Report: Advancing the Home Care Workforce

of this, having been highly successful in creating training and career ladders in this sector and sustaining programs over time. As exemplified by New York City’s Cooperative Home Care Associates, the idea of worker cooperatives is a related strategy that, in specific settings (urban and highly unionized), also has shown promise. Where unions and cooperatives have partnered with state government to design additional mandates and regulations (e.g., Washington), it has positively impacted the industry itself. Implication: • Where there are conditions that are ripe for union entry into a market, policies and programs can encourage LPMs that focus on training and career paths. Showcasing exemplars of this strategy in short reports for review by states and industry leaders could help alleviate fears of unionization and help encourage adoption.  Fragmentation of home care and home health industry and the small size of firms are major barriers to uptake by agencies. While unionized settings represent a hopeful scenario, they are few and far between. Most home care unions are in large east or west coast cities and are therefore less relevant for a large swatch of the country, particularly rural areas in right-to-work states. In these regions, change is likely going to depend on developing a business model that can lead to greater consolidation and integration with other health care industry segments. The three (or more) types of payment streams and aims for home care and home health are one reason the industry has failed to coalesce and become more financially viable. Home care companies are generally separate from home health companies, which in turn are separate from home hospice care companies. This is driven by the funding streams and their different programmatic aims. Medicare’s short-term and intermittent treatment of illness and recovery from the home (and the equivalent in the private insurance market) often rely on part-time or contracted labor. Medicare’s hospice homecare is a more stable segment but is generally stand- alone. And then Medicaid’s long-term services in-home care (and the equivalent in the out-of- pocket market) allows aging in place and aims to prevent nursing home admissions. This fragmentation has been shown to prevent improvement in wages for workers. 56 As Alfers argued in our interview with her and in her monograph on the topic, 57 aligning these funding streams and program aids as an interconnected continuumwould help “optimize employee skills, better train workers for specific tasks, develop cross-functional teams. It could also expand the market that can be efficiently addressed by an individual firm...”. A related issue is the size of the agency. In a study of the home care industry, Alfers found that the 50 largest firms in the industry account for only 25% of total market revenue, suggesting a proliferation of small mom and pop firms and severe industry fragmentation. 57 A GAO report shows that two-thirds of the per-visit cost differentials between low and high Medicare profit margin home health agencies result from

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