July/August 2022

Home Health: Home Health Care: The Evolution of COVID’s Impact
By Jennifer Lutz
Today’s Geriatric Medicine
Vol. 15 No. 4 P. 26

We all likely recall the beginnings of the COVID-19 pandemic, marked by a dearth of medical supplies, a scramble to instill regulations, and exhausted medical workers. The pandemic hit an already struggling health care sector, weighed down by staff shortages and budgetary cuts—particularly the home health care sector.1 And while home health care experienced unique challenges, it often fell outside the purview of public and media attention. At the same time, usage of and reliance on these services has grown, and attitudes have changed since the pandemic’s rocky start.

Unprepared for Crisis
To put it mildly, home health care was unprepared for the pandemic. The sector was the black sheep of an already unprepared system. While the spotlight was on frontline workers in hospitals and nursing homes, home health care agencies continued to see increased demand without a matching increase in workers.2 “We have an aging population, which creates an incredible demand for services, and we’re not necessarily increasing or expanding the workforce to give that care. We had burnout in health care before COVID,” says Sachin Nagrani, MD, medical director of Heal, a home health care service for patients on Medicare and Medicare Advantage.

Home health care workers already faced lower wages and poor mental health. Findings from the 2014–2018 Behavioral Risk Factor Surveillance System showed that 1 in 4 home health care workers experienced fair or poor general health, and 1 in 5 reported poor mental health.3 The findings were linked to factors such as low household income and inability to see a doctor because of cost. “In a lot of our surveys, a lot of home health care workers report feeling undervalued and invisible—I don’t think that’s been fully addressed,” says Madeline R. Sterling, MD, MPH, MS, an assistant professor of medicine at Weill Cornell Medicine.

The fragmentation of the health care system created another challenge. There was no uniting policy—it would be nearly impossible, given the US system. The intersection of private practice and public is one thing, but there’s also the issue of a state-by-state policy approach. While Medicaid and Medicare are both federally regulated, these regulations are broad and each state is left to define its own terms.4 In times of crisis, this can increase complications and decrease effective policy implementation. Fragmentation was combined with budgetary models that hadn’t caught up to the increasing demands on home health care.5 While necessary attention was paid to overflowing hospitals, home health care agencies were left to care for workers and patients—on their own terms and from their own budgets.

Before the pandemic began, home health care agencies were already playing catch-up.

Time, Tools, and People
Shortages in personal protective equipment (PPE) were a problem throughout the health care system, but when it comes to home health care, solutions often came later and at a cost. “It was pretty awful in the beginning; unfortunately, it took time to get home health care workers the resources and support they’ve needed to do their jobs,” says Sterling, who further explains that while now there is no shortage of PPE, the “financing of it is usually left on the backs of the agencies.” Home health care workers function in uncontrolled environments—the patients’ homes.6 The inadequate supply of PPE puts additional stress on an already strained network of workers. In other words, home health care workers suffered from a lack of adequate tools.

It wasn’t just the lack of PPE that hurt home health care agencies. An inability to fully utilize telehealth put many agencies behind the curve and increased risk for contagion. In March 2020, only 39.5% of home health care agencies were using a form of telehealth services. By May that number was already growing—up by 4%.7

Early in the pandemic, concern about infection prompted patients to refuse in-home care. In May 2020, 9.5% of physician visits were refused.7 The result was a decrease in revenues for home health care agencies, which was accompanied by reductions in both clinical and administrative staff. Decreases in staff meant increases in hours worked by already exhausted providers. In addition to a lack of tools, insufficient personnel meant insufficient time.

Keep in mind the fragmentation of the health care system—not all states or individual health care agencies fared the same. Responses to the pandemic depended on individual budgets and practices. For example, Heal immediately switched to telemedicine and only saw patients in person when absolutely necessary, Nagrani says.

When in-home visits were a necessity, the agency took specific steps to keep workers and patients safe. Providers used eye protection and masks (although surgical masks replaced N95 masks during shortages). Whenever possible, a 6-foot distance was maintained. When close contact was required (to take vitals, care for wounds, etc), it was limited to 15 minutes. Patients and their family members also were asked to wear masks in addition to prepping their homes before visits.

Although resources differed across the home health care sector, workers focused on patient safety. “Workers went above and beyond to protect patients, taking additional COVID precautions on top of their usual responsibilities,” Sterling says. The doctor also notes that the pandemic resulted in more infection control protocols—a good thing given the likely occurrence of future pandemics.

COVID Sheds Light on a Workforce Left Behind
It’s important to understand who makes up the home health care workforce; it’s a network that includes nurses, physical therapists, physicians, health aides, and personal care aides.8 A health aide may work with only one patient and their family, while a nurse often visits different patients in their homes. It’s a vast network with growing demand. Job growth for home health care aides alone is projected to increase 33% by 2030. The median salary for a home health aide in the United States is $29,430, while the median salary for all jobs in the United States is $45,760.9

The pandemic highlighted the need to value the workers who care for an aging population. Sterling and colleagues conducted a series of interviews with home health care workers in New York City at the height of the COVID-19 pandemic. The following five main themes were discovered10:

• Workers felt “invisible” despite being on the front lines of the pandemic.

• Workers reported a heightened risk of getting sick.

• Agencies provided varying degrees of support, information, and training regarding COVID-19.

• Many workers were forced to supply their own PPE and pay for additional cleaning products.

• Workers were forced to make challenging compromises in their professional and personal lives.

“COVID shed light on the work of home health care, and more people are aware of the value of these services. However, we can still do a lot more in ways of public recognition,” Sterling says.

Changes for the Better
Efforts to support home health care services are coming from the federal level, but implementation will be at the discretion of individual states. In March 2021, the Biden administration signed into law the American Rescue Plan, whichincluded an estimated $12.7 billion dollars in federal matching funds meant to encourage states to expand home- and community-based services.11 How each state directs that money will depend on its own needs and politics.

Another win for home health care was announced in January 2021 and took effect in January 2022—the expansion of the Home Health Value-Based Purchasing Model, which aims to provide incentives for more efficient and higher-quality care, study new measures of quality and efficiency, and enhance the current public reporting process.

Nagrani explains how focusing on value-based care better supports home health care workers and patients. “If the goal is to see as many patients as possible, you spend five minutes with each and they don’t get better; they come back for another visit and so forth. You aren’t helping the patient, and those five-minute visits add up, straining health care workers and the system.” On the other hand, a value-based care model is focused on results and dependent on a workforce that is properly prepared, trained, and cared for. “There’s a health care worker shortage, which means people can go where they want, and agencies are beginning to realize this and trying to keep workers happy,” says Nagrani, who recommends employers be mindful of health care workers’ time. “Schedule breaks. Schedule lunch. Schedule administrative time,” he says.

It’s also about compensation. In New York State, eyes are on the proposed Fair Pay for Home Care Act, which would set the base pay for home health care aides at 150% minimum wage, or a $35,000 annual salary. As of press time, it’s in committee in the New York State assembly and senate.12 “Wages and compensation are a big part of valuing home health care workers, but some of the relief bills don’t give workers everything they need in terms of time off and benefits. There needs to be an effort to integrate home health care into the health care system,” Sterling says.

Another change that came with COVID is the increased use of telehealth. Continuing to increase access to telehealth among home health care agencies could help to decrease demands on workers and improve the integration of continuous and acute care.13 “The existing changes to telemedicine are still there, but we haven’t yet seen what changes will be permanent—that will have to be a bill signed into law,” Nagrani says.

COVID shone a light on the cracks in the system; the challenge will be filling those cracks.

Looking to the Future
We’re not getting any younger as a population. Public favor continues to gravitate toward aging in the home, with surveys showing that almost 90% of older adults want to age in place.14 At the same time, home health aides have among the highest projected increases in job openings.15 There simply aren’t enough workers to meet the growing need. “I think there will need to be a policy change to address this challenge. Still, whenever that change does happen, there will be a lag because it takes time to train home health care workers,” Nagrani says.

The US population is becoming increasingly dependent on a workforce that’s been consistently undervalued. Change doesn’t just need to come; it needs to come quickly.

— Jennifer Lutz is a freelance journalist who covers health, politics, and travel. She’s written for both consumer and professional medical magazines as well as popular newspapers. Her writing can be found in Practical Pain Management, Endocrine Web, Psycom Pro, The Guardian, New York Daily News, Thrive Global, BuzzFeed, and The Local Spain. In addition to journalism, Lutz works as a strategies and communication consultant for nonprofits focused on improving community health.

References
1. Farrell C. The shortage of home care workers: worse than you think. Forbes. April 18, 2018. https://www.forbes.com/sites/nextavenue/2018/04/18/the-shortage-of-home-care-workers-worse-than-you-think/. Accessed March 24, 2022.

2. Barney J. Growth in home health care failing to keep up with surging demand, study finds. UVA Today. April 15, 2021. https://news.virginia.edu/content/growth-home-health-care-failing-keep-surging-demand-study-finds. Accessed March 24, 2022.

3. Sterling MR, Li J, Cho J, Ringel JB, Silver SR. Prevalence and predictors of home health care workers’ general, physical, and mental health: findings from the 2014‒2018 Behavioral Risk Factor Surveillance System. Am J Public Health. 2021;111(12):2239-2250.

4. Policy basics: introduction to Medicaid. Center on Budget and Policy Priorities website. https://www.cbpp.org/research/health/introduction-to-medicaid. Updated April 14, 2020. Accessed March 26, 2022.

5. Partnership for Quality Home Healthcare. Re: CMS-1730-P: Medicare and Medicaid Programs; CY 2021 Home Health Prospective Payment System rate update; home health quality reporting requirements; and home infusion therapy services requirements. http://pqhh.org/wp-content/uploads/2020/08/FINAL-submitted-Aug24-PQHH-CY2021-Home-Health-Proposed-Rule-Comments1.pdf. Published August 24, 2020. Accessed March 26, 2022.

6. Shortage of personal protective equipment endangering health workers worldwide. World Health Organization website. https://www.who.int/news/item/03-03-2020-shortage-of-personal-protective-equipment-endangering-health-workers-worldwide. Published March 3, 2020. Accessed March 24, 2022.

7. National Association for Home Care & Hospice. National study shows home health care is in a fragile state. https://www.nahc.org/wp-content/uploads/2020/03/NATIONAL-SURVEY-SHOWS-HOME-HEALTH-CARE-ON-THE-FRONTLINES-OF-COVID-19-AND-CONTINUES-TO-BE-IN-A-FRAGILE-FINANCIAL-STATE.pdf. Published June 29, 2020. Accessed March 29, 2022.

8. Edes TE. The home health care workforce. NCBI Bookshelf website. https://www.ncbi.nlm.nih.gov/books/NBK315914/. Published August 4, 2015.

9. Occupational outlook handbook: home health and personal care aides. U.S. Bureau of Labor Statistics website. https://www.bls.gov/ooh/healthcare/home-health-aides-and-personal-care-aides.htm. Updated April 18, 2022. Accessed March 28, 2022.

10. Sterling MR, Tseng E, Poon A, et al. Experiences of home health care workers in New York City during the coronavirus disease 2019 pandemic: a qualitative analysis. JAMA Intern Med. 2020;180(11):1453-1459.

11. CMS launches webpage to share innovative state actions to expand Medicaid home and community-based services. Health and Human Services website. https://www.hhs.gov/about/news/2021/10/21/cms-launches-webpage-to-share-innovative-state-actions-to-expand-medicaid-home-community-based-services.html. Published October 21, 2021. Accessed March 29, 2022.

12. Council calls for passage of state laws to ensure fair pay for home care workers, reduce packaging waste, and expand equitable access to victim services. New York City Council website. https://council.nyc.gov/press/2022/03/24/2153/. Published March 24, 2022. Accessed March 29, 2022.

13. Pogorzelska-Maziarz M, Rising KL, Gentsch AT, et al. Home healthcare patient, caregiver and provider perspectives on use of unscheduled acute care and the usability and acceptability of on-demand telehealth solutions. Geriatr Nurs. 2021;42(5):1029-1034.

14. Nearly 90% of Americans age 50 and older want to "age in place". GlobeNewswire website. https://www.globenewswire.com/news-release/2021/05/10/2226492/0/en/NEARLY-90-OF-AMERICANS-AGE-50-AND-OLDER-WANT-TO-AGE-IN-PLACE.html. Published May 10, 2021. Accessed March 29, 2022.

15. Employment projections: occupations with the most job growth. U.S. Bureau of Labor Statistics website. https://www.bls.gov/emp/tables/occupations-most-job-growth.htm. Updated April 19, 2022. Accessed March 29, 2022.