September 11, 2017

As industry burgeons, home care leaders call for oversight that protects patients, workers

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An aging baby boomer population and increased life expectancy are blowing up demand for home care services.

Home health care providers are more in demand than ever, as the population ages and health care policy makers encouraging home-based care whenever possible.

It's not just that the baby boomer population of about 76 million Americans is getting older; people are also living longer. According to the U.S. Centers for Disease Control and Prevention, those born in 2015 will live, on average, to age 78.8, up from 73.8 a generation ago. The number varies slightly according to race and gender.

Meanwhile, the increasingly important home care industry remains largely unregulated in Massachusetts. Where federal requirements call for home health aides to have a minimum of 16 clinical hours and 75 hours of training, Massachusetts does not require its Medicare-certified home health care agencies to have more than those minimum standards.

Increasing oversight

Where the general goal of better quality care benchmarks is supported, part of proposed legislation to create more oversight concerns local providers and industry advocates.

James Fuccione, senior director at the Massachusetts Healthy Aging Collaborative, noted that the Baker Administration and the Massachusetts Department of Public Health (DPH) are working on regulations for home health services that relate to medical in-home services.

Fuccione added that recently, there have been legislative efforts to address other more supportive and non-medical types of care in the home.

"We hope the finished product from the legislature can be a policy that benefits the caregiver, the person receiving services, and the employers in their attempt to recruit and retain workers," Fuccione said in an email.

Rep. Daniel Cullinane, D-Boston, introduced House Bill 341, a law that would strengthen home care regulations in Massachusetts, in a Joint Elder Affairs Committee hearing in July. The legislation proposes a mandatory service license process to be set up by the DPH and the Executive Office of Elder Affairs. Home health agencies must specify services, service area, and follow an ongoing quality assurance program.

It also calls for a home care worker registry that includes workers' personal information, such as full name, current home address, gender and date of birth, along with their job title, employer name and list of completed training and certification programs.

Home sweet home

Advocates of home-based care say there are many reasons staying home makes sense for seniors and those with chronic illnesses. It's less expensive, and it offers a sense of independence that a hospital doesn't. Home care keeps families and spouses together, and presents less of a risk of infection than hospitals would, proponents say.

"We have documented best practices that show people thrive if they can stay in their home," said Elaine Fluet, president and CEO of GVNA Health Care of Gardner, a 30-year veteran of the industry. GVNA, a nonprofit organization, has a daily census of 120 patients, 90 percent of whom are over 65.

"Many people in their 90s, they want to stay home. They need a little support. It's how they should spend their time and they do very well," Fluet said.

Fluet and David Price, owner of home health care agency BrightStar Care of Milford, support the notion of tougher, more streamlined regulation.

"We compete with other ... companies that don't check workers' backgrounds or immunization records," Price said. "We'd rather see licensure that puts everybody on same playing field," and is better for clients' care overall.

Some objections

But the idea of a home health care worker registry concerns Jake Krilovich, director of legislative and public affairs at the Home Care Alliance of Massachusetts.

"Allowing consumers to see who is coming into their home is something we can get behind," he said, noting that transparency is important in cases filed against workers for elder abuse, for example. But he's concerned about publicizing certain personal information, noting that workers can't opt out of the registry.

"We don't see public safety justification for that. Look, going into these homes is already a risk," Krilovich said, "but allowing consumers or just anyone to search for someone's home address? We want to put a hard stop on that."

"The thought of giving up that much privacy seems really off," agreed Price. "It puts [workers] a step closer to identity theft," and serves as a deterrent for home health aides to enter the field, or for existing ones to stay — in an industry with already-high turnover.

Price sees problems with the worker registry section of the proposed legislation, beyond its requirement to make home health aides' private information accessible to the public.

In cases of elder abuse or a misappropriation of funds, for example, where the home health aide is the reporter, and a family member is accused, the accused would have easy access to the home health aide's home address. In addition, aides who are victims of domestic violence would be at further risk by having personal information made public.

Opting for higher standards

Home care providers can voluntarily participate in more advanced standards of quality. For example, GVNA is a member of the Visiting Nurse Association of America and abides by its standards of conduct. Meanwhile, Krilovich's Home Care Alliance has offered its own accreditation system to members since 2010.

BrightStar is among home care agencies that are accredited by the Joint Commission, a national organization that sets standards for quality of care, continuous improvement and measured outcomes. Standards are set for things like emergency responses, said Price. Numbers of falls and things like urinary-tract infections in patients are monitored. Potential impacts are measured after initiatives are set in motion. Price noted that Cullinane's proposed legislation does not address outcomes, which he thinks is a weakness of the bill.

Price also noted there is already a Nurse Aide Registry maintained by DPH, which offers information on a caregiver's background in cases of findings of elder abuse, neglect, misappropriation of funds or an elder's property. Massachusetts Aging Services Access Points, or ASAPs, meanwhile, are state-funded agencies that provide oversight of home care agencies that are under state contract to provide services to clients who meet low-income eligibility requirements.

With all indicators pointing to rising numbers of seniors living in their homes needing care, and demand for these workers only rising, putting teeth in existing resources and regulations while mandating home health agencies participate — putting the onus on employers for things like background checks — is more logical than setting up a worker registry, said Price.

Fluet aded that a worker registry would feel like the system was somewhat working against organizations like hers, which are out there trying to meet demand with enough employees.

"It would discourage them from that work," said Fluet of the registry. "We don't need the barriers."

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