It wasn't all that long ago that a patient having hernia repair surgery spent at least four days in the hospital. Now this procedure is performed on an outpatient basis, as are dozens of other surgeries that previously required a hospital stay. For patients who are admitted, the trend toward shorter lengths of stay has become the norm-as have reduced payments from the Centers for Medicare and Medicaid Services to hospitals that have "excess readmissions."
Moving patients out of the acute care setting and into community and home-based health care has advantages for both payers and patients. Yet, this trend also raises several concerns, particularly regarding the long-term care workforce's ability to keep pace with the growing population requiring care. Reimbursement issues have also arisen, leading to concerns about worker salaries and the types of services covered by insurers.
WHO WILL CARE FOR PATIENTS AT HOME?
A major challenge is the shortage of nurses available to work in home care. "At the heart of the issue is, are there going to be enough trained nurses to fill this need?" asks Andrea Devoti, MBA, MSN, RN, CHCE, executive vice president of the National Association for Home Care and Hospice in Washington, DC. "The focus in nursing education is still on inpatient and critical care." She notes that health care systems are trying to move away from the inpatient setting. "Most hospitals are becoming mini ICUs, with sicker patients," says Devoti. "We are moving toward home care, but we haven't kept up with nursing education."
Danielle Pierotti, PhD, RN, CENP, vice president of quality and research at ElevatingHOME, a nonprofit whose mission is to unify and strengthen the home-based health care industry, agrees. "The connectivity between education and home-based care is nonexistent, despite the fact that community care is a requirement in nursing programs," she says. Students may shadow a nurse in the home or community setting, but shadowing doesn't expose them fully to this kind of care, Pierotti explains. "If you don't expose students to this experience, they don't know that it exists."
Another challenge is the actual supply of nurses. "There is going to be a shortage of RNs for decades to come," says Pierotti, "but that data is confusing. Some reports tell you we are fine for RNs, but not for aides. The assumption is that we can take all the nurses across the country and spread them out evenly, and then we'll be just fine. It's not acknowledged that there are significant challenges moving them into the home."
Because nursing programs tend to minimize home and community care, there is also some bias against it. "Most nursing students don't even consider home care as an option," says Marysanta Bigony, PhD, RN, a clinical assistant professor of nursing at the Catholic University of America in Washington, DC. "You do need experience before you can function in the home care environment, but not many consider it something they want to do down the line-they think that home care is something you do when you retire."
Bigony points out that taking care of patients in the home has become complex, and it can be overwhelming for families. "Patients are sent home, and it often falls on the family to care for them because there aren't any other resources," she says. "Some of the home care settings look like ICUs, with patients who are on ventilators, have cardiac devices, and need other complex care." (See the editorial on family caregiving in this issue.)
Family members may not live nearby or may have other obligations. "This is challenging for the nurses as well. In a hospital, you can speak with a social worker, but in the home you have to make a lot of decisions," says Bigony. "When we look at readmission rates, we can see that many are due to a failed home care plan-one that wasn't well put together and followed up."
WORKFORCE CHALLENGES
According to the Centers for Disease Control and Prevention (CDC) report Long-Term Care Providers and Services Users in the United States, 2015-2016, more than 1.5 million nursing professionals (RNs and LPNs or LVNs) and aides were employed full-time in 2014 in long-term care service sectors, which the report defined as nursing homes and residential care communities, home health agencies and hospices, and adult day services centers. Care was provided by approximately 67,000 regulated long-term care providers, who served about 9 million people. An estimated 15,600 nursing homes, 30,200 assisted living and residential care communities, 12,400 home health agencies, 4,000 hospices, and 4,800 adult day services centers provided long-term care services that year, according to the CDC report.
The U.S. Department of Labor estimates that more than 3 million personal care attendants were working in the United States in 2018. This is projected to increase 36% by 2028. Although people of all ages receive home care services, older adults make up a large proportion of patients. As the baby boomer generation ages and the proportion of the population ages 65 and older increases, the demand for personal care aides will also continue to grow. Using the latest available data, the Population Reference Bureau has projected that the number of Americans ages 65 and older will almost double by 2060, from 52 million to 95 million. This age group's share of the total population will increase from 16% to 23%.
The need for home health and personal care aides is a pressing one, as evidenced by estimated projections of employment growth in this field. Yet home health aides and those seeking to hire them face several challenges, particularly in terms of recruitment and training, as Joanne Spetz and colleagues observed in an article in the June Health Affairs. Society tends to undervalue home health care, they note, and those working in this field often find there is a stigma associated with this work. Such jobs also tend to pay poorly and provide inadequate benefits, and there is a lack of high-quality training for this workforce.
One area that is particularly problematic is pediatric home care, in which there are significant challenges to finding qualified home care workers, as well as a lack of private insurance coverage. Children who are covered by Medicaid are entitled to long-term care at home, note Carolyn C. Foster and colleagues in their analysis of home health care for children with medical complexity, also published in the June issue of Health Affairs. Yet, a disproportionate percentage of Medicaid spending on these children is directed to hospitals, not home health care. As a result, the brunt of home care often falls to parents, who may need to quit their jobs or reduce working hours to be caregivers for children who have complex medical needs.
Bigony emphasizes that salaries for aides need to be raised. She points out that a person working in the fast-food industry makes only about 50 cents per hour less than a home health aide. "That says something," she notes. And "they don't have to sit through classes or training or deal with the stress of giving care to sick patients. So why come to work here and deal with this job?"
Lower salaries are also a barrier to recruiting more RNs. "It is commonly spoken about, that home care cannot pay what hospitals pay," Pierotti says. She also notes that it's difficult to put these salaries in context, because reliable data aren't available.-Roxanne Nelson, BSN