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Hiring, retaining & managing deskless caregivers

How providers are coping with the ‘new normal’

Companies that offer healthcare, home care, behavioral health therapy, workforce development or other services in the comfort of people’s own homes have important but difficult jobs. Following more than two years of a grueling and emotionally draining pandemic, the needs for their services, leaders in these companies say, are higher than ever. But it’s also more difficult to find qualified care providers. Companies have responded by raising wages, monitoring closely for signs of burnout, even offering discounts to NBA basketball games, among other tactics to attract and retain talented mobile care providers. But many also say scheduling such far-flung teams can be a nightmare and that many modern information systems used for scheduling leave much to be desired. Skedulo spoke with leaders who work for companies or nonprofit organizations, or own franchise businesses, with sizable workforces. Most represented home healthcare or home care services.

Other respondent worked in fields such as:

  • Applied behavior analysis (ABA) therapy for autism patients
  • An independent reference clinical laboratory that services long-term care facilities
  • A hospital-at-home program run by an urban nonprofit hospital
  • Patient services providing in-home interpreters and international patient service run by a large health system
  • Workforce development programs for people with intellectual and developmental disabilities who live in group homes

Respondents who granted Skedulo permission to use their names and job titles are cited in this report, while others asked to remain anonymous.

Important but difficult jobs

Home health agencies and other organizations that provide services in peoples’ homes are inherently difficult businesses to manage. “The most challenging aspect I think is balancing everything,” said Beau Sorenson, COO at First Choice Home Health & Hospice near Salt Lake City, Utah, which maintains an average daily census of around 250 patients.

“There’s your billing, there’s making sure the patients get seen and managing staff. Right now, staffing is a significant issue for us, as I know it is for a lot of people across the country. Just making sure that we have people to go out and see patients and get them taken care of, and
then ultimately get paid for those services.”

Authorizing the right types of visits for payers, including a proper match of nurse certification levels, and staying on top of insurers’ frequently changing rules around reimbursement, are also difficult.

“It is pretty challenging with insurance companies at times, because we do have a significant insurance census,” Sorenson said.

“There are a lot of agencies who are majority Medicare, but we’re actually majority commercial. And as a result, managing those prior authorizations, managing the visits and doing it in a way that we’ll end up getting paid are significant challenges for us.”

It underscores a truth that providing care in peoples’ homes is hard work. At Willow ABA Services, which offers center- and home-based autism therapy services, CEO and owner Tanner Sierks says hiring is a major hurdle, especially for lower-level behavioral technicians. “I think that at one time, this field was glamorized, because you get to work with kids with special needs,” he said. “And I think that’s always part of people’s missions and values as they set out to help people. But then there’s a realization that the job’s not for everyone, and it’s harder
than it looks.”

A thinned workforce

Service providers say labor challenges are paramount, starting with a shortage of qualified workers. Those agencies that employ licensed nurses have been hit by the same nurse staffing shortage plaguing the entire healthcare system; the U.S. Bureau of Labor Statistics projects 194,500 average annual openings for registered nurses through 2029, fed in part by high rates of retirement that have accelerated during the pandemic.

One recent study found that the total nationwide supply of RNs declined by 100,000 in 2021, or 1.8%, the largest drop observed over the past four decades. Burnout is a big challenge. Many respondents say burnout was always a factor in their fields, but the pandemic exacerbated things. Employees, they say, are experiencing
the same emotional challenges as the people they’re trying to help.

“Providing support to people with intellectual and developmental disabilities can be challenging during regular times. COVID made it extra challenging because we couldn’t go out as much into the community,” said Shannon Ross, director of talent experience with The Arc Central Chesapeake Region, a human services agency that provides workforce preparedness training and other life skills in Severn, Md.

Some added that vaccine requirements, which are key to receiving payment from the Centers for Medicare and Medicaid Services, or CMS, have further thinned the pool of available talent. So did the risks of entering long-term care facilities or private homes while the pandemic raged. Another respondent mentioned lack of childcare as a limiting factor for attracting home caregivers. That’s created headaches for many home healthcare providers, who point to the high acuity levels of patients discharged from hospitals that were frequently overwhelmed by waves of COVID patients and grappling with their own staffing issues. As one respondent put it, there are more people who need home healthcare services, and a higher level of help, but fewer people available to provide it.

Not surprisingly, some home healthcare providers say they’re seeing many patients who have gone without care or need more care, since visiting their doctor or a hospital has been complicated by the pandemic. Mental health is also an emerging issue, some say, related to the isolation many patients experienced as the pandemic wore on. But at Denver Health, a safety net hospital, the situation is the mirror opposite in its hospital-at-home program, which it launched to ease pressure on the system as its acute care facilities filled up with COVID patients. Once information about the program and how it would work went out, the program was besieged with applicants, said Natalie Nicholson, associate chief nursing officer. “It was very popular because right now the commutes into Denver metro are crazy, and there’s a lot of desire to be remote workers, since a lot of our nurses are just burned out from the floor,” she said. “So there’s a waiting list for positions.”

Compensation lags behind

For many agencies that provide services in homes, the problem of labor shortages is compounded by what many respondents conceded was an inability to offer competitive pay to home caregivers. At First Choice, Sorenson said there’s been an increase in labor costs for lower-skilled caregivers just to remain competitive in hiring and retention. Before the pandemic, he said, home healthcare aides might start around $13-$14 per hour. Now, it’s between $17 and $20 per hour.

Sorenson cites competition from “easier places to do business,” like grocery stores and fast-food outlets, that also raised their starting wages, as the reason First Choice raised their starting pay. That has increased overall operating costs by about 5%, he said.

“We’ve seen some aides who are almost getting paid as much as we were paying LPNs two years ago,” Sorenson said.

One respondent, who runs lab operations for an independent, regional reference clinical laboratory, said his company has had to adjust its expectations amid a huge shortage of qualified lab technicians. The company no longer requires a specialized vocational certificate, instead hiring candidates who have a bachelor degree and are willing to receive on-the-job training.

But that strategy isn’t failsafe. New hires, who are often straight out of college, quickly discover they can make more money at a hospital, in biotech or another field, and they end up using the laboratory as a springboard to a bigger paycheck somewhere else. That’s left veteran lab staff weary because they’re constantly training new hires, the respondent said. The company has also had to begin staggering training to get one bench up to speed before shifting to another bench of new staffers.

Recruitment & retention tactics

Agencies that employ mobile workers have nearly all found it necessary to raise wages, though many point out that puts upward pressure on the rates they charge and squeezes their margins. They have also responded with a number of other tactics to attract and retain talent, including:

  • Offering quarterly bonuses
  • Offering a clearer path to leadership, including training
  • Giving gift cards and gas cards to mobile workers
  • Setting up times when mobile caregivers can come together and connect, such as company “lunch and learn” events, catered pizza luncheons or barbecue
  • Sending employees to industry conferences
  • Creating and hiring for a new position as “onboarding facilitator” — someone who works closely with new hires through their first 90 days on the job
  • Offering staggered signing bonuses tied to longevity after hiring on, so workers don’t simply leave once they qualify

Helpful tip: At First Choice, Sorenson said the company is considering changing to a different electronic health record system because employees often complain about the difficulty of using the current system.

At Willow, Sierks began a new perk that allows employees who work nine-hour days to take a weekday off every other week. Willow also sometimes sponsors Denver Nuggets or Sporting Kansas City games, where they will cover 20% of the ticket price for anyone who works in applied behavior analysis.

Scheduling challenges

Seniors, who are most often the recipients of home healthcare services, cherish routine, emphasizing the importance for agencies of keeping to a schedule. As one agency franchise owner put it, regularity and dependability give elderly residents something to look forward to.

“We’re trying to customize a care plan for each client to say what’s the right volume of time to have a caregiver in your home,” said Roy Wu, a franchise owner at Home Instead Senior Care in southeastern Washington state.

But scheduling for in-home services can get complicated quickly in a complex field like healthcare.

In a heavily regulated state like Washington, nurse caregivers need to work at the top of their licensure, but they may not get utilized as efficiently as possible.

“So in other words, if you give me a schedule, and I have a client for you four days a week, you’re saying, hey, I can actually work five days a week, but that client only wants four. I need to really identify that and make sure I’m utilizing you as much as possible.” ROY WU.

Ross, of The Arc, says her agency places its direct support professionals, as they are known, inside the group homes. Because of that, training is very site-specific and unlike a retail operation, where workers can easily be used in multiple locations. “If you’re hired to work in a location, there’s training for those specific people, so you can’t be pulled to other areas,” she said. “We will pull people to other locations, but you have to make sure that there are some additional steps before just putting them there. So that’s kind of a challenge.”

Ross said the organization was trying to cross-train employees so they are available at more than one group-home location to be more flexible. That way, The Arc can be more proactive about getting shifts covered when there are openings without having to enlist management in figuring out a solution.

Sorenson said First Choice uses its electronic medical record system to do scheduling, which works well for scheduling specific clinicians at specific times. But it lack any real-time visibility into where the caregivers are, and whether they’re en route to a patient’s home. Often times, staff don’t know where a caregiver has been until they complete their documentation at day’s end, he said.

One respondent, who runs an in-home interpreter service for non-English-speaking patients at a large health system, uses four different systems, including Excel spreadsheets, to do scheduling. Another, who is director of nursing at a mid-Atlantic home healthcare agency, said she uses the EMR system for scheduling but complains about excessive lag in back-and-forth communications.

When clinicians need to make last-minute changes, the office doesn’t know about it unless the clinician calls the office and asks staff to manually update the schedule, she says. There is no mobile app, no ability to view caregiver availability by week or view open jobs, and everything involves manual processes.

Other common complaints about scheduling

  • Home healthcare providers need an easier, automated way to comply with Electronic Visit Verification regulations to verify details like location, times, staffing and sign-ins.
  • They also need a system that can manage different models of in-home caregiving — for example, a home health caregiver or nurse who makes regular planned visits versus a model in which a caregiver lives in the home, where a nurse or case manager makes monthly visits. Different business models can involve different quality or regulatory standards.

The lack of ability to optimize travel routes for caregivers, so they’re not being sent back and forth across town. One respondent said if he sandwiches
together two shifts but forgets to account for drive time, the system doesn’t automatically alert him of that, putting pressure on caregivers and risking leaving
patients dissatisfied.

  • Others cited a desire for real-time information on when caregivers arrive at a patient’s home so they can measure employee efficiency.
  • Scheduling teams often suffer from “app fatigue” and having to toggle between email, EMR, mileage software and other platforms to manage their mobile workers.
  • Many expressed a desire for a scheduling tool that syncs with other systems, such as payroll, onboarding or human resource platforms.
  • They’d like more visibility into caregiver certifications or time-off requests, and the ability to record session notes that are necessary to provide to insurers for reimbursement.

Ross, from The Arc, must contend with staffing ratios that are directly correlated with funding. “There’s some financial pieces in there,” she said. “It’s not just about covering the hours, but also what the best mix of people in a property or unit is so we’re maximizing the funding.”

At the clinical reference lab, one scheduling headache that has arisen is with its phlebotomists, who are also in short supply. The company has had to assign phlebotomists to collect blood samples at multiple long-term care homes — previously, it would send them to no more than two locations before they had to deliver the samples back to the lab. The quality of the blood samples deteriorates the longer they are in the field, and it pushes blood draws later and later into the day. This creates a domino effect that pushes everything else back in the lab.

At JEVS Human Services in Philadelphia, officials are looking for a new scheduling solution to provide a stronger communications interface for its home caregivers, though Chief Operating Officer John Colborn said it needs to be a simple-to-use interface, since some of the nonprofit’s mobile caregivers are not comfortable with technology.

One big issue is the organization’s current solution doesn’t help it respond to missed shifts. “We don’t allow workers to leave their shift until they’re replaced,” Colborn said. “So we have some workers who ended up having to spend a night at home that they didn’t plan to, and that is not popular. And so definitely, we see the relationship between shift coverage and retention.”

Sierks said he sees more automated scheduling as having the potential to improve workflows and boost retention of higher-level positions. Willow consults with several other ABA service providers to manage scheduling and workflows, and many of them don’t have office or operations managers and instead leave scheduling up to location or regional directors.“We tell them, ‘Now you don’t have to worry about scheduling nightmares anymore. You can just focus on what you got into the field for, the clinical side,’” he said.


Asked about his top priority for JEVS, Colborn replied, “it’s adjusting to whatever this new normal is,” adding that the nonprofit’s focus on employment and career-focused work for its clients is challenging, given the constraints of the modern labor market and having to augment much of its work through virtual services, due to the pandemic. “And so I would say, recruiting, retaining and providing a level of economic justice for our frontline workforce is probably one of the central motivating ideas we’re working with right now.”

In an era marked by what some have dubbed the “Great Resignation,” workers clearly have more clout, with the ability to pick and choose jobs that can offer them better pay or benefits — or simply more closely comport with their core convictions.

In this environment, home healthcare, ABA and human services agencies, and other organizations that employ mobile care providers who work in people’s homes face an uphill battle to attract and retain talent, much less manage it. Lacking the financial resources to compete against deeper-pocketed hospitals or employers in other industries, they must turn to other resources to ensure that theirs is an efficient, well-run organization that emphasizes individual contributors.

Deskless caregivers want to be empowered to focus on their jobs helping people, to work at the top of their licensure, at their optimal capacity, with a clear path to advancement for those that want it. Helping them by creating smaller geographic coverage areas, so there’s less distance they have to drive, providing consistent scheduling so there’s less volatility in their income, and helping them to see the same clients to build consistency and predictability, is a great place to start.

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