Biden to DOL: Workers Have ‘Guaranteed Right to Refuse Employment’ If They Feel Unsafe

In President Joe Biden’s first few days of office, he has signed a slew of executive orders, some of which may have an immediate effect on home health and home care agencies.

One executive order, for example, laid the groundwork for a $15 minimum wage. The “Fight for $15” has long been a complicated issue for America’s home-based care operators, many of whom want to pay their workers more but struggle with stagnating reimbursement rates.

In addition, Biden also plans to increase the unemployment benefits add-on by $100 to $400 per week once the current spending package expires in March.

Anecdotally, providers haven’t been too concerned about the additional benefits. But there’s another aspect of Biden’s plan that could make it into a larger issue.

A fact sheet released by the Biden administration on Jan. 22 says that “workers have a federally guaranteed right to refuse employment that will jeopardize their health, and if they do so, they will still qualify for unemployment insurance.”

That is a part of the “new executive actions” to “deliver economic relief for American families and businesses amid the COVID-19 crises,” according to the fact sheet.

Specifically, Biden is asking the U.S. Department of Labor (DOL) to consider clarifying that workers do have the right to opt out of work if they fear it is unsafe for them or their families. Further guidance on which types of workers would apply has not yet been provided.

“The Biden package could certainly create some incremental headwinds for home-based care staffing, as we saw in the summer months last year after the first iteration of the CARES Act implemented the $600-per-week unemployment assistance,” Scott Fidel, an analyst for the financial services firm Stephens Inc., told Home Health Care News in an email last week. “However, we would not expect the staffing challenges to not be as significant as what we saw last year following the CARES Act.”

But with that potential DOL provision, things could get tricky for both home health and home care providers.

Theoretically, if the DOL did clarify that workers can stay home and collect unemployment if they feel unsafe, that could put thousands of home-based care workers in the position to opt out of their jobs for the time being.

Home care agencies have used hazard pay from Paycheck Protection Programs (PPP) loans in an attempt to mitigate some of these issues in the first place. Likewise, hazard pay from the government was supposed to fill holes on the home health side.

Particularly when it comes to Medicaid reimbursement, however, hazard pay has come late and been subject to high taxes. That’s at least the case in Virginia, where checks came in up to three months late and with a 35% chunk taken out for taxes, according to the Richmond Times-Dispatch.

Hazard pay can encourage workers to stay on the job and risk their own well-being, but it’s often not enough to overcome concerns about potentially exposing high-risk family members back home.

In 2019, 43% of American households reported having at least one member with pre-existing conditions.

“President Biden believes that workers should have the right to safe work environments and that no one should have to choose between their livelihoods and their own or their families’ health,” the fact sheet states.

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Biden Administration Includes ‘Home Care Workforce Crisis’ in New Pandemic Plan

President Joe Biden focused on the ongoing COVID-19 pandemic during his first full day in office Thursday. In doing so, he once again drew attention to home-based care and getting the current “workforce crisis” under control.

“Our national strategy is comprehensive,” Biden said during an address from the White House. “It’s based on science, not politics. It’s based on truth, not denial — and it’s detailed.”

Since taking office, the president has signed 10 executive orders aimed at expanding COVID-19 testing and vaccine availability, with an ambitious goal of 100 million vaccine doses by April. The Biden administration unveiled a nearly 200-page pandemic preparedness plan on Thursday.

Wednesday saw more than 184,000 new cases of COVID-19 infection across the U.S., according to a New York Time database. More than 400,000 people have died since the pandemic began last year.

“Things are going to continue to get worse before they get better,” Biden said.

Biden’s pandemic preparedness plan is organized around seven goals, with the first goal focused on “restoring” trust with the American people. Protecting individuals most at risk — partly by expanding access to high-quality health care — is likewise a main goal under the plan.

“Specific actions include efforts to increase funding for community health centers, provide greater assistance to safety net institutions, strengthen home- and community-based services, expand mental health care, and support care and research on the effects of long COVID,” the plan states.

Dating back to his presidential campaign, Biden has proposed numerous investments in home- and community-based services as part of his plan to “Build Back Better.”

Wednesday’s pandemic plan notes that the U.S. Department of Health and Human Services (HHS) — including the Centers for Medicare & Medicaid Services (CMS) and the Administration for Community Living — will be tasked with identifying “opportunities” and “funding mechanisms” to provide greater support for individuals receiving care at home.

The plan also says that the administration will pay “particular attention” to “the home care workforce crisis.”

Washington, D.C.-based LeadingAge was among the first aging services organizations to voice support for Biden’s COVID-19 response.

“This virus has raged out of control for nearly a year, while our community has desperately called for help,” Katie Smith Sloan, president and CEO of LeadingAge, said in a statement. “So to have the new administration lay out plans on Day 1 to put COVID at the top of its agenda is welcome and hopeful news.”

To better track vaccination progress for seniors in congregate settings, in the community and in their homes, the Biden administration is also floating the idea of new reporting measures.

For example, to increase incentives to vaccinate Medicare beneficiaries, the plan explains, CMS will evaluate how to incorporate quality measures for COVID-19 immunizations into its value-based purchasing programs, including Medicare Advantage Star-Ratings, the physician quality payment program and accountable care programs.

One of the executive orders Biden signed directs cabinet agencies to invoke the Defense Production Act to scale up production of materials needed for vaccine shots.

“In the midst of the virus spiking and community spread, we’ve been on the battlefield trying to protect older adults and workers with limited support,” LeadingAge’s Sloan said. “We hope this means the cavalry is coming, especially on testing and vaccine initiatives.”

Another executive order empowers HHS, the Department of Defense and others to provide “targeted surge assistance” to critical care and long-term care facilities, including nursing homes and skilled nursing facilities (SNFs), plus assisted living facilities and more.

The new pandemic plan follows a couple of key HHS and CMS leadership announcements made earlier in the week.

The new administration on Wednesday tapped Liz Richter to lead CMS on an interim basis during the presidential transition. The agency’s website now lists Richter, who has worked at CMS in various capacities since 1990, as acting administrator.

Former CMS Administrator Seema Verma submitted her resignation last week with an effective date of Jan. 20.

The president on Tuesday nominated Dr. Rachel Levine to serve as assistant health secretary. Levine is currently the Pennsylvania health secretary, and a pediatrics and psychiatry professor at Penn State College of Medicine.

Biden already nominated California Attorney General Xavier Becerra to serve as HHS secretary, though he — along with the administration’s eventual pick for CMS chief — must eventually be confirmed by the Senate.

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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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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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‘Once They’re Gone, They’re Gone’: Family & Nursing Care Rebuilds Workforce After COVID-19 Losses

While in-home care providers have always struggled with caregiver retention, the ongoing COVID-19 pandemic made growing a workforce nearly impossible. In fact, many operators are just now recovering from the labor disruptions of last spring.

Take Family & Nursing Care, for example.

The Silver Spring, Maryland-based private-pay home care provider had its total caregiver count drop by nearly 20% from February to April, according to Mitch Markowitz, the company’s vice president of business development.

Family & Nursing Care has gradually built those numbers back up since then, but retention remains a daily struggle for a variety of reasons.

For starters, the in-home caregiver job itself has never been more challenging, especially with new personal protective equipment (PPE) requirements and internal protocols. On top of that, employers must also now compete with stronger unemployment benefits and other health care segments, as many caregivers are leaving home care for hospital jobs.

“What I would say is our workforce, just in general — especially at that certified nursing assistant (CNA) level — is a very nomadic workforce to begin with,” Markowitz told Home Health Care News.

In-home care providers, too, must also learn how to recruit and onboard workers remotely — another difficult task. All of these recruitment-related challenges are barriers to growth for the Family & Nursing Care, particularly because the vast majority of its hiring comes at that CNA level.

Currently, Family & Nursing Care has about 700 clients in Maryland and the Washington, D.C., area. It has an average annual revenue of about $35 million.

The company has run into these issues despite having a retention rate above industry average, according to Markowitz.

For context, the home care industry’s turnover rate hit an all-time high of 82% in 2018, but rebounded to about 64% in 2019, according to the Idaho-based market research and education firm Home Care Pulse.

“We’ve been trying to rebound ever since May,” Markowitz said. “And it’s been very, very slow incremental growth. That’s mostly because those caregivers, once they’re gone, they’re gone.”

Some of Family & Nursing Care’s workers have come back, but not many. Others are new to the company, interviewed and hired through a virtual process.

Although some organizations see virtual recruitment as the new normal, it has been a struggle for Family & Nursing Care. Additionally, based on their experience, it has been far less efficient.

Even before COVID-19, the company was strict and fastidious with its choosing of caregivers. It went above and beyond to find the right ones for the job, which meant that it normally only hired about 9% of the caregivers that applied.

“Prior to COVID, we would bring our caregivers through our office for the interview process,” Markowitz said. “And it was a very in-depth, face-to-face process, because we want to make sure we get the best of the best caregivers. Then we went all virtual, so everything is being done via Zoom and our competency exams are all online. And that limits how efficient we are. It’s been our biggest barrier to rebounding.”

Having an open conference room where prospective caregivers could come and go throughout the day was a much more seamless process. The alternative route, forced by COVID-19, has led to a harder interview process and more logistical issues caused by technology problems and lack of comfort tech-wise on the caregiver’s end.

“Caregivers are more tech savvy than they were 10 years ago, but they’re not super tech savvy,” Markowitz said. “Many haven’t used Zoom before. Many haven’t used some of the tools like DocuSign. So we’re having to do a lot more hand holding than we ever have before, and it just takes a lot more time and energy to bring on the same number of caregivers.”

There were also heightened unemployment benefits in the spring, which are likely returning with the year-end spending bill just signed by President Donald Trump.

It appears there would be a $300 add-on for unemployed individuals.

But on top of that, there was a great amount of confusion for caregivers — whether they were working at the time or not — over whether they qualified for those benefits.

“We had a lot of caregivers — and some were eligible for unemployment, but there were many who were not — who were trying to file for unemployment. [They] hoped that they could earn money without working at all and exposing themselves to the virus,” Markowitz said. “And a lot of our caregivers are also staying at home because of personal issues and child care, just like anybody else. So we’ve been trying to crawl back up.”

The competition with hospitals

An additional issue for Family & Nursing Care has been luring caregivers back after they left for jobs in hospitals during COVID-19 spikes in their areas.

Hospitals, in some cases, are able to pay more than private-pay home care companies. Many are still looking for CNAs and other support staff, as hospitalizations have surged across the country. Currently, 75% of all inpatient beds in the U.S. are filled, with a significant portion of those being tied to the COVID-19 virus.

Even as care rushes more toward the home and companies like Family & Nursing Care offer hazard pay for workers dealing with COVID-19-positive patients, hospitals remain a formidable foe from a staffing-competition perspective.

Markowitz said he isn’t exactly sure how much more hospitals are paying caregivers — or if they’re paying them more at all. It’s also possible that caregivers enjoy the hospital schedule more.

As opposed to a home care position, where there could be 24 hours of cases available on one day and just four hours on the next, hospital shifts tend to be more regimented.

It could also be a perception issue, where health care workers feel as though the hospital is the best place for them to be. But that perception is likely being overhauled, especially during the COVID-19 crisis.

That’s a tailwind Family & Nursing Care is banking on moving forward.

“The tide is turning, and many caregivers already feel that way,” Markowitz said. “You have more control in a home environment, and you have more control over what hours you work.”

“In private duty, for instance, you can say ‘no’ to cases,” he added. “You can’t necessarily do that if you work in a hospital. So there’s definitely a sea change. … It’s definitely something that we’re seeing with our brand in our area.”

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Disease-Specific Training for Home-Based Care Workers Can Improve Staffing, Boost Quality

Personal care aides are tasked with caring for seniors with a variety of health conditions — many of which they are not properly trained in.

And without the proper training, those aides operate in highly stressful environments without the tools to care for their patients adequately. That can hurt health outcomes, increase the caregiver’s emotional burden and also make turnover far more likely in both home health care and home care.

“I think our research suggests that if you equip home care workers with the tools they need, they’re likely to feel more confident and more satisfied with their job,” Dr. Madeline Sterling, a health services researcher in the Division of General Internal Medicine at Weill Cornell Medicine, told Home Health Care News. “So, are there ways in which we could potentially empower these workers — and retain them?”

Of the over 6 million Americans that suffer from heart failure, many rely on personal care aides — both caregivers and home health aides — for support. But formal training in heart failure is not currently “widespread, formalized or required,” according to a recently published study from Cornell.

Cross-campus research from Weill Cornell Medicine and the ILR School led to researchers surveying 323 personal care aides about their training, job satisfaction and care of heart failure patients. The findings were startling in one way — and logical in another.

For instance, about two-thirds of the survey respondents had received none or just “a little” training in heart failure.

For those that had, however, their job satisfaction was 14% higher. They were more likely to feel prepared and comfortable, and they felt that they were performing their job well and providing meaningful assistance.

Of the home-based care workers that had received at least some sort of training in heart failure, over 70% felt confident providing that type of care. Just 30% of those that hadn’t received training felt confident.

“From our prior qualitative work, we’ve also found that a lot of workers would welcome training, especially in certain conditions that they find complex, whether that be heart failure, or other others,” said Sterling, who was a lead author of the Cornell study.

It’s not just that workers would perform better because they’re satisfied with their job.

Knowing what to do — and how to do it — also helps the care outcomes, in general.

The same goes for other diseases.

Dementia and Alzheimer’s disease, for instance, are widespread among home-based care beneficiaries, yet many personal care aides are still not always familiar with best practices when it comes to caring for those patients.

That’s why agencies like Tender Rose Dementia Care Specialists search for top-line workers in the field, and then train them with specific instructions for dealing with memory-impaired patients.

“The biggest difference, I see, between what we do, and what traditional home care does is … we get to know the person who has dementia,” Jim Kimzey, Tender Rose’s founder and CEO, told HHCN in November. “We engage them in activities that bring them joy and meaning, at whatever level they can still participate. What traditional home care tends to do is focus on the physical needs of the client.”

That keeps workers from trying to care for those dementia or Alzheimer’s patients in the same way that they would others. Caring for them in a non-specific way can not only be futile, but also counterproductive.

Training and staffing

Staffing is one of the most important issues facing the home health and home care industries right now. Whether before or during the COVID-19 crisis, agencies have had trouble with finding the right workers and keeping them.

“Could improvement in training — and policies or funding that allow for that training to occur — be one mechanism by which we improve workers’ overall experience and ultimately keep them in the field?” Sterling said.

In the home health industry, the turnover rate increased to 22.18% in 2020, according to the Home Care Salary & Benefits Report from the Oakland, New Jersey-based Hospital & Healthcare Compensation Service.

Caregiver turnover rates in home care are even worse. In 2018, the industry hit a record high with a 82% turnover rate. It dropped in 2019, but still exceeds 60%.

“This study is important because it demonstrates that investing in disease-specific training among home care workers – for example, in cardiovascular disease – may be a way to improve their experience caring for patients,” Sterling said. “These findings support the need for additional training requirements for those home care workers caring for patients with complex clinical conditions, like heart failure.”

Lack of training in cancer care

The same problems exist in at-home cancer care. The cancer care that personal care aides provide can be extremely taxing psychologically.

Still, the vast majority of home-based care workers are in the dark when it comes to the details on specific cancers, especially if they’re not medically trained.

New York City-based Belong.Life, a developer of social and professional networks for navigating treatments in various medical environments, is trying to change that with its Belong Cancer app, which aims to help caregivers with treating cancer patients in the home.

The app gives critical information and tips for home-based care workers, and also lends mental support to users. There are hundreds of thousands of users on the app, which operates in over 100 countries.

“It’s very important to support the caregivers, because without them, patients won’t do as well,” Dr. Daniel Vorobiof, the chief medical director of Belong.Life, told HHCN. “And if we can help the caregiver, to then help the patients, I think that’s a win-win situation. So that’s why we started this.”

The app is free and anonymous — and both patients and personal care aides can join the network. Then there are groups for different communities — for those with cancer, for those supporting loved ones and for professionals delivering actual care.

“The majority of caregivers are not well trained on how to manage specific problems in patients, and we provide them with that,” Vorobiof said. “And also, although caregivers are there for others, they should also be caring for themselves. And we need to give them that support.”

The massive success of the platform thus far is a testament to how wide-range of a problem under-training is among personal care workers, and how addressing it could provide tailwinds to at-home care agencies and associations moving forward.

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‘We’re Looking for the Best of the Best’: Why Dementia-Focused Home Health Provider Tender Rose Cherry-Picks Top Caregivers

As the number of Americans living with Alzheimer’s and other forms of dementia rises, more in-home care providers are rolling out specialized services lines focused on memory care and disease-specific needs. Some providers are even building their entire businesses around dementia.

One such in-home care company is Tender Rose Dementia Care Specialists, which has been the largest one-on-one dementia care provider in its market since 2009.

“All of our clients have dementia. All of our caregivers are highly trained memory care professionals,” Jim Kimzey, the company’s founder and CEO, told Home Health Care News. “Our mission is to improve the quality of life of people living with dementia and their families. It’s not just about keeping them safe and taking care of their physical needs.”

San Rafael, California-based Tender Rose’s service lines include personal assistance, companion care, “couples care” and live-in care. The company — launched by Kimzey and his siblings after their mother passed away following her own battle with Alzheimer’s disease — currently has eight locations across the state.

Nationally, there are more than 5 million people age 65 and older living with Alzheimer’s disease — a number that is estimated to grow by roughly 14 million by 2025, according to statistics from the Alzheimer’s Association. Alzheimer’s disease is the most common form of dementia, with others including vascular dementia, Lewy body dementia and more.

While dementia is prevalent across the general U.S. population, it’s especially present in the home-based care space. One home care provider, for example, recently told HHCN that almost 80% of its clients have a primary or secondary diagnosis of Alzheimer’s or another form of dementia.

As the CEO of Tender Rose, Kimzey believes that there’s value in a company that specializes in delivering dementia care in the home setting. When it comes to caring for seniors with dementia, Tender Rose takes what it calls a “person-centered, activity-based care approach.”

“The biggest difference, I see, between what we do, and what traditional home care does is … we get to know the person who has dementia,” he said. “We engage them in activities that bring them joy and meaning, at whatever level they can still participate. What traditional home care tends to do is focus on the physical needs of the client. Everything is about activities of daily living (ADLs) or instrumental activities of daily living (IADLs).”

One example of keeping a person with dementia engaged, Kimzey said, might be introducing an activity that’s both task-oriented, but one that also allows the individual to flex his or her “creative muscle.”

That kind of approach is generally far more effective than dictating commands or carrying out a random assortment of activities to simply pass time, according to Rachael Wonderlin, a dementia care consultant and author.

“I’m thinking something small, like bringing a little wooden birdhouse to your client’s home and saying, ‘Hey, we’re going to be putting this out in the garden. I could really use your help painting this,’” Wonderlin told HHCN. “That’s a whole hour-long activity where they’re engaged, doing something fun and purposeful. There’s a clear reason why they’re doing it.”

Although home care providers frequently serve individuals impacted by dementia, their expertise is sometimes limited. In fact, in cases where a senior living with dementia doesn’t suffer from any physical limitations, traditional in-home care can fall short.

“One of the things that happens is the person with dementia may actually be physically healthy and they don’t need that much help with ADLs,” Kimzey said. “If a traditional caregiver walks through the door and thinks, ‘My job is to help you when you need to go to the bathroom, bathe, eat or get dressed,’ the person with dementia is like, ‘I don’t need help with any of that. You can leave.’”

The majority of Tender Rose’s clients have had previous bad experiences with traditional home care agencies or with the private caregivers who they’ve hired. Specifically, issues arise when the caregiver hasn’t received training to deal with dementia, according to Kimzey.

“The caregiver who isn’t trained in dementia care — one who doesn’t really focus on quality of life or person-centered activity-based care — has a much higher probability of triggering agitation that creates behavioral problems,” he said.

While many companies have dementia-education programs for their caregivers, these programs are not always comprehensive.

“Giving one day, or half of a day, to a slideshow about dementia is not enough to actually teach people and encourage a dementia-positive environment — or even the ability to market [that an agency has] trained in dementia care,” Wonderlin said. “A two-hour presentation on dementia is not enough for somebody to be able to go into a situation and provide care.”

To that end, Tender Rose trains its caregivers based on methods popularized by Teepa Snow, the owner of Positive Approach to Care and a thought leader in the dementia care space. Positive Approach to Care is an Efland, North Carolina-based company that provides dementia care training, services and products across the globe.

Snow’s methods emphasize the importance of in-person and hands-on training that utilizes roleplaying and interactive discussions.

For Tender Rose, training is only a small part of differentiating itself from traditional home care providers. Tender Rose is also highly selective when it comes to recruiting its caregivers.

“Our labor strategy is to cherry-pick the best dementia caregivers in the industry,” Kimzey said. “We’re looking for the best of the best. We’re not looking for housewives who want a part-time flexible job to get a little extra spending money. We’re looking for professionals who need to work, who love doing dementia care and are good at it.”

In order to retain caregivers, the company offers a higher-than-average pay rate of $23.62 an hour. In comparison, caregivers earned a median hourly wage of $12.80 in 2019, according to PHI data.

Additionally, Tender Rose’s benefits package for caregivers includes health insurance, 401(k) plans, paid-time off and consistent hours with long-term clients.

For providers looking to truly take on dementia care, Kimzey reminds them that it’s crucial to constantly work to improve these care services.

“No matter how good you are at dementia care — you still have room for improvement,” he said. “We’ve been doing this for 11 years and we think that we do it better than just about anybody. And we aren’t nearly as good as we’re going to get. Don’t ever get complacent about how good you’re doing.”

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Why In-Home Care Agencies Need to Rethink Their Staffing Strategies

Home-based care agencies have had to lean on technology during the COVID-19 crisis, whether they liked it or not.

In some cases, that meant conducting remote visits, even if they weren’t reimbursable under Medicare rules. In other cases, it meant having staff work from home in this new, long-term COVID-19 reality.

But telehealth platforms are not the only sort of technology that home-based care providers have benefited from during the COVID-19 crisis. In fact, providers have been leveraging online tools to curb one of the biggest challenges in the industry before the pandemic even existed: staffing.

“We cannot keep thinking about staffing in traditional ways and expect that, as an industry, we’ll see something different,” John Olajide, the president and CEO of Axxess, told Home Health Care News.

Dallas-based Axxess is a home health technology company that develops cloud-based software solutions for providers. Olajide was recently elected to the National Association for Home Care & Hospice (NAHC) board of directors, with his stated goal being to further aid providers with their transitions toward technological savviness.

Care challenges related to COVID-19 are the reason that 37% of surveyed agencies believe their revenue is down in 2020, according to a joint Axxess-Home Health Care News report. Over 30% of those surveyed agencies point directly to COVID-19-related staffing challenges as the cause of revenue loss.

Staffing challenges can often be mitigated by technology, however.

On Axxess’ end, it’s Axxess CARE solution finds qualified, vetted workers in areas where agencies have plenty of referrals, but not enough workers. Launched in 2017, Axxess CARE helps agencies post case times and locations on the platform, allowing clinicians to view and sign up for jobs they’re able to take.

After the job is completed, clinicians then receive payment through the CARE tool.

Generally, it’s a way for agencies to turn down fewer referrals while simultaneously finding the right aides looking for work, according to Olajide, who noted the tool has gained popularity during the ongoing public health crisis. Even if providers have sufficient full-time staff, Axxess CARE can help them fill in the blanks for cases they cannot manage in-house.

“It’s really a staffing and scheduling solution, where organizations can extend their ability to reach people and get additional staff to see their patients,” Olajide said.

Illinois-based Serenity Home Health, for instance, was able to grow its business and scale operations by using technology to help with staffing. Specifically, it used the tool to expand its footprint to 20 new zip codes in just six months.

Over 34,000 in-home care visits have been arranged through Axxess CARE thus far, according to Axxess.

Moving forward, staffing will no doubt continue to be a pain point for a great deal of agencies across the U.S. But home care operators need to understand that the situation won’t get better magically, according to Olajide.

Right now, where there are plenty of people looking for more work and a slew of agencies in every region looking to staff cases, there should be a way to bridge the gap.

“The marketplace just needed to be optimized,” Olajide said. “And COVID-19 was chaotic enough of a situation to make people really recognize that within a situation like this, you need to leverage technology a lot — and more effectively — to optimize this marketplace and match caregivers with the right skills, at the right times, with patients that need care.”

Agencies continuing with the same solutions to manage a staffing problem that never goes away is just like traditional taxi companies wondering why they’re getting less riders with an inferior product, he noted.

The staffing issue will be especially important when winter rears its head. Finding more capable workers will be necessary as flu cases coincide with a likely surge in COVID-19 cases, which will put a lot of pressure and strain on agencies and their staff.

“The data we’re looking at, it shows us that this is a marketplace-optimization challenge where we can leverage technology to really address both the demand and supply sides of the issue,” Olajide said.

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Home Care Careers ‘Are Suddenly on the Map,’ But Recruiting Remains a Challenge

Recruiting and retention in both the home health and home care industries has always been an uphill battle for providers.

In spring, operators had hoped that the job market’s volatility during the COVID-19 crisis would help on those fronts. With tens of millions of individuals forced out of work, they thought, the home-based care labor pool was likely to grow.

There have been some positive signs for recruitment and retention. For example, the Indeed Hiring Lab previously found that home-based care was no longer a job seeker’s market, suggesting agencies were finding the workers they needed.

Anecdotal conversations that Home Health Care News has had with providers — and more recent data from myCNAjobs — is now painting a different picture.

“I think we have to respectfully disagree with that point, because it is challenging for us to find caregivers — and very challenging for us also finding the right one,” Ryan Iwamoto, the president and co-founder of 24 Hour Home Care, told HHCN in September. “That has been probably the biggest challenge that we’ve had.”

24 Hour Home Care is an independent, non-medical home care provider with 20 locations spanning California, Arizona and Texas. Despite its consistent growth and success, recruiting and retention has remained a pain point.

That’s also reflected in a recent, pre-election survey conducted by myCNAjobs, a professional caregiver network that works with home care and home health workers, as well as providers in both fields.

Of 282 respondents in the myCNAjobs’ survey, the majority of agencies — nearly 60% — said they were struggling with recruiting. Over 70% of the agencies said they had recently turned down cases because they were unable to staff them.

Despite more workers looking for jobs in 2020 than any time in recent history, 87% of respondents said COVID-19 has made recruiting harder than it was before.

“COVID will reshape the labor market in many industries for quite some time,” Brandi Kurtyka, the CEO of myCNAjobs, said at the Home Care Association of America (HCAOA) Virtual Leadership Conference in October.

Riding the momentum

Even if recruiting and retention remains an issue for home-based care agencies, they have had the luxury of gaining recognition from political figures in the election cycle and during the COVID-19 crisis that they never have gotten before.

On his end, for example, presidential hopeful Joe Biden announced in July a $775 billion plan to boost the caregiver economy and support in-home care providers.

“One positive thing that I think came out of COVID — and I think this is just a real positive thing for the whole industry — is home care careers are suddenly on the map,” Kurtyka said. “Senior care just got the biggest ‘Got Milk’ campaign that we’ve ever seen.”

Before COVID-19, 19% of caregivers were considering leaving the home care industry, according to myCNAjobs. Only 22% of caregivers saw themselves continuing or exploring a career within home care.

But that could start to change, according to Kurtyka.

“I think we’re starting to see these numbers shift,” she said. “I think it’s really interesting to be a home care agency right now. You have a strong, strong story to tell.”

Home-based care providers have been able to — or are expecting to be able to — gain new clients after COVID-19 has hit institutional-based settings hard. They may start seeing the same from workers.

In other words, health care workers who didn’t used to find home-based care attractive from a career standpoint may start reconsidering.

Finding workers from other industries

For agencies that are finding workers coming from different industries, they’re beginning to realize trends in their hiring practices.

Amy Smith, the corporate VP of revenue cycles at Alternate Solutions Health Network, has had success with hiring restaurant workers on the company’s back-end, for instance.

“After we had already had them on staff, we realized, ‘Oh gosh, why do they work differently?’” Smith told HHCN. “And they would reference skills that they acquired from working as a server.”

Dayton, Ohio-based Alternate Solutions Health Network is a provider of home health care and one of the largest post-acute solutions operators in the country.

When COVID-19 got bad, so did unemployment for restaurant workers. Of the 20.5 million people who lost their jobs in April, 5.5 million of them were from the bar and restaurant industry. While a considerable amount of jobs have been added back since then, the number is still far off from that of pre-pandemic levels.

In cases where a former restaurant worker made it into home care, their restaurant skills enabled them to transition more seamlessly, strapped with the ability to multitask and start certain projects while in the middle of others.

“If an applicant expresses the ability to multitask, regardless of their background, regardless if they’ve ever worked in health care before, it’s great,” Smith said. “It’s about their ability to start, pause, start something else, pause, and go back to something that was started weeks ago.”

Alternate Solutions Health Network wasn’t as interested in hiring early on in the COVID-19 pandemic because its volume had dropped. Now that volumes have picked back up again, the unemployment rate has helped it fill open positions.

The hiring experience during COVID-19 has reaffirmed for Smith and her organization that they need to keep an open mind during the process.

“There are folks who interview who have a specific medical records field degree, and those people aren’t necessarily successful in this job,” Smith said. “They’re not as successful as somebody who’s willing to just work hard. So don’t be discouraged by that lack of experience.”

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Home Health Turnover Rate Hits 22.18%

Home health industry turnover rates have once again worsened in 2020, especially for front-line worker positions.

That’s according to the latest Home Care Salary & Benefits Report from the Oakland, New Jersey-based Hospital & Healthcare Compensation Service, which provides salary and benefits studies for the health care sector. The annual report is published with the National Association for Home Care & Hospice (NAHC).

Released Monday, this year’s Home Care Salary & Benefits Report shows that the turnover rate for all home health employees hit 22.18% in 2020, a slight increase compared to 2019’s rate of 21.89%.

At 36.53%, home care aides had the highest turnover rate of all home health positions in 2020. That number is a sharp increase compared to last year, when the Home Care Salary & Benefits Report had home care aide turnover at 25.36%.

The turnover rates for licensed practical nurses (LPNs) and registered nurses (RNs) were also relatively high in 2020, at 34.30% and 25.85%, respectively. With a rate of 13.88%, turnover for therapist positions remained relatively low, in contrast.

Top-level executives had a turnover rate of 17.54%, according to this year’s report from the Hospital & Healthcare Compensation Service and NAHC.

The 2020 Home Care Salary & Benefits Report is an analysis and compilation of statistics from 1,049 home health agencies, which combined to submit data on more than 43,200 employees working across the United States. Of the home health agencies that participated in the report, 54% were for-profit businesses, with 29% being nonprofits and 7% being hospital-based agencies.

While home care aides had the highest turnover in 2020, they also saw the biggest bump to their base pay. From August 2019 to July 2020, home care aide base pay increased by a national average of 2.78%.

In comparison, the average actual base pay for management positions, RNs, therapists and social workers increased by 2.66%, 2.71%, 2.63% and 2.645, respectively.

In addition to turnover and salary information, the Home Care Salary & Benefits Report provides information on home health workers’ average caseload — or the average number of patients assigned to a specific employee at any given time.

RNs and LPNs had average caseloads of 21.88 and 22.63, respectively. Meanwhile, home care aides, physical therapists and occupational therapists had caseloads of 14.91, 19.76 and 19.06, respectively.

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Nearing 2021 Consolidation Strategy, Trinity Health At Home Keeps Focus on Patient Care

A member of Catholic health system Trinity Health, Trinity Health At Home currently ranks as the eighth-largest home health provider in the country. It will gain even more market share next year, thanks to an ambitious plan to formally consolidate Trinity’s national network of home health agencies with regionally owned affiliates.

Despite the advantages of scale, Trinity Health At Home and its sister agencies continue to operate through various hardships caused by the COVID-19 virus, Mark McPherson, the organization’s interim president and CEO, told Home Health Care News in September.

Those challenges include a shortage of experienced nurses, restricted access to long-term care facilities and more.

“We want to be able to take on new business, but we’re limited by what we can produce, what we can accommodate within our nursing staff,” said McPherson, who also serves as interim CEO of Mercy Home Health and as CFO for the Trinity Health system. “Nursing, in particular, is the area where we are struggling the most to find adequate staff.”

The demand for nursing positions has grown across all health care subsectors, but there has long been an especially high demand in the home-based care arena. That demand has only accelerated due to the COVID-19 pandemic, with most hospitals and health systems looking to shift care into the home.

Overall, the U.S. Bureau of Labor Statistics projects a 14.8% growth in registered nurse (RN) positions through 2026.

While Trinity Health At Home is looking to hire more nurses broadly, the bulk of its focus is on finding and keeping veteran home health clinicians, McPherson said.

“In home health care, it’s difficult to take somebody who’s a new grad, right out of school, then put them in the field,” he said. “There’s just simply too much of a learning curve. There’s just not enough people to bounce issues off of when you’re out there working by yourself.”

Avoiding a ‘bidding war’

With a dearth of home health nurses nationally, McPherson has Trinity Health At Home and other Trinity home health agencies focused on retention. Part of that has meant supporting staff during the public health emergency and rewarding them with financial bonuses whenever possible.

“We’re going to have to be willing to invest in some additional bonuses or forms of compensation to capture those experienced nurses and make sure we keep them,” he said. “Unfortunately, it’s going to be a bit of a bidding war until there’s more of a supply of experienced home health nurses out there.”

In terms of other coronavirus-related challenges, Trinity Health At Home and its peers also faced decreases in patient volumes in spring.

Securing personal protective equipment (PPE) was likewise difficult in the early going, according to Ruth Martynowicz, who serves as interim COO of both Trinity Health At Home and Trinity Health Mid-Atlantic’s Mercy Home Health.

“The biggest problem back then, which I’m sure you’ve heard over and over again, was the lack of readily available PPE,” Martynowicz told HHCN. “With volume, there was a huge impact in March and April, in that patients did not really want to go into the hospitals or have people coming into their homes.”

For the most part, volumes have returned to “business as usual” for Trinity Health At Home and Mercy Home Health. In some regards, patient flow has actually improved compared to pre-pandemic levels, as some referral sources are turning to home health care more frequently.

But a persistent pain point from spring to fall has been access to patients in skilled nursing facilities (SNFs), continuing care retirement communities (CCRCs) and other congregate settings.

“The hospitals are bouncing back, and physician offices are actually thinking of us more frequently,” Martynowicz noted. “The biggest barrier — though this is getting better, too — is in the area of [facilities]. Skilled nursing facilities, CCRCS … have taken longer to come back. They want to make sure that anyone that goes into their building doesn’t have COVID, that they’re using the appropriate PPE.”

Coming together

Aside from the COVID-19 virus, McPherson and Martynowicz are gearing up for the consolidation of all national and regional Trinity home health locations into one entity. In addition to Mercy Home Health, for example, those regionally owned home health organizations include Trinity Health Mid-Atlantic’s St. Francis At Home and St. Mary Home Care.

Overall, there are 15 different entities that will collectively be known as Trinity Health At Home when the consolidation takes place in July 2021.

“Right now, Trinity Health At Home, I think, is around the eighth-largest home care provider in the country,” McPherson said. “When we consolidate all those entities, we should move up to around No. 5, in terms of size.”

Once that consolidation is complete, Trinity Health At Home will have locations in 13 different states, stretching from California in the West, to Florida in South and New York in the Northeast.

Although next year will be the official “year of integration,” McPherson said all of Trinity’s nationally owned and regionally owned home health operations have started coming together to communicate and share best practices. 

“There are some things that Mercy Home Health does better than Trinity Health At Home,” he added. “There are some things that Trinity Health At Home does better than Mercy Home Health. We’re taking the best practices of both putting them together.”

Based in Livonia, Michigan, the overarching Trinity Health includes 92 hospitals and 100 continuing care locations, including PACE programs and senior living facilities, plus home health and hospice services. In total, its continuing care programs provide nearly 2 million visits, annually.

Trinity Health has annual operating revenues of about $18.8 billion and assets of $30.5 billion, with the organization returning about $1.3 billion to its communities in the form of charity care and other benefit programs.

‘We’re doing our best to prepare’

During the spring surge, Trinity Health At Home and Mercy Home Health collectively recorded about 400 COVID-19 cases among patients. For context, the two organizations jointly have a combined census of about 7,000.

When HHCN connected with McPherson and Martynowicz in September, Trinity Health At Home and Mercy Home Health collectively had about 130 cases. Even with cases spiking across the country, that figure has held steady throughout October, the executives confirmed on Wednesday.

Over the last week, the U.S. has averaged about 59,000 new cases a day, with hospitals in some states once again approaching full capacity, reports The New York Times. The daily total could soon surpass 75,687.

“We’re doing our best to prepare for [a fall surge],” McPherson said. “We have an ample supply of PPE, and we’ve never really gotten away from conserving PPE, impressing upon everybody that we need to use the right mask for the right situation.”

To mitigate some of the pandemic’s challenges and the nursing shortage, McPherson said he hopes that lawmakers and the U.S. Centers for Medicare & Medicaid Services (CMS) will come together to create a pathway for telehealth reimbursement in home health care.

“Telehealth also allows us to use the same amount of nursing resources to treat more patients,” he said. “And that’s what we need to be able to do.”

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Arosa+LivHome Doubles Down on Workforce Investments, Launches Emergency Fund for Caregivers

Earlier this spring, a home care worker for Arosa+LivHome and her husband were on the brink of eviction, largely due to the financial strain caused by the COVID-19 pandemic and other uncontrollable circumstances.

To complicate the situation further, the home care worker was pregnant, Arosa+LivHome CEO Ari Medoff told Home Health Care News. In all likelihood, the loss of the couple’s home would endanger the unborn child, he said.

“One of our caregivers was pregnant and facing a devastating amount of distress, putting her pregnancy at risk,” Medoff recounted. “But partly thanks to a new grant program we started this year, she was able to stay in her home and have a successful delivery, a healthy baby.”

Formed in 2018 after Bain Capital Double Impact acquired and combined two regional health care companies, Arosa+LivHome has grown into a diversified home-based care enterprise with operations in seven states and counting.

Arosa+LivHome’s core business revolves around non-medical home care, hospital-to-home transitions and supporting clients with complex conditions. The company also recently dramatically expanded its care management capabilities following its acquisition of Illinois-based Lifecare Innovations.

From the outset, Medoff sought to differentiate Arosa+LivHome from its competitors by investing in workforce development programs, offering above-average pay and rolling out innovative employment benefits not normally found in the home care world. The grant program that helped the pregnant caregiver — Arosa Grant Circle — is a reflection of that mission.

“In the home health care business that we’re in, there are a lot of traditional benefits that don’t really benefit our team members,” Medoff said. “For example, 401(k) plans are important, but it is difficult to plan 20 or 30 years into the future if you can’t pay rent this week.”

Arosa Grant Circle

Launched in late April, Arosa Grant Circle is an emergency fund for Arosa+LivHome caregivers and office staff.

Medoff — who previously worked in private equity and investment banking before entering the home care space in 2014 — had been looking for ways to implement a “rainy day fund” for years. He finally found one in Canary, a New York City-based startup that helps companies of all shapes and sizes craft financial safety nets for their workers.

“The issue has always been that emergency funds are much more geared toward very, very large organizations,” Medoff said. “If you’re Home Depot or General Electric, you have thousands of employees [to help grow funds], plus the resources to navigate all the tax and legal complexities. It’s difficult to serve small or medium-sized businesses with this type of service.”

Medoff was first introduced to Canary after meeting CEO Rachel Schneider at a 2019 event hosted by HCAP, a mezzanine lender out of San Diego and one of Arosa+LivHome’s financial partners.

“We immediately started talking about how what Canary was building could help us,” Medoff said.

Powered by Canary, Arosa Grant Circle allows employees facing financial hardship to submit a request for a no-strings-attached grant, usually in the range of $500 to $1,000. Requests are kept anonymous, ensuring that there is no favoritism in the review process.

“There’s an important degree of fairness and consistency that Canary brings to the table,” Medoff said. “That’s the way it should be, so that it’s not, ‘I really like Mary, so we’ll give her money. I don’t like Sally quite as much, so we’ll give her a little bit less.’”

So far, Arosa+LivHome has approved more than a dozen grants, the CEO noted.

In another example of how employees have used the fund, one caregiver was unable to work because eight people at her children’s day care had been exposed to the COVID-19 virus. Although that caregiver had to quarantine to protect Arosa+LivHome’s clients, she was able to make ends meet until safely restarting home visits.

A 21st century social safety net

Before becoming Canary’s CEO, Schneider worked at the Financial Health Network, a nonprofit dedicated to improving American’s financial health through public policy and research. She also co-authored the book “The Financial Diaries: How American Families Cope in a World of Uncertainty.”

Canary is a relatively new startup, Schnieder told HHCN. It went into product development in early 2019, with “measured” plans to pilot its platform with “a very small number of companies” by the end of this year.

But the COVID-19 pandemic accelerated those plans.

“We were going to bring on about one company a quarter in a really deep, partner-piloted way,” Schnieder said. “And then it became clear that we had to move a lot faster.”

Before the ongoing public health crisis and corresponding economic downturn, about half of Americans were already unable to come up with at least $400 if they had an emergency, according to Federal Reserve statistics. About two-thirds hadn’t saved enough cash to withstand a sudden disruption to their income.

Despite government relief efforts, COVID-19 has drastically increased the number of Americans facing financial hardship. While the U.S. economy added 1.4 million jobs in August, 1.7 million in July and 4.8 million in June, overall payroll numbers are still more than 11 million jobs below pre-pandemic levels.

“We support companies and workers by giving them new resources in moments of need,” Schneider said. “We think that access to emergency funds is a core part of the 21st century social safety net.”

Currently, Canary only works with domestic companies, though it hopes to eventually become a solution for businesses around the world.

In terms of financing a fund, money can come directly from a company’s PnL, from individual employee contributions or from dedicated fundraising efforts. One a fund is created, companies can either hold on to money themselves or let Canary manage it “in a few different ways,” Schneider said.

“Our goal is to make this really easy for a company,” she added. “If you want to start a fund, reach out to us. We have an initial conversation about your goals, how many employees you have and what your expectations are. We have a set of default program choices that you can then adopt.”

‘Getting punched in the nose’

Arosa+LivHome felt the brunt of COVID-19’s impact in early spring, Medoff said. After the virus began spreading across the U.S., Medoff and his team quickly began sourcing personal protective equipment (PPE) and putting the right infection control protocols in place.

“The impact of the virus has come in some pretty distinct phases,” Medoff recalled. “March and April was the ‘getting punched in the nose and trying to figure things out’ phase.”

At no point did Arosa+LivHome ever think about shying away from COVID-19-positive patients, he said.

While the Arosa Grant Circle is in line with Medoff’s existing organizational vision, it can also be seen as a way to attract and retain caregivers at a time when front-line health care workers are at a premium.

Arosa+LivHome plans to continue the grant program moving forward. It additionally expects to continue growing, building off of its eight acquisitions since 2018.

That shouldn’t be too hard now that the M&A landscape is starting to heat up again. The heightened focus on home-based care and all of the setting’s advantages will likewise help drive Arosa+LivHome’s growth in months to come.

“We saw very few incidents of the virus from March through late June, which I think really speaks to the safety of home care and personal care services,” Medoff said. “It’s just a model that has fewer infections and opportunities for mass outbreaks.”

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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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Encompass Health CEO Mark Tarr: It’s in Every Company’s Best Interest to Make Diversity a Priority

Across the U.S., ongoing protests against police violence toward Black Americans and other people of color have caused many companies to take a closer look at issues pertaining to workplace diversity and inclusion.

For some companies, this time has been a call to action, with many announcing plans to develop initiatives aimed at addressing inequality within organizations.

One example is Birmingham, Alabama-based health care giant Encompass Health Corp. (NYSE: EHC). The company’s president and CEO, Mark Tarr, recently joined CEO Action for Diversity & Inclusion, a coalition of more than 1,000 CEOs pledging to advance workplace diversity and inclusion.

Encompass Health’s national footprint includes 245 home health locations, 83 hospice locations and 136 hospitals.

Home Health Care News recently caught up with Tarr to discuss Encompass Health’s larger diversity and inclusion efforts — and how the Black Lives Matter movement has impacted the company.

Below are highlights from HHCN’s conversation with Tarr, edited for length and clarity.

HHCN: Let’s start generally. Can you recap Encompass Health’s highlights and challenges since the start of the year? Specifically, the home health and hospice side of the business.

Tarr: First of all, we started off the year really well, whether it was on volumes or — on the home health side — implementing strategies for the Patient-Driven Groupings Model (PDGM). 

Then came the month of March — and the low point in April [in terms of] the impact from the pandemic and volume drop. The first three-fourths of the first quarter were good in terms of volume. We thought it was going to be a great year. Then this unknown, unplanned thing called COVID-19 hit, and we saw volumes drop. We subsequently saw the volumes start to pick back up at the end of April.

Now, we’ve seen our episodes start back up to pre-pandemic levels.

Both our management teams and the caregivers in the field have worked extremely hard to make sure they’re taking care of all patients in what has been a very challenging setting. 

We’re glad to see the volumes have recovered on the home health side. As far as hospice, we just didn’t see the variations and volatility. We hope we’re over the worst of it.

But certainly, the pandemic is still impacting business out there.

We have seen a shift in patients and their willingness to want to be treated. There was a time period where they were reluctant to let caregivers into their homes for fear of contracting the virus themselves. We’ve done a lot of education and communication with patients in terms of our preparations, in terms of what measures we’re taking with our own staff to prevent exposure and the spread of the virus. 

Encompass Health joined a coalition pledging to advance diversity and inclusion in the workplace. You’re one of more than 1,000 CEOs that have come together for CEO Action for Diversity & Inclusion. Why join that coalition?

I think it’s a good fit with the values and initiatives that we have within Encompass Health. One of our core values is setting the standard. I think it’s important for me as the CEO of our organization to set the standard — and that’s why I felt committed to signing on to this pledge.

It puts us in a nice company with other major corporate organizations. There is power in numbers. You have 1,000-plus companies, and I’m sure that number is growing every day now, as other CEOs evaluate this opportunity. 

This is all happening as we are seeing a larger shift toward greater racial equality, with the Black Lives Matter movement leading the charge. How is this impacting various parts of your company?

We treat a diverse patient population. We are in a wide swath of states. We certainly have a diverse staff across our 43,000 total employees, and that certainly covers home health and hospice as well. That diverse group has obviously been impacted.

I think that this is an opportunity for us.

We can all do better in terms of trying to understand differences and finding commonalities to better our organization.

It’s a good time to look inward. Clearly, the tragic death of George Floyd, which many of us saw on our TV screens, was somewhat of a call to action. I think that it was a prime opportunity for us to better understand what was going on out there in many of our communities. That’s what we’re doing as an organization.

The company is pledging to cultivate a workplace where diverse perspectives and experiences are welcomed and respected. What does this mean for Encompass Health, and what specific plans do you have in place to accomplish this?

Inclusion and diversity have been a priority for our organization for a long time.

We’ve had an inclusion-and-diversity council, which is made up of a number of our staff representing both of our operating segments, as well as our home office. We have a large geographic representation on that council, too.

We’ve used that council to provide feedback to the organization and identify steps we can take to better highlight and implement inclusive actions within our company. We’ll continue to use that diversity council as we go forward.

This has given us an opportunity to look at what we have done over those 10 or 12 years that the council has been in existence. What can we do better? What best practices can we take up as we further investigate and read about what other companies are doing?

Have there been any initiatives, best practices or policies that have sprung from the company’s diversity council that you would want to highlight?

The council has helped us develop an inclusion-and-diversity plan for this next year. The plan is really focused on four areas: workforce, patient experience, supplier diversity and community partnerships.

To give you just a little bit more detail, we have provided scholarships, for example. We have affiliations with five universities and have worked with them to support minority-endowed scholarships for deserving students entering health professions.

In 2019, we were recognized by the Women’s Forum of New York for raising the bar for female board representation. This award went to directors and boards that have at least 30% female representation.

We have an annual partnership with a local school here in Birmingham that has a diverse student population. We have created internship opportunities for these students. They have an opportunity to come and work within different departments in our home office here in Birmingham and get exposed to various aspects of what we do here, whether it’s finance and accounting, human resources, or any of the functions that we have here that help support our company.

Those are just a few of the things that we have done. It’s a comprehensive program, and it’s one that we continue to find opportunities to add to every year.

Encompass Health has long been recognized as a great place to work. What was the company already doing when it comes to diversity?

Well, one thing that happened recently, as part of the Black Lives Matter initiatives, is we have been developing a series of videos that we refer to as “Encompass Health Today.” Our employees will share situations that happened in their lives around racism and how they’ve handled it. We want to create these dialogues so that they can be used as tools out in the field. 

Some call them “uncomfortable conversations,” but they can be very constructive, particularly given the challenges in and around diversity. We released two of the videos now. We have others in the works, and these will be used to have positive dialogues around this sometimes difficult subject matter. 

In addition to promoting these important discussions, what other goals does Encompass Health have when it comes to addressing inclusivity?

Certainly, one of our biggest goals is to increase the strength of the diversity at the leadership levels. We have been aggressively doing that for the past several years. We think we have a lot of opportunities there, whether that is through just organic succession planning or making sure that there are opportunities for employees to participate in leadership development programs.

It’s both a short-term and a long-term goal because it can take a while, particularly if you’re doing it internally.

Our readers always want the “bottom line” connection to a given topic. How does diversity impact a provider’s financial well-being or overall business model? 

I think there are some well-publicized studies that show how companies that build and promote a diverse workforce also do well financially. 

We are no different. We see that as being very important to our overall success, whether that’s through financial growth or otherwise.

If we can build and continue to build upon the diversity that we have within our organization, I think it can help our recruitment and retention efforts, for instance. You can work better as a team because you’re more diverse and have different viewpoints to accomplish a collective goal. I think the patient benefits from that — and the organization benefits from that.

It’s in every company’s best interest to make diversity a priority. It certainly pays off in terms of shareholder value. I think it’s important for both the quantitative and qualitative goals that we set forth.

Shifting gears, I know you just talked about Encompass Health’s plans and goals for the remainder of the year during the Q2 earnings call, but can you close by summarizing how you see the home health and hospice segment performing in the final five or so months of 2020 and into 2021?

We withdrew our guidance, so I can’t say anything relative to future guidance.

Generally, we think that the demand for home health and hospice services is only going to grow in the future. 

We have grown aggressively in the past when you look at our ability to acquire new home health and hospice agencies. We certainly plan on doing that moving forward. One area of focus is what we call our “overlap markets,” where we have home health in addition to one of our rehabilitation hospitals. We’re very committed to that.

More and more patients are going to want to be treated in the home setting. It’s the low-cost setting. There will be an interest from the payers to see what all can be done in the home setting from a care standpoint.

We are in this for the long term. We think that PDGM will likely create opportunities where smaller, struggling agencies are looking for someone to acquire them, so they can be part of a larger-scale organization. That’ll be an opportunity for growth for Encompass Health going forward.

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Finding the Right Employee Compensation Model Under PDGM

Mapping out a clear pay structure and expectations for field staff is imperative for success in home-based care, particularly as margins become slimmer and the Patient-Driven Groupings Model (PDGM) takes hold.

Compensation structure is one of the biggest influences on providers’ margins — if not the biggest. With that in mind, providers need to find one model that works for both employees and their bottom line.

“What agencies want is a pay structure that will support reasonable margins on care,” Sharon Harder, president at C3 Advisors, said Wednesday at the National Association for Home Care & Hospice (NAHC) 2020 virtual Financial Management Conference. “This is really important under PDGM — we no longer have those therapy thresholds that are going to pay us for volume. And so we’re going to have to be really careful about managing our margins.”

C3 Advisors is a consulting firm focused on post-acute health care compliance.

At the end of the day, a pay structure should address four things, Harder explained.

On a basic level, a pay structure should reward outcomes and efficiency rather than visit volume. It should additionally reward the best employees and foster retention, while also creating incentives for good documentation practices.

Pay structures also need to be compliant with applicable wage-and-hour laws.

“We have to remember here, the compensation program is going to create financial incentive for employees, and they’re going to work to meet those incentives,” Harder said. “So when we wanted them to do a lot of visits, that’s what they did. Now, what we’re really looking for is far more efficiency. So [that’s] what we want to focus on [with those four things].”

But if providers are not cognizant of the fourth aspect — labor law compliance — the other three may not end up mattering at all.

“The goal is to find a structure that everyone likes, but then you also have to find a structure the government likes,” Robert Markette Jr., an attorney for Hall, Render, Killian, Health & Lyman, said in a presentation alongside Harder at the Financial Management Conference. “Because everything we do, we have to please the government and follow those various state and federal rules.”

Hall, Render, Killian, Health & Lyman is one of the largest health care law firms in the country.

Otherwise, non-compliance could result in very expensive costs on its own.

The different pay options

There are various ways to pay staff — and each has its own perks and pitfalls.

For starters, there’s a pay-per-visit rate, an hourly rate and a salary. 

In 2020, pay per visit can be a compensation model fraught with challenges, Home Healthcare Solutions President J’non Griffin said Wednesday on the same panel.

Home Healthcare Solutions works with home health agencies on coding, compliance and maximizing reimbursement, among other areas.

“It’s almost like administrators think that [pay per visit] is an easy way to pay,” Griffin said. “But if you really think about what pay per visit is, it is paying for a task, and we have moved past paying for a task in PDGM. We’re actually looking for quality, patient-centered visits — so that may not be our best option.”

If a pay-per-visit model is adopted, it’s also worth considering travel. One clinician could make six visits in a relatively short amount of time, while another may have to travel hundreds of miles to get to six different visits, Griffin explained.

That means an agency has to work out how they’re going to pay an employee for that traveled time.

An additional hurdle is telehealth visits, particularly during the COVID-19 crisis, as they’ve grown exponentially. Home health providers still don’t get paid for telehealth visits, but clinicians are still putting in that time, which means that those providers need to develop a strategy for how to pay for telehealth and in-person visits.

“For [pay per visit], the focus is on expediting the visit and not necessarily on what the patient needs,” Griffin said. “A lot of times, you have nurses or therapists that just go in and do the bare minimum and really don’t delve into what else may be happening with the patient. So pay per visit, a lot of times, is convenient for payroll purposes — but it does have a lot of unintended consequences.”

Hourly rates are the easiest to set up from a payroll perspective on the administrative end. There are usually a different set of rates based on experience and also for things like working holidays.

The difference in an hourly rate in home health, however, is that it relies on an honor system of sorts. Because clinicians are not working in an office environment, providers need to rely on a trust between the administrators and clinicians in order for the hourly rate to be effective.

That includes reporting hours on the road, hours at the home and hours doing documentation.

That can make things dicey when it comes time to pay overtime. If there is a no overtime policy but a clinician claims they’ve worked 40 hours per week in three days, an agency needs to decide if that means that the employee is done for the week.

On the other hand, if there is overtime — and a clinician racks up a lot of hours on their timesheet and continues to work — that could end up being harmfully expensive for the agency.

“There is no built-in efficiency at all on the hourly rate — it’s usually the opposite,” Griffin said. “It’s usually the clinicians that do less that get more money, and the clinicians that are efficient get less money. You have to look at that when you’re setting [this all up].”

Some states and hospital systems may require hourly rates. In that case, there’s no way around some of these issues.

For salaries, agencies have obviously set the price they’re going to pay a clinician, no matter how efficient they are. But if an agency has some salaried employees and some that aren’t, it’s important that they’re using their salaried ones first.

“If they’re on salary, I need to use them first because they’re not being productive to meet their salary if I don’t,” Griffin said. “So then you have to start looking at how you move those chess pieces around to get everybody what they need.”

While salary is a more simple payment system, it does not create incentives for efficiency or better quality.

The mix-and-match, hybrid-type arrangements include “visits plus an hourly rate” and “salary plus an incentive bonus,” but those types of agreements can lead to compliance concerns.

“These can result in great wage and hour compliance complications for agencies,” Griffin said. “Agencies have [certainly] been penalized for not paying properly [with these models].”

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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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Home Care Agencies Can Curb Turnover Costs with Better Preparation, Job Quality

Direct care workers are still undervalued, undertrained and have little opportunity for career advancement, according to a new report from PHI.

Ultimately, that’s bad for home-based care agencies — and their bottom lines.

New York-based PHI is a direct care worker and senior care advocacy organization. PHI typically classifies direct care workers as personal care aides, home health aides and nursing assistants, or more generally those who support seniors and individuals with disabilities.

“Quality care is [contingent upon] quality direct care workers,” Angelina Drake, PHI’s COO and the author of the report, told Home Health Care News. “They will deliver higher-quality care and contribute more meaningfully to the client’s health, safety and well-being if they are better paid, trained and supported.”

Among other findings, PHI found that the direct care workers suffer from inadequate training, a lack of outside understanding of the complexity of the work they do and a system that does not allow many opportunities for meaningful career movement.

One solution in regard to improved training: mandated federal training requirements, according to PHI. This already exists in home health care, as home health aides are required across the U.S. to undergo at least 75 hours of training.

In contrast, personal care aides have no federal requirements and are governed by a mixed bag of state laws and regulations.

PHI recommends that each direct care worker be trained to the point where they have a grasp on a set of core competencies. Broadly, that’s defined as having the skills, knowledge and abilities to complete one’s role.

“The report does conclude with a recommendation that there be a set of core competencies that underlie all direct care,” Drake said. “Once agreed upon and required for states to adopt these standards, they can then build additional training for roles that have greater responsibilities or more specialized responsibilities.”

No agreed upon requirements means that direct care workers’ capabilities look different across state lines, potentially hurting themselves as well as the seniors they’re serving, PHI argues. Workers should also be able to show that they are improving their skills during training — and not just hitting an hourly training threshold — before moving forward.

“Whether you are a personal care aide, home health aide or nursing assistant, there are core competencies that are really central to delivering quality care, and we need to at least ensure that those are in place,” Drake said. “We want competency-based training, which means that participants will need to show that they have acquired skills before they can move forward.”

Only about 60% of states have some sort of home care licensure requirements, according to the Home Care Association of America (HCAOA).

More regulation could help both agencies and direct care workers. Universal training for direct care workers will give them more confidence on the job, allow them to increase their capabilities and ideally get promoted, PHI claims.

That sort of room for improvement creates value for the workers and leads to better care, both of which benefit home care agencies.

“Turnover costs are some of the major expenses that long-term care providers face,” Drake said. “These can be improved by better preparation and job quality for the direct care workforce. And consumer satisfaction is another driver of business that can be improved by quality jobs.”

Other aspects of the direct care workers’ environment that have gone underappreciated are the physical, social and emotional demands, according to the report.

These, of course, have been exacerbated by the COVID-19 crisis.

“Employers need to look at what they can do to improve job quality for direct care workers,” Drake said. “Employers are often limited in their ability to change the base wage for workers, but there are other things they can do to improve job quality to make this a better job all around. A really important piece of that is training.”

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