How Should State Shape Care at Home?


We've all seen the demographic predictions: California's numerous baby boomers will swamp the health care industry with aging bodies -- almost all of them wanting to stay healthy, active and living at home.

That last part -- living at home -- may become a recurring, resounding policy issue in the coming years.

A new report from the UCLA Center for Health Policy Research suggests California policymakers need to pay more attention to health care delivered in the home.

"Almost no data exists to measure the quality of care provided by the rapidly growing industry of private home care providers serving an expanding population of the elderly and disabled," according to the policy brief "Who Is Minding the People Who Are Minding Our Elders?"

A bill in the Legislature this year seeks to more tightly regulate and keep track of the thousands of home health workers. AB 1217, by Assembly member Bonnie Lowenthal (D-Long Beach), would require home care agencies to be licensed and caregivers to be listed in an online database.

Regardless of the fate of Lowenthal's bill, the issues raised in the debate over how to manage home health care will continue to grow in importance as baby boomers age and more home health care services are needed in California.

We asked legislators and stakeholders how California can best shape state policy regarding home health care givers to get ready for major changes ahead.

We got responses from:

  • Assembly member Bonnie Lowenthal (D-Long Beach) | Author, SB 1217

    Balancing Consumer Protection, Business Viability

    For decades, policymakers have worked to build safeguards into our long-term care services. We have licensing requirements for providers large and small and training requirements and background checks for their staff. We have standards in place for all levels of care, from highly-skilled nursing care, to basic assistance with daily living tasks. These protections exist for all consumers, whether they're paying out of their own pocket or receiving state or federally-funded care; with one exception: home care. 

    Although the home care industry is one of the fastest-growing industries in California, only our publicly funded services through our In-Home Supportive Services program require any background checks or basic training. We have more than 1,000 private home care organizations serving countless Californians with nothing more than a business license. While many of the organizations screen and train their staff, there is no statewide standard to ensure compliance, and no way for a consumer to verify that the person they're letting into their home has a clear criminal history.

    At the legislative level, we've struggled for years to find a balance that provides consumers with the protections they need without sacrificing provider viability. Earlier this month, we passed my bill, AB 1217, which would for the first time establish a licensing framework for home care, complete with background checks for the aides that they employ. It includes a registry that will help consumers verify a provider's record. 

    While it doesn't go as far as many would like -- myself included -- and cover all aides, whether they work for an organization, through a referral agency, or on their own; it's certainly not the death knell for the industry that the opposition has made it out to be. It's a reasonable compromise that allows the industry to grow, while protecting consumers. It's a first step toward  ensuring that all of us can age with dignity and choice in our own homes.

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  • Nadereh Pourat | Director of research, UCLA Center for Health Policy Research

    Assessing Quality, Assuring Safety Are Challenging Tasks

    • Home care consists of services provided by several types of formally trained and certified/licensed providers and those without any formal training or certification; and
    • Providers have diverse employment arrangements.

    These variations require different criteria for assessing quality and patient safety. For example, the criteria for assessing quality of nursing services are inherently different from the criteria for assessing quality of home health aide or custodial services. In addition, employment through a licensed home health agency means employees receive background checks, while direct employment by the patient may not entail background checks.

    Assessing quality is further complicated by major differences between home care and outpatient or inpatient care. These differences include lack of a specific and regulated setting for care delivery, lack of direct supervision of workers while care is delivered, and different expectations for outcomes of home care because -- for many patients -- the services are designed to maintain well-being and function rather than to cure or treat. These differences lead to additional challenges to assessing the three major aspects of quality -- structure, process, outcomes. For example, structure for home health care organizations can be measured through staffing, level of training, certification/licensure, and background checks. But for home care agencies and individual providers, licensure may not exist and staffing levels do not always apply. Assessing processes of care is difficult in the absence of objective observations by other trained staff and lack of specific claims data detailing all the provided services. Similarly, outcomes can primarily be measured through surveys of patients and subjective assessment of care delivered rather than more objective measures.  

    These challenges have led to limited knowledge of quality of home care to date, but the low-hanging fruit in this debate is implementation of structural measures of quality such as background checks. Background checks will not guarantee abuse prevention but would provide some assurances for many of the vulnerable patients and consumers of home care. Licensure and certification are other methods of providing assurances for quality of care and worthy of further debate and consideration.

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  • Jack Christy | Senior policy adviser, LeadingAge, California

    Consumers Need Information

    Home health agencies in California are already licensed and significantly regulated. Employees are licensed or certified nurses or other health professionals delivering health care. State and federal mechanisms exist to mediate and enforce state and federal standards for assuring patient safety and high quality standards of care for seniors needing home health care services.

    While these home health care mechanisms may need modernization and updating to accommodate changing needs, the fastest-growing part of services to seniors in their homes are non-medical home care services, which cover a variety of tasks, from help with bathing and dressing, to laundry, grocery shopping, or transportation to the doctor's office or pharmacy.

    Currently, California does not require home care agencies to be licensed or that employees are trained or certified by any recognized authority. Given that California has the largest share of the population age 65 and older in the U.S., and that "aging in place" is the default preference of aging boomers, home care services will explode as the early boomers hit their eighties. Consumers take on risk, allowing un-trained, unknown, or un-wanted workers into their homes and lives.

    Historically, regulatory mechanisms -- such as licensing, registration and certification -- have been successful protecting patient safety and maintaining high quality of care in the Medicare and Medicaid programs. The evolving importance of home care services for addressing the needs of a growing older population is clear. California consumers need basic information about the people and organizations seeking to provide non-medical services to seniors and others in their homes. At the same time, regulatory mechanisms cannot increase the cost of services beyond the reach of consumers, who pay privately for most of this care.

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  • Kathryn Janz | Executive director, Matched CareGivers

    AB 1217 Is Not the Answer

    Medical service guidelines were developed for Medicare, the primary payment source, while none exist for the state and private funded sources, which pay for the non-medical services, such as home care.  Home care licensure is sorely needed.

    But AB 1217, the Home Care Consumer Act, is not the answer.

    AB 1217 deceives the consumer by claiming protection through licensure for home care, yet it exempts over 75% of all home care services, targeting only a portion of the private home care agencies, of which there are two models: those that employ their aides and assume all employer liabilities (the employer model), and those that just pay the aides a gross wage and transfer all employer liabilities to the client (the referral agency). The latter are exempted from the bill's coverage, yet such an agency will be permitted to represent itself "to be a home care organization by name, advertising, soliciting, or any other presentments to the public" and may "imply that it is licensed to provide those services" without being licensed under this bill.

    This union-sponsored bill was written to affect only the employer model, one small sector -- representing less than 20% of all home care. No rationally operated agency will continue the employer model when it can opt out of licensure by flipping to the referral agency model. Consequently, as agencies switch to the referral model, this bill will erode Medicare and Social Security -- the pillars of our safety net for seniors -- and will remove workers compensation coverage for thousands. Moreover, this puts consumers at risk as they unknowingly assume all employer responsibilities for the worker.

    We need home care licensure under the California Department of Social Services that offers regulations similar to other states and in licensure for hospitals, nursing homes and assisted living. There should be full consumer disclosures and a certification process for agencies that choose not to employ their workers. And we need a joint home and assisted living non-medical aide certification curriculum and fingerprinting system under DSS. We need to safeguard the existing entitlements and protect for our aging population from all exploitation.

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  • Steve Edelstein | National policy director, Paraprofessional Healthcare Institute

    New Workforce Development Strategies Needed

    Today, thanks to our nation's 2.5 million home care workers, many elders and people with disabilities are able to live independently in their communities. These workers help clients to bathe, get dressed, eat, administer medications and more. According to the Bureau of Labor Statistics, this workforce is projected to grow to nearly four million by 2020.

    The challenge we face is how to attract people into these new jobs and how to keep valued workers in this field. The work is vital, but also difficult and often dangerous. Yet the pay is low -- on average, less than $10 an hour.  Nearly one in three have no health coverage. And training requirements for home care workers vary from state to state and program to program. In many instances no training is required, leaving workers without the skills and preparation they need to be successful in their jobs.

    What we need are workforce development strategies that are designed to improve poor-quality jobs held by home care workers. Stakeholders and policymakers both have roles to play in promoting these interventions, which can be practice-based (working directly with employers and training programs), as well as policy-based (legislative or regulatory initiatives such as licensing), and often combine the two. The intent of these strategies is to improve low-wage jobs sufficiently in terms of compensation, benefits, job-design, training standards and a host of other measures so that workers can secure a meaningful degree of stability and dignity in their work and consumers can be assured of the quality of the services they receive.  New U.S. Department of Labor regulations extending federal minimum wage and overtime protections to home care workers is a good first step, but much more needs to be done.

    It is time to recognize that these workers are vital to our health, aging and disability services and the key to quality in long-term care. We face an ongoing and growing need for home care workers to support individuals with disabilities so they can live independently in their communities, and to provide assistance to families that care for parents and grandparents.  Improving training opportunities, ensuring livable wages and health coverage, and attending to credentialing and licensure will help us to attract workers to meet the increasing demand for home care workers as more people live with disabilities and our population ages while ensuring appropriate oversight so that our elders are cared for safely and well.
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  • Dean Chalios | President, California Association for Health Services at Home

    New Procedures, Technology Expand Home Care Options

    Multiple studies indicate that home care leads to speedier recoveries and is preferred by most patients and their families. Home care plays a prominent role in all stages of health care and helps people stay independent by combining skilled care and compassion with the latest in health care technology. Quality and highly skilled home care is provided across the full spectrum of health care, including post-acute care following a hospital stay or serious illness; as long-term care for those with a disability, chronic illness, or those in declining health; and care for medically fragile infants, seniors, persons with disabilities, those with dementia and cognitive impairment, and terminally ill patients in need of comforting and compassionate hospice care.

    California's home care agencies provide guarantees and protections to potential clients and patients, their families and the caregivers themselves that do not exist when hiring home care workers independently.

    Agencies conduct drug screening and background checks to ensure caregivers are trustworthy and reputable and agency caregiver employees are covered with professional and general liability insurance and are covered by the workers' compensation system. Agency employed caregivers are also trained to provide the necessary services patients and clients need and are educated on the use of any medical and monitoring devices they may need to operate. Moreover, agencies provide oversight for each individual case, create a care plan for patients and clients, supervise caregivers and ensure that back-up care is provided when caregivers themselves are ill or absent.  Families that employ caregivers directly do not benefit from these functions and take on the added burden of being the employer of record for their caregiver and are responsible for paying Social Security, Medicare, unemployment, disability, and state and federal taxes for each caregiver.

    Home care is a $12 billion industry in our state, and it employs tens of thousands of caregivers to treat our aging population and others in need of home care services. With the exciting advent of new medical procedures, portable technology, skilled staff and caring home care aides, many health services that previously had to be provided in institutional settings can now be compassionately and cost effectively administered in the warmth and safety of home.

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Kathy Janz
The state of home care protections in CA is a very fragile regardless of the newly signed union sponsored licensure bill that pertains to only the 20% of those who receive home care. In the last month, I have seen two examples of consumer fraud. One was a set of emails written to hospital RN and MSW casemanagers through their social media accounts offering rewards up to $20,000 a year for referrals to a specific home care agency. The other situations involves "brokers" going into hospitals to offer One Stop Shopping to casemanagers in order to reduce their work load. These brokers with no nursing , social work or casemangement training go into hospital rooms to "assess" and offer either assisted living or home care services using only agencies signed up with them. They then charge the home care agency 20% of the first three months bill rate. These brokers will spread like wildfire and the cost of home care will rise. The agencies that do not pay kcikbacks will close.
Barbara Hanson
Home care is always the preferred setting for long-term care services. However, if the "MediCal/Medicaid Planning" loophole is not addressed, even more middleclass citizens will go to welfare planners to artificially impoverish themselves to qualify for IHSS. There is a natural dis-inclination to go to a nursing home on welfare that reportedly keeps this welfare planning phenomena in check. Without some improvements in the laws, the more palatable possibility of government financed home care could be over-run. Currently, folks who have saved and/or insured for home and assisted living care are able to have their preferred settings. Take away that incentive for higher quality care with private pay, and few will take personal responsibility for preparing for their 70% risk of needing LTC services one day. With the Boomers here and aging, the government will face severe challenges if no one sees the need to take personal financial responsibility for LTC planning.
Tim Colling
While the legislators and regulators talk a good game about "quality" and "care", this topic has degraded into two things: money and power. Why? Because organized labor, particularly the SEIU, wants the state to provide and control the delivery of care in peoples' homes. Once that's the case, then the legislature, the Democratic majority of which is deeply enmeshed with, and dependent upon, financial support from the SEIU and other unions, will require all home care workers to belong to the SEIU or other unions. This is ultimately about producing dues revenues for the SEIU. If this were not the case, then WHY does the state of California continue to exempt the thousands of home care workers that it already employs (through the IHHS program) from any of these burdensome new regulations? The answer: the unions don't need to do anything to affect those workers: they are ALREADY required to belong to one of the unions. It's all about money and power.
Kathy Janz
CA Governor Brown signed AB1217. He did send a message to postpone the bill under Jan 2016 because it does need regulations written by the Department of Social Services. As of now it demands licensure of all private home care agencies that employ their workers with exceptions for agencies that look identical but do not collect payroll taxes and just issue 1099s (a model unique to CA and Florida), the Medicaid paid IHHS services, the agencies that provide services paid for by CA Department for the Development Delayed and of course all family hired caregivers. It demands aide certification and listing of certified aides on a public web site listing the home care agency that an aide gets a regular payroll (W2) from. The referral 1099 agencies which are not subject to licensure may represent themselves per the bill as licensed . Hopefully the DSS will be proactive in correcting some of the pitfalls in this bill. This is a test of how to make lemonade from lemons and protect seniors .
John Brown
Homecare Agencies have been moving away from the Independent Contractor model towards employee models. AB 241(which has passed), AB 1217, and the recently released DOL rule eliminating the overtime exemption for caregivers will push the industry back towards Homecare Registries. There is a limit to what seniors can afford or are willing to pay to stay in their homes. These regulations have the potential to force seniors into facilities where they don't receive the same level of care they receive one on one in their home. most of the high profile case we are hearing about involving elder abuse are private hires. My agency background checks all of our caregivers. We also run them through a caregiver profiler. We believe happy caregivers and lead to happy clients which is why we do not pay minimum wage.. 70% of our revenue goes to caregiver costs. We are proud members of the San Diego North COC, Murrieta COC, BBB, NFIB, and California Home Health Care Consortium.

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