Think Tank

How Should State Shape Care at Home?

We’ve all seen the demographic predictions: California’s numerous baby boomers will swamp the health care industry with aging bodies — almost all of them wanting to stay healthy, active and living at home.

That last part — living at home — may become a recurring, resounding policy issue in the coming years.

A new report from the UCLA Center for Health Policy Research suggests California policymakers need to pay more attention to health care delivered in the home.

“Almost no data exists to measure the quality of care provided by the rapidly growing industry of private home care providers serving an expanding population of the elderly and disabled,” according to the policy brief “Who Is Minding the People Who Are Minding Our Elders?”

A bill in the Legislature this year seeks to more tightly regulate and keep track of the thousands of home health workers. AB 1217, by Assembly member Bonnie Lowenthal (D-Long Beach), would require home care agencies to be licensed and caregivers to be listed in an online database.

Regardless of the fate of Lowenthal’s bill, the issues raised in the debate over how to manage home health care will continue to grow in importance as baby boomers age and more home health care services are needed in California.

We asked legislators and stakeholders how California can best shape state policy regarding home health care givers to get ready for major changes ahead.

We got responses from:

Consumers Need Information

LeadingAge California is the association of not-for-profit providers of affordable senior housing, assisted living, Continuing Care and Multi-Level Care Retirement Communities, skilled nursing facilities, and home and community-based providers of services to more than 100,000 Californians.

Home health agencies in California are already licensed and significantly regulated. Employees are licensed or certified nurses or other health professionals delivering health care. State and federal mechanisms exist to mediate and enforce state and federal standards for assuring patient safety and high quality standards of care for seniors needing home health care services.

While these home health care mechanisms may need modernization and updating to accommodate changing needs, the fastest-growing part of services to seniors in their homes are non-medical home care services, which cover a variety of tasks, from help with bathing and dressing, to laundry, grocery shopping, or transportation to the doctor’s office or pharmacy.

Currently, California does not require home care agencies to be licensed or that employees are trained or certified by any recognized authority. Given that California has the largest share of the population age 65 and older in the U.S., and that “aging in place” is the default preference of aging boomers, home care services will explode as the early boomers hit their eighties. Consumers take on risk, allowing un-trained, unknown, or un-wanted workers into their homes and lives.

Historically, regulatory mechanisms — such as licensing, registration and certification — have been successful protecting patient safety and maintaining high quality of care in the Medicare and Medicaid programs. The evolving importance of home care services for addressing the needs of a growing older population is clear. California consumers need basic information about the people and organizations seeking to provide non-medical services to seniors and others in their homes. At the same time, regulatory mechanisms cannot increase the cost of services beyond the reach of consumers, who pay privately for most of this care.

New Workforce Development Strategies Needed

We have seen the reports and the media stories about our aging population, particularly our aging baby boomers, and how that will fuel a growing demand for long-term care services. The critical question we have yet to answer is: Who will provide this needed care?

Today, thanks to our nation’s 2.5 million home care workers, many elders and people with disabilities are able to live independently in their communities. These workers help clients to bathe, get dressed, eat, administer medications and more. According to the Bureau of Labor Statistics, this workforce is projected to grow to nearly four million by 2020.

The challenge we face is how to attract people into these new jobs and how to keep valued workers in this field. The work is vital, but also difficult and often dangerous. Yet the pay is low — on average, less than $10 an hour.  Nearly one in three have no health coverage. And training requirements for home care workers vary from state to state and program to program. In many instances no training is required, leaving workers without the skills and preparation they need to be successful in their jobs.

What we need are workforce development strategies that are designed to improve poor-quality jobs held by home care workers. Stakeholders and policymakers both have roles to play in promoting these interventions, which can be practice-based (working directly with employers and training programs), as well as policy-based (legislative or regulatory initiatives such as licensing), and often combine the two. The intent of these strategies is to improve low-wage jobs sufficiently in terms of compensation, benefits, job-design, training standards and a host of other measures so that workers can secure a meaningful degree of stability and dignity in their work and consumers can be assured of the quality of the services they receive.  New U.S. Department of Labor regulations extending federal minimum wage and overtime protections to home care workers is a good first step, but much more needs to be done.

It is time to recognize that these workers are vital to our health, aging and disability services and the key to quality in long-term care. We face an ongoing and growing need for home care workers to support individuals with disabilities so they can live independently in their communities, and to provide assistance to families that care for parents and grandparents.  Improving training opportunities, ensuring livable wages and health coverage, and attending to credentialing and licensure will help us to attract workers to meet the increasing demand for home care workers as more people live with disabilities and our population ages while ensuring appropriate oversight so that our elders are cared for safely and well.

Assessing Quality, Assuring Safety Are Challenging Tasks

With the prospect of the aging population rapidly growing and needing a high level of home care, assessing the quality of care provided by the home care industry and ensuring patient and consumer safety are arguably the most important challenges facing policy makers. However, both issues pose significant challenges for two central reasons:

  • Home care consists of services provided by several types of formally trained and certified/licensed providers and those without any formal training or certification; and
  • Providers have diverse employment arrangements.

These variations require different criteria for assessing quality and patient safety. For example, the criteria for assessing quality of nursing services are inherently different from the criteria for assessing quality of home health aide or custodial services. In addition, employment through a licensed home health agency means employees receive background checks, while direct employment by the patient may not entail background checks.

Assessing quality is further complicated by major differences between home care and outpatient or inpatient care. These differences include lack of a specific and regulated setting for care delivery, lack of direct supervision of workers while care is delivered, and different expectations for outcomes of home care because — for many patients — the services are designed to maintain well-being and function rather than to cure or treat. These differences lead to additional challenges to assessing the three major aspects of quality — structure, process, outcomes. For example, structure for home health care organizations can be measured through staffing, level of training, certification/licensure, and background checks. But for home care agencies and individual providers, licensure may not exist and staffing levels do not always apply. Assessing processes of care is difficult in the absence of objective observations by other trained staff and lack of specific claims data detailing all the provided services. Similarly, outcomes can primarily be measured through surveys of patients and subjective assessment of care delivered rather than more objective measures.  

These challenges have led to limited knowledge of quality of home care to date, but the low-hanging fruit in this debate is implementation of structural measures of quality such as background checks. Background checks will not guarantee abuse prevention but would provide some assurances for many of the vulnerable patients and consumers of home care. Licensure and certification are other methods of providing assurances for quality of care and worthy of further debate and consideration.

AB 1217 Is Not the Answer

California needs to expand and enhance its continuum of services for its aging population. There are frequent news stories about the lack of vigilance in monitoring care, whether it be nursing homes, assisted living or in-home care, and much work needs to be done to shore up our delivery and monitoring systems.

Medical service guidelines were developed for Medicare, the primary payment source, while none exist for the state and private funded sources, which pay for the non-medical services, such as home care.  Home care licensure is sorely needed.

But AB 1217, the Home Care Consumer Act, is not the answer.

AB 1217 deceives the consumer by claiming protection through licensure for home care, yet it exempts over 75% of all home care services, targeting only a portion of the private home care agencies, of which there are two models: those that employ their aides and assume all employer liabilities (the employer model), and those that just pay the aides a gross wage and transfer all employer liabilities to the client (the referral agency). The latter are exempted from the bill’s coverage, yet such an agency will be permitted to represent itself “to be a home care organization by name, advertising, soliciting, or any other presentments to the public” and may “imply that it is licensed to provide those services” without being licensed under this bill.

This union-sponsored bill was written to affect only the employer model, one small sector — representing less than 20% of all home care. No rationally operated agency will continue the employer model when it can opt out of licensure by flipping to the referral agency model. Consequently, as agencies switch to the referral model, this bill will erode Medicare and Social Security — the pillars of our safety net for seniors — and will remove workers compensation coverage for thousands. Moreover, this puts consumers at risk as they unknowingly assume all employer responsibilities for the worker.

We need home care licensure under the California Department of Social Services that offers regulations similar to other states and in licensure for hospitals, nursing homes and assisted living. There should be full consumer disclosures and a certification process for agencies that choose not to employ their workers. And we need a joint home and assisted living non-medical aide certification curriculum and fingerprinting system under DSS. We need to safeguard the existing entitlements and protect for our aging population from all exploitation.

Balancing Consumer Protection, Business Viability

Like other states, California is in the early stages of an aging boom. We’re not just living longer; we’re living longer with a growing list of chronic conditions that will require some level of care. What we’ve learned from research isn’t surprising — most of us want to remain in our own homes and communities as we grow older. We want choices and we want to ensure that the care provided, whether it’s for a loved one or ourselves, is safe and reliable. 

For decades, policymakers have worked to build safeguards into our long-term care services. We have licensing requirements for providers large and small and training requirements and background checks for their staff. We have standards in place for all levels of care, from highly-skilled nursing care, to basic assistance with daily living tasks. These protections exist for all consumers, whether they’re paying out of their own pocket or receiving state or federally-funded care; with one exception: home care. 

Although the home care industry is one of the fastest-growing industries in California, only our publicly funded services through our In-Home Supportive Services program require any background checks or basic training. We have more than 1,000 private home care organizations serving countless Californians with nothing more than a business license. While many of the organizations screen and train their staff, there is no statewide standard to ensure compliance, and no way for a consumer to verify that the person they’re letting into their home has a clear criminal history.

At the legislative level, we’ve struggled for years to find a balance that provides consumers with the protections they need without sacrificing provider viability. Earlier this month, we passed my bill, AB 1217, which would for the first time establish a licensing framework for home care, complete with background checks for the aides that they employ. It includes a registry that will help consumers verify a provider’s record. 

While it doesn’t go as far as many would like — myself included — and cover all aides, whether they work for an organization, through a referral agency, or on their own; it’s certainly not the death knell for the industry that the opposition has made it out to be. It’s a reasonable compromise that allows the industry to grow, while protecting consumers. It’s a first step toward  ensuring that all of us can age with dignity and choice in our own homes.

New Procedures, Technology Expand Home Care Options

Home care and hospice agencies provide quality care to individuals in the privacy, security, and familiarity of their homes at a fraction of the cost of providing such care in hospitals, nursing homes and other institutional settings.

Multiple studies indicate that home care leads to speedier recoveries and is preferred by most patients and their families. Home care plays a prominent role in all stages of health care and helps people stay independent by combining skilled care and compassion with the latest in health care technology. Quality and highly skilled home care is provided across the full spectrum of health care, including post-acute care following a hospital stay or serious illness; as long-term care for those with a disability, chronic illness, or those in declining health; and care for medically fragile infants, seniors, persons with disabilities, those with dementia and cognitive impairment, and terminally ill patients in need of comforting and compassionate hospice care.

California’s home care agencies provide guarantees and protections to potential clients and patients, their families and the caregivers themselves that do not exist when hiring home care workers independently.

Agencies conduct drug screening and background checks to ensure caregivers are trustworthy and reputable and agency caregiver employees are covered with professional and general liability insurance and are covered by the workers’ compensation system. Agency employed caregivers are also trained to provide the necessary services patients and clients need and are educated on the use of any medical and monitoring devices they may need to operate. Moreover, agencies provide oversight for each individual case, create a care plan for patients and clients, supervise caregivers and ensure that back-up care is provided when caregivers themselves are ill or absent.  Families that employ caregivers directly do not benefit from these functions and take on the added burden of being the employer of record for their caregiver and are responsible for paying Social Security, Medicare, unemployment, disability, and state and federal taxes for each caregiver.

Home care is a $12 billion industry in our state, and it employs tens of thousands of caregivers to treat our aging population and others in need of home care services. With the exciting advent of new medical procedures, portable technology, skilled staff and caring home care aides, many health services that previously had to be provided in institutional settings can now be compassionately and cost effectively administered in the warmth and safety of home.