Home Care Industry Strives to Stay Off ‘Regulatory Menu’

Throughout the past few years, home-based care — especially the private-duty industry — has gained greater recognition as a key part of the overall health care continuum. With that increased prominence, though, has come greater scrutiny.

As part of an increase in attention, home health and hospice providers alike have made strategic moves to add or expand personal care services in their business, both through merger-and-acquisition deals and partnership arrangements. The Centers for Medicare & Medicaid Services’ (CMS) decision to officially add non-skilled in-home care services as a supplemental benefit for Medicare Advantage plans starting in 2019 has only added fuel to that fire.

The private-duty industry’s continued rise to prominence has made it a regulatory target on state and national levels alike, industry leaders told Home Health Care News.


Home care’s business landscape and regulatory climate will be discussed during The Private Duty Symposium on Sept. 12 in Tinley Park, Illinois.

To gear up for the symposium, HHCN recently caught up with representatives from the three groups behind the event. HHCN spoke with Sheila McMackin, founder and past president of the Home Care Association of America; Sara Ratcliffe, executive director of the Illinois HomeCare & Hospice Council; and Jason Speaks, manager of policy and communications at LeadingAge Illinois.

In addition to her experience with the Home Care Association of America, McMackin is the owner of Wellspring Personal Care, which serves the Chicago metropolitan area.


It really seems like we’re in this pivotal moment for the home care industry. What are the big issues or topics going on right now, whether in Illinois specifically or nationally, that agency leaders need to be following? 

McMackin: For us, for our associations, legislative efforts can be a really big deal. With our membership in Illinois, we have 100 members, made up of providers of private-duty home care. We’ve been working for close to 15 years as an association doing a lot of legislative work.

The Chicago City Council has put together the Fair Work Week [Ordinance]. As it stands right now, it will be incredibly onerous for our providers.

The other bill that we’ve been directly involved in is the Alzheimer’s Disease and Related Dementia Training Act, or Public Act 099-0822. It was passed. It’s now law. It’s in the rules-making process right now with the Illinois Department of Public Health (IDPH).

The Alzheimer’s training bill was put together by the Alzheimer’s Association and it was based on its take on anecdotal information from consumers saying, “I engaged this home care agency, and they said they could provide care for my Alzheimer’s father. They don’t know what they’re doing.” There’s a lot of good that [this bill] does. Originally, it was pretty onerous, but with negotiation with IDPH and the Alzheimer’s Association, they’ve really crafted reasonable regulations. If you advertise yourself, put yourself out into the marketplace as having services for Alzheimer’s or dementia clients, then you have to train your workers, you have to have someone who is identified as the trainer, and that trainer has to have a demonstrated competency.

There are a bunch of organizations out there that do dementia training.

The other big-ticket item is HB-313, which in Illinois is the sunsetting of the Nurse Practice Act.

Ratcliffe: What the Fair Work Week Ordinance essentially does … It means an employer needs to post work hours, I think, two weeks in advance. If work hours should change within 24 hours — and the employee loses hours — then the employer will have to pay them for the anticipated hours they were scheduled to work. If they don’t, [employers] could see a $500 fine per infraction.

The problem with this being rolled out to health care or home care workers is that you’re dealing with patients with a whole variety of things that could change from day to day. You could have a patient that goes back into the hospital. You don’t know two weeks in advance if that’s going to happen. That’s not anyone’s fault. It’s just what could happen. You could have a patient die. You’re not going to go provide home care services for that patient anymore.

It would be a huge burden on the employer in an industry that is centered on the needs of the patient.

Speaks: For Illinois, the Fair Workweek Ordinance was on my list as well.

Something else that we’re looking at in our association is the explosion of technology, particularly with seniors. Over the last five years, the usage of technology for seniors has quadrupled. Because of that, we formed a technology committee with chief information officers and IT staff who are provider members. We’re looking at all the different things going on there, particularly with seniors and how technology translates into their expectations coming into home care and the continuum of care of services that we represent, such as senior housing all the way through nursing homes.

We’re talking about wearable technology. I know there are some HIPAA issues, but we’ve been talking about how even Alexa could be a benefit to caregivers as well as seniors.

Those are some pretty interesting topics that are, of course, specific to Illinois. What about on a national level? What are some of the broader, overarching issues you’ll be highlighting during The Private Duty Symposium later this month? The event is in its fifth year, and I know you’re expecting a good showing of agency leaders, owners and people from related sectors, including attorneys, accountants and insurance representatives. 

Ratcliffe: We need to talk about workforce. We represent home health and private duty home care. In both industries, we have a shortage of workers in the home. How do we tackle that? How do we retain good workers?

We’ve been trying to focus on that a lot — making nurses and unskilled workers aware that it’s an option to work in the home. But how do we provide enough benefits and incentives to keep workers so we don’t have a high rate of turnover, especially on the private duty side?

That’s a good question. How can the industry accomplish that? Is it all about higher wages and more robust benefits packages? HHCN has reported on how some providers are turning to specialized training programs as a means to recognize and retain workers.

Ratcliffe: I think that definitely is one of the things that can be done. It’s investing in your employees. Having been an employee for more than 30 years, I feel comfortable saying that if an employer is investing in my professional development, then it makes me feel like I’m part of the team.

I think looking at organization culture is very important, too, especially with a younger, millennial workforce. So is being more cognizant of work-life balance and creating a culture where each employee feels connected to the mission.

Home care is gaining more prominence and recognition as a piece of the overall care continuum. Why does that matter? 

McMackin: It’s clearly important. I started the Home Care Association of America 16 years ago, starting out with 30 people, 30 organizations around the country. We now represent, I don’t know, 3,000-plus members.

In the state of Illinois alone, if you look at the IDPH website and look at the number of licensed home service agencies, we’ve gone from a few hundred to close to 900 — and that’s in a matter of a couple of years. There’s a massive explosion in this industry. This industry is taking off. As a result of that, it’s really important that we take a close look at regulatory issues.

If you don’t have a seat at the table, you’re going to be on the menu.

When you have explosive growth in any industry, it’s automatically going to mean eyes are going to be on you and regulation is coming. We, as an industry, have to be really involved with day-to-day development of regulation to make sure we don’t get eaten alive.

Ratcliffe: Private duty is absolutely important and growing in the post-acute care continuum. I think that being recognized by CMS, with the Medicare Advantage expansion to include services that support health that aren’t necessarily skilled nursing services, is a clear example of that. As we’re looking at the patient as a whole person and not just their medical needs, but also their psycho-social needs and the needs that they have in their home, it’s going to continue to be more and more important, especially as our baby boomers are aging.

Speaking of Medicare Advantage, HHCN has had a lot of conversations lately with providers, including recently Addus and Elara Caring, about expanded opportunities. Some industry insiders feel like the Medicare Advantage plan is really just a first step toward making home care more widely available under the broader Medicare landscape. And how it’s a chance to gather data and really show non-skilled home care’s value. What are your thoughts on that?

McMackin: There’s no doubt in my mind that this is an opportunity.

The fact of the matter is, in our industry, we don’t have a lot of data collection. When we do, it’s sometime weak. That makes comparing past and current data frustrating because a lot of information is anecdotal.

We know in our heart of hearts that what we do truly matters. We keep people out of hospitals. But if you don’t have measures, does that really matter?

With this event coming up Sept. 12, what other issues or messages might you have for home care providers?

McMackin: I have a million of them.

Over the last couple of years, I’ve been really concerned about the growing need for us to have more of a clinical purview, or clinical offering. Often I find a reluctance to talk about clinical topics. How do you handle patients or clients at a higher acuity level? What type of staff do you need to do that? Do you need an RN or nursing oversight to handle certain types of things? What are some of the best practices and what are some of the programs people have in place to do that?

As we go forward with all of the changes in the health care delivery system that are potentially out there, I believe that we, as an industry, are going to be faced with more and more and more clients who require — and are coming to us — with higher acuity levels.

This concept of us being non-medical, I think that’s going to have to shift.

I feel like the current M&A activity going on in home health, home care and hospice is related to those sentiments. You know, more and more home health providers who are serving high-acuity patients realizing they need a home care branch in their business.

Ratcliffe: There’s a lot of room and opportunity to look at partnerships and how home health and hospice can work more closely with private duty. We have several agencies that have all licensures, but there are plenty that don’t.

Written by Robert Holly

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