Nursing homes and other senior living facilities are not the only places where COVID-19 is creating a health care crisis for frail older adults and their care providers. The other setting at risk: private homes, where the vast majority of older adults get both personal and post-acute care. And the pandemic is creating enormous challenges for those seniors, their families, and the workers and home care agencies that provide those critical services.
Roughly 12 million people receive some form of care at home, compared to about 2 million who live in nursing homes or assisted living facilities. Yet, few have noticed that many of the nation’s more than 12,000 home health agencies are under increasing financial and clinical pressure that put their ability to support families at risk.
Limiting ability to care
We have no real idea how many older adults living at home have COVID-19, or how many have died from it. And it is likely that we never will know about many who die at home without getting medical care.
The plight of these home care agencies threatens to ripple through the health system. It limits their ability to provide care at home for many COVID-19 patients who have been discharged from the hospital—a potentially safer alternative than skilled nursing facilities. It makes it harder to rehab non-COVID patients at home. And it reduces the supply of paid support for the 85 percent of frail older adults with chronic illness already getting their care at home.
These firms may be struggling even more than nursing homes to find personal protective equipment for their staffs. They have too few coronavirus test kits for either staff or clients. Many are reporting high rates of staff absenteeism. Some staff are sick with COVID-19. Others fear they will become sick. And many are staying home to care for their children whose schools are closed.
Complete care redesign
Ken Albert, president and CEO of Androscoggin Home Healthcare + Hospice, a firm that serves 2100 patients a day in nine counties in Maine, says COVID-19 has upended his business and clinical model: “In four weeks, we have completely redesigned our clinical workflows, how we approach care in the home setting, and how we navigate staff, relationships with patients, [and] infection control.”
To protect clients, many agencies want their staffs to take time off if they feel ill. Yet, relatively few provide paid sick leave. A few states require paid leave for care workers with COVID-19. But home health workers appear to be exempt from a new federal law requiring leave for those with COVID-19. On average, home health aides make less than $10.50 an hour, and nearly one-in-five have no health insurance.
In addition, aides often work in facilities as well as for private clients, adding to the risks. Travel is a growing challenge for those who must use public transportation—significantly scaled back in many cities due to the risks of COVID-19.
In an effort to boost their financial stability, Medicare has begun distributing $30 billion to health care providers, including home health firms. But that funding only applies to agencies that accept Medicare, and must be used only to offset coronavirus-related costs. It will not benefit those that take private pay clients only, including uncounted thousands of individual gray market aides.
Separately, Medicare also has provided more than $34 billion in advance payments to its providers, including home health agencies, to help with cash flow. And it has eased many regulations.
A new business model
COVID-19 has vastly changed the business environment for home health firms. Many private pay providers have lost clients who require a few hours of care a day. Family members, many of whom have been laid off from their own jobs, are providing that care themselves.
Private duty aides no longer are allowed in nursing homes and most assisted living facilities.
Because many states have banned elective surgery during the pandemic, occupational and physical therapy volume has plunged. That business already was under pressure due to unrelated changes in Medicare rules.
At the same time, home care agencies that provide long-term care are getting some new business. Some older adults who are leaving care facilities or not moving in at all in the wake of COVID-19 now need home care.
But that business requires staff and equipment. And many home care providers are facing crippling shortages of both.
Staff shortages were a growing problem even before COVID-19. The pandemic has made them far worse. In many markets, agencies are competing with better-paying hospitals for nurses and aides, even as disease itself shrinks the supply of available workers. Some agencies say they are hiring newly-unemployed restaurant servers for low-skilled work.
Ellen Bolsch, CEO of THA Group, a firm that provides a wide range of home health, personal care, and palliative and hospice care in coastal Georgia and South Carolina, says she is retraining therapists to provide some nursing services, such as wound care. She and others are increasing their use of telehealth, though Medicare still won’t pay for many of those services.
And then there are the chronic shortages of personal protective equipment (PPE) and timely testing. Home care agencies are far down the priority list for both—well behind hospitals, nursing homes, and first responders. Bolsch is paying $10 for N-95 masks that once cost less than a dollar.
Unable to get masks from his state or the federal government, another home health owner turned to a local retailer of sex toys who sourced his products from China. He found a Chinese middle-man who, for cash up front, arranged an order of protective masks.
Neal Kursban, who owns Family & Nursing Care, a private pay agency in Silver Spring MD, says, “we desperately want to serve” COVID-19 clients. But he’s run into multiple roadblocks, including shortages of PPE, lack of access to testing, and slow results from tests he can get. While his firm has designated special teams to care for COVID-19 patients, staff and clients need to be tested regularly for the system to work.
Waiting for tests
Bolsch still is waiting for results of a test taken two weeks ago for a staffer exposed to a COVID-19. “It can take three days, it can take three weeks,” she says.
Without a negative test, an aide who is exposed to a COVID-19 client might have to self-isolate (and, at many agencies, not get paid) for 14 days.
Home health care can be more cost effective than skilled nursing facility care. While outcomes in general may not be better, home care may well be safer and in the era of COVID-19. Yet, like most of the rest of the health care system, home care agencies are operating under enormous burdens.