Poor Onboarding, Lack of Innovation Fuel Home Care Turnover

While the need for more home care workers is pressing, regulatory complexities can make it difficult and confusing for nurses, therapists, aides and caregivers who are new to the industry.

That’s one reason Tina Marrelli has continually updated “The Handbook of Home Health Standards: Quality, Documentation and Reimbursement.” First published in 1988, the text—which is often used in home health agency training programs—is now in its 6th edition.

Home Health Care News caught up with Marrelli to get her take on the labor challenges in the industry, what executives can do to put their staff in the best position to succeed and the changes she’s seen during her decades-long career.


To kick things off, can you tell our readers a little bit about yourself and what made you want to write your book, “The Handbook of Home Health Standards: Quality, Documentation and Reimbursement,” which is currently in its 6th edition in 2018? Besides being an author, you have a master’s in nursing, you’re a registered nurse (RN) and you’re a fellow of the American Academy of Nursing. You’ve also previously worked at Medicare’s central office, specifically focusing on Medicare Part A’s home care and hospice policies and operations. 

I’ve been in home care a long time.

I wrote the first edition of [“The Handbook of Home Health Standards”] back in 1988. Similar to now, we were having quite a few denials at the time and lots of regulatory complexities being added. That first edition of that book was 231 pages and, after the second edition, that started to really jump. I think that says something about the increasing complexity, which really puts a lot on [providers’] leadership, making sure they know the rules and apply the rules.


I imagine it’s changed quite a bit since 1988 as we’ve shifted toward value-based care? 

Absolutely. I like to say we’re shifting—or we should have already shifted—from volume to value. In other words, “What did I bring to this visit to move this patient along the care continuum for improved outcomes?”

Since 1988, too, of course, we’ve had OASIS. I think there’s a lot more interdisciplinary or inter-professional care planning, which is a really good thing. We’re all working toward the same patient goals and outcomes. This new edition actually has new sections related to comfort consideration, because I think it’s time we bring more compassionate care, especially given that our Medicare population is aging. What we did 20 years ago is maybe not the best thing right now.

The oldest of old—people who the National Institute of Aging defines as over 85 [years old]—are the fastest growing segment of the older population. Just skin care, mobility, safety and other quality pieces are more important than ever. There’s more risk as these people become older and have more frailties.

Shifting gears, what do you think home health and home care agencies need to do to better retain their workers? Demand for labor far outpaces supply, so what are some things executives can do to make sure employees, hard to find in the first place, aren’t leaving? 

I’ve talked to a lot of clinicians and aides because of my books, and because I consult. Again, I’ve been doing this a long time, so I have a lot of close, long-term relationships with clinicians and [industry] leaders, people who maybe were clinicians themselves.

One of the things that I hear is people feel like they didn’t get a front-end orientation or effective onboarding. That’s so important, especially when people don’t come from home care. It’s not apples to apples. I’ve had great clinicians—who were recruited because they’re great clinicians—tell me about their experiences. I’ll never forget, I had one clinician call me and thank me because my book really helped her. But then she said that’s the only orientation she got. She didn’t last.

[Clinicians and staff] really need to be supported. [Executives] need to ask: “Do we have a strong mentorship program? What’s our onboarding look like? Can we do better?” Then, [they] need to make somebody is check in on [new hires] from time to time. I know operations can be crazy busy, but I always say to people, “How much does it cost that we’re not keeping them?” Just not financially, either. Think about the patients who maybe keep getting a new case manager.

Recently, I was in a retention [focus group]. I asked a provider, “Can you tell me why your aides are leaving? Why, for one quarter more per hour, they’re leaving their jobs?” He said it was because they were having child care problems. In those cases, we should think about implementing a more innovative program, maybe providing day care services. That’s really thinking out of the box.

And, remember, we won’t have to recruit as much if we’re more effective at retaining.

If we just recruit, recruit, recruit, we’re still going to have people moving around constantly.

There are a lot of providers, I know, trying to better support workers through software improvements or technology-based platforms on mobile devices. Do you think further implementation of those tools are part of the solution for retaining employees?

Care coordination and care communication is always a really good thing. Emerging technology can be really helpful, but people need that front-end education beforehand.

There’s so much talk about improving the transition of care from hospital to home, but there’s also still work to be done. In your view, what is needed to better streamline transition of care?

This is really where effective case management comes in. Is there one person who knows a soon-to-be-new patient in your organization the best? Somebody who follows them across the continuum? Instead of a “handoff,” it needs to be a “handover,” something that’s done carefully and comfortably. To me, “handoff” implies that you’re just passing somebody along. There needs to be one person who can look at data and validate it.

There are so many moving parts, and patients are so much more complex.

Is there something that home health or home care executives maybe don’t understand or fail to grasp about the work nurses, home health aides and caregivers are doing? Is there a disconnect anywhere at the C-suite level? 

I encourage [executives], if they can, to make a visit. If somebody can go out and do a meet-and-greet, I think that can be helpful to really see what patients and their problems are. Sometimes, there is a disconnect there. Sometimes, too, I think social workers aren’t used enough with their specialized skills to get community services involved.

And, again, it’s so important to teach and mentor new team members.

I think health care is really changing. In-home care can have a huge part in that. I think we need to step back and look at home we provide care and what our value is. For sure, our value is we meet people where they are, literally, behind their front door.

Written by Robert Holly

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