COVID-19 Intensifies Home Care Workforce Challenges: Agency Perspectives
ASPE ISSUE BRIEF
Melissa Hunter, MSW, Natalie Mulmule, BS, Kristie Porter, MPH, and Denise Tyler, PhD
June 1, 2021
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ABSTRACT: Home care (including home health) agencies have faced many challenges because of the COVID-19 pandemic. These agencies provide services and supports that help individuals remain safely in their homes. Although people receiving these services are some of the most vulnerable, many agencies reported that clients suspended services at the beginning of the pandemic. At the same time, home care staff were hesitant to enter client's homes and work with them in ways that often require sustained in-person contact. This brief provides findings from an environmental scan and interviews with agencies and advocates, highlighting the most common challenges faced by home care agencies during the pandemic and the strategies agencies used to mitigate them.
This report was prepared under contract #HHSP233201500039I between HHS's ASPE/BHDAP and RTI International. For additional information about this subject, you can visit the BHDAP home page at https://aspe.hhs.gov/bhdap or contact the ASPE Project Officers, at HHS/ASPE/BHDAP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201; Judith.Dey@hhs.gov, William.Haltermann@hhs.gov, Iara.Oliveira@hhs.gov, Marie.Squillace@hhs.gov.
DISCLAIMER: The opinions and views expressed in this report are those of the authors. They do not reflect the views of the Department of Health and Human Services, the contractor or any other funding organization. This report was completed and submitted on March 2, 2021.
Home care (including home health) agencies have faced many challenges because of the COVID-19 pandemic. These agencies provide services and supports that help individuals remain safely in their homes. Although people receiving these services are some of the most vulnerable, many agencies reported that clients suspended services at the beginning of the pandemic. At the same time, home care staff were hesitant to enter client's homes and work with them in ways that often require sustained in-person contact. This brief provides findings from an environmental scan and interviews with agencies and advocates, highlighting the most common challenges faced by home care agencies during the pandemic and the strategies agencies used to mitigate them.
"Some of that just has to do with definition, and some of it is recognition that the work they're doing is important."
Workers not recognized as essential. State definitions of essential workers differ, and some states do not designate home care workers as essential personnel despite their high risk of exposure to COVID-19 and close contact with clients. Because of this, these workers have faced difficulties in obtaining personal protective equipment (PPE) and testing for COVID-19, accessing some clients living in residential facilities, and obtaining the vaccine. Further, when states began implementing lockdowns, agencies felt they had to prove the work they were doing was necessary and feared their staff would be prevented from seeing clients. Several agencies and advocacy groups noted the extra work they took on at the local, state, and federal levels to ensure their staff were deemed essential, including working with attorneys to outline the roles of their workers and speaking to government officials on an ongoing basis to clarify definitions.
Access to PPE. At the beginning of the pandemic, as usual supply chains were disrupted, many agencies were forced to find alternative sources of PPE. This required reaching out to suppliers with whom they did not have existing business relationships or using personal connections. Because home care agencies and their workers were not deemed essential, they were not a priority to receive available PPE. When agencies were able to find available PPE early in the pandemic, surge pricing was rampant and agencies reported vendors were often unable to fulfill their orders and meet delivery dates. Challenges were amplified by high PPE burn rates due to agencies' stringent infection control policies. Agencies found ways to overcome these challenges, and at the time of the interviews they reported that PPE supplies had returned to normal.
Access to testing. Agencies also faced a lack of access to testing. Testing was essential to keep staff and clients safe, and to ensure staff who were exposed but did not have COVID-19 were able to continue working. One provider described driving from one urgent care to another hoping to put his credit card on file so he could send his staff somewhere to get tested. Another agency noted that the local hospital did not have enough tests for staff, and was told to treat staff who may have been exposed as if they were COVID-positive, regardless of whether they had symptoms. This created staffing challenges at a time when agencies were already struggling to retain workers.
|Workforce Challenges||Mitigation Strategies Used by Agencies|
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Access to the vaccine. During interviews with home care agencies and advocates in December 2020 and January 2021, access to COVID-19 vaccines was an emerging issue for home care workers. Home care workers did not receive prioritized access to the vaccine like other health care professionals because they were not designated as essential health care workers.
Lack of guidance from government agencies. Home care agencies noted a lack of direction and consistent information from federal and state government agencies. Although they found some helpful guidance from the Centers for Disease Control and Preven, they felt left to fend for themselves to update their infection control protocols and policies to be appropriate for COVID-19, including policies related to testing their employees.
"Many workers left the field in those first few months. There's long been a workforce shortage in direct care, and it was amplified in that moment."
Staffing shortages. Existing staffing shortages worsened due to the pandemic. Staff choose to stop working for various reasons. Some feared getting COVID-19 or exposing family members or clients. The closure of schools and childcare centers placed another burden on the workforce. Although agencies, and sometimes local governments, attempted to support staff by helping them find childcare or providing flexible schedules, many staff still needed to leave their employment to care for their families during this time. Other staff left due to reductions in available hours.
Difficulty recruiting staff. Despite an increase in unemployed workers who might be able to fill roles, agencies reported it was harder than ever to find talent, in part because these jobs often have low wages and do not provide full-time hours or comprehensive benefits. COVID-19 added a very real threat to physical safety that potential employees may have had a hard time overlooking. Different training and certification requirements -- especially for aides, personal care workers, and direct service providers -- also made it more difficult to recruit staff from other health care sectors. While there was a temporary relaxation of training requirements in many states, several stakeholders noted concerns about those changes and uncertainty regarding whether staff hired under these conditions would eventually be required to complete more training.
Transportation issues. Several agencies noted that staff felt unsafe using public transportation, and clients were uncomfortable having people in their homes if they had been on public transportation. A lack of safe, reliable transportation made it difficult to maintain sufficient staffing during the pandemic.
Reduced census. Agencies reported decreases in their client loads at the beginning of the pandemic. This was a result of elective surgeries being canceled, people being afraid to let others into their homes, and family caregivers beginning to work from home and believing they would be able to take on the caregiver role. Some agencies had to reduce staff hours, which caused additional staff to leave their employment.
Strategies Used to Mitigate Workforce Challenges
"... [A] lot of our franchise owners and their office staff really stepped in and started making their own face masks to have that in the interim to provide that to their staff. So, they were very creative."
PPE. Without PPE available through typical suppliers, agencies found other ways to get what they needed. For example, some agencies started making their own face masks. Agencies joined together to buy PPE as a group. This group purchasing power helped them get PPE at a reasonable price as prices surged. Agencies worked together to buy the large quantities of PPE required to guarantee delivery. The ability to "have [the] buying power that was necessary to be able to get the supplies" was critical to agencies.
Additional pay and benefits. To retain workers, agencies incentivized staff through hazard pay, incentive pay, and bonuses made possible through federal disaster relief funds received by agencies as a part of the Coronavirus Aid, Relief, and Economic Security Act and Paycheck Protection Program (PPP) funding. Benefits such as paid sick leave, paid time off, and retirement benefits may have been used by some agencies to entice staff to stay. Some agencies also furloughed employees with the option to return.
Shifting to new virtual processes. Home care agencies reported trying to maintain flexibility in their approach to dealing with COVID-19. Many agencies allowed office staff to work from home and tried to move aspects of patient care that did not require in-person work to a virtual setting. They began utilizing more technology in their hiring processes and in client care. This included using virtual platforms to conduct interviews and onboarding, and providing clients and caregivers with tablets and oximeters for remote monitoring. This investment in technology was an important part of helping staff (including potential employees) and clients stay safe.
Flexible staffing and scheduling. Agency leadership allowed staff to change their schedules to address new constraints from a lack of childcare, or reassigned staff who were uncomfortable going into homes. One agency said, that as long as it worked for patient care and for their staff, they did what they could to accommodate schedules. Agencies used flexible staffing arrangements -- such as having staff fill administrative functions on top of their client-facing roles -- to offset staffing reductions.
"The training is really important for the frontline because they're in the homes with nobody else."
Infection control. Agencies reported doing what they could to help employees stay safe. They implemented screening protocols for staff and clients, who were asked about their symptoms and potential exposure before every shift and visit and were provided with additional follow-up and support, as needed, if responses indicated a risk of infection. Agencies also augmented their infection control procedures through increased training and education and advocacy groups worked to ensure their members had accurate, useful information and tools.
Increased communication. To ensure staff were kept up-to-date on infection control policies and could inform leadership of any challenges they were facing, communication between agencies and their staff became increasingly important throughout the pandemic. Providers started regular "town hall" meetings with agency leadership and staff. Providers also used informal education initiatives to communicate with staff and share resources on a variety of topics such as the epidemiology of the virus, proper hand washing techniques, and the safety of the vaccines. Even though staff could not be together physically, agencies found it important to stay in regular contact and show appreciation for their workers. Some chose to send inspirational texts and thank-you notes. Agencies reported wanting to make sure their staff knew they were well cared for,heard, and recognized.
Other types of supports. Agencies also supported their employees in various other ways, such as utilizing back-up staff or volunteers, hiring from other sectors when possible, and working with family caregivers. Some agencies helped their staff find childcare, paid for ride services so they did not need to take public transportation, provided meals, or created grant programs to cover employees' unexpected costs. Many providers noted the importance of supporting mental health during this time by providing regular check-ins or setting up phone lines that employees could call if they wanted to talk to a counselor.
Though the pandemic has created many challenges in the home care sector, agencies and workers have worked hard to keep caring for those who are most vulnerable. The pandemic created roadblocks to accessing PPE and testing, and notably intensified workforce shortages. These issues were exacerbated because home care workers were not designated as "essential workers." Interview participants reported implementing helpful flexibilities and supports for staff, such as better communication, shifting to virtual training, hiring and service provision, and flexible staffing and scheduling to accommodate staff needs. However, consensus was that ensuring that home care workers are recognized as an essential part of the health care workforce is critical to increasing recruitment and retention now and in the future.
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HHS OFFICE OF THE ASSISTANT SECRETARY FOR PLANNING AND EVALUATION
Hunter, M., Mulmule, N., Porter, K., & Tyler, D. COVID-19 Intensifies Home Care Workforce Challenges: Agency Perspectives (Issue Brief). Washington, DC: Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services. June 1, 2021.
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