The Capacity for Home and Community-Based Care in Rhode Island

Most people prefer to remain in their homes and communities as they age, rather than moving into institutional settings. Home and community-based services (HCBS) can help make that possible. There is growing evidence that appropriately integrated and managed HCBS can promote independence, safely support older adults in their own homes, and moderate the demand for more costly acute or residential care.¹ Research also shows that rebalancing government spending to focus more on HCBS and less on institutional care may save taxpayers money.²

With these benefits in mind, Rhode Island has slowly been shifting toward a greater emphasis on HCBS. The question remains, however, whether the state will be able to meet the increasing demand for home care. Our research examines Rhode Island’s capacity to provide effective HCBS to its aging population, identifies barriers to meeting the growing need for HCBS, and offers recommendations for improving and integrating the state’s HCBS system.

The research is based on interviews with twelve executives and owners of home care agencies (two non-profit and ten for-profit providers); five key state and non-profit leaders associated with HCBS; and three supervisors of elder care case managers for Community Action Program (CAP) agencies, which are contracted by the state to provide case management, assessments, and referrals to home care for older adults on Medicaid.^(a)

We also conducted a focus group with nurses, case workers, and social workers from Community Programs at the Rhode Island Executive Office Health and Human Services (EOHHS). In addition, we analyzed data from EOHHS reports and HCBS referral data from the Community Action Program and Neighborhood Health Plan (NHPRI), one of the state’s largest Medicaid health plans.³

What is Home Care?

Home care includes a range of medical, therapeutic, and other services delivered at a patient’s home with the goal of promoting health and well being, maximizing independence, minimizing the effects of disability and decline, and preventing or delaying the need for institutional care. In some cases, home care serves high-need patients, such as paraplegics and bedbound individuals, who would otherwise need to be in a nursing home. Other clients require fewer hours of care or only need household services like help with chores.

In Rhode Island, there are two levels of home care providers: those that deliver nursing care and other skilled health services, and those that provide personal care and homemaking services. Home nursing providers offer services from registered or licensed practical nurses including assessment of a patient’s condition, wound care, medication monitoring, and other medical care; licensed social workers who provide psychosocial support to patients and family members; and physical, occupational, and speech therapists who provide therapeutic interventions. Their work is primarily reimbursed by Medicare. Home care agencies, on the other hand, are primarily reimbursed by Medicaid and provide services requiring supervision by a registered nurse, but not the delivery of direct nursing care.^(b) These include personal care and assistance with activities of daily living such as bathing, feeding, and toileting, provided by certified nursing assistants (CNAs).

Home Care Workers: The Backbone of the System

The bulk of home care is provided by direct care workers, including certified nursing assistants (often called CNAs or home health aides) and homemakers, who provide help with daily household chores such as cooking and laundry. As the delivery of long-term care has increasingly shifted from institutional settings to private homes and communities, the number of home care workers has expanded rapidly. Nationally, the home care workforce doubled in size over the past 10 years and is projected to increase by 38% from 2014 to 2024.⁵ In Rhode Island, health care support occupations are expected to grow 13% by 2026, and nursing assistants, personal care aides, and home health aides comprise 70% of this workforce.⁶

Despite this growth, the expansion of the home care workforce is not keeping pace with demand and there are continual reports of workforce shortages.⁷ Across our interviews and focus groups, a lack of home care workers was identified as the central barrier limiting the state’s capacity to provide HCBS. Home care agency executives interviewed for this study reported that home care workers are their greatest asset and the heart of their business. As one noted, “CNAs are my golden nuggets. If I can match a CNA with a patient, that CNA stays with the patient and this prevents trips to the emergency room and the hospital.”

Many home care executives reported that an industry-wide shortage of workers leaves them unable to meet the demand for services. The Executive Director of one of the state’s larger nonprofit home care agencies stated, “We could handle double the patients but we need the staff.” All executives interviewed indicated that they were understaffed and had openings for CNAs that they were unable to fill. They cited wait times ranging from two weeks to one month before finding staff to cover a new client, and reported turning away as many as 20% of referrals due to inadequate staffing.

The Rhode Island Division Elderly Affairs (DEA) contracts with CAP agencies to provide services to older adults in the community. CAP case managers echoed concerns about a shortage of qualified home care workers. They expressed great frustration regarding difficulties in securing services for their clients, often due to a lack of CNAs. Since December 2016, the DEA has been collecting data from CAP agencies on the number of current and new referrals to homecare. The agencies make an average of 236 new referrals to home care each month, and that number is growing. Of the 236, more than a third (around 83 clients a month) are approved for services but unable to begin receiving care due to lack of an available provider.^(c)

Even if clients are matched with a home care worker, they may not be able to obtain the number of care hours or the schedule they need due to understaffing.^(d) On average, there are 293 recommended care hours per month that CAP clients are not receiving. CAP agencies contact multiple home care providers to find coverage but vendors are often unable to accept cases, primarily because CNAs are not available. When clients cannot receive timely services, they are more likely to return to or be admitted to long-term care institutions.

Many of the clients who end up on waiting lists for home care have complex chronic conditions such as congestive heart failure or behavioral health issues like depression, panic attacks, and bipolar disorder. These patients need care workers with specialized training, such as CNAs, who are hard to find. Patients with significant needs are often forced to turn to long-term care institutions if they cannot obtain home-based services. There is also a shortage of English-speaking CNAs for clients who are hearing impaired or have trouble communicating with care workers for whom English is a second language. In addition, there is a lack of workers in certain regions of the state. The inability of CAP agencies to make referrals is especially problematic in South County and parts of Northern Rhode Island, including Woonsocket, Foster, and Glocester, where there are fewer CNAs.

Low Wages & Limited Career Opportunities Deter Workers

Because home care requires little education, experience, or training, it is an accessible occupation for workers with educational or language barriers. However, a number of factors limit the attractiveness of a home care career, most notably low wages, scarce benefits, and limited opportunities for advancement. These obstacles circumscribe the capacity of the industry to meet the growing need for home care. As one case manager supervisor stated in our interviews, “It is a workforce issue. We need well-trained staff and providers. The job has to be attractive and we need to reward and compensate people appropriately.”

The home care executives we interviewed all concurred that the major barrier to recruiting workers is low wages. Wages in the sector have remained relatively stagnant over the past 10 to 15 years and have not kept up with inflation. Earnings for many home care workers in Rhode Island fall below the minimum level necessary to support a family, according to the MIT living wage calculator for the state. The average starting pay for a home care CNA in Rhode Island is $10.95 per hour, barely above the minimum wage.⁸ Many fast food and retail positions pay more than what a CNA earns.

As a result of these low wages, one in four home care workers in the U.S. lives below the poverty line and over half rely on some form of public assistance.⁷ Many home health aides work other jobs to make ends meet, sometimes at hospitals or nursing homes where wages are higher. Despite working several part time jobs, they may still have a limited income and no benefits. While some agencies offer healthcare benefits, many CNAs forgo the insurance because they are unable to afford the co-shares or co-payments.

Home care jobs are largely funded by Medicare and Medicaid, and a key reason wages are so low is that reimbursement rates have been relatively stagnant over the past several years. In FY2017, Rhode Island increased its reimbursement rate for home care workers for the first time in nearly a decade.^(e) The state budget designated $4 million to raise wages as much as 7.5% for personal care attendants and home health aides employed by home care agencies.^(f)

However, home care executives reported that the change resulted in only a slight increase in earnings (wages still range between $11 and $15 per hour) and had no impact on recruitment efforts or turnover rates because the increased wages were still not competitive with neighboring states or wages in the nursing home sector. Wages for CNAs, for example, only increased from $10.50 per hour in FY 2016 to $10.95 per hour in FY 2017.⁸ This mirrors the findings of research on similar increases in other states, which has been inconclusive as to their impact on CNA turnover and retention rates. 

The wage increase was structured as a pass through, meaning all the additional funds had to be passed on to employees in the form of higher wages. This structure does not account for increased costs to agencies, such as payroll, worker’s compensation, hiring costs, and other overhead expenses. For some agencies, the wage pass through actually had a negative financial impact – as CNAs’ wages rose, agency expenses increased as well but were not offset due to the pass through.

Home care executives recognize staff are their greatest asset and acknowledge the need to increase wages, but generally view a legislated wage pass through as detrimental to their long term sustainability, particularly for smaller companies that do not have private clients with which to subsidize losses on the Medicaid side.^(g) Between 2016 and 2017, five home health agencies closed in Rhode Island, including one of the largest non-profit home care agencies in the state. The major reason for these closures was unsustainable Medicaid reimbursement rates that impacted the agencies’ ability to hire and retain staff.

Given the low wages they are able to offer based on government reimbursement rates, home care agencies face steep competition for a limited pool of workers, particularly CNAs. For example, CNAs can earn hourly wages of $14 to $15 per hour in nursing homes and $12 to $13 per hour in assisted living facilities, making it difficult for home care agencies that pay less to compete. Government reimbursement rates for nursing home care tend to be higher and, unlike rates for home care, have included consistent cost of living increases over the years. In addition to competing with other types of facilities, home care executives report that they are losing workers to neighboring states.^(h) Agencies in Rhode Island are not competitive with Connecticut or Massachusetts, states where 2017 Medicaid reimbursement rates were nearly 40% higher.

Recruiting and retaining home care workers is also compromised by the fact that the career offers little opportunity for professional growth and advancement. Despite the increasing complexity of the work, there are few openings for promotions or advanced positions with increased wages. Reimbursement rates do not allow for increased compensation as CNAs gain knowledge, develop new skills, or complete specialized training. Furthermore, because agencies are so understaffed, they cannot allow workers time off for professional development, and often resort to using webinars, online training tools, or information shared in paycheck stuffers as modes of training.

Some states have attempted to address these issues by creating more opportunities for professional advancement and wage growth. For example, Oregon developed a three-tiered career ladder for its personal support workers (PSW), who work with clients with developmental disabilities and mental illness. PSWs are classified as regular, enhanced, or exceptional based on their training and certification, and are paid more at the higher levels.⁽ⁱ⁾ Oregon’s Home Care Commission also sets competitive rates for its SEIU unionized home care employees.^(j) As of February 2017, their wage was $14.50 an hour, 33% higher than the national median of $10.87 an hour for a home health aide in 2016.⁵

Perspectives from the Interviews

The Need for Greater Training and Support

While low wages are the most significant barrier to expanding the home care workforce, there is also a need for more robust training, improved recruitment and onboarding, and greater on-the-job support. The problem of adequate training and support looms large, as workers are increasingly caring for more complex cases requiring specialized training. In addition to assistance with intimate tasks such as eating, bathing, and dressing, more and more patients require help with multiple chronic conditions, including psychosocial and behavioral health needs. Even with training, workers may feel unprepared or unsupported to confront the ever more complex and challenging nature of their work.

Financial and socioeconomic barriers can stand in the way of interested individuals becoming home health workers. People may struggle to afford the cost of the training, which ranges from $650 to $3,000; transportation to the training; and childcare during the training. Even the background check and vaccinations required for licensure can be a financial strain. Applicants may have limited work experience and lack basic job skills such as effective communication. Many home care workers do not have at-home supports such as child care and stable housing, and even getting to work can be difficult, as low wages make it hard to secure reliable transportation.

These barriers result in low recruitment and retention numbers. Agencies that offer CNA training programs, such as Homefront and Ocean State Nursing, said recruitment for classes was low and the number of students who actually graduate from the training has been declining. Some agencies report over a 50% drop in applications in recent years. Furthermore, typically only half to three-quarters of those who sit for the CNA licensure exam pass. Employee turnover is also an issue, with agency executives reporting annual turnover rates between 33% and 61%.

Home care executives report that much of the turnover is due to home health aides feeling unprepared or unable to handle the complex patients they encounter. The work of home care aides is physically and emotionally demanding, but employers are not addressing this in a systematic and supportive way. Work often occurs in isolated and potentially unsafe home situations with no on-site support, supervision, or security. Some patients with behavioral health problems may even pose a safety threat to CNAs.

In response to this host of barriers, home care executives suggested simplifying onboarding procedures to facilitate the hiring process and making Rhode Island comparable to neighbors like Massachusetts, which has less stringent requirements and a more efficient background check system. Executives also stressed the need for training that is focused specifically on home care, with clinical rotations in home and community settings. (Many existing CNA training programs are geared for work in nursing homes.) Rhode Island might consider following the path of Massachusetts, which has a separate licensure for home care CNAs. Specialized trainings in topics like behavioral health, chronic disease management, dementia, and geriatric care could both improve the quality of care and create a career ladder with potential pay increases for workers.

Some states have also tried apprenticeship models that provide an opportunity for CNAs to strengthen skills and competencies with commensurate bumps in pay.  Apprenticeship combines training and on-the-job learning to develop specialized skills, creating a career ladder with financial incentives that can improve retention and job satisfaction.

Other Factors Limiting Rhode Island’s HCBS Capacity

While a shortage of home care workers is the primary challenge, a number of other issues impact Rhode Island’s ability to provide home and community-based services to its older population. These include a lack of safe, affordable, appropriate housing for older adults; few affordable home maintenance and renovation services; and a dearth of reliable transportation options.⁹

Individuals we interviewed also identified a gap in community services due to the recent elimination of 66 positions at the Department of Human Services (DHS) in anticipation of the launch of the Unified Health Infrastructure Project (UHIP) computer system. Many of these staff provided case management and referrals to community resources for Medicaid recipients. The elimination of this workforce shifted that responsibility onto unprepared home care workers and overwhelmed CAP case managers. It created an added burden for home care providers and CAP agencies to deal with many of the social, financial, and mental health issues faced by older adults, needs that often cannot be adequately met by a home care worker. 

Problems with UHIP implementation have also resulted in six to nine month delays in eligibility determinations for Medicaid applicants seeking long term services and supports and halted referrals to home care agencies from DHS.^(k) As a result, some care executives and CAP staff believe that many older adults in the community are going without needed care. On average, 293 CAP clients per month are not approved for home care due to outstanding eligibility issues, typically related to LTSS eligibility. Sometimes the wait is so long that clients pursue other options, such as moving in with family or into a nursing home facility. 

Although the downsizing at the Department of Human Services has created challenges, it could also present an opportunity to enhance the home care workforce by including community health care workers in the home care team. Community health workers could address the social determinants of health and navigate services to enable older adults to remain in their home.

Expanding Rhode Island’s Capacity to Care for Older Adults at Home

Roughly two-thirds of Americans age 65 and older will eventually need some type of long-term care, ranging from personal care assistance for managing daily activities to intensive nursing care.¹ Providing these services at home whenever possible, rather than in institutional settings, can save taxpayers money and promote seniors’ health and well-being. However, our research strongly suggests that there is not enough capacity in Rhode Island to handle an increasing number of home care patients. As the director of one of the larger non-profit home care companies in the state said in our interviews, “We need an infusion of investment in homecare if we want to rebalance.”

The most significant area where investment is needed to meet the growing demand for HCBS is the recruitment and retention of a trained, competent, and caring workforce. Our study reveals a serious shortage of qualified home care workers due to low wages, limited benefits, demanding work, barriers to training, limited on-the-job support, and a lack of career advancement opportunities.

By expanding career opportunities and increasing compensation and job benefits to match other healthcare settings and neighboring states, Rhode Island can attract more competent and caring individuals to home care. This may involve increasing Medicaid reimbursement rates and setting higher wages in the $16 to $18 per hour range. It could also entail creating opportunities for career advancement, such as specialized trainings, tiered career ladders, and apprenticeship programs. In addition, onboarding procedures could be simplified to make it easier for CNAs to start working and more efficient for agencies to hire them. Better on-the-job support and ongoing professional development could help agencies retain workers and offer higher quality care.