12 States Share the Ongoing Effects of COVID-19 on Home Care in Their State

We’ve reached out to our state association partners across the country to get their high-level take on the state of home care in their prospective states. Here’s what they have to say. 

As we’ve mentioned in weeks prior, COVID-19 is affecting our everyday lives and no one could have predicted it’s existence let alone it’s impact on our industry in 2020.

With the wealth of information being blasted at us from every channel, sometimes it’s hard to know what’s truthfully happening around us locally, let alone regionally or nationally. With that in mind, we’ve decided to reach out to our state association partners across the country and get their high-level take on the state of home care in their prospective states.

The leadership of these associations have graciously compiled and condensed their thoughts on the impact of COVID-19 in their state. These brief overviews display what they’re currently seeing, hearing and experiencing first-hand as they communicate with home care agencies throughout their state.

For easy access, we’ve linked to each region here:

PACIFIC

CENTRAL

GREAT LAKES

SOUTHERN

NORTHEASTERN

Pacific

California – Dr. Lucy Andrews, Executive Chair of California Association for Health Services at Home

We seem to be in a bit of a holding pattern. We have been in a statewide lockdown since mid-March and while we have learned and adapted many processes most are still holding their breath to see if there is another spike in their area of the state.

So, what exactly has changed?

We all have become logistics managers with sourcing, delivering, and managing precious PPE supplies. We all have had to learn new skills related to procurement logistics and distribution! Most agencies are subtlety shifting to long term planning for the new world of COVID 19.

This means changing how you onboard new clients as well as staff. How you redo workflow processes to decrease contamination opportunities. Most agencies have some form of visit prescreening mechanism that helps protect staff and clients and detect issues early on. Most of us will keep these in place for the foreseeable future.

Many agencies are working to regain clients that took a care pause because of fear of COVID 19 are showing fatigue and agencies are offering enhanced infection control measures and hopefully we will see those clients come back on service soon.

Agencies are reconnecting with hospital liaisons as elective surgeries are starting to come back, slowly but come back none the less.

Other issues are finances, of course, the PPP loans, and managing the workforce are all things that keep owners and administrators working and moving forward.

The state association,  CAHSAH is working on a regular basis with the Department of Social Services’ Home Care Bureau to temporarily waive some regulations that are near impossible to comply with right now such as TB testing as a hiring criterion. The department has been very helpful in understanding the dilemma that agencies are facing and we look forward to continuing this collaboration with the department.

We know we will get through this pandemic and come out stronger as agencies who help protect and keep frail elderly and disabled persons safe at home. This is our time to shine and let the world know that home is the best place and we are here to help!

Washington – Shawn D’Amelio, President of Washington Home Care Association

Washington was the hotbed of COVID-19 and once AGAIN Washington has proved that we are stronger together! Click Here to see the results of Governor Jay Inslee’s quick actions to contain COVID-19 in Washington. This is my favorite chart because it showed Washington at the top and by acting quickly and working together (or should I say 6ft. apart) we successfully moved to the bottom. That said, there is still a lot of work to be done.

While In-Home Care is considered an essential business, we still took a hit. 81% of companies surveyed said they had clients put service on hold and about 66% said that they had caregivers refusing to take shifts because they were worried about COVID-19.  Typically, In-Home Caregivers do not own PPE, therefore many companies did not have it on hand and as we know, there was and is a shortage in the country so it took a bit for everyone to get it and get it dispensed to caregivers. As of last week, 85% of companies surveyed are still reporting a shortage of PPE.

What we know for sure is that over 90% of the companies surveyed reported that they had not had a caregiver or a client diagnosed with COVID-19. Home Care is the safest option for Long Term Care and home care will be the preferred choice for many families moving forward.

The Washington Home Care Association (WAHCA) has worked closely with the Department of Health and advocated for DOH Waivers of WACs During COVID-19:  Here is the most current list of home health and hospice In-Home-Services waivers approved of by DOH. All of the background check WACs are addressing waiving the fingerprint requirement since WSP is temporarily not offering this service.

WAHCA was happy to be included in a COVID-19 Briefing on Long Term Care for State Legislators along with Leading Age Washington, The Adult Family Home Council and the Washington Health Care Association and the Washington State Hospital Association. There is great concern by legislators around how skilled nursing facilities and other long-term care housing is handling the crisis. All participants lamented the lack of access to PPE and testing. The group requested that there be a standing order from Dr. Kathy Lofy, WA State Medical Officer from Dept of Health for testing so they don’t have to get a physician to sign the orders.

The group asked that DOH be the lead for all coronavirus information instead of 3 different health care agencies. It gets a little confusing getting information from DOH, DSHS and HCA. They are also looking for limited liability for their businesses during the pandemic for health care provider claims. Workers can be operating under dangerous conditions, but they requested a higher standard for what might be considered gross negligence.

Central

Utah – Matt Hansen, Executive Director of Homecare & Hospice Association of Utah

Home care providers have reported an average decrease in gross revenue of approximately 20% during the COVID-19 public health emergency. Most of the decline is related to reduced referrals for “non-essential” personal care and impaired access to clients due to social distancing precautions. Greater reductions in gross revenue have likely been avoided thus far because clients and families often consider personal care services to be even more essential than the skilled services that they may have been receiving through home health.

Compounding the impact of decreased revenue is the increased costs of personal protective equipment (PPE) and labor/employee retention. Many agencies have had to pay hazard pay and overtime in order to maintain safe and responsible care. The industry has requested and is hoping for direct support from the State in the form of stimulus money and/or Medicaid waiver program hazard pay rates. We recently learned that one of the programs, the New Choices Waiver, has been approved for a temporary rate increase, though the rate table has yet to be published.

Arizona – Zach Shaw, Board President of Arizona In-Home Care Association

AZ hasn’t really peaked in cases. From the association perspective, we’ve only received about 3 calls requesting information on COVID-19 questions and how to deal with those clients. Most agencies have decreased in client census, primarily due to clients not permitting caregivers in the home.

Average hours have gone up and call volume has gone down. Call volume has gone down approximately 10-15% for most agencies. Companionship service has decreased, but there has been an up-tick on essential services for clients coming out of hospitals/facilities.

Approximately 15% of caregivers are applying for unemployment, but most agencies are winning the appeals in most cases. Caregivers have been found making up excuses to apply for unemployment, but agencies are coming back and saying these caregivers have full time employment opportunities.

Nebraska – Janet Seelhoff, Executive Director of Nebraska Association for Home Healthcare & Hospice

Overall, home health referrals declined when hospitals canceled elective surgeries. Governor Ricketts allowed elective surgeries to resume on May 4, 2020 if hospitals meet certain capacity requirements. We are hopeful that this will help increase home health referrals. Overall, hospice referrals have not been impacted as much. However, some facilities aren’t allowing hospice providers to enter and provide care and services. They are concerned about potentially spreading COVID-19 to hospice patients, even though hospice providers are complying with CDC and infection control guidelines and practices and wearing PPE.

In regard to a 30-day PPE supply there is a shortage of available PPE for home care and hospice providers. Our association is working with the public health departments and the Nebraska Department of Health and Human Services as well as vendors to help our members acquire PPE. Some home care and hospice providers have been able to secure PPE if they are part of a hospital-based system.

From a caregiver recruitment standpoint, the shortage of nurses is a challenge that continues whether there’s a pandemic or not. It’s possible that some home care providers will experience an increase in the number of applicants, given the significant number of layoffs in healthcare and other industries.

Our association has submitted waiver requests for telehealth options to allow for expansion of telehealth use in the home during the COVID-19 health crisis, where appropriate, and reimbursement of telehealth services at the same rate as an in-person visit. A waiver has been approved for Medicaid clients.

As an association we’ve shared information with our members on how to apply for PPP and/or EIDL loans as appropriate. We’ve hosted webinars with NAHC and the Home Care and Hospice Financial Managers Association on how to document use of CARES Act funds. We’ve also shared updates with our members about IRS guidance and PPP loan forgiveness.

Throughout the entire pandemic, we’ve encouraged home care and hospice providers to adhere to CDC guidelines and utilize their infection control practices and plans.

Great Lakes

Indiana – Katie Ociepka, Director of Development of Indiana Association for Home and Hospice Care

Indiana agencies have faced a limited supply of PPE as well as a portion of their client base that has been asking agencies to not provide services in order to avoid having anyone come into their homes.  Agencies have done their best to continue serving clients via tele-services, checking-in and ensuring that all client needs are met during quarantine.  The limited supply of PPE prevents agencies from being able to fully meet CDC standards for PPE, but we do hope that more regular shipments and the resulting increases in supplies will allow agencies to use PPE without needing to re-use or go without it, particularly for agencies providing non-medical services only.

As the Governor and local officials look to begin opening businesses, we expect caregivers to return to work and more services needed from agencies.  This will allow providers to return to their full capacity and look to potentially take on care for individuals who have been unable to access it or begin services during quarantine.

Southern

Kentucky – Katie Ociepka, Director of Development of Kansas Health Care Association

Agencies operating in Kentucky have faced similar issues to those in neighboring Indiana and around the country, with the changes to regulatory standards being the primary concern for operations with the flexibility that has been granted.  Developing screening and reporting tools for staff and clients have been a priority.  Providers of Private Duty have also indicated needs related to PPE, with hand sanitizer and gowns being particularly difficult to access.

As cities begin the process of opening local businesses throughout Kentucky, agencies will look to take on additional services for clients beyond the current essential or basic/essential services being expected of them, while also bringing their own operations back from a virtual setup to in-person operations and addressing all employee risks and needs as a result.  Finally, for both Indiana and Kentucky, the question of agency liability has been consistently raised as a concern.  As we have seen from our nursing home counterparts, home and community-based providers will also need heightened levels of immunity in order to continue to act in their safety-net capacity.

Louisiana – Matthew Rovira, CEO of Leading Health Care of Louisiana

The in-home caregiver industry in Louisiana has performed better than institutional settings in protecting its recipients from COVID-19.

Long-term institutional care settings have been hit hard by CV-19. One-third of the State of Louisiana’s 2154 deaths have been in institutional care settings (710 deaths to date).

The number of CV-19 cases in home and community-based settings has not been reported; however, with our census of over 1000 we have only had two confirmed cases with one death.

I contribute our low infection rate to our ability to be flexible with staff to reduce the number of in-person contacts that a recipient encounter. After the Governor of Louisiana announced his Emergency Declaration in March, we immediately began limiting the number of staff into a home.   I achieved this reduction by the following:

  • increasing overtime worked by 20%
  • allowing family members to be paid staff
  • increasing the number of hours worked in one period
  • increase use of technology to perform supervisory visits
  • doctor visits done remotely
  • bulk grocery shopping
  • increased the length of each prescription
  • suspended documentation timelines

Additionally, we continue to retrain staff on proper use of PPE, in-home sanitation, and proper hygiene.    There is more work to do to keep our loved ones safe; however, the in-home care model has performed well under this emergency Pandemic.

Florida – Kristen Wheeler, Executive Director of Private Duty of Home Care Association of Florida

Florida providers are reporting much the same as the rest of the country, I’d expect – seeing a slight decrease in services due to clients cancelling or putting services on hold, citing that they prefer not to have anyone in the home right now. Staffing shortages do not appear to be a problem that has been brought to our attention; I expect that is because of the service cancellations, thereby freeing up caregivers that otherwise would be assigned to a case or cases.

The Governor of Florida ordered his stay-at-home order in late March. Following that order, we did hear reports from providers about staff being stopped while traveling and told they were not to be out. To assist with this, Florida’s Surgeon General released an official letter allowing those providing medical care to be on the road. Providers and their staff were encouraged to keep a copy of this letter with them along with employer identification in the event they were questioned. This seems to have helped while the stay-at-home order was still in effect.

Looking forward, as the COVID-19 pandemic continues to evolve, one thing that is becoming clearer is that home and community-based services are sure to be more in demand than ever before as COVID positive clients are discharged from hospitals and continue to recover at home.

Obviously, this means that having ongoing access to PPE is critical and, while we’re hearing that gloves and masks are much easier to get now than they were early on, gowns are in short supply. Some ALFs and SNFs as well as some clients themselves are asking that home care staff be in full PPE in order to enter the residence.

Northeastern

Virginia – Marcia Tetterton, Executive Director of Virginia Association for Home Care and Hospice

Early on, we conducted a PPP survey of members.  Of those that responded 20% did not apply.  Of those that did apply for a PPP Loan only half received funding.  We have caution members that there are significant reporting requirements attached to these loans and that they need to work closely with their accountant to ensure compliance.

Through the entire pandemic, we’ve encouraged members to comply with CDC Guidelines which has presented a challenge as these guidelines continue to change.  Antidotally,  I hear that larger or hospital based home care organizations with more robust infrastructure have had fewer challenges obtaining PPE.  I have also found it interesting that in Virginia there has been a great deal of random variability in the distribution of PPE from the state stockpile.

In regard to referral sources, we saw an initial drop in referrals for skilled home health. On the skilled side with a freeze on non-emergency surgeries slowed the number of hospital and skilled referrals significantly.

We also saw a drop in private-duty and Medicaid personal care. Family members were at home and available to provide care or patients were afraid of a potential exposure to COVID-19.

Fast forward a few weeks and referrals are growing for all types of  home care. This does come with a caution, not all of referral sources are providing adequate health care information especially if the patient is Covid-19 positive.  Transparency continues to be an issue.

Maryland – Dawn Seek, President of Maryland-National Capital Homecare Association

Here in Maryland, PPP Loans are still difficult to get for many providers. I don’t have any specific numbers but many of the small providers I have spoken to are in the process of applying and many are finding it a difficult process.

Anecdotally, the home care associations across the country are all non-profits, but do not qualify for any of this relief. We have no income coming in as we cannot hold our events as usual and there has been limited interest from members for any webinars unless they are COVID-19 related.  We are hoping for relief in the Stimulus 4 package

In regard to overtime payroll, many of the home health agencies have partially or fully furloughed employees as their revenue is down around 30%.  The usual elective surgeries have been put on hold, so there is not the level of referrals they are accustomed to and the COVID-19 patients are just now starting to surge into homecare.

The private duty agencies are struggling with OT on several levels. For the Medicaid agencies who have a workforce shortage or are simply just trying to minimize the number of caregivers in a client’s home, they are barely breaking even or losing money on any case with OT as Medicaid has refused to pay OT.  For the private duty agencies with the same issues, they cannot increase rates to most of their clients as they will run the risk of the clients cancelling services due to cost.

Several of the homecare associations are lobbying congress for hazard pay for front line workers.

Agencies are struggling to obtain and afford the PPE that is required.  Agencies have spent thousands of dollars on PPE to protect their staff.  Until this week, PPE was extremely hard to find. I spent hours each day sourcing PPE vendors and vetting them before letting my members know what was available.  PPE that is available often takes weeks to receive and then the price is much higher than it has been in the past. Further, some PPE vendors have very high minimums making it impossible for the smaller agencies to afford to purchase a shipment. Some mask minimums were so high that an agency would have to come up with $250K to afford an order.  Keep in mind, this is not a cost that cannot be passed on to the payer, whether that is an insurance company, government payer, or private pay client.

Some agencies have what they need but at a high cost, some are still struggling as they are trying to afford PPE.  Gowns are hard to come by right now and there is concern that many of the N95s and KN95s being sold are not meeting the 95% filtration rate to truly protect the workers. I am hearing that hospitals in some cases are sending the patient home with a certain amount of PPE to get the agency started.

Training requirements are relaxed by CMS for home health agencies, along with supervisory visits.  Recruitment is difficult as many caregivers are afraid or lack childcare. Also, the current unemployment situation leaves an unemployed caregiver making more than an employed caregiver, hence the desire to get hazard pay for the caregiver who are working to keep them working and to coax the unemployed caregivers back into the workforce. Training for the direct care workers is difficult due to the numbers. Plus, there is a shortage of the equipment needed to properly fit test masks and it is hard to fit test some of the available masks.  It is also hard to keep up as CDC and the Maryland Dept of Health keep updating practice. Right now, we are still functioning in a crisis standard of care mode, which is essentially do the best you can with what you have to work with, which in some cases is not much.

New York – Al Cardillo, President of Home Care Association of New York State State

Every day, the professional and compassionate work of home care enables highly needy, complex, and service-intensive patients to maintain their health and quality of life at home.

Every day, home care works miracles for patients and solutions for the health care system.

Every day, home care responds with individual and family support in a manner and venue unlike any other service.

In COVID, the miracles, dedication and impact of New York’s home care agencies and personnel are at unprecedented levels. Workers have risked their own health and safety beyond measure, have kept patients in safe and essential care at home, and have continued to transition from hospital-to-home those who are post-acute, rehabbing and chronically ill, including many who are COVID-afflicted. Home care is serving core roles in hospital decompression, surge mitigation and assistance across the continuum in addition to the extensive in-home care it provides. Agencies are also voluntarily acting as receiving and distribution sites to further render protective supplies to hundreds of fellow agencies in cases where, stunningly, no formal structure was instituted by government’s incident command to deliver these essentials to the home care sector.

As the pandemic entered and has surged in New York State, home care has responded from the outset, resilient and masterful in the management and delivery of care through enormous challenges. Home care has faced:  lack of priority access to personal protective equipment from the state/regional incident command structure; patient and family resistance to medically needed in-home care fearing COVID contagion; affliction of health personnel by COVID as well as impact from COVID isolation measures, school closures and family illness; reduced health personnel availability for service delivery; rocketed costs, lost revenue and no relief funding; multilayers of regulations and procedures taking endless periods to waive, and some still awaiting needed flexibility; and more.

An overarching challenge has been policymakers’ and incident commanders’ major lack of understanding of home care and core aspects of the service. This includes the need and complexity level of the patients, management and human issues in service delivery, and the overall vital role that home care serves in COVID response and in the system as a whole. This serious knowledge gap has been an underlying factor across all of the individual challenges, and especially now in the effort to secure desperately needed financial support in federal and state COVID aid. Agencies, particularly in the COVID epicenter of New York, continue to shoulder massive costs and losses in their unwavering response to COVID, and must be supported for sustainability through COVID and for home care’s pivotal role beyond.

In addition to advocating daily assistance for our agencies and frontline personnel in COVID, our state association – the Home Care Association of New York State – has also proactively sought and received Mother Cabrini Foundation funding to create new COVID interventions through home care. These initiatives, which we are now preparing to launch, will:  train home care clinicians across New York State to conduct COVID testing at home, which will promote early care, mitigation of morbidity, prevention, worker and family safety, and more accurate measurement of COVID incidence and prevalence; and, also create a statewide Virtual Senior Center (VSC), building upon the VSC pioneered by our member agency Self-help Community Services in NYC, to provide vital psychosocial and health connection for the isolated homebound.  A third initiative, currently in development, will partner HCA with hospital association partners to create a statewide Hospital-Home Care Collaborative for COVID and beyond.

We salute the incredible and compassionate work of New York’s home care agencies in COVID – and every day. We respectfully ask policymakers, payors and the public to do the same, and to reinforce their salute with the tangible support agencies need to sustain their vital and heroic service.

Industry Takeaways & Looking Ahead to a New Normal

Whether you made it through each region, state by state or just skimmed your own region, there are a number of underlining takeaways at an industry-level:

  • Demand continues to rage for PPE supplies across the nation, but supply seems to be leveling out slightly and is becoming more obtainable in most places

  • As cities and states phase out of stay-at-home orders, hospitals will begin elective surgeries again, providing a resurrection of referrals and clients coming home from these surgeries.

  • Technology is weaving its way into our everyday operations as a dominant tool internally and externally. Things like employee video-call interviews, telehealth supervisory visits and phone call or text messages to employees and clients will become mainstream post-crisis.

  • Standardized data collection is crucial to show the value that home care brings to our health care system and the people we serve.

  • Now, more than ever before, home care is staking its claim as an essential component in the health care continuum.

From the words of Vicki Hoak, President of the Home Care Association of America (HCAOA), “While our purpose and goals remain steadfast, our new normal is already here and will continue to evolve in the months ahead.  Experts say that COVID-19 will not be going away until a vaccine is discovered, so for now our industry must remain vigilant in developing a new standard of care.”

If you’d like us to add an update of your state, please send it my way! You can reach me at [email protected] 

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