America’s Home Care Infrastructure Is Crumbling. Here’s How to Fix It.

As part of his administration’s recently unveiled American Jobs Plan, President Joe Biden wants to set aside $400 billion to better support the nation’s home-based care system.

While specifics still need to be worked out, a large chunk of that funding would be used to improve the wages of home health aides and other caregivers who work in the home.

That, in theory, would allow in-home care providers to more effectively recruit and retain workers, which would then ultimately save the U.S. health care system money by keeping patients in the lowest-cost setting.


“The American Jobs Plan is going to help in big ways,” Biden said during a March 31 speech in Pittsburgh. “It’s going to extend access to quality, affordable home- or community-based care. Think of expanded vital services like programs for seniors. Or think of home care workers going into homes of seniors and people with disabilities, cooking meals, helping them get around their homes and helping them be able to live more independently.”

For a variety of reasons, retention is particularly difficult in both the home health and home care industries.

For minimum-wage, entry-level positions in home care, for example, potential caregivers often end up poached by $15 an hour jobs in the retail or restaurant business. In home health care, top nurses frequently leave their agencies for higher-paying hospital jobs.


Market research and education firm Home Care Pulse put the 2019 home care turnover rate at about 64%. Meanwhile, the turnover rate for all home health employees surpassed 22% in 2020, a slight increase compared to the previous year, according to the Hospital & Healthcare Compensation Service.

Dorothy Davis, president and CEO of Visiting Nurse Health System Inc., discussed persistent workforce challenges her organization faces during a virtual press conference hosted by LeadingAge on Thursday.

The Atlanta-based Visiting Nurse Health System cares for about 6,000 patients across its home health, hospice and private-duty home care lines, plus its Medicaid waiver long-term supportive services division. The 74-year-old organization normally conducts between 2,500 and 3,000 in-home care visits per week, with the average age of patients being 79.

“What is consistent across our entire health system is the workforce shortages and the workforce gap,” Davis said during the press conference.

Currently, Visiting Nurse Health System has about 750 care professionals who are part of its team. Demand for the provider’s services far outpaces its available labor supply, meaning Davis and her team are often forced to turn away patients.

“We have turned away over 500 patients in the last four months due to workforce shortages,” Davis said. “And what that means for us — and for, more importantly, patients and families, and just looking at the broader economic impact — is those individuals are not being served at home.”

Generally, more attention has been paid to home-based care and in-home care workers since the COVID-19 pandemic began.

Yet in reality, home health and home care providers have struggled with recruitment and retention for years, largely due to stagnant — or nonexistent — government funding.

“Right now, we don’t have the infrastructure for aging services that we need, and the systems that we do have are crumbling,” Katie Smith Sloan, president and CEO of LeadingAge, said during the press conference. “The COVID-19 pandemic made clear the tragic human consequences that can happen when our systems are weak from significant shortages of staff to provide care to chronic underfunding of all kinds of services. But make no mistake, the need to renew and revitalize our aging services infrastructure existed even before the horrific last year.”

Separate from Biden’s proposal, the Washington, D.C.-based LeadingAge has its own blueprint for better senior care in the U.S.

Among the blueprint’s provisions, the aging services nonprofit is calling on long-term care policymakers to permanently increase the Federal Medical Assistance Percentage (FMAP) by 10% for both home- and community-based services (HCBS) and nursing home care.

The American Rescue Plan increases FMAP by 10% for HCHB, but only on a one-year, temporary basis.

LeadingAge additionally argues that the government should make meaningful changes to immigration policies to support hiring foreign-born workers at all levels and positions in aging services.

Specific to HCBS, the trade group is urging policymakers to invest more heavily in Programs of All-Inclusive Care for Elderly (PACE) while broadening the Medicare home health benefit to include more personal care services. The Money Follows the Person (MFP) program should also be made permanent, the LeadingAge blueprint points out. 

The American Jobs Plan — which Democrats would most likely have to push through Congress via the reconciliation process — similarly calls for an expansion of MFP, which allows certain Medicaid users to more seamlessly transition from a nursing home back into the home.

“I’ve worked in aging services since the 1980s, and there has never been a greater opportunity for change than now,” Sloan said. “We are pleased that the administration and Congress are turning their attention to rebuilding our country’s infrastructure, and we must ensure that investment includes the essential needs of our growing population of older adults.”

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