Demographic Trends, PDGM Forcing Home Health Providers to Get Creative About Staffing

At-home care organizations across the country are grappling with how to attract and retain staff. Moorestown, New Jersey-based Bayada Home Health Care has tried to solve the industry-wide pain point by exploring creative solutions, including university partnerships.

Reasons for at-home care workforce challenges are numerous.

On a macro-level, the United States has a rapidly aging population, with about 10,000 baby boomers — people born between 1946 and 1964 — turning 65 every day. In turn, the population of people 65 and over is estimated to be more than 80 million by 2050.


Most of these aging adults prefer to age in place. In fact, according to AARP statistics, about 77% of adults over 50 favor remaining in their homes and communities as they get older, though other recent research has somewhat dampened estimates.

Without creative solutions, demographic and preference trends mean at-home care providers will face a persistent workforce shortage certain to impact care delivery — and their bottom line.

“Everyone is struggling in recruiting primary, hands-on caregivers, whether they be certified home health aides, hospice aides, personal care aides, private-duty aides or caretakers,” Andrea L. Devoti, executive vice president for the National Association for Home Care & Hospice (NAHC), told Home Health Care News. “Part of the issue is the cost of living in various parts of the country and the competition for these employees that are working for $9 to $15 an hour. These people work very hard — they are the backbone of the caregiving industry, and there is a lot of competition from other industries for those very same people.”


Washington, D.C.-based NAHC is an industry association that represents the roughly 33,000 home health, hospice and home care organizations operating in the U.S.

Bayada — one of the largest and oldest home health providers — is taking several innovative steps to combat the workforce challenge. Forming long-term partnerships with local and national universities is one example.

As part of its university-partnership efforts, Bayada coordinates with university nursing programs to make sure students and recent graduates are familiar with home-based care.

“One of the things we’ve done is something as simple as coordinating clinical rotations and basically saying, ‘In these couple of offices, we’ve got slots if you want to send your nurses out to get some experience in the home,’” Mike Johnson, president of home health for Bayada, told HHCN. “We have them travel along with one of our nurses. We’ve done this with physical therapy programs and occupational therapy programs, and that’s a way to get out there and let these new professionals know that home health is an option.”

Bayada has more than 28,000 employees and 360 offices in nearly two dozen states. In addition to its U.S. footprint, Bayada operates across six countries.

Researchers have also highlighted the need for nursing students to be exposed to home-based care earlier in their education as part of a January study published in Nurse Education Today. Too often, experts say, nursing curriculums focus predominately on hospital and acute-care settings.

“Many people in the community — and students when they begin nursing school — think about nurses as working in hospitals,” Olga Jarrín, an assistant professor at the Rutgers School of Nursing, previously told HHCN. “For nursing students to have greater exposure to positive experiences in the community and in-home care is a big way to improve health care for older adults. It’s important to find ways to make nursing students interested in home care as a career and help them understand the types of care patients can receive when they leave the hospital.”

Home health apprenticeships

Bayada provides home-based nursing, rehabilitative, therapeutic, hospice and assistive care services as part of its business lines. In 2016, the company announced plans to transition to a not-for-profit model.

In addition to offering clinical rotation hours, the home health provider is leveraging its university partnerships to hire nurses, physical therapists and occupational therapist right out of school — and investing in their professional development with an apprentice-like onboarding period.

“You can say [that] anyone can hire somebody right out of school, but remember these people are going to be working unsupervised and alone in a patient’s home,” Johnson said. “So, just hiring them and doing a regular bit of training isn’t the same as with [new hires] working in a hospital. In a hospital, you are surrounded by people, you can ask questions. We’ve put together a very specific onboarding where you partner a new graduate nurse with an experienced home health nurse or therapist for a period of six to nine months.”

To date, Bayada has worked with Temple University and Thomas Jefferson University, both in nearby Philadelphia.

Currently, it is looking at forging relationships with a number of local nursing and physical therapy schools as well.

Whatever the method, at-home care industry leaders say that when it comes to recruitment and retention, providers should leave no stone unturned.

“We’ve seen everything from advertising in religious organization newsletters to posting signs in grocery stores, companies offering referral bonuses, as well as apprentice programs,” Devoti said. “Many larger companies are beginning to look at ways to set up training programs right in their office.”

PDGM and the nursing-to-therapy question

Retention is also an essential part of the staffing puzzle, as the average cost of turnover for a nurse, ranges from $37,700 to $58,400, according to the 2016 National Healthcare Retention & RN Staffing report.

Besides demographic changes and consumer preferences, the upcoming Patient-Driven Groupings Model (PDGM) also presents challenges when it comes to staffing.

In general, PDGM will require providers to revisit their staffing mix, making sure they have the appropriate professionals in place to deal with the model’s reimbursement changes.

Along those lines, providers will need to evaluate their therapy-to-nursing staff ratio because therapy services will no longer be based on volume, but rather more closely tied to patient characteristics.

“With PDGM coming, one of the key elements of that model is that CMS is going to eliminate the service code in their payment methodology, which paid additional dollars for additional therapy visits above a certain threshold,” Johnson said. “This means a flat, fixed rate based on the functional picture of the client at the start of care.”

Home health providers that provide the most in terms of therapy services compared to their industry peers — those in the lowest nursing-to-therapy ratio quartile — are projected to see a 9.6% payment reduction under PDGM, according to BlackTree Healthcare Consulting data.

In contrast, home health providers that deliver the most nursing care — those in the highest nursing-to-therapy ratio quartile — are projected to see a 17.3% payment increase under the overhaul.

“The revenue coming from therapy is very likely to decrease, and I have to start thinking about whether we have enough therapists and nurses given how we are paid today. And when payment changes, does that mean we have too many of one and not enough of the other?” Johnson said. “I don’t know the answer to that yet.”

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