This article is sponsored by The Joint Commission. This article is based on a Home Health Care News discussion with Gary Bachrach, Executive Director of Business Development, Home Care Services at The Joint Commission and Vicki Hoak, Chief Executive Officer at HCAOA. The discussion took place on November 16, 2022, during the HHCN Home Care Conference in Chicago. The article below has been edited for length and clarity.
Gary Bachrach: I’m honored to be here with my good friend, Vicki Hoak, CEO of Home Care Association of America, to talk about what’s going on in the personal care and support space. Vicki, what do you see as the best opportunities in the personal care and support space?
Vicki Hoak: Well, let me begin by saying where we are today as far as the home care industry because I think that’s important. We are really at a crossroad. We can turn left and accept the status quo and whatever else comes our way, or we can take that right turn.
I like to say, “Let’s take the right turn.” It’s going to go uphill a little bit, but taking that right turn, I think we’re going to see a lot of opportunity coming our way because as you know, we are getting another look. I think people are recognizing the value of home care, but we have a lot to do.
Let’s think about it for a minute. We don’t have any kind of national standards, but there are an estimated twenty-six to twenty-eight thousand home care agencies in this country. We have a very loud voice.
Unfortunately, though, we are speaking in different corners of the world these days. With that 26,000, we need to make sure that we elevate our profession. In order for us to become that viable player at the table with home health, with all healthcare providers, we’ve got to come up with some national standards. Our association is very, very keen on developing national standards, if not having a state license for home care. Right now, 30 states license, which means that 20 don’t.
What does that mean in states like Michigan and states like Arizona, that have no standards of care? For our association, the trade association that represents this sector exclusively, we’re very much looking for some kind of national standard. We also know that if we’re truly going to become that player in that healthcare arena, we’ve got to have data to prove our value.
I know we’ve had a lot of good research projects; BrightStar has done some good things, but we as an industry have to come up with some core metrics so we can evaluate how well we are doing. Does four hours or eight hours of personal care really reduce the hospitalization, really cut down on falls? Then we also have to take a look at our scope of services. I think there is a big gap between what a home health agency can do, and what a home care agency can do.
We are constantly struggling. Here in Illinois, our members were successful in expanding their scope of services because there is a hole out there that our families can’t get care when they need it. They just want someone to come in and help with medications or give eye drops. These are services that are needed by our growing elderly population. Yet, home health agencies aren’t going to go out just to do that, and yet we as home care really have our hands tied because our scopes are so narrow.
Bachrach: Vicki, I want to follow up on one thing that you mentioned. We talked about national standards; we talked about state licensure. We have a lot of key people here in the audience. What do we need to do from your perspective? What could we do to support that mission? What could we do to make enough noise to make that matter?
Hoak: As a trade association, we always go back to advocacy. I’m always shocked that when I go over to the capitol, I have to spend the first 10 or 15 minutes just explaining who we are and what we do. Are we home health? Are we private duty? Are we home care? It’s to the point where an undersecretary at HHS, at the height of the pandemic, said, ”I didn’t know about you.” Those were her words: ”I didn’t know about you.”
Those kinds of things get in the way of really delivering our message and elevating this sector. I believe that we need to be doing work with Medicare Advantage plans. I believe in my heart, it is going to grow, but I know it’s tough right now. I have members yelling and saying, ”Vicki, they’re not paying enough.’ They give me two hours of care. It’s not enough.” Folks, think back, I remember in the early 2000s when Medicaid budgets really were pretty much nursing homes. It was all about long-term care. Fast forward to where we are now: 65% of our Medicaid budgets are going to home- and community-based services.
I think what we have to do is get our own house in order and do a lot of advocating on behalf of families. One thing about home care is that I can’t think of another healthcare provider that relies on family caregiving as much as we do. How are we incorporating that family into our care plan?
Back in September, we saw the release of the very first national strategy for supporting family caregivers. I hope you all had a chance to look at that pretty mammoth report, but it talks about how we need to incorporate family caregiving and working closely with our professional caregivers. I just think the best experience you can have with home care is when you have an engaged family caregiver that’s working right alongside your professional caregiver.
Bachrach: That’s great. You talked about Medicare Advantage a little bit. What other trends are you seeing as far as reimbursement, payer, those types of things?
Hoak: Well, we know that there are more plans offering in-home support, which is what we’re called under the Medicare Advantage plans. Last year there were about 745 plans offering this as a supplemental service. In 2023, that’s up to 1,090, I believe. The plans are seeing the value. The only problem is that there are over 4,000 Medicare Advantage plans out there. A thousand of them are offering in-home support. Right next to in-home support, though, they’re also offering a lot of family caregiver support programs. I think right now, as far as MA plans are concerned, they’re offering this and you’re seeing it on the Joe Namath commercials, right, Gary?
Hoak: That’s because it’s a competitive edge. People like it, they want to hear, “Oh, I get that. I get meals delivered and all that.” We’re also seeing, and I’m hoping that as this plays out, we’re going to start seeing much more transparency in the Medicare Advantage plans. We all hear that even some people are doing it, no one’s doing it wonderfully. No one’s saying it’s the best thing I’ve ever done. In time it will happen.
Remember, CMS just did an RFI asking people to talk about how we can improve Medicare Advantage plans. I know our association submitted comments, and one of them was that we want to know who’s actually getting these supplemental services? Is it indeed impacting the Medicare costs? Is it reducing hospitals? I think the other thing they’re asking is, show us some data to prove that. We go back to the data, which is all about outcomes.
Bachrach: Speaking of data, and you’re across the country all the time, probably traveling more than you’d like to be, but what are the biggest challenges that you’re seeing now?
Hoak: Well, I think it’s the workforce. I think it’s something that we all are grappling with. I was in Connecticut just the other day and I am starting to see a little bit of give that people are starting to see more people come in. I think our members, our providers are getting smarter at recruitment and retention. I think we all recognize that recruitment is going to have to be different depending on the group you’re going after.
I think the other thing that’s coming out with recruitment is that people today are looking to work for a company that has a culture of caring. They want to say they care about me, the employee. I think we saw that when the highest satisfaction among our caregivers, as well as our clients, was at the height of the pandemic. You have to wonder… why was that? You know what it was folks? We were communicating more. Every day we were talking about, “Okay, here’s the recent guidelines.” Every day we were talking to our families about what we’re doing to protect their loved ones.
I think we have to go back to that and remember that. I think the workforce is going to continue. We have our caregivers, but we know we can’t give you all the hours of care. How can technology assist in those hours when we’re not in the home?
Bachrach: What’s on the minds of some of the members that you meet with on a regular basis? What are some of the things that they’re asking and talking about?
Hoak: Cost of services, which was another thing that was mentioned [repeatedly during the conference panels]. I think it’s also important when we talk to our officials, our members of Congress and state legislators, that the bulk of home care is being paid for by families. We’ve got to continue to strive to make our services affordable. I know that our providers are struggling to do that, because we all know that wages are important. We all want to pay better wages, and we are, but what is that balance to still be affordable?
I think that’s one of the reasons why our association has several legislative initiatives that help families continue to support them and pay for services. I think that’s another thing we have to think about. What can we do to support families to continue to do what they’re doing? That could be the tax credit that we’re supporting. It could be the Elizabeth Dole Act that we’re hoping is going to pass this time around. That’s for our veterans. Why is it, Gary, that for a vet who wants to stay at home, the cost of care can only be 65% of the cost of a nursing home? The Elizabeth Dole Act that’s right now in Congress would allow us to be 100%.
Those are the kinds of things we have to continue to do to make it affordable. Anything we can to make those families continue to do what they’re going to do.
Bachrach: A lot of people in the audience are from all over the country. What are the next states to be on the alert for? Since you’re on the inside and know what’s going on a state-by-state basis, do you have any thoughts?
Hoak: We just got licensed in Ohio and thanks to many of you out there, we were very involved in drafting regulations. However, there seems to be some silence on the part of the health department there. We have the draft regulations. We still don’t know though where the finals are, so we’re watching Ohio.
We are working with West Virginia, we’re working with Arizona, Michigan, and as well as Connecticut. Connecticut has a registration, but no real license for home care, so we’re working with them. I understand why providers get worried about asking for oversight. I get it. But, if we as the industry initiate it and we structure the regulations to be business-friendly and really key in on consumer protections, I think we’re always going to have a better product in the end.
Bachrach: I’m going to ask you a question about Ohio since we just went through that rough exercise. What lessons learned can we have coming out of there? Because I feel like personal care and support got left out. Even though there was involvement, I know folks from The Joint Commission were involved, and many other organizations were trying to help make that standard a little bit of a level playing field.
Hoak: I think that’s another thing that I’m seeing out there. A lot of our members are looking for accreditation, which I think is excellent. When we started working in the Ohio arena with regulations, we said, “If you are accredited, you should have all of the license requirements waived, just prove that you’re accredited.”
This is a great example. As soon as we, in the sector that we’re in, talk about anything skilled, everyone says, “Well, you’re talking about Medicare-certified home health.” With the draft regulations that came out, the disappointment was that the department gave accreditation to home health as a wave, but not to us. Their absolute statement to me was, “Well, we didn’t think you had accreditation, Vicki.”
We have got to get out of that mindset, that just because we want to do a little bit more; yes, we do want to do some skilled services; that there is a place for that that’s not in the Medicare home health arena. We will be looking at that.
Bachrach: Well, again, that one was particularly frustrating.
Bachrach: Because we were involved from the beginning, and we did talk about personal care and support and perhaps for all the accrediting organizations to be a place to get on board.
Hoak: To be that standard of care.
Bachrach: To be that standard of care. In closing, the sad thing is, it’s harder to get a dog license in some states than it is to get your license here for home care. That’s very disappointing for our family members who need that level of care.
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