Home Care Free-for-All

Vol. 18 •Issue 7 • Page 27
Home Care Free-for-All

Not All Caregivers Are Trained for Tasks at Hand

There has been a significant change in the demographics of home care over the past 12 years. The payment schedule is perhaps the best indicator of these changes. In 1991, for example, only 14 percent of Medicare’s long-term care spending was designated for in-home care services. By 2003, this percentage had more than doubled to 33 percent.

This is consistent with a decrease in payments to nursing homes during this same time period. Experts contribute these shifts in spending to:

• Shorter hospital stays,

• Increased acuity at discharge,

• Growth in assisted living communities, and

• Increasing popularity of long-term care insurance.

Sadly, the increased demand is in many instances being filled by an unregulated workforce. Private duty and home health aid agencies are springing up all over. Many are highly competitive and not always scrupulous.

In some areas, a lowest-bidder mentality has taken root. Because of this, practitioners who are licensed and credentialed and could provide viable and needed services can’t compete and are in many instances being locked out of the opportunity of doing so.

Types of Home Health Agencies

The exploding home care industry has created several different types of home health agencies.

First, there are the full-service agencies, which provide a range of services. For this type of agency, the staff usually consists of a core of full-time employees.

Second, there are specialty agencies that provide an exclusive brand or line of care like ventilator management. These too are usually staffed by a core of licensed professionals.

What these home care providers have in common is they must be licensed in order to bill for their services.

But there is a growing trend toward the creation of a third type, referral agencies or registries that provide independent contractors to provide services.

Depending on the state laws in existence in the various jurisdictions, there can be a vast difference in the requirements these three types of agencies must fulfill, the services they must provide and the insurance and licensure requirements with which they must comply.

In many states, the referral agencies view their service as a referral to an independent contractor only. The independent contractor is responsible for ensuring that all applicable licensure laws, liability insurances, etc., are up to date.

In many cases, they are; but when they are not, it is the consumer who may literally suffer. The patients may think they have hired Spiffy All-American Nursing Services, which is fully licensed and bonded. In fact, however, they may have unknowingly hired Miss Failure T. Comply, who is not licensed at all. Her only claim to professional fame may be the fact she once nursed her mother-in-law through a bout with shingles.

Some Basic Questions

OK, that is probably a little extreme. And we may well ask: Why do we as RCPs care whether the “nurse” or home health aide, who gives our patient a bed bath, is from a reputable agency or not?

Not really a tough question. We care because they are seeing our patients, sometimes daily, and the care they provide can have a direct impact on the care we as therapists provide later. An unsupervised nurse or aide would not be adequately trained to identify problems that may arise in the home situation. From a technical perspective, the aide may think it is perfectly OK to store liquid oxygen canisters between the wall and the gas hot water heater.

I am sure the canisters do tuck into such places very nicely out of sight. Nonetheless, it is probably just not too smart to store them there.

Other potential problem areas arise as well. If the patient on the ventilator wants to take a tub bath, isn’t it possible for an aide to think it is OK to just put two extension cords together and run them into the bathroom? If the tubing doesn’t reach, can’t the aide merely set the ventilator in the sink?

Patients, of course, are not trained to recognize clinical problems as they arise. If Mr. Four-Packs-a-Day Jones is short of breath, Miss Failure may think it appropriate to turn the oxygen up to help him catch his breath and also encourage him to take his medicine to help him relax and sleep better.

The point is simple: These care providers are unsupervised, and they often lack the resources they need when they have a question or concern.

Advocacy Groups Acting

Fortunately, advocacy groups from across the country are starting to wake up to the potential dangers of unregulated caregivers. Advocates are lobbying for legislative initiatives in various state legislatures to regulate the services being provided. Among the states is California, which has forged ahead with AB 2704: Underground Economy in Home Care.

Referred to as the “Berg Bill” because of its sponsor Pat Berg, the proposal is intended to assist patients and providers in making informed choices about private personal home care services through knowledge of potential employer/employee relationship and workers’ compensation and tax liabilities.

The bill is currently in “suspense” in the California Senate Appropriations Committee. Not surprisingly, it has received heavy opposition from housekeeping and home care referral agencies.

Illinois is also getting into the act with its Home Care Consumer and Worker Protection Act, which is slated to be introduced in the legislature this session.

Keeping a watchful eye on all of this grass-roots activity is the National Private Duty Association (NPDA), a trade group for full-service agencies that provide private-duty home care. NPDA is working with its state chapters to draft legislation and mobilize forces in support of similar measures. To aid in the cause, NPDA has drafted a position paper on how regulations and other factors are driving up the cost of home care. The cost issue is of concern to many; in fact, the Health Policy Institute of Georgetown University has developed a fact sheet outlining some of the concerns.

As RCPs, we know all too well the painful reality of what it takes to pass state-by-state licensure laws. Would a national initiative be better? Are you aware of what is happening in your state? Is it going to impact your licensure laws?

These are questions only you can answer for your state. Are you involved?

Ultimately, it is the patient who pays the price for a poorly managed home care industry. Many of these are elderly people dealing with chronic or debilitating illness. Typically they have limited incomes and limited options. Having poorly trained caregivers providing medical help is not exactly the caring home care situation we would like to face if we were the patient.


•National Private Duty Association


•California Association for Health Services at Home


•Health Policy Institute Georgetown University


Margaret Clark is a Georgia practitioner.

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