Community-Based Home Care Work Group Policy Priorities

COMMUNITY-BASED HOME CARE WORKGROUP

BHRAGS Home Care Corp • CABS Home Attendants Service, Inc. •

Community-Based Home Care Workgroup

The Community-Based Home Care Workgroup consists of 11 nonprofit home care agencies. Collectively, we serve nearly 11,000 community members a year across the five boroughs of New York City and surrounding counties, employing nearly 14,000 New Yorkers.

Nonprofit home care providers have faced particular challenges. Specifically, Medicaid, the largest payer of home care and long-term care in New York State, has exacerbated the home care crisis through chronic low reimbursement rates. Nonprofit home care agencies are beholden to the rates and requirements laid out by Medicaid and NYS. We cannot compensate our workers justly or run the best quality programs when faced with inadequate Medicaid reimbursement.

Background

New York State (NYS) has the fourth oldest population in the nation, with 3.7 million people aged 60 and over.  By 2030, 5.2 million people in the state will be 60 and older, with 1.81 million New Yorkers will be 75 or older. The rapid aging of the population will cause an unprecedented demand for home care. 

An estimated seven out of 10 people over the age of 65 will need some kind of long term care. In addition, there are over a million New Yorkers with disabilities, chronic illnesses, or other functional complications that require direct and immediate care, creating a significant population in NYS that require direct care support to live and age in dignity. Care that takes place in homes and in communities is often preferred by consumers, higher quality, and less costly overall than institutionalized care. 

Because of the growing needs of people with disabilities and an increasingly aging population, the home care sector is the largest employer in the nation. Yet, it continues to face shortages. NYS has over 330,600 home health care workers, with 187,000 home care workers servicing NYC alone. A 2018–2019 statewide survey of home care agencies has shown that 17 percent of these positions were left unfilled due to staff shortages. With growing demand, New York is the epicenter of a national home care worker shortage with a projected shortage of 50,000 workers by 2023, and over 83,000 by 2025. These jobs are overwhelmingly filled by women, people of color, and immigrants. 

Policy Priorities

At a time when racial, economic and gender justice need to be addressed as a top priority, we have laid out the following policy priorities within the nonprofit home care sector that highlight how nonprofit community-based home care providers, their workers, and the communities they serve can receive equitable support and resources:

1. End Medicaid Global Cap – Home care is funded substantially by government payors – the State’s Medicaid program represents 87% of home care and personal care services, which includes through managed long-term care plans (MLTCs). What exacerbates the sector’s low wages are depressed Medicaid reimbursement rates that do not cover the full and true cost of delivering home-based care. Particularly for nonprofit providers, home care agencies are beholden to the rates and requirements laid out by Medicaid and NYS, which makes it extremely difficult for providers to compensate their workers adequately or competitively because of these unfunded regulatory mandates and the exclusion of basic operational expenses from rate formulas. Any significant home care pay reform will need to require additional funding by Federal and State Medicaid support. This cannot happen without increasing or eliminating the Administration’s policy of a Global Cap on annual spending increases tied to medical inflation rates.
   
    
2. Fully Fund 24-hour Home Care – The 13-hour rule has been set and enforced by the State since the 1970s. Home care workers are being assigned 24-hour shifts by Medicaid where they are only paid for 13 hours of work, with 8 hours of unpaid sleep time and 3 hours of unpaid meal time. NYS determines home care regulations and compensation from contracts with NYC Human Resources Administration (HRA), local agencies, MCOs and MLTCs; support by court decisions; and 1199SEIU union agreements. Because of these pre-existing contracts, nonprofit home care organizations must accept 24 hour live-in cases. However, because of Medicaid reimbursement, providers can only compensate those workers for the 13 hours unless a worker documents and reports interruptions, which imposes yet an additional burden on the workers. Home care agencies must comply with the DOL regulations and their contracts which are funded from rates set by the Department of Health using a formula based on a 13-hour work day (as originally set by DOL). In order to provide worker compensation for all hours on the job, ensure that patients get needed and adequate care in the least restrictive setting in accordance with the Olmstead Act, and not impose onerous reporting requirements on home health aides, we recommend that DOH reimburse all 24 hours of a 24-hour shift. We are supportive of Assemblymember Epstein’s bill A3145A and Senator Persaud’s bill S359 which would end the 24-hour shift in favor of making 12-hour split shifts the industry standard. It is critical to ensure that this bill does not reduce care hours for patients and continues to provide care in the least restrictive setting, is fully funded, and makes allowances for certain cases where 24-hour continuous care is appropriate (such as in certain cases of dementia, or by live-in family caregivers) although those 24-hours should then be fully compensated, including breaks. NYS should allocate approximately $1.1 billion in Medicaid to better support patients who require 24-hour care and their workers and to enact the Epstein/Persaud bill. It is also critical that this bill is paired with measures like Fair Pay for Home Care to ensure that we are simultaneously addressing the workforce shortage so that there can be enough workers to fill these shifts.
   
    
3. Pass Fair Pay for Home Care – Nonprofit community-based home care providers work hard to ensure that the home care workers we employ are representative and reflective of the communities we serve. We believe the best care comes from providers who understand and represent the same values and cultural understandings of our communities and patients. We also believe that those providers are best able to deliver quality care when the value of their work is fully acknowledged through fair compensation. To combat the current and projected workforce shortages, improve wages in order to boost worker recruitment and retention, and meet growing demand, the legislature must pass Fair Pay for Home Care (S5374 May/A6329 Gottfried) and ensure it is fully funded in the FY 2022-2023 State Budget. This legislation would raise home care worker pay to 150% of the highest area minimum wage across the State. An investment in the home care workforce would wipe out the home care workforce shortage in less than five years – creating 20,000 additional home care jobs per year for the next decade. Fully funding this bill is estimated to cost between $3 and $4.5 billion, and could be supported with federal funds. The State should set minimum requirements for payments from Medicaid managed care plans to home care providers; create incentives for investing in the workforce through improved compensation, training, advancement opportunities; and generate other innovations. NYS should also conduct an industry-wide analysis to determine compensation levels and corresponding reimbursement rates at every level (inclusive of nurses, therapists, social workers, administrative staff in addition to all aides) to competitively recruit and retain a talented home care workforce. 
   
    
4. Pass the New York Health Act – The New York Health Act would provide universal long term care coverage, allowing for coverage of true care needs and providing the opportunity to assess cost-savings through expanded coverage.

5. Increase Publicly Available Data Collection and Evaluation – The State should collect, audit, and analyze sector-wide data – much of which is already reported to the State – and conduct evaluations. Examples of this data could include number of clients served, number of employees, number of 24-hour cases, changes in these numbers over time, employee retention and turnover rates, average length of staff vacancies, and disaggregated data by nonprofit and for-profit agencies and size of agencies. This data, if made publicly available, would help quantify budget needs and evaluate the impact of policy changes. Efforts to collect data must also be fully funded by including this work in the overall home care rate development formulas.

6. Fund Certification and Enhanced-skills Training – A home care workforce begins with required training and certification of eligible workers to fill PCA, CNA and HHA positions. NYS must fully fund HHA certification training to proactively build a pipeline of eligible workers to enhance recruitment efforts. Enhanced-skills training must be added to create a career ladder with the ability to increase skills and earnings to retain and incentivize home-based workers. Enhanced-skills training must be culturally and linguistically appropriate and should include disease specific interventions (Alzheimer’s, diabetes, etc.), use of technology, other specialized skills, preceptor and mentoring programs to help recruit new workers into the field. Workers should be incentivized to complete additional training by compensating them for participation in required training and certifications.

7. Support Innovation in Home Care and Community-Based Services – NYS should utilize future 1115 waiver funding to support community-based providers with the implementation of innovative and evidence-based services that deliver on the triple aim of improved patient experience, improved outcomes and reduced cost. 
   
    
8. Enhance Industrywide Oversight – NYS should establish a Public Home Care Advocate’s office to act as a liaison and resource hub for employees, employers and home care recipients as well as to determine what long-term care should look like. 

9. Align the DOH Request for Offers (RFO) for Licensed Home Care Services Agencies (LHCSAs) with ARPA Workforce and Value Based Payment initiative to take advantage of the State’s significant investment in this program. Priority should be given to nonprofit community-based organizations that already provide related critical services, eliminating system fragmentation and promoting independence and dignity for patients served.

10. Create a centralized data system via the Home Care Registry to track a universally HHA Inservice – Home health care workers are required to have 12 hours of Inservice annually. Oftentimes aides who work for multiple agencies attend Inservice trainings for each agency. By creating a centralized data system it would enhance the continuity of care to client, worker retention, and be cost effective to the system.

11. Enforce DOH updates to home health agency rates – DOH should increase rates to cover wage increase, workforce support and all related needs, in accordance to calculations generated by HCP. These rate calculations should be implemented by plans across the board, as required by the Public Health Law.

12.  Adjust Reimbursement Rates to include Technology and Telehealth Needs – The pandemic has required a much faster adoption of telehealth and the use of home-based technology by patients and providers. However, existing Medicaid rates do not reflect this major transition and grant support has been limited. Providers must be funded to implement patient and home health aide training, supply devices (phones/tablets, remote health monitoring, etc.), and support access to free or low-cost WiFi and adequate provider bandwidth to facilitate connections. This is an essential cost that is not currently calculated into the reimbursement rate but will improve delivery of home care, home health aide field-based management and supervision, and program administration. Home care providers and aides have direct access to patients every day and can ensure that they continue to have access to much needed services even when in-person treatment is not a safe option. Finally, NYS must enact permanent laws, replacing temporary waivers, that create rate-parity for telehealth services whenever the same service is available in-person. Without rate-parity, all other investments in telehealth may be compromised. 

13. Reimburse for COVID-19 Related Cost Coverage – Provide reimbursement for all COVID-19 related costs and enhance reimbursement rates to include COVID-19 related costs for the duration of the pandemic, including PPE, remote training, purchasing equipment and technology to support remote care of patients and supervision and support of workers, and more. 

14. Adopt HCA’s New York Home Care First Policy – Ensure prioritization of home care services by adopting the NY Home Care First state policy. Proposed by HCA, the policy would align state laws and procedures to ensure home care is an accessible option across the continuum of need, and a first option prior to institutionalization. 

For more information, please contact Wayne Ho, President and CEO, Chinese-American Planning Council at (212) 941-0920 x 143 or who@cpc-nyc.org.