Even Physicians Need Patient Advocates When Hospitalized

As an independent RN Patient Advocate, I guide and advocate for individuals in a variety of healthcare situations.  On occasion these individuals are medical professionals, which suggests that we’re all vulnerable and confused when hospitalized.  Here are highlights of a recent recommendation letter that advises every person to engage with someone qualified to advocate for you.

“As a person who practiced medicine for more than 30 years in the Chicago area, I thought I was quite familiar with hospital medicine. But recently I was hospitalized and confronted an experience that was extraordinarily challenging.

Luckily, I had made arrangements before this totally unexpected hospitalization to have Stephanie Frederick as my patient advocate.

Stephanie was essential in communicating with the various providers and making sense of what was really going on. She also prodded them to meet with both of us to review progress.

My recommendation to anyone facing potential hospitalization is to arrange in advance for a patient advocate. Personally, I can recommend Stephanie without reservation. If you engage her services, she will make sure she understands your medical condition, medications and other vital information before you are hospitalized.

When and if you are admitted, she will be directly involved as your care proceeds and provide effective communication from you to medical providers and update you on their thinking. She will also provide information on drug interactions and dietary recommendations if appropriate.

All in all, I would hesitate facing even “routine” hospitalization without Stephanie in my corner.”

Dr. T.C., Tucson AZ

Medical Improv For Building IPU's (Integrated Patient Units)

IPUs (integrated practice units), a concept advanced by Porter, M.E. and Lee, T.H. (see article below) promotes organizing holistic care for groups of patients with similar needs.  It’s been noted that cohesive teams who follow patients over time are able to do a better job of delivering quality patient care.  In order to optimally perform, trust, communication, coordination, and collaboration must be infused at every level of these healthcare organizations.  Medical Improv is a fun, creative way to actually PRACTICE building these necessary teams.


Teamwork can help healthcare organizations compete more 
effectively in today’s marketplace.

How can healthcare providers differentiate themselves from their competitors? This question is becoming increasingly important in the evolving healthcare marketplace, with its growing emphasis on provider competition for market share. If providers deliver the exact same services as their competitors in the same way, they inevitably will end up competing on price, and margins will fall. On the other hand, providers that effectively differentiate themselves from their competitors gain an opportunity to retain or increase their market penetration, and share in the value that they create.

Regardless of how much of a provider’s revenue comes from fee-for-service or from some form of value-based payments, one of the best competitive differentiators from a strategic standpoint is demonstrating exemplary teamwork. Provider organizations with great teams are more effective in improving quality and reducing costs than are organizations whose clinicians are disorganized and do not work well together. With strong teamwork, morale is higher, which typically translates into lower turnover. And high-performing teams give provider organizations an excellent chance for success in new payment models, such as bundled payments.

Providers should recognize that effective teamwork doesn’t happen by accident. Organizations that work to cultivate teamwork have a competitive advantage that can translate into business success.

Why Teamwork Matters Now

Teamwork is a crucial topic for healthcare organizations today that demands the attention of senior executives. The tremendous medical progress that has occurred over the past few decades has enabled providers to do much more for patients than they could in the past, but it has also made treatment more complex. Delivering comprehensive care requires multiple individual clinicians, each having an increasingly narrow focus. All too often, these clinicians do not even know each other. They could walk right by each other in the hallways and not know that they were collaborating in the care of the same patient.

The resulting perception of disorder and lack of coordination contributes to patients’ concerns about whether their clinicians are truly working together on their behalf. And the actual disconnects in the care process exacerbate these concerns by leading to safety issues, reduced quality, and inefficiency.

The lack of coordination and teamwork also is dispiriting for physicians, nurses, and other clinicians, who are aware of it and absorb complaints about it from patients and their families. These clinicians often feel anonymous in their own institutions and unsupported by any meaningful degree of respect from close colleagues because such relationships are so rare. From an operational perspective, clinicians who lack a sense of loyalty to their colleagues or their institutions have little compunction about leaving, which creates additional expense and further problems with morale and a poor patient experience. Unfortunately, this picture all too accurately represents the status quo in many organizations and within many subsets of providers.

Even if change were not sweeping the healthcare marketplace, creating a spirit of teamwork would be an important undertaking. But in today’s environment—with every provider organization seeking to grow, with employers and payers developing bundled payment arrangements, and with new entrants seeking to siphon away some of the most profitable services—the goal of delivering superbly coordinated care to retain patients has become a strategic imperative.

Teamwork Works

Better teamwork promotes greater quality, a better patient experience, and a prouder work force, all of which contribute to better financial performance. These relationships are demonstrated in three analyses performed in early 2016 to assess the value of teamwork.

The findings of an analysis of the relationship of teamwork and quality are summarized in the below exhibit. The concept of teamwork is assessed through employee-reported data on how well different units within the provider organization coordinate their work. Two different types of publicly reported data are used to assess quality. The 12 top bars reflect the correlation between the response of participants in a patient experience survey regarding their perception of teamwork within an organization (represented by the statement “Units coordinate with each other”) and their responses regarding other aspects of their experience with that same organization. The bars projecting to the right signify a positive statistical correlation—and the further they project to the right, the greater the correlation coefficient. The fact that all ratings extend to the right means that a perception of teamwork correlates with an overall better perception of the patient experience. The bottom bar, which goes to the left, indicates that a strong sense of teamwork among the employees correlates with a lower rate of central-line-associated blood stream infections (CLABSIs), an important patient safety indicator.

Significant Correlation Between Units Coordinate with Each Other and Rate of Central-Line-Associated Blood Stream Infections

The exhibit below shows analyses of teamwork as it relates to employee engagement data. The correlations indicate that organizations with better teamwork have a workforce that is more engaged in other ways. The rows are three variables that reflect the sense of teamwork within the organization. The columns are other key employee engagement variables. The numbers in the cells are the correlation coefficients, all of which are positive and highly statistically significant. The bottom line is that teamwork tracks with employees’ sense of pride and desire to remain with the organization.

Intercorrelations Among Employee Perceptions

The third exhibit shows the relationship between hospital financial performance and patient experience (a key output from teamwork). For this figure, hospitals were divided into quintiles based on their patient experience data (a summary of their performance on HCAHPS survey measures). The hospitals’ publicly reported operating margins tended to track with patient experience performance.

Quintiles Grouped by Integrated Service Reliability Score

These figures do not reflect experiments in which hospitals were randomly assigned to “good” versus “bad” teamwork conditions, so these analyses do not prove cause-and-effect relationships. For example, there are surely many other factors that influence financial margin. But the train of logic that good teamwork contributes to better care, and that better care contributes to better financial health, seems unassailable.

Real Teams Versus Pick-up Teams

Building teamwork that confers a strategic advantage requires more than senior management exhortations that everyone get along and work together. Teams have to know that they are a team. They have to know why they exist. They have to understand their performance and want to improve.

As organizations grasp the effect of competition on value, their understanding of the nature and importance of teams is deepening. Not long ago, physicians tended to think of teams as groups of personnel who would do their bidding and enhance their ability to perform billable services. But with today’s more patient-centric focus, with an explicitly greater emphasis on meeting patients’ needs than on simply generating relative value units, there now is a greater need for healthcare teams to be multidisciplinary groups that can address all of a patient’s care requirements in a way that is simply not feasible for unfocused pickup teams. For example, with pickup teams, clinicians who are supposed to be working together on behalf of a patient may not actually know each other, are less likely to share knowledge in informal interactions, and exert less peer pressure on each other to maintain high standards of teamwork and individual excellence.

Yet assembling multidisciplinary groups with complementary roles and responsibilities also is not enough. The goal of having clinicians practice “at the top of their license” is important, but there is an even more critical objective: fostering the identity of the team as a single unit with the goal of meeting patients’ needs. That means team members should be prepared and motivated to help each other and be adaptable in meeting patients’ needs, whatever they may be.

This insight that teams are much more than “focused factories” producing services—e.g., hernia repairs or cataract removal—is inherent in the concept of integrated practice units (IPUs) advanced by Michael Porter and this author.a IPUs are organized to provide holistic care for groups of patients with similar shared needs, usually defined by conditions (e.g., breast cancer or diabetes). The premise is that those conditions are best treated by teams that can follow patients over time, which enables them to do a better job of educating patients than a single physician can during sporadic office visits.

IPUs also are prepared to meet the most common other needs that occur in patient segments. For example, patients with diabetes require treatment of diabetes, of course, but many also need care for kidney, cardiac, and neurological complications. Having the personnel that can meet these common care requirements integrated within the IPU ensures patients receive care that is better, smoother, and more efficient.

Key Steps for Building IPUs

Although no team can meet all the needs of all patients who have a common medical condition, being able to meet most of the needs is a major competitive differentiator for a healthcare provider. For this reason, senior executives take the following steps to create IPUs that embody the very essence of teamwork.

Decide where the organization will compete. No organization can differentiate itself on everything. If organizations cannot make choices, the risk for mediocrity on everything is high. Provider organizations should identify the conditions for which they will marshal their resources to improve value, and then commit to doing what is necessary to meet patients’ needs as efficiently as possible.

Identify who should be on the team. The objective here is to identify those disciplines that, by working closely together, can deliver high-value care. Nonphysician clinical personnel such as physical therapists, pharmacists, and nurse educators obviously are critically important, but so are administrative personnel to assist patients with scheduling and financial issues.

Strive to co-locate the team. Teams need to know each other, not only to exchange information but also to build trust and real relationships. Team members should want to work hard to earn the respect of their colleagues, and should hate the idea of ever disappointing them.

Measure the outcomes that matter to the patients the IPU was created to serve. These should not be process measures that team members feel are most likely to be under their control. The measures should be actual targeted outcomes, including a high-quality patient experience. These are the performance measures that will draw market share to the team and the organization.

Establish true leadership and accountability. Someone should be in charge of the IPU, and ideally, it should be its own business unit—a profit-and-loss center. Only when teams are truly responsible for their financial performance do they work relentlessly to improve efficiency. Note that once that accountability is created, the IPUs will be intensely interested in understanding their true costs, so they can try to manage them.

Negotiate contracts that reward efficiency. Bundled payments are the most obvious example. Payment should align with the move from volume to value in health care.

Push transparency of performance metrics. These metrics should ideally be made available publicly via the internet, but if not, they should be disseminated internally through sharing of data among providers, including those in other organizations. The major impact of transparency is to drive improvement by providers. Nothing works as well.

Teamwork is not just a human resources issue. It is a necessary strategic focus for the entire senior leadership team. Just as senior executives give major attention to amassing financial capital, so too must they amass social capital, which is created through relationships and the way personnel work with one another to achieve shared goals. Given the complexity of health care today, social capital is at least as important as financial capital. After all, organizations often can borrow money, but they cannot go elsewhere to arrange infusions of trust, coordination, and collaboration.

Progress in medicine is wonderful, but it also can be disruptive. Coordination is the antidote for that disruption, and great teams reflect coordination in its purest and most powerful form. Through IPUs and other innovative models, excellent teams are emerging wherever providers are seriously tackling the challenge of high-value health care. These models provide vehicles through which healthcare providers can improve their care and achieve business success.

Thomas H.Lee, MD, MSc, 
is chief medical officer, Press Ganey Associates, South Bend, Ind., and a member of HFMA’s Massachusetts-Rhode Island Chapter.


a. See Porter, M.E., and Lee, T.H., “The Strategy That Will Fix Health Care,” Harvard Business Review, October 2013.

Publication Date: Monday, November 28, 2016

Health Professionals as Patients: Collaborating for Our Holistic Health

A new advocacy client of mine is a MD.  His stress levels have been off the chart, and his self-care skills negligible.  As a RN Patient Advocate, I helped navigate his 1.5 week hospitalization, and was present for his discharge to home.  I’ve suggested an anti-inflammatory diet, acupuncture, and guided imagery.  He’s agreed to everything, and is researching other complementary modalities.  Keep an open mind, and recognize that “other” licensed providers have ethical modalities that aid in our whole-person well-being.  Connect and collaborate for our collective health!


What it feels like to be a patient from a doctor’s point-of-view

Anonymous | Conditions | November 3, 2016

For the first couple of years of medical school, the constant stream of exams and the anxiety that came along with each one seemed never-ending. I told myself that it was worth sacrificing my personal health to better the lives of others.

I put off addressing my own mental health needs to keep advancing to the next level of education. I let stress manifest itself in new ways that my body wasn’t used to. I compulsively ate away my feelings with total disregard to both my physical and mental health. I was diagnosed with polycystic ovarian syndrome (PCOS) and became pre-diabetic by the end of my first year. I thought to myself “everyone goes through things like this during medical training. I’ll lose the weight next year”.

Another year went by and along with it came a new diagnosis. I started having terrible headaches that were different from the migraines I had become used to. I became preoccupied with my headaches. If I wasn’t in overwhelming pain, I was having anxiety about when my next headache would occur. After going through months of diagnostic imaging studies and to various physicians, I finally found a cause to my pain. By the end of my second year, I developed a medical condition known as idiopathic intracranial hypertension or pseudotumor cerebri.

My neurologist said that if my headaches weren’t well controlled, I could lose my vision. The pressure in my head could even get so bad that it could cause my brain to herniate if severe enough. It was a huge wake-up call. It’s hard to say how much medical school played a role in the development of my condition, but my headaches and instances of increased intracranial pressure have correlated highly with my stress level.

Making steps towards leading a healthier life by implementing exercise into my daily routine and identifying stressors has improved my symptoms greatly. The process of being a patient has taught me empathy for the patients that so often feel dismissed in our health care system.

A physician recently took the time to research the effects of the anti-inflammatory diet to augment the medications for my condition. The fact that he went above and beyond to provide me with an alternative to the medications that have been failing me for the past few months made me feel cared for. I invite health care professionals to take the extra 5 minutes to examine the current research and alternative modalities to medicine being used to treat your patient’s condition. It can make a huge difference in their quality of life.

My call to action to other graduate students struggling with chronic diseases and mental illnesses during their training processes is this: take care of yourself. You can’t take care of anyone if you’re dead. Your health is worth saving. Ask for help when you need to and advocate for what you believe in.

The author is an anonymous medical student who blogs at Naked Medicine.

Being at Home at the End of Life

As a RN Patient Advocate, I frequently engage in discussions with in home patient-clients and families about “safety vs. independence”.  Can the patient accept the risk of staying at home, perhaps falling again, or hurting themselves in some way? We discuss “what if” scenarios.  It’s immensely important that everyone be “on the same page” so that the burden of decisions doesn’t lie with any one caregiver.

How To Spend Your Final Months At Home, Sweet Home

There’s no mystery about what older adults want when they become seriously ill near the end of their lives.

They want to be cared for at home. For as long as possible.

It’s easy to understand why. Home represents familiarity, safety and identity — the place where we belong.

Yet health systems aren’t rewarded financially for making “time at home” a priority like they are for reducing the number of patients readmitted to hospitals.

Researchers from the Dartmouth Institute for Health Policy and Harvard Medical School argued that should change recently in the New England Journal of Medicine.

Health systems should focus on “outcomes that matter to patients,” they wrote, citing a new national analysis of terminally ill patients.

Where these patients — most of them older adults — spent their last 180 days varied significantly across the country. People had the most time at home in Mason City (145.82 days) and Waterloo, Iowa (144.61 days), and the least time at home in Idaho Falls, Idaho (118.83), and Shreveport, La. (119.15 days).

Multiple factors contributed, including the availability of medical and social services and seniors’ financial and caregiving resources.

Do a few more weeks spent at home matter? Yes, if what patients truly value is taken seriously, the researchers asserted.

They describe a patient who had been in the hospital six weeks and finally returned home accompanied by a family member. “Just to see familiar photos on the wall made us feel we could breathe again,” that family member said.

What’s needed to make care at home possible during the last six months of life? We asked several experts:

Reallocating resources. “We have to reallocate resources within the healthcare system to the home setting,” said Dr. Diane Meier, a geriatrician and director of the Center to Advance Palliative Care in New York City.

This is already happening, to some extent. Medicare is testing the feasibility of bringing comprehensive medical services directly to frail, ill seniors through its Independence at Home demonstration project, now in 14 locations.

And house call programs that send physicians into seniors’ homes are beginning to expand across the country. To find a program near you, check this web site sponsored by the American Academy of Home Care Medicine.

Clarifying priorities.  If staying at home at the end of life is a priority, this has to be communicated – clearly and frequently — to your family, caregivers, and physicians, said Dr. Thomas Lee, co-author of the New England Journal of Medicine study and chief medical officer at Press Ganey, a firm that tracks patients’ experiences with care.

Tradeoffs have to be part of this discussion.

Lee gives the example of his 89-year-old mother, who lives by herself in a condominium in Boston’s Beacon Hill neighborhood.  Though she’s fallen several times, she’s refused to consider moving to assisted living or having a paid caregiver come in to help.

Being safe isn’t his mother’s foremost goal; independence is, Lee said. And that means accepting the risk that she could fall again or hurt herself.

Every time he sees a frail elderly patient, Dr. Thomas Cornwell asks “do you want to go to the hospital if you get sicker or do you want to stay at home?”

“If a crisis occurs, let’s say an exacerbation of congestive heart failure, and your values haven’t been discussed, you’ll generally end up in a hospital and, at least temporarily, in a nursing home,” said Cornwell, who has made over 32,000 house calls and is affiliated with Northwestern Medicine in metropolitan Chicago.

Making medical decisions. Take advantage of services designed for people with serious illnesses who need help at home.

One is home-based palliative care, which addresses worrisome symptoms such as pain or nausea that otherwise could send a vulnerable older adult to a hospital.  In this model, a doctor, nurse and social worker join together to address a patient’s needs after a comprehensive assessment.

Home-based palliative care is still relatively new and not widely available. To learn more about programs in your area, go to www.getpalliativecare.org. Contact a few and ask if they offer these services or know of another organization that does.

Hospice care is similar in its approach, but only for people expected to live six months or less. The vast majority receive care in their homes. Unfortunately, most adults wait to sign up for hospice services until the last several weeks of life, missing out on potentially valuable assistance.

Getting needed help.  Meier worries that an emphasis on home-based care for people with terminal illness could translate into more work for family caregivers who shoulder the burden of this care, not more support.

Currently, caregivers patch together services as best they can. Medicare doesn’t pay for aides who help frail, ill seniors bathe, dress, toilet, take their medications, keep their house clean, and prepare breakfast, lunch, or dinner.  Low-income seniors can qualify for help from Medicaid, but the amount of assistance available is limited and varies by state.

There’s no easy solution to this “how can I get the help I’ll need?” dilemma. Be realistic about the cost of care (about $10 per hour, on average, with wide geographic variation) and the resources you have available.  Also, be realistic about other elements of caring for someone at home, including the skills that will be required and whether the environment can support this challenge.

“Are the bedroom, the bathroom, and the kitchen on the same floor?,” asked Cornwell. “If not, you’re going to have a problem.”

Building community. “You’re going to need support” from family, friends or other social contacts if you’re trying to manage a serious illness at home, said Laura Connors, executive director of Beacon Hill Village in Boston.

Her organization sends volunteers into seniors’ homes to help in various ways on an as-needed basis. Older adults pay an annual fee to participate in the community’s social events and qualify for discounted home care services.

As with children, it “takes a community” to care for vulnerable older adults, Connors said, and you need to know “who’s going to be there for you.”

Benefits Shift – Paying Employees to Care for Sick Parents

“One study by MetLife estimated that U.S. businesses are hit with $17.1 billion in annual productivity losses from full-time employees doing intense caregiving for family members.” As an independent RN Patient Advocate, I’ve helped individuals, their families, and company employees navigate our complex medical system. Caring for our elderly parents is a condition that won’t go away, and bravo for the companies that are finding ways to get the help that’s needed for their employees.


Paid Time Off to Care for Your Parents—Seriously

Rebecca Greenfield rzgreenfield

Companies have found a powerful new benefit to add to their arsenal of perks: paid time off to care for sick spouses, parents, and children.

As the hiring market has tightened over the past year, companies have beefed up their benefits packages, adopting more generous parental leave policies and student debt repayment benefits to attract and keep employees. And the benefits arms race continues apace. In the past month, two large employers are leading the way with a new benefit, offering what is generally called elder care but includes spouses and kids as well. Deloitte will give its employees 16 weeks of paid time off to care for sick relatives. Vanguard Group will allow up to two paid weeks.

Few companies offer paid elder care. The Society for Human Resource Management’s 2016 benefits report found that 2 percent of companies subsidize such care. While 75 percent of the more than 1,000 companies surveyed for the Families and Work Institute’s 2014 National Study of Employers said they provide time off for employees to provide elder care without jeopardizing their jobs, it’s often unpaid.

The Family and Medical Leave Act, the federal law that covers maternity leave, requires employers with 50 employees or more to provide 12 weeks of unpaid time off “to care for an immediate family member (spouse, child, or parent) with a serious health condition.” Only 12 percent of U.S. private sector workers have access to paid family leave through their employer, according to the Bureau of Labor Statistics, and that doesn’t necessarily include elder care.

As baby boomers age out of the workplace, their millennial children, who now make up the largest share of the labor force, will have to care for them. Much like raising a newborn, taking care of a sick or dying relative takes a great deal of time and emotional energy. If a parent has an unexpected terminal illness, for example, a child might need to (or want to) take a significant amount of time off to care for him or her and say goodbye.

Employees stress “the need to get to doctors, to make arrangements to interview care providers, and how difficult that was,” said Kathy Gubanich, the head of human resources at Vanguard, of the company’s own workers. Often, she said, what people need is “a little bit of time to figure all of these things out.”

Even if most young workers haven’t experienced these crises yet, they know they will be grappling with them, and most can’t afford to jump in unpaid. A Deloitte survey found that 88 percent of respondents are for expanding leave policies to include care beyond maternity and paternity leave.

For companies, offering paid elder care is not only a hiring and retention play but potentially a productivity booster. It’s tough to balance working with caring for—or just worrying about—a sick loved one. One study by MetLife estimated that U.S. businesses are hit with $17.1 billion in annual productivity losses from full-time employees doing intense caregiving for family members.

Both Deloitte and Vanguard are using the Family and Medical Leave Act as a framework for administering the benefit. Employees have to apply for the time off, showing that the family member has a “serious illness.” As defined by the act, that is a condition involving inpatient care or continuing treatment by a health-care provider.

“It essentially says someone has got an illness that incapacitates them and you, as a caregiver, can take time off to help them,” said Mike Preston, Deloitte’s chief talent officer. Deloitte’s policy requires that employees take no less than three consecutive days off, because it’s meant for serious care, not for quick stints to pop in on the person or pick up a few things. Workers can spread the 16 weeks out across the year.As with any extended leave, simply offering time off doesn’t mean employees will take it. Leaving work for any amount of time or occasion can jeopardize an employee’s role in some workplaces. That’s why men resist paternity leave, for example. Rosanna Fay, writing for the Atlantic, said her experience caring for her two terminally ill parents while juggling work was like going on maternity leave.

“When I returned home after a two-week hiatus following my mother’s death,” she writes, “my colleagues welcomed me with cards, gifts, condolences and a new job description that left me with nothing challenging to do.”

But the first step toward normalizing a benefit, as with parental leave, is offering it. If elder care follows the same pattern as other hot perks, more companies competing for talent will follow Vanguard and Deloitte’s lead.

“I think it’s becoming a bigger and bigger deal,” said Vanguard’s Gubanich. “I think more and more firms are going to look to these kinds of programs to differentiate themselves.”

Communication and Collaboration Needs in Home Based Care

As an independent RN Patient Advocate I collaborate with home health, home care, skilled care, families, and all the healthcare providers in between. I see a lack of respect everywhere I turn, and caregivers (hospital and home) that feel squeezed between administrative mandates and patient expectations. I consider learning and practicing HOW TO communicate and collaborate across the great divide of health care agencies and professionals to be an important first step. This applies to leaders, administrators, caregivers, office staff….everyone must be engaged in learning new tools so that the patients we care for ultimately benefit.

The home care provider sector is one of the fastest growing in healthcare and even when measured against other industries. This is particularly true in the US and around much of the rest of the western world. This is mainly because most governments have now recognized that home care can save considerable money every year by treating patients or dealing with high care need people (such as seniors) in their own homes instead of in hospitals and other institutional providers. Over the last five years, these factors have contributed to an annualized revenue growth rate in the sector of almost 5% per annum and a home care and home health sector with combined estimated revenues of around $90 Billion.

Before we go on to look at what the future potentially holds for this sector within the large healthcare industry, let’s distinguish what we mean by “home care” versus “home health”. Home health generally refers to agencies that provide a skilled service in a person’s home (in the US typically under a Government run Medicare payer source). Skilled services include those provided by a registered nurse, physical therapy, and occupational therapy. Home care, on the other hand, generally refers to mainly private pay services in a person’s home (mainly because there is little or no government or insurance coverage for it). Most home care agencies provide basic personal care and homemaker services. Personal care typically relates to bathing, personal hygiene, dressing, transportation, light housekeeping, and meal preparation.

Despite strong growth, particularly in the last decade or so, sector profitability (on both sides) has been under pressure. The largest payers for home health services are government programs. But these budgets have shrunk greatly, and decreased funding has thus resulted in reimbursement cuts for the industry and has suppressed operating profit. However, the numbers of adults aged 65 and older, as well as the fact that people are living longer means that home care and home health will continue to grow in both size and reach over the next 20 years. The question is therefore how will this growth occur and what major challenges will need to be overcome? In this article we want to describe six areas that need to be carefully considered.

Client Satisfaction

In both home care and home health clients are not only highly varied in their needs (ranging from the young seniors to the “old-old” and with “light support” needs to a number of specialized and chronic “heavy support” needs) but they can readily switch from one agency provider to another. In addition, seniors are not the only ones to make the judgment call about whether or not they are satisfied with the service but their children (who often pay for home care) are also likely to take a view as well. The implications of these expectations, is that every home base care provider needs to take client satisfaction extremely seriously and seek to tailor their services as much as possible. This might be to offer specialized services, in areas like Alzheimer’s or COPD for example, or to better match a carer with a customer and his or her personal, social or health needs.

Access to greater numbers of high quality people to provide care

Since 2014, the so-called “baby-boomer” population has been retiring at the rate of 8-10,000 people every day. This is a situation that will continue for almost the next 20 years. Combined with the cost savings to be had from treating people at home and making sure patients are not re-admitted to healthcare intuitions, this has meant that there are many more home care agencies chasing more home care staff. This presents both a quantitative problem (there are not enough people to currently meet the demand) and a qualitative problem (the quality of people has declined on average). Both of these challenges can only by addressed by recruiting more people to come into the sector and training both existing and new recruits to operate at a high standard of care.

Developing and retaining home care and home health staff

Historically, home based care staff came into the sector with little or no direct qualifications or much in the way of experience. But in this fast-changing area, which is both growing in number and in terms of having more demanding clients, this is not sustainable. Home care and home health workers therefore need more and better training and even more importantly need to be nurtured to stay in the sector. This need for better retention strategies has many facets to it. Apart from regular and ongoing development it entails designing the work to be more interesting, giving the individuals chances to progress to more interesting/higher level work over time, learn about and use a wider range of technology and designing more creative reward and recognition approaches, just to name a few.

Navigating the law

Most western countries are starting to regulate the home care sector to a much greater extent. In the US, for example, the law has gone much further to create more rigorous licensing standards (although these vary by state)and to dictate employment conditions. The two most pressing of these employment condition changes relate to treating all staff that work almost exclusively for a given agency as a full-time employees (and not as contractors) and for all care employees and contractors to be given overtime pay when they go beyond minimum hour standards. Both of these stipulations add to agency costs and either squeeze relatively low margins in the sector or make the costs of care higher to the customer (whether they are paying cash or seeking reimbursement).

Getting paid

The home-based care market has two sides to it-cash revenues (around 10% of the population or 15% of the value) and reimbursable revenues, where insurance or government schemes operate). Home care is heavily cash pay based and home health is heavily reimbursement based. In both cases however, home based care organizations are under pressure to get paid for their services. At average rates of $20-$25 per home care non-overtime hour, service is only affordable to individuals and families that are typically earning above median wages (especially if a senior needs considerable care or has a chronic condition). Home health is more expensive (typically $30-$65 per non-overtime hour) but is often fully or heavily reimbursable. However, a provider still takes the risk of rendering the service and receiving the expected reimbursement, both in terms of time it takes and quantum (and it may fall considerably short of expectations thereby reducing profit margins).

Making the best use of technology

Healthcare in general has been slow to adopt technology compared to other industries and this is perhaps even more the case in home-based care. However, gradually this is changing with technologies such as the deployment of a variety of medical devices to monitor vitals, for example, sensors in the home, smart phone and tablet based applications and telemedicine all being increasingly used. Perhaps more interestingly, there are now several care platforms, which operate, that use web-based technology to better match carers and clients and to schedule service using a range of technology. This has helped to lower costs to clients in some cases although a determination of whether the quality of care has been improved has yet to be determined.


Home based care as a sector is growing rapidly due heavily to the “boomer” population retiring and living longer. This is also because it’s estimated to be anywhere from 30% to 60% cheaper to render the care that is needed in a home setting than in an institutional environment of any kind (such as hospital, skilled nursing home, assisted living facility, or hospice, for example). However, the industry faces many management-side challenges that need to be quickly addressed if it is to continue to grow and thrive in the future.