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November/December 2022
Home Health: Home Health Worker Shortage Requests for home health continue to pour in, especially among the Medicare population (which will encompass all baby boomers by 2030).1 Despite the increase of 1,368,500 jobs between 2010 and 2020, many of those requests are not being met. Demand for home care continues to rise, driven by an aging population, changes in hospital policy, and patient preference. In 2019, New York reported that roughly a quarter of home care patients were unable to find aid; that was before COVID made things worse. Our nation isn’t getting younger. Aging adults need help dressing, bathing, walking, and eating; so do disabled populations. Despite this dependence on home care workers, low pay, difficult conditions, and insufficient sick leave fuel a crisis that’s only getting worse. What’s Behind the Shortage? The move toward home health care is likely good for the federal budget. A recent McKinsey report found that transitioning spending from in-patient to home health care would positively benefit providers, payers, and patients.4 Part of this is due to the type of care people will be needing; an aging population points to more long term care needs, particularly as chronic disease remains America’s greatest health concern.5 Providing this care in the home is often more cost-effective than providing it in a hospital. Add to that America’s acceptance of telehealth, and patients could rely on in-home care, supported by virtual visits with their primary providers. The demand for home health workers makes sense; the problem is meeting that demand. “We are certainly seeing homecare agencies unable to take on new cases because they don’t have enough workers, and we are absolutely seeing needs not met,” says Kezia Scales, PhD, senior director of policy research for PHI. Despite job growth in the millions, there simply aren’t enough home care workers entering the market. Add that to high turnover rates and the shortage seems more expected than extraordinary. “We’ve had recruitment and retention problems with this workforce for a while. These tend to be undervalued and not particularly high-quality jobs in terms of compensation, benefits, training opportunities, and career advancement. These have been a challenge for a long time, but with COVID-19, the challenges were exacerbated enormously,” Scales says. In 2020, the median hourly wage for home health workers was just under $13. In Texas, it’s roughly $10 an hour, and in New York, it’s just under $15, below the poverty line for a family of four.1 Home health workers are dressing, bathing, and feeding America’s aging population; training focuses on those daily tasks, and little education attends to the physical and social demands that come with direct care, particularly when supporting people with complex health conditions. If home health care is meant to take the brunt of America’s increasing health care needs, this will need to change. In most cases, home health workers are a patient’s primary point of contact; they’re familiar with a patient’s changes in appetite, mobility, and overall condition—invaluable information to a primary care provider. Channels are lacking to facilitate this communication. Additionally, the high turnover in workers interrupts continuity of care. “It affects patients and health care providers across the board,” Scales says. She also notes that it doesn’t affect all patients equally, explaining that those who are dependent on Medicaid are the most vulnerable to the shortage. Private agencies have more flexibility in terms of pay, benefits, and sick leave. Agencies that work with Medicaid are constrained by aspects such as limits on reimbursements. Changes at the state level are necessary to protect these patients and caregivers. COVID-19 made home health care even more attractive; it also made the job more difficult, dangerous, and undesirable. Within the first 18 months of the pandemic, less than one-half of states provided workers with hazard pay.1 Scales notes that many of these workers suffered without paid leave and experienced increased economic challenges. “As a consequence, we saw the workforce contract even further. Now, we’re seeing a real challenge to bring workers into these roles and meet ever growing demands. Those preexisting challenges combined with the added layers brought on with the pandemic created a struggle in meeting this systemic shift to in-home care,” Scales says. Within this struggle, both patients and caregivers are burdened. The overburdened system is bucking at the seams. An overworked and underpaid home health worker is ill-equipped to meet the challenges of the job; the current model sets them up for failure. Changes for a Better Future From the federal level, the American Rescue Plan Act, which was one of the federal COVID relief packages, did help some. “It included a short-term increase in the federal match for State Medicaid home and community-based care,” Scales explains. While the American Rescue Plan was helpful, it’s a short-term solution. Additionally, some states are going a step further. For example, New Jersey established a minimum hourly reimbursement rate for personal care services delivered under Medicaid-managed care. States, including Washington and Tennessee, are working on developing training programs for direct care workers that link to advancement opportunities and wage increases.9 Few states have actually increased pay, but some, such as Colorado and New York, have done so. Colorado raised minimum pay for direct care workers to $15 an hour in 2022, and New York raised minimum pay to $18 an hour.10,11 The failings of many states to do more during COVID shed a light on issues outside of pay, particularly sick leave and hazard pay. “These workers continued to provide services (even as other services were scaled back) so their jobs became that much more difficult and riskier. On top of that, these workers often experienced added economic pressures when they had to take time off and didn’t have access to paid leave,” Scales says. That’s a problem, especially as the United States continues to tilt further toward home-based care. PHI has its own set of recommendations based on research over these past years. One recommendation is to assure long term care financing programs address the needs of consumers and workers. This involves strengthening Medicaid to improve direct care jobs, increasing reimbursement rates, and creating stronger public financing. Of course, increasing wages is a recommendation, but it goes beyond a higher hourly rate. Many home health workers cannot find full-time work because of scheduling limitations and poor management of worker and patient timetables. In its recent report, the PHI specifically suggests that policymakers should study scheduling barriers that long term care employers and direct care workers face and invest in evidence-based technology solutions to help align scheduling requirements and availability. We’re looking at a shortage of workers, while 1 in 5 workers who want to work full-time aren’t being given the hours. Increased compensation also includes paid sick days, comprehensive paid family and medical leave, and affordable childcare. A third recommendation is strengthening of training programs, which would include a national standard for direct care competencies and fund training to support these. Fourth, the PHI recommends funding, implementing, and evaluating direct care workforce interventions. A primary focus of these is on the integration of direct care workers into patients’ care teams, which would help primary care providers, patients, and direct care workers. Finally, the PHI recommends improving data collection and monitoring of direct care workers. This would lead to more specific solutions to address the growing problems that tie into the workforce shortage. The complexity of this shortage requires a systematic shift in the way we think about home health care. We’ll need to treat workers as an integral part of a patient’s team, which they are. We’ll need to provide the training, compensation, and benefits to support this. The system is demanding more from our home health care workers; shouldn’t health care workers be demanding more of the system? — 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 2. Long-term occupational projections (2020-2030). Projections Central website. https://projectionscentral.org/Projections/LongTerm. Accessed September 14, 2022. 3. The value of aging in place. USC Leonard Davis School of Gerontology website. https://gero.usc.edu/students/current-students/careers-in-aging/the-value-of-aging-in-place/. Published February 1, 2022. Accessed September 14, 2022. 4. From facility to home: how healthcare could shift by 2025. McKinsey & Company website. https://www.mckinsey.com/industries/healthcare-systems-and-services/our-insights/from-facility-to-home-how-healthcare-could-shift-by-2025. Published August 1, 2022. Accessed September 14, 2022. 5. Chronic diseases in America. Centers for Disease Control and Prevention website. https://www.cdc.gov/chronicdisease/resources/infographic/chronic-diseases.htm. Published May 6, 2022. Accessed September 14, 2022. 6. National Governors Association. State strategies for sector growth and retention of the direct care health workforce. https://www.nga.org/wp-content/uploads/2021/10/NGA_SectorGrowth-DirectCare_report.pdf. Accessed September 16, 2022. 7. Home care members win permanent wage increase. 1199SEIU website. https://www.1199seiu.org/magazine/home-care-members-win-permanent-wage-increase. Published April 19, 2022. Accessed September 16, 2022. 8. Strengthen training standards and delivery systems for direct care workers. PHI website. https://www.phinational.org/issue/data-collection-quality/. Published September 6, 2022. Accessed September 16, 2022. 9. Placing a higher value on direct care workers. Commonwealth Fund website. https://www.commonwealthfund.org/publications/2021/jul/placing-higher-value-direct-care-workers. Published July 1, 2021. Accessed September 26, 2022. 10. HCPF website. https://hcpf.colorado.gov/. Accessed September 26, 2022. 11. Final state budget includes minimum wage increase for home care aides - HCA-NYS. HCA website. https://hca-nys.org/final-state-budget-includes-minimum-wage-increase-for-home-care-aides/. Published April 10, 2022. Accessed September 26, 2022.
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