Report: Top Changes in Home Health Operations

Home health care agencies are outsourcing more services and dealing with more difficulty when it comes to hiring nursing staff, according to the fourth biannual National State of the Industry (SOI) Report for Home Health and Hospice, by Fazzi Associates.

The 2016-2017 report surveyed 751 home health agencies on operations and best practices, with analysis on the ongoing “dramatic changes” in the field.

Fazzi Associates is a home care consulting firm based in Massachusetts that engages in best practices research studies and is one of the largest home health coding outsourcing providers.


Here are some of the top changes home health agencies have reported over the last few years, according to the SOI report:

Hiring Difficulties

Not surprisingly, one of the biggest changes home health agencies reported is how they deal with hiring and finding nursing care staff. Compared to the 2014 report, there was a 77% increase in overall respondents that said they found hiring field nursing staff “very difficult.” Home health agencies regularly cite recruiting as a top challenge, and the caregiver shortage is costly to providers.


“Every time that number goes up, you know it’s costing a lot of money,” Bob Fazzi, managing partner at Fazzi Associates, told Home Health Care News on Monday. “The shortage comes from the number of nurses who are retiring, and there are not the numbers coming in to take their places. In some areas, agencies are finding it difficult to fulfill responsibilities without staff to provide the services.”

Fazzi estimates that it costs agencies about 1.5 times an employee’s salary to replace them. Looking ahead, the crisis of not enough workers is very likely to continue.

“Systems are competing with each other [for nurses]—from hospitals and long-term care,” Fazzi said. “With increasing demand for the aging population and less clinicians in the field, that puts us into a crisis. And that number will get worse.”


From 2014 to 2016, the number of home health care agencies—particularly larger agencies—that outsourced services, including coding, rose significantly. Only 6% of respondents said they outsourced coding in 2014, while 29% said so in 2016. While this represents a jump in use, other health care providers have been more prominent in outsourcing many services for proper clinical documentation and coding. In particular, outsourcing services is more prevalent among hospitals and health systems, though more home health agencies are likely to outsource in the future.

“The way it tends to work is that … home health is following the hospitals simply because they are often the earliest adopters to go after things because they are trying to improve quality and save money,” Fazzi told HHCN.

Of respondents that do not outsource coding, another 11% said they were planning to consider it within the next year, according to the report.

The majority of agencies reported that they outsourced coding to complete the function, followed by outsourcing to supplement internal coding and to cover for time when staff are not available, such as vacations and holidays.

Technology and Function

Just 63% of respondents said they had the capability to receive and/or transmit electronic health record (EHR) information to and from health care providers that are not part of their own agency or system. Respondents that do have this capability ranked higher in quality and those that responded they did not, according to the report.

In addition, there was a “significant difference” in profitability between agencies with different EHR capabilities, with EHR users seeing higher Medicare margins, according to the report.

Among EHR systems, Fazzi predicts more consolidation across current providers.

In the realm of telehealth, 23% of respondents said they use a telehealth or telemonitoring system—technology communication systems (video or non-video) that are used to transfer health information from the home to a provider.

From 2008 to 2014, Medicare spending on telehealth visits jumped from $2 million to nearly $14 million, with higher rate of usage in states with large rural populations.

However, the increase in 2016 was only a slight one over 2014 results. Home health’s adoption into telehealth may be slow in part because it is still evolving in how digital health can be utilized across the health system.

“In the long run, it will do nothing but grow,” Fazzi said. “Over the next couple years, we will get a better sense of how home health interacts with the health system as a whole.”

Just as home health agencies have seen operational changes from 2014 to 2016, more are likely to come, as 29.5% of respondents indicated that their agency will likely not stay the same over the next 12 months. This was due to a combination of merging or affiliating, acquisition activity, selling, closing or being unsure about their future.

Written by Amy Baxter

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