Ep:04 High-level Assessment of PPE, Fiscal Stability and Home Care Advancement Opportunities

Miriam Allred (00:05):

Welcome to Vision |The Care Leaders’ Podcast. I’m Miriam Allred, with Home Care Pulse.

New Speaker (00:15):

Today on Vision, I’m excited to speak with Al Cardillo. Al currently serves as the President of the Home Care Association of New York state. He has served in the healthcare sector for over 30 years in many leadership positions, ranging from development administration, legislation and finances. On top of all of his duties with the Association, Al also teaches at the Albany College of Pharmacy and Health sciences, and at the University of Albany in the Master’s of Social Work Program. Al thanks for joining me today.

Al Cardillo (00:47):

Thank you so much, Miriam and thank you, Home Care Pulse for this opportunity.

Miriam Allred (00:52):

Great. Well, let’s jump right in. We’ve got a lot to talk about. So I want to start out by talking about the current state of home care in New York. We all know that New York took a pretty hard hit early on and continues to be a front runner of the pandemic, but I’d like to hear it from your perspective. What’s the journey been like over the last few months and what, what does the current state look like?

Al Cardillo (01:16):

Well, Miriam it’s, it’s really been a time like no other, you know, it’s one, that’s seen challenges and pressures that really defy the ability to describe it. Looking at the overall state of home care, there’s the physicality aspect to it. And then there’s the spirit that drives a relentless commitment to the mission and the venue of this field that I believe really sets it apart from all others. So I’d really like to start and responding to your question with that and the positives that frame, the state of home care though really greatly overlooked in the public incident command discussions in the wake of COVID a home care. Once again is demonstrating its resilience, its adaptability and brilliance in its continuity in its service to patients, you know, while having to navigate through unprecedented and treacherous circumstances, home care has continued to come through and its mission to the patients and its pivotal role in the system.

Al Cardillo (02:16):

And that’s what service in New York to between eight and 900,000 individuals. And with, with the involvement of over 200,000 workers. So when you think of the size of the care that the population being served, the care that’s being provided, it’s amazing. And, and when compared to other sectors as well, when, when one considers that each and every household is a unique care setting and each and every household presents a unique set of challenges. Now, operationally of course, in COVID home care agencies have been deeply impacted in the COVID effect and fears for the patients of the workers on the case of their immediate safety and that of their family, the health impact, the, the stresses and site psychosocial impacts, which are continuing and the effect on the overall availability and adequacy of the supply of the workforce, which means access to services.

Al Cardillo (03:12):

So worker recruitment training and entry into the field are emerging as additional concerns on top of what are routinely major ongoing challenges in the area. And then of course there’s the extremely heavy financial tall that COVID and stay budget impacts are taking on agencies. And that’s particularly in the hotspot high incidents areas of the COVID, but going back to the positives I believe that the S the state of home care is coming into yet another new opportunity to be viewed in preeminent roles in public health and prevention in its capacity to fill fundamental and partner roles in the overall healthcare system, and to be considered as a first option in patient care, rather than the alternative option. And I think the tragedy of COVID in nursing and rehab facilities really emphasizes this point, you know, to what extent are individuals much more safely and, and better served if they could possibly refer, be referred for care at home, whether they have a chronic illness, or especially if they’re rehab patients, when they’re only going to be in a facility for a short period of time. And I believe that the I believe that what has really occurred in the system is going to replant the focus of decision makers and, and potentially of the system broadly into the optimized use of home care in the system.

Miriam Allred (04:41):

Yeah. I appreciate the positivity and you’re exactly right. There’s a new opportunity that’s emerging and we’re here to capitalize on that opportunity. So tickets into our discussion, I want to talk about three areas that we’ve identified as, you know, pain points, but also good topics of discussion today. The first being supportive, emergency preparedness, you know, diving into the supplies and the resources, and we’ll move into, you know, I just want to kind of highlight, we’ll talk about the fiscal stability of agencies right now from a local perspective, and then also, you know, the expansion of home care and the advancement and the role of this industry, you know, moving forward. So, so diving into the emergency preparedness, what has the journey looked like to obtain supplies and resources in your area?

Al Cardillo (05:27):

Well, it’s been both incredibly challenging and incredibly congenial. And, and I think, I think both of those elements need, need a bit of discussion. So on the challenge side it has really been a struggle throughout trying to obtain adequate supplies among the limited stockpiles and those stock, the Lowe’s limitations were especially severe upfront when when supplies were really were being prioritized most heavily for hospitals and in New York, that was a, you know, I would say almost an exclusive focus and you know, closely connected with the limited volumes and just competition for those supplies. It was the ability to be recognized for priority access to those supplies. So in effect, making the case for home care and hospice, that, that those, that those supplies are truly needed. You know, we worked a couple of years ago to, to pass an essential personnel bill in New York state, so that home care and hospice workers would be viewed as essential personnel, but believe it or not, there were locality some major localities that that, that basically did not even include home care and hospice on the list of entities that were deemed to need personal protective equipment.

Al Cardillo (06:44):

So it was a struggle to overcome simply that barrier on top of the supply barriers. Then of course, if once you could prove that you needed the supplies, there was the challenge of actually getting those supplies. We have the state of New York actually helping at one point by, by sending supply trucks to regions, but there was no no system that was established to obtain the PPE from those supply trucks and get them to places where providers could receive them. So we were, you know sorta on the phone trees trying to line up providers who would volunteer to go and pick up the supplies and then further distribute them in New York city, in particular, we had to reactively recruited a series of volunteers who would, who would receive and stage and distribute on a weekly basis supplies to, to other providers. So, you know, I think that paints a picture of the significance of the, of the PPE issue and an access.

Al Cardillo (07:43):

But I think it also shows a weakness in the incident command structure, such that it relied on a grassroots effort to distribute the supplies in an emergency when that really should become part of the responsibility of the, of the ICS structure. And the last thing I will talk about in the challenge side is certainly the cost. So, you know the, the, as the supplies were limited, and there were proprietors that were, you know, stepping up to offer access, the costs were, were, were way beyond what would be the norm for the supplies. And of course, again, that’s an issue of supply and demand and providers really ran into very, very significant financial holes, just trying to keep up with the cost of the equipment. I do want to comment on the, on the congeniality side, cause I think that that’s really very important. What we really found was a great degree of volunteerism.

Al Cardillo (08:33):

As I alluded to a couple of moments ago by providers who were willing to receive equipment and share with colleagues, there was a lot of collaboration and making that happen. We work with our, our sister association and the state to, to help them help make that occur. There were also partner offerings. So for example, in our association, we have managed longterm care plans, who are members, one of our larger ma I managed longterm care plans blue cross actually obtained supplies and, and, and made them available for providers. And then they were distributed through the volunteer network that I mentioned. And then there were community partners, businesses, and other partners that saw that we were in desperate need of supplies, hospitals and they helped out a great deal. So I think that, so I think that’s a, you know, that really you know, paints, paints that, that, that dual picture that you know, of, of both the challenge and the, the colleagueship that was associated with this

Miriam Allred (09:31):

Most definitely. And that’s a pivotal role as the association, you know, to be that resource for the providers in your area and working with your network, you know, to obtain that supplies. One follow up question with the fear and concern of research is happening now, you know, in, through the fall, do you feel like the issue has been solved? Is there enough supplies to go around?

Al Cardillo (09:56):

Well I that’s, that’s an excellent question. And I’m, I’m very appreciative that you asked if it there’s really an uncertainty as to whether or not the supplies will be able to keep up with what the emerging need is. And in fact in New York city, right now, there’s consideration of shutting down the supplies that would be coming from the city health department to providers through the network. And, you know, we are, we’re working with the city to urge their continuation. I think one of the flawed beliefs is that because there is a flattening of the curve, or there was evidence of a flattening of a curve that that’s somehow equates to a discontinuation of need or diminishment of need when actually universal precautions and infection control procedures require that you treat each case as an unknown. That means that you need the appropriate PPE for the safety of the worker and the patient, regardless of whether that curve is bending.

Al Cardillo (10:52):

You know, so we’ve, we are really putting a, an advocacy press on at both the state and the local levels to continue the flow of supplies and to continue, whatever support can be provided to home care agencies for that we’re working at the federal level as well, to try to ensure that that home care is you know, is recognized for priority access. And I’m very pleased to say that we wrote and applied and received approval of a grant a philanthropic grant that will assist in the distribution of the supplies in cases where there’s no formal network and we have to create the infrastructure.

Miriam Allred (11:29):

Yeah, that’s fantastic. And I think yet to continue to keep that pressure on, because there is still a lot of unknown, but you’re right, the supplies are necessary and will continue to be in necessity moving forward through the unknown. So, so appreciate your responses there. Let’s move on to the topic of fiscal stability. I want to hear, you know, what does the financial landscape look like for a provider right now? Well,

Al Cardillo (11:54):

It’s a very challenging environment. It’s first of all, it’s challenging because you know, we have our state and I’m sure States across the country are in a major cost containment mode. You know, they’ve, they’ve exhausted, tremendous resources in trying to respond to the epidemic within New York alone, just even prior to the COVID epidemic. Our state was in a $6 billion deficit and looking to carve a couple of, a couple of billion dollars out of Medicaid and Medicaid longterm care. So when one looks at the continuing let’s say, frugality of the payment system, which which, which creates a struggle for agencies, I think on an ongoing basis. And you add the COVID impact. It’s a pretty severe situation in New York. For example, we’ve estimated based on the data and based on agency experience about a $200 million a fiscal hit two certified agencies within the state.

Al Cardillo (12:52):

And, and, and, and then broader when you add all of our licensed agencies to the mix. So it’s a very uncertain environment. We also, as I mentioned, we are operating in an environment of cutbacks and limitations. If we need more PPE, there’s no built in reimbursement for PPE. There’s no built in reimbursement to accommodate worker impacts and shortages. So it’s a very again, it’s a very challenged fiscal environment right now. One thing is that the federal government has just issued the the proposed PGGM rule, which in total looks like a continuation without major alterations of the rule that’s been in place, which will accord us some stability and a small market basket increase. So that’s at least something that gives us something that we can work with. But again, we, we were functioned in the overall situation of, of, of financial fragility, as an example, in New York state, something like 70, some percent of our home health agencies are operating in a below margin.

Al Cardillo (13:57):

74% of our hospices are operating below margin and over 50% of our managed longterm care plans are in a negative premium position. So that, that I think portrays a very fragile structure rate negotiations and the compression that results from that are also big challenges. So as providers work to negotiate rates with the, with, with health plans that’s already a very, you know, a tight and a, and a, you know, difficult circumstance. But to the extent that premiums are, are, are marginal for plans, they don’t have the dollars necessarily to work with for the rates and the cost structures that providers need. We’re advocating for federal relief. You know, home care was not, well-recognized in the first several aid packages, and we’re working as a state and many other States and knack at the national level to advocate for for home care relief, especially in this fourth stimulus package, which we hope will come soon.

Miriam Allred (14:59):

So drilling down to the agency level level, the home care provider level, what would you recommend the short term and longterm priorities be for a provider right now?

Al Cardillo (15:12):

Well, I think one of the, one of the significant pressures is the is the is, is the importance of the workforce and the sustainability of the workforce. I mean, we, you know, we have a situation where you know, there’s, there’s a push for, for an enhanced pay for those that have been on the front lines and, and, and that will be continuing, but I think, I think the agencies really have to look across all their potential areas for efficiency, including looking at pack, practice patterns and re-examining and reevaluating assumptions that that, that contribute to ongoing costs that, that perhaps could be, you know, where those patterns could be altered to, to avoid costs and, or, you know, to, to diminish expenses. I think, think also is the need to look at opportunities in working with partners who, who will view the, the value of home care, you know, in the overall provision of services and, and in effect be a, a financing partner and investment partner in the services that are provided even within COVID, we’ve seen these opportunities step up.

Al Cardillo (16:20):

So for example, one of our agencies made, it’s made clinical staff available to to locations where there was retirement housing or aggregate senior, senior living, or senior senior residents in order to do testing of individuals in those settings and also testing of the workers. So that was a, not only a contribution to the public health, but clearly became a source of financial support for the agency in that broadened role. And that’s something that we very, very much encourage. We, we’ve just applied and, and, and we’ve received approval for four additional grants that for example, a grant that will partner our association with our state hospital association in creating a statewide hospital home care collaborative. So identifying ways in places where home care agencies and hospitals can synchronize pre acute and then post acute. And again, those, I believe that those are important areas for for innovation and for again, future financial stability.

Al Cardillo (17:28):

Another, another thing that we’ve initiated statewide is is testing the we’re training. We’ve, we’ve already signed up to train over a thousand clinicians home care and hospice clinicians in the state to do COVID testing at home. And we have the, the authority and the funds to go well, well beyond that, and we’re still promoting that, and we’ve also received approval to implement on a statewide basis. Something called a virtual senior center, which is a model that was pioneered by self-help a home care in New York city that we want to make available across the state, which could then be a new service and additional service for the isolated individuals at home, but that agencies could offer. And that not only makes sense in the COVID environment, but makes sense more broadly in terms of outreach and care.

Miriam Allred (18:18):

Yeah, that’s incredible. I appreciate you bringing up that, that partnership between your association and the hospital association of New York. I’d love to hear a little bit more about that. Was that an effort that you, as an association, you know, basically created and we’re proactively seeking that out, or how did that formulate and how has it been formulating over maybe the last few months or years?

Al Cardillo (18:40):

Yes, so, so, you know, w we, when looking at areas of need, and we did, we did a statewide surveys early on is as COVID was just starting to surge. And one of the things that really struck me was that I think only 2% of home care agencies reported that they’d been contacted by their hospitals or public health departments to assist in a role in COVID, which, you know, when you consider the, the volume of individuals in the community and the expertise in home care just didn’t make sense. So, so in, so as one of the areas of followup, you know, I, I spoke to the hospital association and I said, you know, would, would there be, would you have an interest in working with us if we were to try to create a collaborative between hospitals and home care, so that we could assist with surge prevention, we could assist with, with the ER and hospital avoidance to keep people safer, to contain costs again, and to help contain the, the hospital serves.

Al Cardillo (19:35):

And then on the far end, supporting decompression and supporting successful care and safety of individuals upon discharge. I also had, had read an article that, that covered the profiles of a number of patients that were referred from hospital to rehab and all of them all of them develop COVID and they all died in the article. And I thought, you know, if home care were at were an initial first option consideration, perhaps we could make an impact in preserving life, you know, in these, in these situations. And I found our state hospital association partners to be very, very excited and enthused to work with us. And also there, we have a regional hospital association that represents substantial community and rural hospitals who are also going to be part of this partnership. So we actually just received approval for this, and we’re going to be launching right in the coming weeks and looking, looking for a re a very robust effort that also encompasses the endorsement and the co-promotion of our state officials.

Miriam Allred (20:39):

Wow. Yeah, well, we’ll have to touch base as that rolls out, because I think that’ll be really interesting to see how those referrals come and go between your, you know, throughout that partnership. It will be interesting to see how, you know, the efficiency really just kind of plays out so exciting stuff, really happy to hear about that. Moving forward, I want to talk a little bit more about, you know, the expansion of home care. I’d love to hear you highlight maybe the four, three or four major advancements that home care has made in the last few months.

Al Cardillo (21:12):

Well, one of the areas, you know clearly is in the area of new protocols and practices for addressing the, the, the, the serious emergency and, and, and, and circumstances that we’ve seen in the wake of COVID. So that really, you know, crosses the crosses the, the territory of, you know, again, effective transitions, effective communications with hospital partners, but also once, once home and in the community, what are, what are the critical procedures and protocols that really should be followed to, to prevent infection, to prevent the transmission of, of of, of COVID, or, or, you know, really frankly, any other transmissible disease you know, that would, that would be like in effect. So so we had, so when we started out in COVID, everything was, you know, folks were, were, were, everything was formative, you know, folks were, were, were, were looking into their own practices to figure out what to do next and how to do it better, but as those advancements were created and, and, and sort, and put together providers you know willingly shared that.

Al Cardillo (22:20):

And and, and I think that that represents a step forward across the field in terms of the, the you know, this, this, this more at least to date and level of practice to to address these issues. Visiting nurse service of New York was really I think a main leader in this process, you know, they, they served over 2000 COVID patients. They still have COVID patients. And and the protocols that they established were really, I think, a model, you know, for not only for New York, but they were, they were presented in national webinars and again, very graciously shared across the country. So I think that that was a really very, very important development and advancement for home care. I think another important area, you know it’s just the, the, the demonstration of, of, of, of home cares capacity of it’s positioned to respond in a and to these kinds of emergency conditions.

Al Cardillo (23:18):

When you’re really look across across the, the, you know, the entire array of the system home care, continued to care for individuals who really were of, of extraordinary need and found ways to, despite all the challenges and obstacles to come through. I think, as an advancement it’s, it’s a demonstration of what home care can do and, and, and does, and roles that it can fulfill within the system. And those are important roles for hospitals, physicians, and other partners to observe, and then to, you know, sort of become part of their own template for how they view you know, I think services in the future. So, and so those were a couple of very important areas and, and, and, you know, really along with the demonstration of the very heroic efforts of the individual workers, clinicians, practitioners, who risked their lives in some cases gave their lives for this mission, you know, and for their patients, you know, as we look at, at the, at the necessity to support home care and to support those workers I think it’s a huge, you know, understatement, it’s a huge underscore of how important and sacrificial these individuals are in their daily work and in their daily mission.

Al Cardillo (24:32):

And I think the point has been very well proven by the, by the success of their work and patient care. So those are a few of I think of the very important areas and advancements that we’ve seen.

Miriam Allred (24:44):

I love it. I love your passion, and I love the energy, you know, in your voice, just talking about the successes that we’ve seen in the last few months, it’s been a trying time, nonetheless, but to hear, you know, your positivity and your passion come through, it’s incredible. And I know the providers and the leaders listening. Appreciate that. So to wrap up the conversation, I just want to, to hear your take on how providers can get involved in local advocacy, you know, you represent the association and, you know, their state associations in every state across the country. And I want to hear you know, what you’d recommend for a provider and how they can get involved in, in their local advocacy.

Al Cardillo (25:26):

Well, one thing that’s very critically important is, is really just the basics. Do you know, many times agencies, as we speak to our agencies and, and seek to engage them grassroots they’ve never had a contact with her, with their state official, their local officials or federal officials, or if there are contacts it’s, when there may be pressing a button to launch a legislative action, you know, a call for, to support a bill, which is very important, but what’s really important is for decision makers to know, Oh, you know, who these agencies are, what kind of work do they do? How indispensable are they to their constituents, who they employ and what those employees do? What, one of the things that we certainly found and found within this emergency, and, and I think, you know, whether it’s hurricane Sandy or ice storms or others, what we typically find is that decision makers do not understand the breadth of what home care is.

Al Cardillo (26:21):

They know it’s something being done in the home, but they don’t understand the breadth and capability. So, so from the standpoint of the basics to have basic connections between agencies and officials, where agencies, the aid officials know who they are, maybe they have their brochures, they invite them to town meetings. It’s that acquaintance is very important. The other thing of course, that when there are grassroots efforts for legislative action or budget action or fiscal action agencies really need to be involved in that, you know, and being involved in that means calls and letters, but how much better is it, if the officials who are receiving those calls and letters know who you are, you know, have heard from you maybe every other week. And, and, and one thing that’s very important in that process, again, is to tell the story, you know, there’s a blue sign in every town that says where the hospital is, but there’s no blue sign for home care agencies.

Al Cardillo (27:13):

So, you know, you have to create Metro metaphorically, you have to create that sign so that people know who you are be in the paper, beyond the radio, just simply be part of your broader community. And and, and engage with those kinds of engage with those kinds of stories as to what, what you do, what your value is. And also engage with the critical partners. Because very often the officials will look to say, well, my hospital needs this. My physicians need that. But if they understand that that with the coming with the hospital is the home care agency, without which they can’t discharge their patients, or with the physician is the home care agency without whom they have to admit patients to the hospital. You know, that’s an important part of the understanding and appreciation for what home care is. And I think a very deep part of the advocacy.

Miriam Allred (28:03):

Yeah, great response. I love the metaphor as well. I just appreciate everything that’s been said. I’ll, you know, it’s a pleasure to hear from you and for you to represent home care in the state of New York. We know there’s still a lot going on and a lot more to be done, but we appreciate your, your perspective and your positivity. And, you know, on behalf of home care pulse, we’re grateful for your opinions and for all the advocacy that your association does in New York, but really the, the example that you’re setting for the rest of the industry. So thank you so much for taking the time to chat today. I hope we’ll stay connected over the coming weeks, as you know, your plans continue to unfold and as the pandemic resolves, but as the opportunities continue to arise for home care,

Al Cardillo (28:47):

Thank you so much. And again, thank you for this opportunity and thank you for all that you do to spread the message about home care, to help inform and educate, and really stimulate the leadership across the country.

Miriam Allred (28:59):

Most definitely. Well, it’s been a pleasure Al. We hope and wish you the best moving forward, and we’ll be in touch.

Al Cardillo (29:05):

Thank you, Miriam.