Alternative Home Care Employment Models: From Workforce Sharing to Self-Directing Strategies

This article is sponsored by Axxess. This article is based on a Home Health Care News discussion with Lucas O’Connell, VP of Operations at AssuranceSD, Francesca Rinaldo, head of clinical strategy for home care at Sharecare, and Christina Andrews, senior director of professional services at Axxess. This discussion took place on August 30, 2023 during the HHCN FUTURE Conference. The article below has been edited for length and clarity.

Home Health Care News: In this panel, we’re going to be talking about alternative home care employment models. Please tell me what your organization does, and what you do for your company.

Christina Andrews: I’m an internal and external consultant. At Axxess, we provide solutions for the care-at-home industry. Whether it’s home health, hospice, palliative home care, we have a solution that meets that specificity so we can keep care in the home, where we know all of our patients and clients and family truly want to be.


Lucas O’Connell: AssuranceSD provides financial management services and self-direction across 13 states. We essentially provide the back office, employer-related, and payroll functions to individuals who self-direct folks who are aging, have an intellectual developmental disability, or part of the VA system.

Francesca Rinaldo: I lead growth and strategy for our homecare line of business called CareLinx by Sharecare. CareLinx is a national network of about 450,000 primarily non-medical care providers, so we provide personal care, ADLs, companionship, but we also have a growing number of clinicians on our platform as well. We work with payers, providers, employers, as well as directly with consumers to provide those homecare services.

HHCN: Christina, why has employee engagement been such a point of focus for you? Also, what are some unique ways providers can engage with their employees?


Andrews: Employee engagement has been something I’ve been connected to for many years because at the end of the day, for us to do what we need to do for the care-at-home industry, we need the employees. The pandemic really gave us an opportunity to look at employee engagement differently through a lens. Typically, we hear more about the experience component, right?

That’s when you hire someone, what is their connection to their overall job, then specificity, their communication with their manager? What was their onboarding experience? What did that look like? Now, we’re hearing a lot of buzz about well-being. Meaning the well-being of the organization or the whole person, so leaning in and taking a look at, what do the social determinants look like for each employee? Financial, health, the mind, body, and spirit.

When you put those two equations together, the experience as well as the whole being, that promotes greater success within retention, as well as recruitment of top talent. When we think about today, only one in four employees feel that their organizations truly are tuning in to their well-being. One in four. However, when an organization adapts that employee engagement program, the experience, plus the well-being, 69% of the employees state, “I’m not going to look for another job. I’m connected.”

79% of the employees state, “I’m not feeling the burnout like I used to.” That is important because your employees can be the word of mouth for the next top talent. They are five times more likely to say, “This is the employer of choice. Come work alongside me and work with this organization.” The other thing that the pandemic has done for us is it’s allowed us to look at our culture, so what is culture? Is it a mission or a vision statement or is it truly the fabric of your organization?

What I mean by the fabric of your organization, its key characteristics that are palpable that you can feel. As a leadership team, have you defined what those characteristics look and sound like? Hustle, hunger, love of learning, self-starter, humility. What does that look like? The reason why that’s important is because those characteristics, if you recruit with those characteristics, you are going to attract ambassadors versus employees.

Ambassadors are individuals who are going to help your organization scale. It’s going to help bridge the gap with workforce scarcity because they’re going to own the success. They’re not just an employee who is showing up, checking off functions, and ultimately saying, “Thank you for my paycheck.” When you put those components together, the well-being, the experience, and culture, it allows you to tune in to a different set of personas.

I think this is very unique for the homecare industry. You have an opportunity to attract the career caregiver, someone who’s been caring for individuals in their community their whole lives, but, “Hey, now, there’s a profession? I can actually do this with flexibility?” You can also attract young adults that need that sense of purpose.

For women with multiple children or a spouse who travels quite a bit, it rounds out that care profession within them. In addition to empty nesters, they need that connection again, as well as retirees. What’s my purpose after I retire? All of that and the combination of the employee engagement truly will help us bridge this gap that we’re experiencing today.

HHCN: At AssuranceSD, Lucas, how has technology played a role in employee engagement? Then also, how does it meet different generations of employees where they’re at?

O’Connell: In a self-directed service model, typically, a friend or family member is going to be your caregiver. Finding those caregivers, identifying who those best matches are, having an element of choice as opposed to maybe a more kind of traditional assignment allows for technology to bring folks both within your community, people who live around you but you might not otherwise come in contact with, to have that opportunity.

It’s also important to self-direction to note that many of those caregivers did not see themselves as caregivers. They see friends or community members who they’d like to help out with. Sometimes they just begin as a backup caregiver. Over the course of time, I think you made a great point, Christina, in terms of the professional caregiver concept, they take to it. They get the bug. You find that the caregiver workforce grows and expands organically as a result.

Rinaldo: At CareLinx, the company was really founded on the premise of bringing not just high-quality care to care recipients and their family members but also really creating an ecosystem within which we support what I personally think is the most undervalued resource in the American healthcare system, which is the non-medical caregiver or, potentially, the unpaid family caregiver. We really leverage the technology to get them better pay because they can negotiate their rates with faster pay.

We often do same-day pay with our caregivers. Then we also provide them with resources for professional development. For example, we partner with CareAcademy to train them in specific programs. When we work for a payer, for example, if there’s specific training we need to implement, we often leverage CareAcademy. They often use our platform almost like a LinkedIn for their caregiving career.

In that way, we’re actually able to draw in a lot of the personas that Christina was talking about, the unpaid family caregivers who now suddenly have this realization, “Wow, I am a caregiver. I can bring my skills to other families.” I was actually just talking to a young man over the weekend. I was at a restaurant with my husband, who was trying to break into the wine industry. At the same time, he actually became an unpaid caregiver for one of his neighbors, who’s an older adult man who lives by himself.

They have this wonderful relationship where, basically, he goes in and he provides those personal care services. I said, “You could do this as part of your career.” He was like, “Really? There’s a resource for that?” I said, “Yes, absolutely.” We can use the technology to really engage with people who maybe don’t even realize that they have the skills to do this and really build the capacity of the network.

Andrews: I love that you bring up the fact of professional development. In 2025, 75% of the workforce will be made up of millennials. When we think about today, we are living in an employee-driven market. What that means is we’re much savvier about the employer that we’re going to choose, right? The millennials say, “The number one thing that I’m looking for in my employer of choice is professional development.”

I was on LinkedIn the other day looking, perusing. In North Carolina, I saw an ad for a local care-at-home industry provider that literally said, “Hey, you come work for us as a home health aide. I’m going to invest in you today, send you to go get your certification.” At hello, even before applying, they’re like, “Wow, you’re already looking at how you’re going to professionally develop me within the care-at-home industry.”

Well, technology has a way of really engaging individuals at onboarding. It could be non-medical skilled, non-skilled, but what is your role? What’s the specificity of your role? How do you even use the technology to do the care that you need to do or to perform the role? It also can take them through ongoing training as well as development.

Then we also have providers here that have looked at different ways of engaging employees. I’m not really much of a gamification person, but some of these engagement platforms encourage your staff to refer to your organization. We think about right now having to pay for bonuses or retention. The gamification allows them to spread out what that looks like based upon performance and annual reviews. Really looking at technology and how it’s going to embrace driving that overall engagement, especially as we have those generations to come like the Gen Z-ers and the millennials.

HHCN: Lucas, for those in the audience that might not be familiar with the two distinctions, what is the difference between self-directed programs versus self-determination?

O’Connell: That’s a great question. Self-determination is really a philosophy, a concept. I think it’s perhaps best embodied in the phrase that many of you may have heard, “Nothing about me without me.” It’s the idea that the person is at the center of care and that they have choice and control over services that are delivered. Many of you are practicing self-determination in agencies that you manage today.

Self-direction or self-directed services are more specific. In self-direction, the individual is actually established as a household employer. We obtain an employer identification number for them and they recruit, train, and essentially manage the caregivers or employees that provide services to them. Self-directed services include personal care. In many cases, respite, transportation. In some programs, folks can even purchase goods or services through what is always an individualized budget.

CMS also identifies the need in self-direction for an information and assistance resource or a support broker. That individual’s critical in educating that individual in that family, in many cases, how to self-direct services. The prospect of waking up one day and being able to supervise or manage an employee is intimidating at best. The support broker really provides a foundation for that individual to be successful.

In most programs, we have employer authority as part of self-direction. That simply means that that individual is able to make decisions, again, hire, fire, manage employees. Something exciting in many self-directed programs is called budget authority. Folks essentially are able to take what otherwise would’ve been an allocated amount of money, funding that they would use in a more traditional agency environment, and spend it within certain parameters and rules as they see fit.

That also allows for caregivers to receive a more competitive rate of pay. Maybe they use unpaid or generic resources to offset maybe less hours being provided by that more highly-reimbursed caregiver. It’s an exciting movement. It started in the ’90s as a result of a Robert Wood Johnson Foundation grant. Today, there are self-directed programs in every state.

HHCN: There’s obviously, clearly, and maybe always going to be a gap between workforce scarcity and ultimately just a provider or an agency feeling good about where they’re at from a staffing standpoint. How can technology bridge that gap?

Rinaldo: One of the things that we leverage our technology for at CareLinx is really understanding the density of available workforce in a particular market ahead of a program launching. What we do is we can actually look at the ZIP code level, how many non-clinical, as well as clinical providers we have registered on the network, whether or not they’re recently active within the last 30, 60, 90 days.

Then we can create education and incentives around reactivating those providers if they haven’t been recently active ahead of a program launch. We typically would do that with four to eight weeks of runway because we want to engage them at the right time so that we pique their interest and then they’re engaged in taking the shifts that are available through that program. We don’t want to do it so far ahead of time that they actually lose interest.

Andrews: Business intelligence comes to mind. In the last session, she spoke a little bit about the dashboard opportunities within technology to predict burnout. That capability exists today. Whether you’re looking at full-time PRN, you’re looking at the shifts, visits, weekends, weekdays, the communication with their direct manager, point-of-care documentation. Is it during the shift or is it after the shift?

There are so many metrics that really apply itself to overall burnout. As an owner, as a manager, you can address it more proactively. The other thing too would be route optimization. I think that’s what you were referring to too. That’s huge because the travel time for caregivers, depending on if you’re urban or rural, could also equate to burnout because what they want to do is be in the home caring, not driving around everywhere.

In addition to schedule optimization, especially if you’re serving multiple pockets, how are you managing that overall scheduling component of employees with caregiver matching? The caregiver matching, I think it’s an attraction for an employee who is looking at an employer of choice because you get to know who I am, my skill set, my certification, my license, what I may or may not like as it relates to, “They have dogs in the home.” He or she may be a smoker. Maybe they live in an area that I’m not that comfortable with. That caregiving matching also can be attractive when choosing an employer of choice because you’re looking out for my well-being.

HHCN: Lucas, AssuranceSD had success with these alternative models, particularly when it comes to retention rates. What is it about self-directed care and that model lends to some of these higher retention rates?

O’Connell: The turnover, the attrition within the self-direction workforce, is notoriously low for a few core reasons. First of all, the interview itself and the recruiting is conducted by the individual receiving services, often in tandem with family or what we call a circle of support. Individuals who are interviewing often are doing so in the participant’s home. They know exactly what they’re getting into. It often comes with a little bit of introduction and an actual hands-on education regarding what that work is going to entail.

In self-direction, you typically won’t have a caregiver providing services to more than one individual. Maybe two at most. Again, to this earlier concept, we often see members of the immediate community, maybe teachers, members of the clergy, even folks that individuals run into at the grocery store, being petitioned to interview. That relationship of almost one-on-one really does make for a meaningful experience. We continue to be amazed at how long caregivers remain with the individuals served. It’s probably one of the most impressive aspects of self-directed programming.

HHCN: Francesca, Sharecare recently announced it will bring its care management and transitional care programs for high-risk populations to more than just Medicare Advantage beneficiaries. Two-parter, how do you try to implement those programs and what are those conversations like when talking to health plans?

Rinaldo: Yes, so just to give you a little bit of context, we worked with one of our health plan partners last year to do an actuarial analysis to look at the impact of a very focused transitional care benefit, personal care, non-medical support in the home for 15 hours after a hospital or skilled nursing facility discharge. We basically compared eligible engaged members to eligible non-engaged members. These were matched cohorts, so we matched them on age, gender, level of risk.

What we found is that even sending a non-medical caregiver into the home for a very focused period of time in that first 60 days after discharge was resulting in a 21% reduction in 30-day readmissions for those high-risk older adult populations. We obviously are very excited about these results. We’ve been working with our health plan partners to now take these learnings and expand them to other high-risk populations.

For example, we’re working with one of our partners to implement these transitional care programs in high-risk maternity and postpartum populations, complex chronic pediatric populations in their families, and complex behavioral health populations. The idea is, when we’re talking to the health plans, we really want to make sure we’re closely integrating with our clinical and care management teams, and we’re really tailoring these programs to the specific needs of the populations.

We know, for example, for an older adult population, some of the root causes of readmissions are going to be not fully understanding the discharge instructions or not having a medication reconciliation or follow-up in a timely manner in the first 30 days post-discharge. Potentially, fall risk. For the maternity population, those risk factors are going to be really different, right? We’re really tailoring these programs and providing the same in-home support, but making sure that we’re engaging the members with the caregivers to do different types of screenings and assessments that can really help us to fully understand their current risks and also uncover new ones.

HHCN: From a quality perspective, obviously, with the rise of value-based care, how can technology provide clinical intelligence and guidance as a way to keep outcomes and some of these high-quality scores at the forefront? Christina, you want to start with that one?

Andrews: I would say, again, business intelligence, starting your day, ending your day, focusing on the quality metrics that you are leveraging to get a seat at the table for the future. How does that align with the quadruple aim? Making sure the specification of those metrics truly align with all four of those elements because, ultimately, quality plays into all of those other areas. We were talking about that earlier. The other thing too is the models in which your technology provider offers. Is it just a one-type model or does your technology partner offer controlled flexibility to fit your unique models? Because that will also provide guided validations to ensure that you’re focused on the quality that matters.

HHCN: Lucas, anything else to follow up on that one?

O’Connell: I would just offer that when you have that continuity of caregivers, especially when folks know the individual personally or have a relationship that spans more than several months into years, the opportunity to gather data points shift-by-shift, day-by-day, and the implications is drastically greater. It’s taking something that’s entirely quantitative and making it more qualitative as a result of, in this case, opportunity self-direction gives.

HHCN: Francesca, anything to add?

Rinaldo: This dovetails with the themes from the panel just prior to ours, but I think there’s a huge opportunity to use different data sources to risk stratify populations. We’re using claims, ADT data, pharmacy data, but one of the things we found, which actually adds a whole another unique dimension to data, is the data that is actually being gathered by caregivers in the home. We leverage our mobile app to actually have caregivers conduct different types of screenings and assessments or even just record their observations.

It adds this depth that you don’t get, for example, via a telephonic care management assessment for social determinants of health because you actually have someone there in the home who has eyes on the patient and can really understand like, what does their food insecurity look like or what does their transportation insecurity look like? One of the things that I really encourage people to do is think outside the box about the different data sources that you can incorporate to help you really focus your resources in these complex populations.

HHCN: Clinical outcomes is obviously a huge part of this, but then also just financially, I feel like cost-effectiveness is often brought up when considering the pros and cons of this type of care. When promoting these models, how can they help the bottom line for providers and for families, patients, members?

O’Connell: I think the theme throughout these couple of days is the workforce shortage. In self-direction, you essentially have family members and individuals being served acting as very passionate and empowered recruiters on behalf of the caregiver workforce. That’s not just limited to those folks who are being served in self-directed programs. You find that communities and states where self-direction is robust and well-invested in, the actual caregiver population across the board surges.

This is an incredible population of people. These are folks who don’t necessarily appreciate how rewarding caregiving can be until they have that opportunity. In so many instances, we meet folks who have had business education backgrounds who have found their way to caregiving and will do all they can to remain in the industry. The cost of recruiting that I know many of you are stifled by is really, really well-served by self-directed services.

HHCN: Francesca, what about from your perspective?

Rinaldo: When I think about managing cost of care at scale, I think about efficiency, removing those redundancies, those repetitive steps. I think one of the risks when you implement new models of care is that you’re basically introducing new variability into an already established system. With that variability comes additional cost. I think that’s a risk we run with implementing some of these new models. The flip side of that is if you’re really thoughtful about how you implement them and you really think about coordination of care and data sharing across providers and settings of care, you can mitigate some of that risk.

HHCN: Christina, when Francesca mentions efficiencies, when you hear that, what do you think about that? What is Axxess doing to help bridge that gap?

Andrews: It’s basically reducing the redundancies. How many times does an individual have to input the data versus how it flows from one component of their care delivery into another component? Reducing redundancy, but what you were making me think of is I was on a call with a client the other day who actually pulled the data together, positioned himself at a table with two payers based upon the care models that he implemented to show how he was saving on cost, improving quality.

Again, that’s very attractive if you use the data to position yourself at the seat at the table. Optimization of workflow, utilizing the data, leaning into the quadruple aim really helps to round out what it needs to look like. The other thing that Francesca made me think of, I had an opportunity to have a conversation with a CEO/president of UnitedHealthcare over a couple of regions. He flat out said, “If I have a provider coming to the table wanting to get into the payer world, if they don’t align with the quadruple aim, if their model doesn’t align with the quadruple aim, we’re just not going to look at it.”

HHCN: How can these alternative models address those aims in a way that traditional care models might not be able to?

Rinaldo: Again, when I think about our model really founded on the idea of self-determination, self-direction, and the example that always comes to mind when I think about these models is work that we’ve done for respite relief in collaboration with the Elizabeth Dole Foundation and the VA. What we found is when we were doing the need-finding and working with Elizabeth Dole Foundation to implement these programs and really talking to the veterans and trying to understand their needs, we found that a lot of them were very hesitant to allow newcomers into their homes.

We created a pathway where when a veteran enrolled in the program, they could actually designate additional family members or neighbors or friends who could become that caregiver. Then we created onboarding processes where we would basically vet and train those designated caregivers by the veteran at the same level that we would any other professional caregiver on our network. That really ended up in everybody winning because the veterans were getting great quality care.

We were building the capacity of the network in those markets because those caregivers, once they were onboarded to the network, could also then provide care to other veteran families in their local geographic area. You’re also containing the cost of care by building up the supply and then you’re driving great outcomes because you’re building that trust and that relationship. When the caregiver really knows the patient, they’re able to identify those early signs of clinical deterioration or those social factors that can lead to poor outcomes.

O’Connell: My favorite example is the impact self-direction has on underserved communities. We’re all familiar with the challenges of finding and deploying caregivers in rural settings. The challenges that come with tight-knit communities that are maybe not open to bringing folks into their home that they don’t know. When you have a strong self-directed program, people are able to, again, engage within their communities, recruit within their communities.

Then those caregivers are highly knowledgeable because they’re from the community about other resources that exist outside of personal care, respite, and the like. You’re also empowering that individual in the decision-making and choice to own health outcomes in a really unique way. We find that attendance at regular doctor visits, medication administration routines, this idea that I am owning my health and my experience because of the additional choice and control I have lends itself to better outcomes, higher quality of care, and definitely a happier patient and team member at the end of the day.

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