior executive vice president of operations.

“One thing that we have learned within our businesses is that you have to be mindful of — and protective of — not only the clients but also of your employees as well,” Davis said at the Financial Management Conference.

While infection control has always been a major aspect of home health, the public health emergency has pushed this to center stage on the non-medical home care side as well.

Additionally, amid the COVID-19 emergency, there have been a number of regulatory exceptions, waivers and other changes.

For Kindred at Home, the Centers for Medicare & Medicaid Services (CMS) and its move to broaden the definition of “homebound” under home health rules has been critical, according to David Causby, the company’s president and CEO. CMS’s goal in the expanded definition was to expand access to home health services, especially to populations at heightened risk for contracting COVID-19.

“This is something the home health industry has been pushing for an extended period of time,” Causby said at the Financial Management Conference. “I think with COVID and … the homebound status relief, we’re really starting to see some real qualitative outcomes, in regards to being able to treat seniors in their home.”

Atlanta-based Kindred at Home provides home health, personal care and community care services in almost 800 locations across 40 states. The provider organization also offers hospice care, palliative care, skilled nursing services, social services and therapy services.

Ranked at the largest home health provider in the country in 2019 by LexisNexis, Kindred at Home operates under the umbrella of Humana Inc. (NYSE: HUM)

Like many providers, Kindred at Home has leaned on telehealth use during the COVID-19 emergency. But Causby believes more relief around telehealth use for home health care is needed.

“While there’s no reimbursement associated with that today, we believe continuing to demonstrate the outcomes and the value of this will be something that, hopefully, CMS will take a look at in the long run,” he said.

Aside from lessons learned, the three Financial Management Conference panelists shared a sneak peek of what they will be prioritizing in their companies’ annual budgets for 2022.

One common theme among the home health leaders — technology.

Kindred at Home’s focus will also be on redesigning the company’s clinical innovative programs.

“We will be focusing on building out new clinical design programs that will have a lot of the technology associated with it,” Causby said. “We’re already starting to look at how we would redesign those clinical innovative programs to possibly care for seniors over a much longer period of time. The ability for these patients not to have to end up back in the ER or an acute setting will change how clinicians think about being task-oriented.”

On the vendor side, all of this means budgeting for more growth.

“As a technology provider, we are budgeting for even more growth next year,” John Olajide, founder and CEO of Axxess Technology Solutions, said at the event. “We’re continuing to hire as our business grows rapidly, not just in the U.S. but globally as well. We’re also continuing our strategic partnerships around expanding all our interoperability solutions to ensuring that our clients are positioned for success long term.”

Additionally, John Hopkins Home Care Group has plans to invest heavily in skilled-nursing-at-home models and hospital-at-home models.

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August to Usher in Onslaught of Home Health Audits

For months now, home health providers have had to worry about an onslaught of new issues, from volume disruptions and personal protective equipment (PPE) shortages, to cash flow problems and lack of telehealth reimbursement.

One long-time stressor they haven’t had to fret about, though, is being audited by the Centers for Medicare & Medicaid Services (CMS). But that’s about to change.

While CMS temporarily paused audit activity back in March as a result of the COVID-19 emergency, it has announced plans to resume enforcement Aug. 3. That means, on top of everything else, home health agencies could also have to worry about proving they haven’t been overpaid by Medicare.

As if that wasn’t enough, at the same time, they could be hit with new, additional types of audits on financial relief received as a result of the CARES Act.

Combined, the various forms of increased oversight could create a huge paperwork burden for already overworked home health providers in the months to come.

PPP audits

While normal fee-for-service Medicare audits are expected to begin in just a few days, audits of Paycheck Protection Program (PPP) loan recipients could start soon thereafter.

Specifically, such audits are expected to begin later this year, according to Matt Wolfe, a partner at the law firm Parker Poe.

That applies to both home health and home care provider PPP loans recipients, none of whom should get too comfortable — even if their PPP loans are relatively small and have been forgiven.

Although the Treasury Department and the Small Business Administration (SBA) have said borrowers who got less than $2 million in PPP loans are considered to have made their requests in good faith, that doesn’t guarantee such loan recipients won’t be audited.

“I think a lot of folks may have breathed a false sigh of relief when they saw that,” Wolfe told Home Health Care News. “But then when [the SBA] issued the interim final rule, they made clear that they retain discretion to audit a borrower regardless of the amount. So if I am a provider, and I received a PPP loan less than $2 million, … it is still critical [to] keep good records to be able to justify retention of loans and the forgivability of the loans.”

According to an HHCN analysis of SBA data, more than 15,000 home-based care providers nationwide received PPP loans of less than $150,000. Approximately 7,400 home-based care providers got loans above $150,000.

All of those entities run the risk of being audited by SBA.

That risk exists for up to six years after the loan is issued. The audit lookback period is on the longer side, but it’s not unheard of, Wolfe said. 

“It’s twice as long as the lookback period typically for IRS audits,” he said. “It is similar to some state Medicaid agencies’ lookback periods. It’s longer than most types of Medicare audits. And it is theoretically shorter than the lookback period that the Department of Justice or U.S. Attorney’s Office would have in a False Claims Act.”

To protect themselves from audits, home-based care providers should keep a paper trail to demonstrate their thought process for each step of the PPP lifecycle. That includes documents to prove an agency’s economic need and justify the amount of the loan, as well as for documentation illustrating how the money was used.

Provider Relief Fund audits

Provider relief funding can also be audited.

If home health providers received more than $10,000 from the Provider Relief Fund, they’ll be expected to report how they used the money by Feb. 15, 2021, according to new U.S. Department of Health and Human Services (HHS) guidance.

“Anytime that HHS is going to be requiring that providers issue reports, they’re not just going to take the providers’ word for it,” Wolfe said. “They’re going to then analyze those reports, and those could lead to further audits in terms of how those funds were used.”

HHS plans to release more details on Provider Relief Fund reporting requirements by Aug. 17.

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24 Hour Home Care Gets Candid About Logistical, Day-to-Day Aspects of MA Partnerships

While the Medicare Advantage (MA) home care opportunity continues to expand, cynics have been quick to criticize it.

Some say the opportunity is too small to be worthwhile — and that it’s more of a trendy talking point than a viable business option for most home care providers.

In 2020, only 619 of more than 3,000 MA plans nationwide decided to offer some sort of in-home support services, according to data shared by ATI Advisory. Of course, that was before the COVID-19 emergency, which experts have predicted will add fuel to MA’s home care fire.

On top of that, MA plan reimbursement for home-based care providers is notoriously low. Amedisys Inc. (Nasdaq: AMED) President and CEO Paul Kusserow painted a picture of MA home health rates — different from home care rates — during a recent presentation.

“I still think that Medicare Advantage is the place to be for us, but not under the current reimbursement,” Kusserow said. “Average reimbursement on a visit for Medicare Advantage is $125 a visit, versus $165 for fee-for-service Medicare.”

While such figures and statistics have been well-publicized, the actual day-to-day of what it’s like to provide home care to MA beneficiaries is not. In fact, that’s another common criticism of MA partnerships — few people really know what they’re like.

As such, Home Health Care News set out to learn more.

To discuss the more granular details of working with MA plans, HHCN recently connected with Gavin Ward, a regional director of strategy for 24 Hour Home Care. The Los Angeles-based home care provider is one of the few agencies nationwide to have secured those highly sought after MA partnerships.

Ward dove into what services his agency provides to MA beneficiaries, how often it provides them and more — including how much of 24 Hour Home Care’s revenue was funded by MA plans in 2019.

You can read HHCN’s conversation with Ward below, edited for length and clarity.

HHCN: First of all, how many hours on average do you spend caring for MA beneficiaries per month?

Ward: Our partners are grateful for the flexibility we have in caring for their members, as MA plans are not currently designed to fund full-time caregiving long-term.

Authorizations vary per plan, and most are short-term, averaging less than a month of care and during a transition. An average length authorization would be for 20 total hours of care.

What’s the most common type of home care service you provide for MA members?

Most of the members receiving care from us require some form of personal care and transfer assistance.

Our caregivers receive additional training upon hire to ensure they are safely and properly caring for members’ needs, especially during the pandemic — which is why we’ve developed safety protocols with our team, which includes an infectious disease physician.

I’m interested in hearing more about what the process looks like when you get a request for service from an MA plan. Can you provide more details on that and how it differs from the intake process for other clients?

Each health plan varies, but we continuously work to understand our partners’ ecosystems and to serve as an extension of their teams.

Like most contracted partners outside of the MA world, we serve alongside a case manager or social worker, care coordinator, and/or authorization assistant for each client. Our plan partners appreciate that we have dedicated care coordinators for each client as well as a dedicated intake team seven days per week to accept new cases.

The main difference with MA clients and our general client base is that we are not accepting payment information, nor discussing the cost of care.

How does payment work? Generally, do you get paid more during months when you care for more MA beneficiaries or is it more of a flat monthly rate?

While I can’t go into the fine details of the payment process, what I can share is that we file via a third-party claims system, which could present a challenging onboarding process if an in-home care organization is not equipped with the right personnel and systems. 

Smaller firms may struggle learning and adapting to these systems, but we have a strong, knowledgeable accounting team that has learned these systems and can invoice properly.

Some MA plans are also not used to working with non-medical agencies and may go through their own challenges ensuring their systems are designed to properly accept non-medical home care claims.

Do you have any statistics you can share regarding how much of your revenue is attributable to MA plans?

MA plans are still in their infancy stages, and we are appreciative of the opportunity to be selected and partner with them to provide care to members that are in need. As a result, it is still too early to disclose impact, which the plans themselves will also likely state.

Less than 1% of our revenue was funded by MA plans in 2019.

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Why More Home Care Agencies Are Building Their Businesses on Culture-Based Care

Over the years, home care providers that have provided specialized care have positioned themselves to stand out among their competitors. Some providers have gone even further — tailoring care to best fit the needs of their clients’ ethnic or cultural backgrounds.

One such company is Circle of Life Home Care, a Minneapolis, Minnesota-based provider that serves Native American communities, both on and off reservations. Circle of Life Home Care operates across Minnesota, Montana, Colorado, Arizona, New Mexico, South Dakota and North Dakota.

There are a number of different brands under Circle of Life Home Care’s banner. Each brand is designed to serve a number of different nations.

For instance, Circle of Life Kola provides home care services in North and South Dakota, caring for seniors that are part of the Sioux tribes. The company’s Soaring Eagles brand provides care on the reservations for the Navajo Nation in Arizona and New Mexico.

The COVID-19 emergency has had a devastating impact on the Navajo Nation, which has faced some of the highest rates of the virus in the U.S. This is compounded by health care access barriers. 

Circle of Life had to be proactive in its response to the public health emergency, Himmat Singh, CEO of Circle of Life, told Home Health Care News. 

“As a company, we were ahead of the curve in immediately issuing guidelines for providing care during the pandemic, which relied fully on guidance issued by the CDC and other global health organizations,” Singh said. “We set up both internal and online platforms to disseminate information, best practices, policies and training. We also invested heavily in PPE.”

Circle of Life also cares for seniors that are part of the Apache, Zuni and Hopi tribes.

One of Circle of Life’s main focuses as a company is providing culturally sensitive care to individuals. This is especially important when taking into consideration the history of forced displacement and the ostracization of Native American people, according to Singh.

“There’s this concept of intergenerational trauma,” Singh said. “So being culturally sensitive takes time. Even in my case, I’m still a student.”

While most home care companies strive to provide high-quality care to seniors, the idea of honoring clients holds additional weight and takes on a cultural significance among the communities that Circle of Life serves, according to Singh.

“Honor is a huge component of the Native American [culture],” he said. “I’ve always felt, for us, it’s not just a home care services company. There’s a huge cultural piece that is at the crux of what we do. It’s a special ‘extra sauce’ that is almost intangible.”

Generally, when a caregiver begins working with a senior there’s an adjustment period while both parties get to know each other. Caregivers who understand cultural nuances remove an additional barrier that allows them to zero-in on the well-being of the company’s clients.

Circle of Life is also attuned to the specific health concerns of various Native American communities.

“For example, when we look at the health issues impacting Native Americans, the number of people who have chronic diabetes or liver problems is significantly worse than any other population in the U.S.,” Singh said.

Indeed, in some Native American and Alaska Native communities, the diabetes rates among adults are as high as 60%, according to the CDC and Indian Health Service (IHS).

Even as non-medical care providers, home care workers often play a major role in helping seniors avoid rehospitalization. Having a sort of cultural shorthand potentially lowers the chances of a caregiver missing vital care needs, according to Singh.

Overall, Circle of Life has roughly 1,400 clients.

Most of these clients have stayed with the company over the years. When clients do leave, many end up returning, citing a disconnect between them and a more mainstream provider.

“They believed that no one understood their unique circumstances,” Singh said. “What really distinguishes us … is most of our folks and our leadership are Native, especially at the grassroots level of the offices. These are people who know the life of our clients.”

Business opportunities, recruiting 

Home care agencies that can serve micro-targeted communities develop a level of client loyalty and satisfaction that few businesses can match.

From a business perspective, that can help with word-of-mouth referrals and financial stability, since so many clients often stay on service as long as they need home care.

These built-in advantages are partly why the number of community-specific home care agencies has spiked in recent years, according to industry insiders. 

“We can attest that specialization as a differentiator is truly what stands out from the medium agency to the master’s segment,” Todd Austin, chief operating officer at Home Care Pulse, told HHCN in an email. “The best use case for this would be dementia or Alzheimer’s. Agencies that use this as a unique [offering] have the highest hours per client and were the fastest growing in the industry. The same could be said for cultural specialization.”

Lombard, Illinois-based Sahara Home Care was initially founded to serve the South Asian and Middle Eastern communities. While the company has since broadened its client base, it hasn’t shifted its focus away from taking care of these particular senior populations.

The personal care company offers senior assistance and respite care services to over 3,000 clients across 10 locations.

For seniors, getting older can make additional adjustments more daunting, Samina A. Saeed, program coordinator at Sahara Home Care, told HHCN.

“At a seniors age, it can be hard to accept change,” Saeed said. “So they feel more comfortable with their own culture, whether it’s food, daily routine and especially their own language.”

One of the biggest challenges home care providers continue to face revolves around the recruitment and retention of caregivers. For companies such as Sahara Home Care, there is the additional responsibility of hiring workers who are attuned to the culture of the communities they serve.

In order to recruit caregivers, Sahara Home Care’s outreach team has found that getting out into the community and attending culturally significant events help.

“Our outreach team goes out and does marketing at the cultural holiday events like Diwali and Eid al Adha,” Saeed said. “They attend all different kinds of religious events.”

Additionally, Sahara Home Care relies heavily on word of mouth, which is possible because of the company’s strong ties to the communities they work with.

On the retention side, the company has a number of benefits in place including profit-sharing, annual bonuses and travel mileage perks.

Sahara Home Care and Circle of Life aren’t anomalies.

Across the U.S., other in-home care providers that have built specialized client bases include Sagrado Corazón, Casa Central and First Nations Home Health, all of which have focused on fulfilling the care needs of Latino, Asian or Native American communities. Asian American Home Health — an affiliate of Kindred at Home — is another example.

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PPP Loans Have Helped Save More Than 160K US Home-Based Care Jobs

The Paycheck Protection Program (PPP) has helped home-based care providers who received less than $150,000 in loans save more than 160,000 jobs nationwide, according to data from the Small Business Administration (SBA).

States such as Texas, California and Florida saw the highest number of home-based care jobs retained as a result of the program. Meanwhile, unlikely suspects such as Idaho, Ohio and Missouri saw PPP-recipient agencies retain the most home-based care employees on average.

Home Health Care News discovered those trends while analyzing July 14 PPP data from the SBA. That data includes the number of workers employed by each PPP recipient, as well as the total loan amount granted to each awardee.

For the analysis, HHCN sorted the federal SBA data by NAICS code to identify home-based care PPP recipients that received less than $150,000. From there, HHCN broke the data down on a state-by-state basis.

The North American Industry Classification System, or NAICS, is a classification of business establishments by type of economic activity. NAICS codes are used by government agencies and businesses in Canada, Mexico and the U.S.

Home-based care providers in HHCN’s analysis include all those with the NAICS code 621610, which is used for “establishments primarily engaged in providing skilled nursing services in the home.” In addition to home care and home health agencies, that includes businesses in realms such as home infusion therapy and in-home hospice, among others.

In total, PPP loans helped more than 15,000 home-based care agencies retain a combined 160,175 jobs, the data suggests. In other words, that’s how many aggregate workers are employed by those loan recipients, who might otherwise have gone out of business without the PPP money.

HHCN has yet to review the data for providers that received more than $150,000 in PPP loans.

Explore: Total jobs retained by state

This map shows the total number of home-based care jobs retained by PPP recipients in each state. Darker blues represent more jobs saved. Hover over a state to see the total number of jobs saved there. (Graphic by Kosti Marko/Home Health Care News)

Contextualizing the numbers

PPP was created by the CARES Act to help small businesses navigate the COVID-19 emergency. It set aside billions of dollars in forgivable loans for businesses across a bevy of industries, including home health and home care.

One of the biggest goals of the program is to help businesses keep their workers employed. As such, an important condition of loan forgiveness is that recipients must keep up their staffing levels and wages.

If a PPP loan recipient doesn’t have a full-time employee count equivalent to pre-coronavirus levels by Dec. 31, that recipient won’t be eligible for full loan forgiveness. It will have to pay back a portion of the costs.

Consequently, the aforementioned SBA PPP job retention numbers assume that all PPP recipients will keep the employment levels they had when they applied for their loans. That data could be incomplete.

“PPP loan data reflects the information borrowers provided to their lenders in applying for PPP loans,” an SBA spokesperson told HHCN in an email. “SBA can make no representations about the accuracy or completeness of any information that borrowers provided to their lenders. Not all borrowers provided all information.”

Additionally, it’s worth noting that some PPP home-based care recipients could fail to meet the requirements of the program and lay off employees anyway.

State stars

Texas saw the most home-based care workers retained as a result of PPP loans, with 21,541 employees at recipient agencies benefiting.

California and Florida retained the second and third highest number of home-based care jobs. In California, that number was 19,186, while 11,039 jobs were saved in Florida.

Those numbers make sense in context of the large amount of PPP funding Texas, California and Florida received. In a previous analysis, HHCN found that those three states saw the most agencies receive loans, with more than 5,400 home-based care recipients getting about $224 million combined.

Meanwhile, the trends in Idaho, Ohio and Missouri were more surprising.

For example, Idaho of all states saw its 60 home-based care PPP recipients who got less than $150,000 retain the most employees on average, at about 20 each.

Meanwhile, Florida agencies, by comparison, retained an average of only six jobs each.

While it’s unclear exactly why Idaho home-based care PPP recipients retained the highest number of workers, Robert Vande Merwe, executive director of the Idaho Health Care Association, speculated it could be a result of low wages.

“Idaho still has the federal minimum wage of $7.25 per hour,” Vande Merwe told HHCN in an email. “And the Medicaid rate is VERY low for home care.”

Joe Russell, executive director of the Ohio Council for Home Care & Hospice, had other ideas for his state, in which agencies retained an average of 17 jobs each with PPP funding.

He said the average pay rate for an aide in Ohio is about $13 per hour.

“I would venture to guess that those states that have a higher number of jobs saved are probably looking at a larger number of larger agencies getting these PPP loans,” Russell told HHCN.

That appears to be true in the case of Idaho, Ohio and Missouri, the lattermost of which also saw agencies retain an average of 17 jobs each.

But agencies big and small and in those states and beyond continue to need state and federal financial support in addition to PPP, according to the Missouri Alliance for Home Care.

“While the PPP monies did greatly benefit some in the home care industry, the enormous cost of additional personal protective equipment (PPE), decreased utilization, additional staffing, overtime, hazard pay, etc., has had enormous revenue impacts on home care providers,” Carol Hudspeth, executive director of the Missouri Alliance for Home Care, told HHCN in an email. “As a result, the home care infrastructure is in great jeopardy at a time when it is needed the most.”

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Biden Announces $775B Plan to Boost the Caregiver Economy, Support In-Home Care Providers

Senior care — an increasingly important topic that’s too often overlooked on the campaign trail — is back in the spotlight.

And maybe this time it will have some staying power.

Presumptive Democratic presidential nominee Joe Biden has floated a sweeping new 10-year plan that seeks to dramatically change the way older adults are cared for in the United States. Specifically, the former vice president’s proposal calls for a $775 billion overhaul of the nation’s caregiving infrastructure, which is largely made up of women and people of color.

Biden’s campaign announced he would discuss the “21st Century Caregiving and Education Workforce” plan Tuesday afternoon during a speech in New Castle, Delaware.

Policymakers and government officials have long undervalued and under-invested in older adults for decades, LeadingAge President and CEO Katie Smith Sloan told Home Health Care News in an email.

The COVID-19 pandemic has now exposed the devastating impact of that failure, she added.

“The vital role of family and paid caregivers has never been clearer, nor has the reality that our current system needs to be rebuilt to meet the needs of a rapidly growing older population,” Smith Sloan said. “Any candidate for president should be focused on this important issue – as we expect older adults and their loved ones will be this November.”

Washington, D.C.-based LeadingAge is a nonprofit trade organization that represents a variety of providers operating in the aging services field.

While few details were made available prior to the speech, the Biden campaign said the proposal would lead to 3 million new caregiving and education jobs during the next decade. Additionally, the plan seeks to create pathways for former caregivers to re-enter the workforce if they choose to do so.

Robert Espinoza, vice president of policy for New York-based advocacy organization PHI, also told HHCN that the plan appears to be a step in the right direction.

PHI advocates on behalf of home-based care workers and the individuals they serve.

“It’s encouraging to see Joe Biden prioritize caregiving issues on the national stage, including the importance of expanding home- and community-based services to more Americans,” Espinoza said. “However, to ensure access to home care and other caregiving supports, we must also transform the quality of direct care jobs, from higher compensation to improved training and career advancement opportunities, and much more.”

Nationwide, aging experts estimate that about 10,000 baby boomers turn 65 each daily. In order to keep up with their demand for home care service and general preference for aging-in-place, the home care industry will likely need to fill at least 4.2 million more caregiver jobs by 2026.

But low wages generally make finding caregivers a difficult task. Roughly one in six U.S. caregivers currently lives in poverty, according to PHI data.

Besides supporting the “caregiver economy” in the senior care space, Biden’s proposal also looks to strengthen America’s child care system. Senior care and child care providers have both been hit hard by the coronavirus, which began spreading across the country in March.

Despite challenges related to sourcing personal protective equipment (PPE) and maintaining an adequate front-line workforce, home-based care organizations have played a key role in caring for older adults and other high-risk populations during the coronavirus emergency.

In his $775 billion plan, Biden seeks to use $450 billion to boost senior care. CNBC reported that some of those funds will be used to increase Medicaid funding to states, in part to eliminate the 800,000-person waiting list for community-based and in-home care.

Biden’s plan would also fund programs to create 150,000 new jobs for community health workers and invest in innovative new models of long-term care outside of traditional nursing homes.

Supporting Medicaid home-based care should be a focus of the upcoming presidential election, according to David Totaro, chairman of the Partnership for Medicaid Home-Based Care (PMHC).

Headquartered in D.C., PMHC is an advocacy association whose members include Medicaid home care providers, managed care companies and other senior care stakeholders.

“PMHC is pleased to see that Medicaid home-based care is a priority issue for the upcoming election,” Totaro told HHCN in an email. “Given the impact of COVID-19 on long-term care facilities, it is time for federal leadership to remove the institutional bias within the Medicaid program and recognize home- and community-based care as a cost-effective and consumer-preferred option for seniors and individuals with intellectual and developmental disabilities who wish to remain safe and healthy in their home.”

Another aspect of the plan: the establishment of a nationwide Public Health Jobs Corps.

The Administration for Community Living — part of the U.S. Department of Health and Human Services — floated such a concept in November of last year.

Apart from adding to the caregiver workforce, Biden has also signaled his intent to improve working conditions by backing the Domestic Workers Bill of Rights Act.

The home care industry has largely opposed such legislation, which would create additional administrative requirements like predictive scheduling.

In terms of funding Biden’s caregiving plan, his campaign noted it “will be paid for by rolling back unproductive and unequal tax breaks for real estate investors with incomes over $400,000 and taking steps to increase tax compliance for high-income earners,” The Wall Street Journal reported.

“These plans are really about easing the squeeze that working families all over this country are feeling every day,” a senior campaign official said Monday while briefing reporters on the Biden proposal. “Our country is experiencing a caregiving crisis.”

Biden isn’t the first presidential candidate to push for long-term care reform.

Last August, presidential hopeful Bernie Sanders (I-Vt.) tweeted that “no senior should have to sell their belongings or spend their life savings just to be able to age in place.”

Similarly, former presidential candidate Cory Booker, a senator from New Jersey, released a long-term care plan that included aging-in-place funding last July.

At the time, voicing support for aging in place and long-term care reform failed to bring either candidate newfound momentum. As the national conversation continues to revolve around the coronavirus, though, senior care could turn into a core campaign focus during the 2020 president election.

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Ambulance Crews and In-Home Care Providers Seek Collaboration — Not Competition

As hospitals continue to experience overcapacity challenges due to the COVID-19 emergency, 911 ambulance crews and community paramedics have found themselves treating more patients at home.

Historically, ambulance crews and community paramedics — both of which operate in the emergency medical services (EMS) space — have always provided some degree of care in the home setting. To do so, they’ve often worked alongside traditional home health and home care agencies, too.

“There’s been a certain amount of care [or treatment] in the home for many years,” Hanan Cohen, paramedic and director of corporate development at Empress EMS, told Home Health Care News. “On the 911 system, it’s not at all uncommon for an EMS crew to respond to a multitude of emergencies. After assessing and, sometimes, treating the person, … they may decide not to go to the hospital.”

New York-based Empress EMS is a partner of PatientCare EMS Solutions, which provides emergency ambulance and other critical health care logistics services.

Typically, if patients or family members decide to forgo a hospital visit, paramedics can speak to the medical control physician and explain that treatment has been given. Patients can then sign a release stating they are willing to stay home, avoiding a costly hospitalization, according to Cohen.

It’s not uncommon for ambulance crews and community paramedics to respond to asthma attacks, diabetic episodes, minor wounds, chronic seizures, cardiac arrests and more.

“All of this is in-conference with a physician,” Cohen said. “We’re always using established protocols, including state and national standards of care when we treat them. It’s not an ad hoc [process].”

The public health emergency has amplified care in the home from ambulance crews and community paramedics in both volume and service level, according to Cohen.

“Many states and regions have enacted protocols to try to decompress the hospitals and prevent surges from becoming completely overwhelming,” he said. “Patients with more minor but standardized COVID-19 symptoms — respiratory complaints, chest pains, mild difficulty breathing, loss of taste — would be treated in the home unless there were other comorbidities or an instability.”

Despite providing care in the home, ambulance crews are not compensated for this work by the Centers for Medicare & Medicaid Services (CMS).

And that lack of compensation causes a sort of ripple effect among other payers, according to Cohen.

“CMS is the guiding force in health care reimbursement on the EMS side. They are the largest payer, they provide oversight, and they guide a lot of public policy,” he said. “In having Medicare not pay for treatment in place, then, certainly, it’s very easy for most other payers to agree with that. There’s this position from the large federal payer and this view [from other payers] of, ‘If they don’t feel the need to pay, why should we?’”

For now, Cohen’s agency, Empress EMS, has applied to CMS’s Emergency Triage, Treat and Transport (ET3) Model. ET3 is a five-year payment model pilot program that will grant ambulance crews more flexibility, including reimbursement, around providing care for Medicare Fee-for-Service beneficiaries.

The pilot program will begin in Fall 2020.

EMS and in-home care providers

Overall, the U.S. emergency medical services products market is anticipated to reach $15.09 billion by 2025, data from suggests.

With EMS crews delivering more care in the home, some traditional in-home care providers worry their services may be overlooked.

Generally, the theory is that if ambulance crews and community paramedics eventually begin receiving reimbursement under Medicare for treating patients in place, this may create more competition for the home-based care providers that may have otherwise been called in.

But experts are quick to dismiss this line of thought.

“We don’t feel like there would be any competition,” Kathie Smith, vice president of state relations for home- and community-based care at the Association for Home & Hospice Care of North Carolina (AHHC), told HHCN. “We feel like it would be a collaborative approach. The goal is to keep people in their homes as long as possible if it’s safe. It’s going to take a village of different types of providers so to speak — EMS workers, community resources and caregivers.”

AHHC is a nonprofit trade organization that represents roughly 800 home health, hospice, palliative care, personal care and private-duty nursing providers in North Carolina.

While there may be overlap between ambulance crews treating patients in the home and in-home care providers, there are many different requirements surrounding both groups.

“Home health is totally different,” Smith said. “If anybody wanted to get into home care or home health, they would have to go through the proper channels of licensing and certification. There are many complex rules for actually providing home health around physician orders, face-to-face encounters, plans of care, certain types of documentation. It is a different approach than what may be being provided through a community-paramedicine program.”

Despite the differences, there is room for potential partnerships between community paramedics and in-home care providers.

“We always like to work in partnership with different types of community resources,” Smith said. “For example, if a person in the community had frequent falls and had diabetes, community paramedics may be involved to provide education and resources within their scope, but at some point they may need to make a referral to a home health agency for ongoing skilled care with a plan of care and physician certification for treatment involving a nurse or therapists.”

Likewise, Cohen believes that future partnerships are possible — and necessary — in order to fill care gaps.

Empress EMS already works closely with half a dozen home health and Visiting Nurse Service (VNS) agencies.

“Certainly, there are a wealth of interagency relationships between 911 and home health, or paramedics and home health,” he said. “Being involved very heavily in the national stage with this there are perceptions that there is competition. When you look at the actual working relationships, whether it’s in Texas or New York or other states, they seem to complement each other well.”

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In-Home Care Providers on the Lookout for Next Stimulus Package

Although concrete details are largely unknown, in-home care providers remain on the lookout for the next coronavirus-related stimulus package.

Specifics on a possible fifth stimulus package could be released as early as this week, policy experts believe. 

“I think that’s the question, whether or not a package comes together that everyone agrees to before the August recess — or potentially after it,” Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare (PQHH), told Home Health Care News. “We’re seeing new spikes in different parts of the country, which has added renewed pressure.”

PQHH is a home health care advocacy organization based in Washington, D.C.

Senate Majority Leader Mitch McConnell (R-Ky.) and Treasury Secretary Steven Mnuchin have reportedly been working on a draft of the legislation for the past several weeks, with Mnuchin saying the next phase of relief should go toward industries hardest hit by the coronavirus.

“We are monitoring economic conditions closely,” Mnuchin testified on Friday in front of the House Committee on Small Business. “Certain industries, such as construction, are recovering quickly, while others, such as retail and travel, are facing longer-term impacts and will require additional relief.”

Broadly, a fifth stimulus package will likely focus on a number of topics, including funding for school reopenings, litigation immunity for certain industries and continued unemployment benefits, according to reports from The Hill.

“One thing the majority leader in the Senate has said is that there needs to be some form of business immunity from potential liability related to COVID-19,” National Association for Home Care & Hospice (NAHC) President William A. Dombi told HHCN. “The other forces that are in play range from an extension of the federal unemployment insurance to further expansion of the Paycheck Protection Program (PPP).”

NAHC is also a D.C.-based trade organization. Its provider members span the full spectrum of home-based care.

So far, more than 15,000 home-based care companies have received more than $666 million in PPP loans of under $150,000, an HHCN analysis found.

Additionally, the next potential stimulus package could pave the way for an expansion of the Provider Relief Fund. It could also provide added federal support for state and local governments.  

One question that looms large is the total amount of the next stimulus package, according to Dombi.

“I think we’ve moved from whether there would be one, to how much it will be and what will be in it,” Dombi said. “Is it going to be a $1 trillion program, a $2 trillion program or a $3 trillion program? This seems to be somewhat fluid. The bill that came out of the House earlier — the HEROES Act — was over $3 trillion.”

The White House has, informally, indicated that a $2 trillion package is a possibility. Meanwhile, McConnell’s office reportedly wants the next stimulus bill to be around $1 trillion. 

In-home care providers may benefit from another stimulus bill in several different ways.

One is an additional injection of cash into the Provider Relief Fund. There are parts of in-home care that haven’t received funding, including private-duty home care and private-pay services, for example.

Some providers have only received 2% of their total revenue in terms of financial support, but are experiencing a cost increase that is close to 10%, according to Dombi.

Another measure that would help providers is special funding for front-line workers, who are facing additional risk due to the public health emergency.

“It goes by many different labels: premium pay, hazard pay, combat pay,” Dombi said. “There needs to be something to encourage people to come into doing that work, particularly at the lower end of the wage scale.”

Dombi also called for child care support for essential front-line workers.

“If the schools will not be uniformly open five days a week for all students, somebody is going to need to care for those children,” he said. “Generally, that falls on parents, unless those parents also need to go to work. So how do we take care of those child care needs for those front-line workers?”

On the Medicare home health side, NAHC would like to see authorization for reimbursement of telehealth services.

“Without a doubt, important advances have happened to provide some flexibility, but we think it’s falling short of realizing its value by not having any direct reimbursement for those services,” Dombi said.

For in-home care providers, now is the time to advocate for the industry at the grassroots level, as the situation remains fluid.

“[Providers] need to be engaged and explain why there is still a greater need for support for health care providers than currently exists, and that in-home care needs those supports as much as hospitals do,” Dombi said. “By our very informal count, there are more patients with active COVID-19 infections in home settings than there are in hospital settings. We have opportunities — we have no guarantees that further supports will be made available.”

Top Republicans in Congress planned to meet Monday with President Donald Trump to discuss the next COVID-19 aid package, The Associated Press reported.

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PPP Tax Debate Could Cost Home-Based Care Agencies in the Long Run

Home-based care providers who received loans under the Paycheck Protection Program (PPP) could face unexpected expenses when it comes time to file their 2020 taxes.

That is, unless the government intervenes.

“Congress clearly intended that PPP funds would be nontaxable,” Leon LaBrecque — a lawyer, accountant and chief growth officer at Sequoia Financial Group — told Home Health Care News. “[But] the IRS has ruled that expenses associated with the generation of tax-free income is not deductible.”

In other words, Congress and the IRS are looking at PPP money through two different lenses of tax law. And the tax theory the IRS is applying circumvents Congress’s intention of making PPP loans nontaxable.

Even though the money isn’t considered taxable income, per the CARES Act, expenses associated with the loans can’t be deducted from a recipient’s income, according to Bill Sanders, a shareholder and tax group chair at the law firm Polsinelli.

Deductible expenses lower one’s tax liability, which, in turn, typically lowers the amount of taxes that person or entity must pay.

“Either one of those creates a taxable event: Either you have to recognize [money] as income or you can’t deduct it on the expense side,” Sanders told HHCN. “One [way] or the other, you’ve got to pay taxes on that amount.”

Unless something changes, the opposing rules will mean higher taxes for thousands of home-based care PPP recipients come April.

According to an HHCN analysis, more than 15,000 home-based care providers across the country received PPP loans of less than $150,000, with the average loan amount being slightly less than $45,000. Combined, the home-based care PPP loans add up to more than $666 million.

HHCN has yet to analyze the number of providers that received PPP loans above $150,000.

The IRS’s current interpretation of program funding poses a threat to these providers and other loan recipients, according to Sanders and LaBrecque. Even if providers’ loans are forgiven, they could be hit with a huge financial burden in the form of taxes on PPP money at a rate as high as 30% to 40% — which they’ll have to pay out of their own pockets.

“The only way that you’re going to be eligible for [PPP loan] forgiveness is if you use the money … for payments to employees, for rent, for mortgage interest and all those kinds of things,” Sanders said. “But if you’ve used the money and you’ve spent it to stay open, you’re not going to have any of that leftover to pay taxes on it.”

In many cases, PPP recipients applied for the loans out of dire necessity amid coronavirus-related economic struggles. After all, that’s what the program was designed for: to help small and mid-sized businesses stay afloat and keep paying their employees amid the COVID-19 emergency.

While businesses in nearly every industry have struggled during the coronavirus outbreak, home-based care providers have faced a unique set of challenges.

For one, home health and home care agencies operate on paper-thin margins, even in the best of economies. The coronavirus has stretched those margins even thinner, all while home-based care has become more important than ever as a means to keep seniors safe.

When the virus hit, nonmedical home care providers saw volumes — and revenues — dip as patients turned away caregivers out of fear. Plus, agencies saw unexpected workforce expensenses pop up.

For example, many chose to dole out additional hazard pay as a way to show caregivers appreciation and keep them in the workforce. One such agency is Excel Home Care, which received more than $6 million in relief funds — and opted to give all of it directly to its caregivers.

Meanwhile, Medicare-certified home health agencies dealt with all those struggles and more. For example, many have been forced to provide telehealth visits rather than in-person visits when appropriate to keep patients safe — though such visits are not eligible for reimbursement from the Centers for Medicare & Medicaid Services (CMS) and do not count toward Low Utilization Payment Adjustment (LUPA) thresholds.

The PPP tax burden could be the final nail in the coffin for loan recipients, Sanders said.

“They’re already going to be in a position where they’re … teetering on shutting down or bankruptcy,” he said. “I think it’s going to be a very difficult situation.”

Sanders isn’t the only one who thinks so. A coalition of 18 health care organizations — including the American Association for Homecare — have written to Congress urging them to ensure COVID-19 funding and provider relief are not taxable.

“It is critical that the actions taken to support front-line caregivers and hospitals are not diluted by technical issues around the taxability of support funds,” a letter said.

Lucky for PPP recipients, lawmakers seem to be on it. Bipartisan legislation was introduced back in May, but there’s no telling how long it will be before it makes its way to President Trump’s desk.

The sooner that happens, though, the better, according to LaBrecque.

“Congress should remedy the situation if it intends PPP to be fully tax free,” LaBrecque said. “[This] is a story with a short fuse.”

Provider Relief Fund tax problem

The PPP isn’t the only coronavirus-related relief that has unforeseen tax implications.

The CARES Act Provider Relief Fund does, too. It paid out $175 billion to hospitals and health care providers amid COVID-19, including Medicare-reimbursed home health providers.

Come tax time, such relief payments must be included in a provider’s gross income if that provider is for-profit, according to the IRS.

However, tax-exempt health care providers are exceptions. Their Provider Relief Fund payments are not generally subject to tax except under special circumstances.

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UnityPoint Health Seeks Home Care Partner for New SNF-at-Home Model

Long-term care centers such as skilled nursing facilities (SNFs) have taken the biggest hit as a result of COVID-19. More than 40% of all virus-related deaths have been tied to nursing homes, a statistic that is scaring away a large number of potential and former residents

Instead of facility-based care, more seniors are now opting to receive care at home. That, in turn, is accelerating the pace of health care innovation and pushing higher-acuity patients into the home.

But UnityPoint Health was already ahead of the curve. The health system started developing its new SNF-at-home program in the middle of 2019 before the COVID-19 emergency hit.

“Our goal is definitely to provide the right level of care in the right setting,” Mag VanOosten, president and chief clinical officer of UnityPoint at Home, recently told Home Health Care News. “We really believe home is where people are meant to recover.”

West Des Moines, Iowa-based UnityPoint is a health system with hundreds of locations across Illinois, Iowa and Wisconsin. It serves patients across a total of nine geographic regions with its hospitals, clinics and home-based care offerings. 

UnityPoint at Home is a comprehensive home care company that offers a range of home-based services.

Its new SNF-at-home program, which is still in development, will fall under Care at Home, which includes all of the work that UnityPoint does for its accountable care organization (ACO) and at-risk contracts.

“[Care at Home includes] things like post-discharge home visits under waivers, and the hospital-to-home program … in addition to what we’re doing on the home health side,” VanOosten said, noting that SNF-at-home program falls under her purview.

UnityPoint at Home and Care at Home are both part of the health system’s population health structure, but Care at Home is an actual clinic. VanOosten oversees both, which together include all home-based programs. 

While UnityPoint has well-established home health and hospital-at-home programs, SNF-at-home is different.

“Caregiver support is the difference,” Jenn Ofelt, COO of UnityPoint at Home, told HHCN. She has primary responsibility for traditional clinical service lines, such as home health, hospice and the ancillary supports that go along with those services.

When the SNF-at-home program gets up and running, it will target a very specific population of seniors, Ofelt and VanOosten noted. They bucketed SNF referrals coming from hospitals into three groups to explain. 

The first bucket is filled with patients who might not need SNF-level care, but rather, could be well cared for using home health without much additional support. These patients are typically the target of SNF-diversion efforts by home health providers, a tactic some experts expect to skyrocket as a result of COVID-19.

The second consists of residents who have especially intensive needs and appropriately require 24-hour SNF-level care.

Then there’s the third bucket, which is filled with the patients UnityPoint is hoping to help with its SNF-at-home program.

“That’s the group that is eligible [and appropriate] for skilled care, but with some additional help, we really could take them home with services that we’re able to provide either under Care at Home or with home health,” Ofelt said.

In other words, the SNF-at-home model combines home health with home care to fill each individual patient’s caregiver gap.

“Maybe that’s [at] nighttime,” Ofelt said. “Maybe that’s [for the] bathroom or for [activities of daily living]. Maybe it’s 24/7 care, but there’s a caregiver gap.”

Origin story

UnityPoint’s SNF-at-home concept was born out of its successful hospital-at-home program, which has some of the best outcomes for such a model nationwide. For example, UnityPoint’s hospital-at-home program, which is modeled after the program developed by Johns Hopkins University, boasts a 3% hospitalization rate.

Those metrics caught the attention of payers, which suggested the SNF-at-home model several months ago.

“We were approached by some commercial payers who said, ‘Not only would we like you to do hospital-at-home for us, but we would like you to do SNF-at-home for us,’” VanOosten said. “[That] was the first that we had heard of it.”

Following that conversation, UnityPoint got to work developing protocols and figuring out what was necessary to make such a program work. Then the coronavirus hit, pushing program development somewhat to the backburner.

Finally, things are getting back on track.

“Now we’re back working on that and talking with our payers about that model,” VanOosten said. “We’re ready to stand that up and go live as soon as we find a private care partner.”

Because UnityPoint does not currently provide non-medical personal care services itself, it needs such a home care partner to make the program possible. After all, filling patients’ caregiver gaps is a key part of the program.

While UnityPoint has talked to multiple potential partners, it has yet to settle on one. Ultimately, it’s looking for an agency that would be a good cultural fit and would be willing to take on some risk.

“There’s a wide variation in the awareness of … how they could fit in with an ACO-type model,” Ofelt said. “We’re really looking for a partner that can see beyond that billing-the-patient-by-the-hour [model] and really [see] that value-add and proactive provision of service for a value-based arrangement and payment on the on the back end of a shared savings-type agreement.”

UnityPoint hopes to have the SNF-at-home model ready to roll out by Q4 2020.

Much like its hospital-at-home program, the model will serve patients in central Iowa, with an expected monthly census of about 10 to 15 patients, according to VanOosten.

COVID-19 case study

While the SNF-at-home program has yet to officially debut, the COVID-19 emergency allowed UnityPoint to do a small trial run of sorts.

“As a result of the pandemic, … there was a huge change in the workforce, [with] a combination of people working from home, as well as people out of work,” Ofelt said. “We were able to capitalize on that opportunity and use those caregivers that were now available to assist patients to go directly from home.”

Instead of supplementing home health with paid personal care workers, loved ones helped fill the caregiver gap to make the impromptu SNF-at-home program possible.

It became important amid COVID-19 because hospital and ACO discharge planners were having trouble getting patients safely placed into SNFs post-hospital discharge.

“[They were] reaching out to home health to say, ‘Are any of these patients able to go home?’” Ofelt said. “We had SNFs that were just flat out refusing to take new patients. We had SNFs that were putting all patients that had been in the hospital in one wing, whether they were COVID-positive or not.”

As of early July, those five patients were back on their normal trajectory of care, according to Ofelt.

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Excel Home Care Distributing $6M in CARES Act Funds to Its Caregivers

Caregivers at Excel Home Care can expect a pay bump in the coming weeks.

Horsham, Pennsylvania-based Excel Home Care is a non-medical personal care agency that began operating under the Help at Home umbrella in 2017. Help at Home is a Chicago-based home care company that operates in 13 states.

In May, Pennsylvania Governor Tom Wolf signed Act 24 of 2020, which granted state providers of long-term home- and community-based services relief funding from the federal Coronavirus Aid, Relief and Economic Security (CARES) Act.

On Monday, Excel Home Care announced it would distribute the entirety of the CARES Act relief funds it received from the state of Pennsylvania to its caregivers for their service during the COVID-19 public health emergency.

Excel Home Care received relief funds in excess of $6 million.

The personal care agency has earmarked all of the funds for employee bonuses. Josh Drebes, regional vice president of the company, said the pay boost is a “hero’s bonus.”

“The caregivers and the administrative support teams are counted on by vulnerable citizens,” Drebes told Home Health Care News. “We wanted to give back and support their health and well-being. We wanted to make sure that they were rewarded for providing this care through these tough times.”

As essential front-line workers began facing higher risks while performing their job duties amid the COVID-19 emergency, the question of additional pay or hazard pay has been pushed to the forefront.

Aside from rewarding workers, additional pay can also mean retaining workers. While it’s too early to tell, Drebes believes the extra funds will significantly help with the company’s retention efforts.

“Every caregiver hired by us through the end of this year is going to receive a $400 sign-on bonus,” he said. “They’re also going to qualify for the general pay, which will be a monthly bonus stipend at the end of every month for the rest of this year.”

As a company, Excel Home Care is no stranger to providing aid to its employees. In collaboration with Help at Home, the company sponsored a $1 million employee assistance fund in order to provide grants for workers facing financial difficulties earlier this year.

“They actually got to apply for money we raised,” Drebes said. “We called it the Cares Fund, and it provides grants for employees who had personal challenges related directly to the pandemic.”

In this respect, Excel Home Care isn’t an anomaly. Throughout the public health emergency, many providers have been enterprising and have provided incentives for caregivers working in the field.

Hackensack, New Jersey-based CareFinders Total Care, for example, provided appreciation pay for all workers in light of COVID-19.

“It’s definitely going to be a financial hit for the company, but I don’t know if we could really go forward as the same company and not do something like this for our team,” Jim Robinson, the company’s CEO, previously told HHCN. “It almost moves out of financial decision-making into, ‘What’s the right thing to do?’”

Meanwhile, in-home care provider Preferred Care Home Health Services supplied over 500 employees across Fort Myers and Naples, Florida, with care packages, according to the Fort Myers News-Press.

Looking ahead, Excel Home Care is focused on the fund distribution rollout.

“We want to try to get the money into the caregiver’s pockets as soon as possible,” Drebes said. “Within the next 30 days, we’re just trying to make sure we have everything all set in place.”

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Only 25% of Home Care Agencies Track Hospital Readmission Rates

Hospital readmission rates are one of the most important markers of success in the post-acute and long-term care spaces. But a large number of home care agencies still don’t keep track of those metrics.

Overall, 75% of home care agencies did not track readmission rates at all in 2019, according to recently released data from Idaho-based market research and education firm Home Care Pulse.

Historically, home care has largely been focused on activities of daily living (ADLs) and social determinants of health — things that sometimes fall slightly outside of the medical lens. With that in mind, it’s not entirely surprising that one-quarter of home care agencies haven’t been tracking their clients’ readmission rates.

Increasingly, though, home care agencies are taking care of clinically complex, chronically ill individuals, people who are constantly in and out of hospital settings. Additionally, agencies are starting to develop relationships with Medicare Advantage (MA) plans and accountable care organizations (ACOs), both of which seek to curb health care spending and keep their members in the lowest-cost settings possible.

Today, if a home care agency wants to be competitive in the MA landscape or win partnerships with ACOs, it likely needs to have advanced data capabilities, Home Care Pulse CEO Erik Madsen told Home Health Care News.

But it’s not always that simple, he noted.

“It’s one of the challenges,” Madsen said. “The industry is very much relationship-based. And that also brings some downside in my opinion, because companies are slow to embrace technology, they’re slow to embrace data, they’re slow to embrace some of these other areas that other [adjacent] industries have taken more seriously.”

Moving forward with data

Without a doubt, direct relationships between home care agencies and their clients will continue to be important. But without embracing data, even agencies with the most quality relationships could fall behind.

Improved operational procedures could bring agencies to the next level, but they’re not always on the top of their priority lists.

“[Home care agencies] are slower to adopt those operational processes and procedures that they’re going to have to if they want to compete in the next decade,” Madsen said. “It’s just a fact.”

Part of the problem is that a vast majority of home care agencies operate on a smaller scale, with razor-thin margins and relatively small administrative teams.

In these situations, many agencies looking to invest in their data capabilities don’t know where to start. But that way of thinking needs to change, Family Resource Home Care CEO Jeff Wiberg said during HHCN’s Medicare Advantage Summit in June.

Family Resource Home Care is a large, independent home care operator out of the Pacific Northwest. The agency recently invested in new software to collect all sorts of data, partly to prepare itself for more MA business in the future.

“I think we’d really be putting our head in the sand if we don’t start gathering details and information that will help position us as an industry to really demonstrate our value,” Wiberg said. “[That 25% number] — that’s a big wake up call to say, as an industry, we need to be collecting more of this data.”

As one of the home care agencies to embrace data, Family Resource Home Care tracks a whole lot more than just readmission rates, too. It’s other focus areas include tracking emergency room utilization and fall rates for its clients.

Family Resource Home Care additionally keeps tabs on its census and how many clients are living with multiple co-morbidities, among other information. It also separates hospital readmission rates into different categories, including hospitalization rate prior to home care admission.

“Getting away from that pen and paper [system] is going to be key,” Wiberg said.

‘Winning a seat at the table’

Even for the agencies that are collecting hospital readmission data, nearly 40% are using Excel spreadsheets or another less-than-scientific way to track numbers, according to Home Care Pulse.

“The average agency, they’ve just got a couple of people working, between answering the phone and trying to recruit, retain, train and do check-ins,” Madsen said. “Margins are small enough that they don’t have an overabundance of staff. So they’ve got to identify what are those two or three key [data] points that they want to track are and then really dial in on those.”

In 2019, the typical home care agency collected anywhere from $800,000 to $2.8 million, on average. The majority of them have been in operation for over seven years, usually relying on just one location for business.

Omaha, Nebraska-based Right at Home is another home care organization that has invested in data capabilities and tracking client readmission rates. As a franchise system, Right at Home has nearly 500 U.S. locations.

Right at Home had been working to develop its data strategy even before new MA opportunities started to appear. The steps the U.S. Centers for Medicare & Medicaid Services (CMS) has taken to open up MA to home care only accelerated those efforts.

“Let’s make sure that we’re on a path to cleaning up our data and trying to get better access to our data as a system,” Right at Home CEO Brian Petranick said at the HHCN MA Summit. “[The MA tailwinds] gave us some fuel for our message. Now we have [even more reason] … to collect data.”

Among its efforts, Right At Home tracks patients’ changes in condition and takes a special interest in a wide array of social determinants of health.

Cincinnati-based FirstLight Home Care has likewise invested heavily in its data capabilities, according to CEO and founder Jeff Bevis.

“We went ahead and pursued an actual [electronic medical record] and have that component in our software platform now.” Bevis said during the MA Summit. “If home care companies are able to really track that data and go away from pen and paper … that’s going to make all the difference too.”

The top home care providers in the country are becoming more and more intricate with their data collection.

The smaller agencies, with a few simple steps, can kickstart a better system for themselves and paint a brighter picture for home care overall along the way.

“The next decade in home care is going to be just phenomenal as we start to become more mature as an industry [through these processes] and get more opportunity to have a seat at the table,” Madsen said.

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Aging-in-place Ally Oak Street Health Files to Go Public

Oak Street Health — a network of value-based primary care offices for Medicare beneficiaries  — has filed the initial paperwork to go public. The Chicago-based organization announced the news Friday. 

While Oak Street Health doesn’t provide home health care itself, its interdisciplinary care teams are equipped to provide telehealth visits and in-home care in addition to center-based services. Plus, its mission to help seniors age in place aligns with that of home-based care agencies, and Oak Street’s growing presence could mean more opportunities for those providers down the line.

When the initial public offering (IPO) process is complete, Oak Street plans to trade on the New York Stock Exchange (NYSE) under the stock symbol “OHS.” While the company has yet to determine the number of shares it will offer or their price, the S-1 form Oak Street filed with the U.S. Securities and Exchange Commission (SEC) lists its proposed maximum offering price as $100 million.

Founded in 2012, Oak Street Health operates more than 50 centers across eight states, serving more than 85,000 patients, mostly under capitation arrangements. It provides a variety of services, such as those in the behavioral health, pharmacy and primary care realm, just to name a few examples. 

The company boasted $200 million in revenues for Q1 2020 on its S-1 — a 72% year-over-year increase. It estimates the annual total addressable market size as about $325 billion, according to the S-1.

Home Health Care News reached out to Oak Street Health for additional details on the IPO, but the company declined further comment for this story.

However, Oak Street did connect with HHCN back in 2017. At the time, then-senior vice president of growth and business development John Woolley told HHCN it was not formally partnering with any home health providers, but rather that it works with various organizations on a patient-by-patient basis.

Still, Woolley said it was open to establishing home health partnerships in the future. The idea is to serve as many seniors as possible who might otherwise struggle to remain in their own homes as they age.

“Nine out of 10 patients recommend us, but there is still a lot to be done,” Woolley said in 2017. “We are just scratching the surface for a population of patients that has been underserved.”

Then, in 2018, the company added Amedisys Inc. (Nasdaq: AMED) President and CEO Paul Kusserow to its board of directors.

Kusserow is expected to be elected to Oak Street’s board of directors once the offering is completed, according to the S-1.

“Kusserow is a valuable member of our Board due to his experience as an executive at several large health care companies and as the CEO of a public healthcare services company,” the S-1 said.

While it’s unclear what Oak Street’s relationship with home-based care providers will be going forward, it’s promising to see home health represented in its leadership.

Additionally, the more organizations working to keep seniors at home as they age, the more opportunities home-based care providers will have to help them in one way or another.

Oak Street attempting to go public comes less than a month after the company’s most recent expansion.

In June, Oak Street announced it will establish hubs in New York and Mississippi by the end of 2020. Timing wise, the expansion will allow Oak Street to serve more vulnerable populations amid the ongoing coronavirus public health emergency.

Since its founding, Oak Street has seen a 51% reduction in patient hospital admissions compared to overall Medicare benchmarks, according to the company.

“We have been able to meet the unique challenges presented by the pandemic, and our ability to adapt and provide care for our patients at this critical time is a testament to Oak Street Health’s innovative value-based health care model,” CEO Mike Pykosz said in a statement. ​“Our patients always come first, and with our upcoming entry into New York and Mississippi, we are furthering our company’s mission of rebuilding health care as it should be.”

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Leading During Disruption: How Synergy HomeCare’s New CEO Took Control Amid COVID-19 Chaos

Securing stockpiles of personal protective equipment (PPE), doubling down on company-wide training efforts and implementing educational initiatives are just some of the responsibilities that home care leadership teams have taken on during the COVID-19 crisis.

While most home care agencies were navigating the public health emergency over the past few months, Synergy HomeCare’s CEO had the additional responsibility of getting acclimated to his new role.

In April, Charlie Young took the reins of Synergy as its chief executive officer. Young is only the second person to lead Synergy, taking over the role from founder Peter Tourian, who is now the company’s executive chairman.

NexPhase Capital-backed Synergy is a Gilbert, Arizona-based non-medical home care franchise that offers companionship services, in addition to personal assistance, housekeeping, live-in care and 24-hour home care services. Currently, the franchise company operates throughout the U.S., serving roughly 25,000 clients and employing about 20,000 people.

Home Health Care News recently caught up with Young to discuss the company’s newly launched educational campaign, its growth strategy and why Young isn’t ready to walk away from Medicare Advantage (MA) opportunities just yet.

Below are highlights from HHCN’s conversation with Young, edited for length and clarity.

HHCN: We last connected with Synergy in 2019. Can you recap the company’s highlights and challenges since then?

Young: Here’s what I can share with you from my perspective. Synergy HomeCare is a really cool and unique company in the home care space. It’s a company that has been franchising since August of 2005 — 15 years. We now have 160 or so franchise partners that operate in 350 markets around the United States.

I think there was a time period in 2009 through a couple of years ago where Synergy was focused on growing its business and building out the foundation of what the brand would stand for, not only for its franchisees but also for the caregivers and the clients we serve.

There’s been a renewed interest in the growth of Synergy. Two years ago, the company was sold. We are now owned by NexPhase Capital, a private equity company. I, along with others, was brought into the fold to bring Synergy to the next chapter of growth. That’s where we’re focused now going into the future.

COVID-19 has moved home care into the spotlight. Can you talk about how your company has handled the public health emergency?

We’ve handled COVID-19 by recognizing the role that we play in the health care continuum, more specifically in helping our clients maintain their independence and livelihood at home.

We’ve seen two things happening: We’re seeing people move out of hospitals, skilled nursing facilities (SNFs) and nursing homes. We are also seeing people who were at home and well cared for needing to have that care continue. Our franchise partners around the country– and their caregivers — are the front lines.

Many of our operations around the country are working with COVID patients and making sure that they’re maintaining safety standards. As a company, we are making sure caregivers have access to PPE and proper training on how to keep themselves safe, too.

On the client side, it has been about attacking social isolation. Through our senior connections program, we make sure that the clients we serve are staying connected to the communities around them. This means, in some instances, enabling connections with our clients and their loved ones through video chat and other communications.

In many cases, our franchisees around the country are making sure that the match between caregiver and client is a good and solid one. They are maintaining consistency and continuity between the client and the caregiver. We think it’s important at this time to have that level of continuity for safety and to ease any concerns.

We’re also focused on helping our franchise partner locations around the country recruit new caregivers. With the economic fallout that has come from COVID-19, we have a great service to bring to the community and a lot of opportunities for caregivers. We’re finding that there are new types of caregivers coming to the market, as hospitality workers, restaurant workers and retail workers are out of work because of the pandemic.

How have you handled being a relatively new CEO during a public health emergency?

Before I started, there was a lot of anxiety and apprehension about starting this role during these times. However, I think that now that I’ve been at it for three months, I can take a step back and say it’s been a hidden blessing.

When you start a new job as a CEO, you’re thinking about how to bring the team together. You’re thinking about the process of sitting down in person with your employees. Since Synergy is a franchise company, I thought about getting out on the road and going to visit franchisees and spending a lot of time in the field. Obviously, these things couldn’t happen. Our corporate office was shut down. I couldn’t travel to see our franchisees and I’ve been heavily reliant on Zoom. What I’ve found is that I’m able to have much more intentioned conversations with our employees and with our franchise partners. I’ve also been forced to be more creative than maybe I would have been otherwise.

Since I wasn’t able to go visit our franchise locations, I built a series of CEO roundtable discussions. I met with over 100 franchise partners, either one-on-one conversations or through the roundtable. For the roundtables, we would put 10 franchise partners on a Zoom call with me for an hour and a half. I had a set of questions for them, but I also gave them plenty of time to ask me questions as well. In the span of seven days, I was able to meet with an incredible number of franchise partners and hear from them about what they thought the opportunities were for Synergy HomeCare.

It was a level of exposure to the grassroots of the business that I wouldn’t have had if I was physically traveling to our locations.

One of the secret weapons of Synergy HomeCare is the connected nature of our network and how we learn from each other and support each other in normal times, but also during the pandemic.

Synergy recently launched an educational campaign about a technique called “benevolent probing” that can assist adult children in determining if their parents could benefit from home care. What’s that about?

We know that oftentimes home care comes because of a life event. There’s been a hospitalization, a surgery, a fall in the home or some other event that has caused the loved ones of the client to rally and evaluate whether they need care. This program is designed to help family members identify and keep track of where “mom and dad” are in terms of their need for extra support in advance.

We know that if you can proactively provide care, then you can extend the independence cycle of the time by which our clients are active at home — even if they need a little assistance and support to do that.

This program is about a series of questions and things that loved ones can look for when interacting with seniors and their families. Things that might tip them off about change taking place in the home. It’s all about tracking activities of daily living (ADLs) and keeping up with them.

Helping people have these hard conversations earlier, in a more productive manner, is going to serve our clients in the end.

For the last 10 years, Synergy has grown at an average rate of 20% year over year. This has largely been due to organic growth. Can you talk about the company’s growth plans moving forward?

We’re still in the early stages of formulating strategy. When you think about growth, there are two primary ways that will grow Synergy. One: We currently occupy about 350 territories around the U.S. I think there’s plenty of upside growth for more Synergy outlets and markets that we’re not serving at the moment. The demand for Synergy HomeCare franchises is strong. I think the pandemic is only fueling that demand for franchise territory. I think that our challenge in that process will be to make sure that we’re bringing the highest quality franchisees into our system.

The second: Organic growth. My definition of organic growth would be, “How do we take our existing franchisees and help drive growth into their business?” I think we’ll be focused on that quite significantly. We will be looking at how we can drive a deeper penetration into our markets through marketing and sales activities, by forming new referral relationships at both a local and national level. I think that there is a definite upside for growth within our existing system.

Beyond referrals, I think product and service offerings are an area that we will take a closer look at. What are the things we can do for our clients that we are not focused on today? I think technology will have a bigger role in how we provide service to our clients.

When I connected with your predecessor last year, Medicare Advantage was the growth avenue the company was most excited about. Can you talk about the inroads the company has made on the MA front?

Everyone in the home care industry is bullish on the fact MA will be an opportunity in the future.

However, we have not seen the Medicare Advantage switch being turned on yet. Payers are just not there yet when it comes to offering home care as part of the plans. But we are not walking away from it.

What area will be the company’s main point of focus for the rest of the year?

For the rest of the year, we will be very much focused on helping our franchise partners and the caregivers that work for them settle into the new normal of the pandemic. No one should think or believe that it will be going away anytime soon. These are the conditions by which we’re working. That means making sure that everyone is up on the latest protocols and has appropriate levels of PPE.

Beyond that, our focus will be on figuring out how we provide care to growing populations, as we see the number of hours for home care starting to come back. There are COVID-diagnosed patients that need care — and clients who don’t have the virus and also need care. We need to be able to provide services to both of those populations and prepare our franchisees to do that.

I think that Synergy is poised for significant growth in this industry. It’s a young industry, and there are many players in the home care space. I think over the next several years, you’re going to start to see the industry mature and certain players within the playing field will mature faster than others.

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Record Low Senior Housing Occupancy Could Be a Boon for In-Home Care Providers

While few industries have been left unscathed by the impacts of the COVID-19 emergency, the senior housing market has been one of the hardest hit. But a decline in senior housing occupancy could leave room for in-home care providers to step up and fill long-term care gaps.

Overall, senior housing occupancy hit a record low in the second quarter of 2020.

Specifically, occupancy in independent living, assisted living, memory care and nursing care fell 2.8 percentage points in Q2 2020, declining from 87.7% in Q1 to 84.9%, according to new data from the National Investment Center for Seniors Housing & Care (NIC).

NIC’s findings are the largest quarterly decline since the organization began reporting this data more than a decade ago.

“Without question, the data shows there was a huge impact,” Bob Kramer, founder and strategic advisor at NIC, told Home Health Care News. “I think this came about for a number of reasons. Many providers shut down new admissions and new tours, or at the very least did them on a very careful basis. When you combine public fear of the setting with the mandated ban on new move-ins, that’s going to have an effect.”

The NIC data shows that assisted living occupancy, in particular, saw a significant decline. Assisted living occupancy decreased by 3.2 percentage points to 82.1% in Q2.

“That stands to reason because people who utilize assisted living are frailer,” Kramer said. “They have more chronic conditions and a greater need for assistance with activities of daily living (ADLs). There is more intimate contact with the staff.”

While it’s still too soon to tell when senior housing occupancy levels will return to pre-COVID numbers, a desire to avoid these settings could open the door for in-home care providers to attract would-be residents.

“Clearly, it’s an opportunity,” Kramer said. “Right now, there are fears, by some, about congregate settings. There’s a desire to be able to age in place. I think it will be a huge boon to those that are aging-in-place facilitators — and those that provide home care and home health.”

That said, one thing providers looking to hone in on this population will need to address is the potential for social isolation.

One of the main attractions of senior housing is the social aspect of living in these communities, according to Kramer.

“If you look at seniors housing as only providing care, this is a great boon to those who provide care to people in the home,” he said. “The reality is the greatest selling point of senior housing is not the care. That’s often the reason why people move in, but its greatest selling point is social engagement and human connection.”

On this front, many providers have already began taking steps and creating initiatives to address social isolation among seniors.

Omaha, Nebraska-based Right at Home, for example, began offering free call-checking services at many of its locations. The company also partnered with local musicians and theater groups to stream events for clients.

Seniors already faced social isolation, but the public health emergency compounded this, Brian Petranick, CEO and president of Right at Home previously told HHCN.

“It’s often difficult to get out and do the things that they like to do in normal times,” he said. “It’s difficult [for seniors] to go to church, get to the store or different things like that. Now, I think what’s happened during the pandemic is that this has been exacerbated. It’s been, partly, exacerbated due to the fact that family members now can’t come into the house, in some cases.”

Right at Home is a home care franchise system with nearly 500 U.S. locations. Right at Home and Right at Home International are wholly-owned subsidiaries of RiseMark Brands.

Looking at the 31 primary markets that NIC follows, San Jose, San Francisco, Baltimore and Tampa had the highest seniors housing occupancy levels in Q2. Houston, Atlanta and Las Vegas had the lowest occupancy levels.

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How to Draft an M&A Agreement When PPP Loans Are Involved

Smaller home-based care agencies could be forced to close their doors as a result of the coronavirus, creating merger-and-acquisition opportunities for larger providers in the space. 

However, the Paycheck Protection Program (PPP) adds a new layer of complexity to some of those M&A opportunities, specifically if an acquisition target is the recipient of a PPP loan.

It’s unclear how many home-based care providers have received loans under the program, but about 13% of all loans issued so far have gone to businesses in the health care and social service spaces. Plus, dozens of home-based care providers have received larger PPP loans of $150,000 or more, according to data released earlier this week.

Before entering a deal with a PPP recipient, buyers should consider how many employees the home-based care agency has, what the PPP loan total is and when the loan will be forgiven, among other factors.

If buyers decide to proceed with the transaction after all that, there are also special considerations they should take into account when pricing the deal and creating the purchasing agreement, according to Philip Feigen, attorney and shareholder at the international law firm Polsinelli.

“You need to look at [if there were] any salary reductions or reductions in [full-time equivalents] (FTE) that would cause the borrower to not get full forgiveness so that you can price that out when you’re making an offer,” Feigen said.

He and his colleagues shared that tip and other advice during a recent Polsinelli webinar designed to help attendees navigate the M&A deal landscape when PPP loans are involved.

The PPP was born out of the CARES Act earlier this year as a way to help small to mid-sized businesses make payroll and finance other expenses amid the COVID-19 emergency. PPP loans are forgivable if recipients meet certain criteria, such as spending a certain amount of the money on payroll and keeping salaries relatively steady.

But if PPP recipients fail to meet those requirements, the Small Business Administration (SBA) could decide to audit them. That’s one reason buyers of PPP recipients should make sure to include certain covenants in their purchase agreements to protect themselves.

Polsinelli attorneys recommend buyers include covenants that require acquisition targets to do everything they can to ensure loan forgiveness, if they have yet to obtain it. That includes requiring them to use all funds as required under the CARES Act and to apply for loan forgiveness within a set period of time agreed upon by both parties. 

Additionally, buyers should include a provision requiring sellers to comply with any future audits, as well as to provide certain documentation, regardless.

“It’s important to make sure that the seller is maintaining all of their records for at least six years, or at the very least providing the buyer with a copy of all the records,” Sara Ainsworth, Polsinelli associate and attorney, said on the webinar. “The SBA has that six-year time period to come back and review all the loans, so it’s important to make sure that documentation is available.”

Agreements should also indemnify the buyer against PPP-related issues such as seller ineligibility, non-compliance with loan terms, audit investigations by SBA or taxes owed related to the CARES Act.

Escrow option

In a typical M&A deal, a buyer might get a representation and warranties insurance policy to further protect itself against losses that arise out of the buyer breaching certain agreement terms. But that’s less of an option in M&A deals where PPP loans are involved, Feigen said.

“It’s been our experience so far that none of the insurers are willing to do reps and warranties insurance with respect to the PPP loans, just because it’s so new that they can’t get their hands on what the potential liabilities are,” he said.

As an alternative, Feigen suggests setting up an escrow account in the amount of the PPP loan.

Once the loan is forgiven, the seller can have that money back. If it’s not, the money can help.

“To the extent [the PPP loan] is not forgiven, partially or all, then that becomes money that is either used to pay the loan back or goes back to the buyer, who would pay the loan back,” Feigen said. “A lot of sellers might be uncomfortable with that, and there’s a lot of potential liability related to it, but we’ve been seeing that used in transactions.”

Finally, Polsinelli attorneys say it’s important to lay out what will happen with any remaining PPP loans in M&A agreements.

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Buyer Beware: Factors Home-Based Care Providers Should Consider Before Acquiring PPP Recipients

Pre-coronavirus, the home health and home care industries were already poised for historic consolidation, thanks to the Patient-Driven Groupings Model (PDGM), rising minimum wages and other operational pressures.

Industry leaders predict that the COVID-19 emergency will only drive M&A further going forward. However, home-based care businesses interested in picking up new agencies should heed caution, especially if their potential acquisition targets are recipients of loans under the Paycheck Protection Program (PPP).

So far, dozens of home-based care agencies across the country have received PPP loans of more than $150,000, according to Small Business Administration (SBA) data released earlier this week.

SBA has not released a list of smaller loan recipients, so it’s unclear how many in-home care agencies in total are participating in the program. What is clear, however, is that acquiring a PPP loan recipient comes with risks.

“There are more issues as a purchaser or buyer to beware of in a transaction,” Philip Feigen, attorney and shareholder at the international law firm Polsinelli, said. “But a lot of these things are equally as applicable if you’re on the seller side.”

Feigen and his colleagues ran down a brief checklist for potential buyers during a recent Polsinelli webinar. The considerations are key to ensuring home-based care organizations don’t enter deals that could introduce undue audit risk or eliminate PPP loan forgiveness opportunities down the line. 

Factors to consider

The CARES Act created the PPP just a few months ago to help small and mid-sized businesses stay afloat during the COVID-19 emergency. The program set aside billions of dollars in forgivable loans to help eligible applicants make payroll and finance certain other expenses such as rent, utilities and mortgage interest.

Loan forgiveness is conditional on borrowers meeting certain requirements. For example, they must spend 60% of the loan on payroll costs and not cut employees’ pay by more than 25% to be eligible for full loan forgiveness, among other requirements.

The program has been met with widespread confusion by recipients, about 13% of whom are health care and social services businesses, according to SBA data.

That’s only complicated by the fact that the SBA has updated and clarified the PPP rules dozens of times since the program was introduced in April.

As such, it should be no surprise that doing deals with PPP recipients means additional complications and unknown variables. Those should be taken into account before a home-based care provider agrees to acquire a PPP loan recipient.

First, potential buyers should be mindful of the number of employees an acquisition target has, as well as its financial information and the dollar amount of the PPP loan it has received, Feigen said.

One reason for that is so buyers can adequately weigh their audit risks, as the SBA has said that it will audit all PPP loans of more than $2 million dollars.

Once a transaction contract has been signed, the buyer and seller are officially affiliates, which have some implications in the eyes of SBA.

“On the loan forgiveness application, one of the questions that … the [PPP] borrower has to respond to is whether or not they have a loan of more than $2 million or whether, along with its affiliates, it has loans of more than $2 million,” Sara Ainsworth, Polsinelli associate and attorney, said on the webinar.

On top of that, a seller can have additional affiliates.

As such, it’s important for a buyer to consider when a potential deal would close: before or after the seller has received forgiveness for their PPP loans.

If the buyer times the transaction during the loan’s 24-week covered period, it could see a reduction in the loan forgiveness amount it’s eligible for. The purchaser runs that risk if it takes on the loan but fails to bring on the seller’s employees — or if the overall number of employees is less than the number present when the loan was issued.

“It’s potentially problematic if the buyer has fewer employees — because at that point, you really are looking at a likely reduction in the total forgivable amount,” Ainsworth said. “It’s also an issue if the buyer does not take the PPP loan but does take the employees, so the seller is left with the PPP loan, but a lower amount of employees, possibly down to zero.”

Buyers should also ensure that acquisition targets had economic need for the loan and that they have used the funds properly and followed the rules of the program.

Finally — and potentially the most important factor to consider before spending time trying to negotiate a deal with a PPP recipient — home-based care providers need to make sure that it’s allowed. Because the PPP is so new, that’s still somewhat up in the air.

Depending on language in the loan documents, a buyer may need to get the lender’s permission before they can proceed with the transaction. Others banks are handling M&A questions as they arise.

“A lot of banks that we’ve been dealing with … aren’t sure how to handle this situation,” Feigen said. “The reason they’re not sure how to handle this situation is the SBA has not taken a position on whether borrowed can undergo a change of control and how that would affect eligibility for forgiveness.”

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‘A Decrease in Need’: Home Care Agencies Face Less Profitable Transportation Lines Amid COVID-19

Over the past several years, many home care agencies have invested heavily in transportation business lines to help their clients stay connected and active within their communities. The industry’s turn to transportation has been so popular, that ride services are often seen as core offerings for many agencies.

But while transportation services remain important, the ongoing coronavirus emergency made those business lines less profitable in the near term.

Prior to the COVID-19 crisis, there was a clear effort to “Uberize home care,” especially in regard to on-demand transportation services. Now, that’s not so much the case, Kerin Zuger, chief of strategic growth at Right at Home, told Home Health Care News.

Omaha, Nebraska-based Right at Home is a home care franchise system with nearly 500 locations in the U.S. The company is a subsidiary of RiseMark Brands.

Often built on partnerships with Uber (NYSE: UBER) and Lyft (Nasdaq: LYFT), transportation services garnered a lot of attention in the home care world in 2019 and early 2020. In addition to keeping clients connected, agencies also saw transportation services as a way to keep clients safe after leaving the hospital while maintaining visibility.

Internally, transportation programs also helped keep workers happy, as many home care agencies used them to coordinate rides for caregivers going from client to client. Furthermore, transportation offerings additionally allowed for some agencies to begin dipping their toes into government money by making headway in the Medicare Advantage (MA) world.

In MA, transportation is covered for non-medical purposes under the new Special Supplemental Benefits for the Chronically Ill (SSBCIs) initiative.

But currently, the Centers for Disease Control and Prevention (CDC) is urging those who are 65 and older to stay home whenever possible. The CDC is doing the same for those who have an underlying health condition,too.

“I would speculate, as an industry, that there is going to be a huge decrease [in transportation line volume],” Zuger said. “CDC actually recommends not using services like Uber and Lyft, particularly for those over the age of 65. So with everybody right now referring to the CDC and their recommendations, that’s just kind of scary.”

Los Angeles-based 24 Hour Home Care, which has its own transportation platform — RideWith24 — was one of the first home care companies to get into the transportation business and to partner with a ride-sharing giant like Lyft. The agency provides professional caregiving services to older adults and individuals with developmental disabilities in California, Texas and Arizona.

24 Hour HomeCare has experienced the COVID-19 transportation fallout first hand.

“We’ve faced quite a few challenges,” Irene Perez, 24 Hour Home Care’s community partnerships coordinator, told HHCN. “We have seen a decrease in clients calling in for transportation, and we’ve seen a decrease in contracts and ride requests. And a lot of that was about clients feeling uncomfortable.”

24 Hour Home Care used to experience a volume of about 2,500 rides per month. That total decreased almost 50% to 1,300 in April, though it has since rebounded slightly to over 1,500 per month.

In order to curb some of its woes, 24 Hour Home Care has relied on its partnership with Heal, which is an on-demand doctor service. Heal does house calls for patients who can’t or aren’t willing to leave their homes for doctor visits, which is one of rides home care agencies used to facilitate.

Right at Home, like 24 Hour Home Care, has partnerships with Uber and Lyft. For its clients, Right at Home has tried coordinating rides ahead of time so they know who the driver will be.

Both companies also try to reduce risks in other ways, like ordering larger vehicles instead of more compact cars.

Otherwise, putting a caregiver or patient in a rideshare could be considered risky, given the inherent closeness between the driver and rider in most car situations — and the amount of potential exposure.

“I think one thing we want to emphasize with all of our clients is that we cannot eliminate risk — period,” Gavin Ward, a regional director of strategy for 24 Hour Home Care, told HHCN. “What we can try to do is mitigate risk.”

Relying on Lyft and Uber has presented other challenges as well.

If there are fewer Uber and Lyft drivers available — which there have been — that means longer wait times and less efficient transportation overall, which was one of the perks of transitioning to ridesharing in the first place.

More headwinds

Another headwind for transportation lines has been the uptick in telehealth.

Telehealth claim lines increased 8,336% in the U.S. from April 2019 to April 2020. It used to represent 0.15% of medical claim lines; it represented 13% of claim lines in April, according to new data from FAIR Health’s Monthly Telehealth Regional Tracker.

A claim line is an individual service listed on an insurance claim.

If patients can experience visits virtually more often, the transportation line is immediately devalued.

“Before the pandemic, we were seeing this really big shift to Uber in home care, right?” Zuger said. “It’s [going to] be interesting to see what happens to those organizations [who invested so heavily in that]. … I have to think that those types of organizations have seen a pretty significant decrease in need.”

Still, in the end, transporting caregivers, patients and resources will continue to be a need.

Companies will just need to increase their creativity for their transportation lines for the foreseeable future — especially if they view them as a crucial revenue stream.

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Milliman Actuary: COVID-19 Adding Fuel to Medicare Advantage’s Home Care Fire

The coronavirus could be the match that finally sparks the Medicare Advantage (MA) boom for home care.

The explosion has been a long time coming. It all started when the Centers for Medicare & Medicaid Services (CMS) first expanded the scope of MA supplemental benefits in April 2018.

The move opened the door for MA plans to cover in-home care for the first time, creating new, highly sought after opportunities for home-based care providers. However, those opportunities were few and far between, with only 3% of plans offering in-home support services in 2019.

Adoption rates improved slightly but significantly for 2020, thanks in part to CMS yet again widening the scope of which supplemental benefits MA plans could offer. In 2020, 148 plans decided to cover in-home support services, compared to only 51 the year before, according to international actuarial consulting firm Milliman.

But that increase could be nothing compared to what the MA industry will see as a result of COVID-19.

Thanks to mid-year MA flexibilities from CMS and the country’s current aversion to congregate senior care settings, the virus is poised to throw even more fuel on the MA home care fire, according to Catherine Murphy-Barron, a principal and consulting actuary at Milliman.

Murphy-Barron recently connected with Home Health Care News to share her outlook on the MA landscape amid the coronavirus, as well as what she expects to see from plans and CMS on the home care front in the year ahead.

You can find the conversation below, edited for length and clarity.

HHCN: What big-picture changes are you seeing in MA amid the coronavirus?

Murphy-Barron: It’s hard to even know yet what 2020 is looking like, except that it’s all quite in upheaval.

When the coronavirus was just starting out in March and April, we were trying to put together bids for 2021 — so it was sort of shooting in the dark because we were still trying to understand what’s happening in 2020.

Obviously, consistent with every line of business, Medicare is experiencing huge drops in discretionary services. At the same time, the Medicare population is the age bracket that is really most at risk related to COVID.

So how are those factors offsetting each other — and how do you deal with the implementation of telemedicine and all of that?

It’s still playing out. Telemedicine obviously has a huge impact on Medicare. The ability to use that and the expansion of that benefit this year has been large. Hopefully that will continue into the future.

For the dual plans, particularly the special needs plans (SNPs) and the institutional special needs plans (I-SNPs), they’ve taken a huge hit. I have a number of provider-owned Medicare Advantage clients, so they tend to be smaller and they tend to be dual.

They tend to have gotten hit quite hard with regard to if they have beneficiaries who are in skilled nursing. They’ve seen a huge hit with regard to their enrollment — obviously they’ve lost quite a few of their members and some of their staff.

The impact is quite different depending on who you are, what kind of a plan you are and where you are in the country. Trying to figure out what that will mean for 2021 has been quite difficult.

So what are you expecting for 2021?

That depends on the client and what they think.

What we’re trying to do is figure out: What do we know? What would it look like if it was a normal year? And how do we adjust that based on how we think this will play out?

Part of what is helping is some of the expansions CMS has made in the past few years with regard to supplemental benefits [like in-home care].

People aren’t able to go into a nursing facility or don’t want to stay in a hospital long term. So [plans] can now provide some of the home care and in-home support services that previously were quite limited unless you were a dual special needs plan.

As we think about going into 2021 … people will probably still be somewhat uncomfortable with group settings like adult day care or skilled nursing facilities. You might see the use of these [in-home] benefits as a way to supplement some of the care and get people the care they need without having to put them at risk from a COVID perspective.

This was going to happen anyway. Supplemental benefit flexibility was a huge plus for MA from a social determinant of health perspective. I think COVID is reinforcing some of the steps that CMS was already taking.

Initially, MA plans were slow to adopt in-home supplemental benefits. Do you think COVID-19 will add fuel to that fire?

I think it will, especially on the dual side of things.

It gives options to beneficiaries. The people who have been caring for them at home because they’ve been working from home will eventually have to go back to work. How do you balance the fact that you need additional care? You don’t particularly want to have in-patient or facility-based [care right now].

Having those options gives people more choice.

CMS recently gave MA plans new mid-year flexibilities in light of the coronavirus, so plans hypothetically could be adding new in-home care benefits right now. Do you have any idea how many are doing that?

We don’t yet. It’ll be a couple months.

But generally, if you look at what was happening for 2020 with last year’s bids, plans definitely were taking advantage on the home care front, and I don’t think that will change for 2021.

We’ve seen CMS announce new in-home supplemental benefit allowances the past two years in a row. Do you think we’ll see any further expansion of those allowances this year?

They gave plans a lot of choice with regard to what they could do under those benefit expansions. So I think what we’re gonna see is that plans will experiment over the coming years.

I haven’t heard that CMS is planning to add more or change anything, but they definitely are expecting to see plans take advantage of this. I think the number of plans offering these in-home flexibilities will only continue to grow as plans get more comfortable with what they can do and how they can use them.

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