At a press conference early this month, members of the State Legislature pressed momentum on legislation (S.6640/A.8064) to cap the number of hours weekly (50 hours) and daily (12 hours) that a home care aide may be asked to work.
The intent of this legislation is noble, which HCA made very clear in our own response to the media as we fielded numerous calls for our position.
But the issues of aide scheduling, supports, compensation costs, and safe access to care at home are much deeper and require more surgical answers than a hard statutory line on allowable hours worked.
HCA takes seriously and honors the hard work of home care aides who provide critical services to the most vulnerable New Yorkers. We especially honor aides who dutifully care for patients whose needs are so complex or so severe that these patients require 24-hour care.
The fact that such needs exist — and that these needs can be served in the home, instead of in a nursing home or other facility — is one big reason why this legislation, in its present form, should not be enacted.
Flexibility needed amid workforce crunch, increasing medical complexity
Patients receiving care at home today would, just a few years ago, be in hospitals and nursing homes. This shift to the community is thanks in large part to state policies and reforms which have transformed the practice of health care.
In staffing up to meet this growing demand for service, the home care system is also beset by a well-documented workforce shortage. For instance, our survey of HCA members this year finds that between 28.25% and 38.95% of a provider’s potential or actual case admissions, on average, are delayed or hindered by labor shortages.
Making matters more difficult are layers of state and federal regulations, procedural rules and demands that consume and strap resources necessary for direct patient-care activity.
If the current allowance of 24-hour shifts (with applicable sleep and meal times) were required to be split into two 12-hour shifts by more than one aide, as intended by this bill, the critical question remains as to whether a qualified workforce and funding exist at levels to meet the needs of patients requiring this intensity of service under the split shifts.
Otherwise the consequences would be dire: higher rates of institutionalization, for example, or increases in ER/hospital use because patients opt to remain at home but without the level of services necessary to maintain their health and safety there.
Research and practice tell us that care-continuity is vital — and especially so for consumers with extensive home care needs.
Elsewhere in this edition of HCA’s Capitol Report, you’ll read about the work of one home care agency to support the needs of children with severe autism spectrum disorder. This story underscores the importance of caregiver continuity, familiarity and structural predictability in meeting each patient’s specific emotional, social and behavioral needs. In these cases, as with patients suffering from forms of dementia or severe disabling conditions, 24-hour/live-in care (with applicable sleep and meal times) is often the most suitable and safest course. A caregiver’s shift change can cause anxiety, confusion and discomfort, as well as greater exposure to communication lapses.
In general, home care strives to match a caregiver with the specific needs of each patient. While aide continuity-of-care is essential for all patients, this is especially important for patients who require 24-hour care.
As a whole, S.6640/A.8064 makes no provisions for:
- The care dislocation and worker shortfall impacts that it would create.
- Training the additional workforce needed (and the lack of workforce at present to fulfill this need).
- Additional large costs of expanded compensation to aides or their employers for the additional aide wages.
- The consequence that more patients will be driven from their homes to long term care facilities.
It has been suggested that the bill’s stricter shift requirements would be a stimulus for entry of aides into the field, but it remains to be seen whether this is even a practical assumption.
Cost impacts and the state budget
Implementing this bill would cost billions of dollars over multiple years. This includes not only an expanded number of compensable shift-hours but also training and supervision of individuals additionally staffing cases and/or newly entering the field.
On the question of cost, one factor that gets lost in the discussion is the fact that 87% of home care is covered by government programs, namely Medicaid and Medicare. This bill, by prohibiting 24-hour shifts, would reverse a longstanding state Department of Labor (DOL) policy guidance on compensation rules under which state governments and other payors fund wages affordably on a standard of hours that exclude payment for certain meal and sleep times — a policy recently upheld by the state’s Court of Appeals, defended by DOL, and codified in recent DOL emergency rule-making.
An alteration of this payment structure would cost the state Medicaid program an additional $1 billion per year, according to estimates. If this legislation were enacted — absent an accompanying budget increase — the home care system would collapse for this 24-hour population. Such an expense increase would need to be shouldered at a time when the state is otherwise looking to constrain costs.
In short, this bill cannot be done without a funding mechanism that would put enormous new cost pressures on the state Medicaid program.
Solutions
Nothing is more important than supporting the home care workforce and ensuring access to care. As you have read from previous editions of HCA’s Capitol Report, HCA advanced a series of bills this past legislative session that would help fund compensation and provide other non-wage supports for the home care workforce. HCA stands ready to help inform the discussion and offer productive ideas to meet the seriousness of this issue. We also are prepared to do so mindful of all potential consequences to patients, to the state’s health care system and, most importantly, to the hard-working staff who are central to home care.
HCA has met and is scheduled to meet with key chairs, legislative leaders and staff to discuss our major concerns with this legislation as well as other avenues for supporting home care workers that we can mutually work to implement.
If your offices would like to discuss this legislation further with HCA, please do not hesitate to contact HCA’s Director for Public Policy and Advocacy Alyssa Lovelace at alovelace@hcanys.org.