Cuts put strain on home health aides as reforms lead to fewer staffers, lower pay

Colleen Diskin, The Record

By the time Isatu Bundu, a home health aide, arrives at the apartment of her third client of the day, she’s ridden five buses.

The 22-year-old full-time nursing student works three days a week as a home health care aide, usually leaving her Prospect Park home at 6:30 a.m. to begin her commute to clients in Ridgefield and Englewood. It’s 3 p.m. by the time she reaches the four-room apartment of Rose Taylor, a 94-year-old Englewood widow who is determined to keep living on her own even though she needs Bundu to shop for groceries, do her laundry and take care of other housekeeping tasks.

Seniors like Taylor are cared for by the Visiting Homemaker Home Health Aide Service of Bergen County, a non-profit agency whose mission is to find and train a workforce to tend to the basic living needs of a growing population of elderly. The majority of the agency’s workers rely on public transportation to get toand from the three to four homes they visit in a day. They start at $9.50 an hour, and even after years of service, can’t hope to make more than $15 an hour.

More often than not, it’s the working poor who take care of society’s shut-ins — the vulnerable looking out for the even more vulnerable.

But these tenuous arrangements are strained these days. The non-profit agencies are in danger, a victim of government and market changes, from managed care reforms to the rise of national elder-care chains.

Only seven members remain in the Home Care Council of New Jersey, the trade group that represents non-profit providers of home health care. At one time, the group had more than 30. Some of the agencies that are still functioning have had to stop or cut back on their services to Medicaid patients, who are unable to pay for help on their own.

“There used to be one non-profit serving every county in New Jersey, and some counties had two,” said Ken Wessel, former chairman of the council and longtime head of the agency that serves Passaic County.

While large private home health care chains are also providing care, those that  work in the non-profit sector say important community ties could be lost without the non-profits. The non-profits have a long history of teaming with other community organizations to provide a more rounded array of services — like delivering meals, counseling services and other low-cost or volunteer efforts to assist the elderly in addition to home health needs.

“The for-profits will not always be there for the poorest of the poor in the same way that the non-profits have been,” said Jeanne Martin, director of Pascack Valley Meals on Wheels.

Bergen County’s Visiting Home­maker agency and Passaic County’s HomeCare Options are among the few non-profits that remain afloat and are still accepting Medicaid clients. But their operators say their futures could be in jeopardy if they can’t find a way to make up for the shortfalls that followed substantial cuts in Medicaid reimbursements three years ago.

“We’re losing money like crazy,” said Ed Remsen, executive director of Bergen’s Visiting Homemaker agency.

HomeCare Options, which serves 1,500 people and has close to 300 employees, is pinning its hopes on seeking more private-pay clients and obtaining more grant money, said Alexis Barry, its executive director. Bergen County’s Visiting Homemaker agency hopes to participate in more centralized services arrangements, like an assisted living program begun in 2014 at a Westwood senior citizen building, in which one of its aides is stationed throughout the day rather than having to travel from location to location.

To address transportation headaches, Remsen recently found a donor to subsidize an Uber program for the agency’s workers, who often must turn down jobs in northern Bergen County because there aren’t adequate bus routes.

“If we don’t change the business model, we’ll be out of business in two to three years,” Remsen said.

Cut in reimbursement

The financial foundations of the non-profit home care providers came unglued in 2012, when New Jersey turned over management of its Medicaid-financed home health aide program to four insurance companies.

The move was billed both as a cost-saver and a way to meet the state’s goal of shifting long-term care out of institutions and into homes and communities, where many older people want to remain. The insurers, it was said, would do a better job of deciding who needed round-the-clock care and who could be cared for at home. The state hoped this would lead to the creation of more support programs in communities.

But within months of taking over, the managed care companies cut reimbursement rates to the agencies that train, hire and deploy home health workers, from $15.50 an hour to as low as $13.80.

“Reimbursement levels are lower than they were 20 years ago,” said Chrissy Buteas, president of the Home Care & Hospice Association of New Jersey, which represents both for-profit and non-profit providers. “This, across the board, is a major concern for all of our providers, both for-profit and not-for-profit. I hear the same concerns from our small mom-and-pops to our largest providers.”

Buteas’ organization and other advocates are pushing for passage of legislation that would force managed care organizations to raise home-care reimbursement rates to $15.50 and provide for an inflationary increase in the rate every five years.

One of the sponsors, Assemblywoman Valerie Vainieri Huttle, D-Englewood, said she hoped the bill would get a hearing in May, when she and other supporters will try to make the case that the home health industry won’t be able to retain workers at the current reimbursement level.

“We’re looking at the poorest of the poor taking care of the poorest of the poor,” Huttle said.

The trade group that represents the managed care companies said any increase in reimbursements needed to be accompanied by a spending increase for Medicaid — already a $12 billion program that serves 1 in 5 New Jerseyans.

“If taxpayers or lawmakers believe the funding for home health agencies should be increased, the key challenge will be how and where to find the funding,” said Sarah M. Adelman, vice president of the New Jersey Association of Health Plans. “Increasing rates — even in small percentages — has an enormous impact on the state budget, and any funding increases compete with other public goods, such as education, transportation infrastructure and so on.”

Her group estimates there are 150 home health care agencies accepting Medicaid in the state. “New Jersey does not face a shortage of home health agencies or aides to serve the Medicaid population,” Adelman said.

A spokeswoman from the state Department of Human Services said the agency had not heard of seniors having difficulty finding help. “I don’t have any data immediately available but we do know anecdotally that access has been increased in the areas of personal care assistance, self-directed services and home health,” said the spokes­woman, Nicole Brossoie.

But a number of elder-care advocates say that if the reimbursements aren’t increased, even the for-profit programs will find it difficult to sustain the care they are offering to Medicaid recipients.

While the industry as a whole decries the rate cuts, among those hit the hardest have been the non-profits that had long forgone the chase for patients who pay the bills themselves to focus on the Medicaid population and to create programs that served the community in other ways, like volunteer shopping programs and partnerships with other non-profits.

The Visiting Homemaker Service of Hudson County, previously one of the state’s largest non-profit providers, initially tried to fight the reimbursement cuts. In 2012, it filed a lawsuit against the state and Horizon Healthcare, the largest of the four managed care companies participating in the Medicaid program, seeking a temporary injunction to prevent lowering the reimbursement rates. The lawsuit was dropped when other agencies declined to sign on and share in the legal fees, said John Buck, who was the executive director at the time.

A year later, the Hudson County agency decided it had to discontinue those services altogether and focus on its other mission, child-abuse prevention, said Buck, who now heads the National Institute of Home Care Accreditation.

Meanwhile, the Visiting Homemaker Service of Warren County has scaled back on Medicaid services. In past years, 50 percent of the agency’s 450 clients were on Medicaid. Now it’s 19 percent — and all of them are clients who were already receiving services before the rates were cut. Executive Director Peggy Suydam laments the decision to no longer take any new Medicaid cases but also said the agency needed to decrease the Medicaid percentage further if it wanted to stay afloat.

“It saddens me to see the state of home care at this point,” Suydam said. “It is an uphill battle just to provide care to those who need it.”

Wessel said many of the non-profits that closed their doors altogether thought it would be counter to their missions to cut wages and risk having a less-reliable, less-experienced workforce. “It doesn’t serve anybody’s interest to have a caregiver who is barely able to survive on what you are paying them,” Wessel said. “They aren’t going to stay in the job long, and it doesn’t help the client if you have to keep bringing in a new aide every few months.”

Indeed, many older people resist getting help at home because they don’t want a series of unfamiliar faces showing up at the door, Remsen said.

Doreen Wheeler, one of the Bergen County agency’s veteran employees, has been going to the Englewood home of Hazel James, 92, for about six years. In two-hour visits four days a week, Wheeler does a number of household chores and also helps James, who is weak from congestive heart failure and edema in her legs, move about the house and bathe.

They are comfortable with each other. “She knows what to do and she does it so I can just relax and not have to worry about anything,” James said of Wheeler.

Likewise, Wheeler, who guesses she has worked for Visiting Homemaker for at least 18 years, said she appreciated that the agency tried to keep her assigned to the same roster of clients. She said she had come to know her clients well in visits that last about two to three hours, which made her feel in a better position to help.

“If you go to someone’s house just once or for only an hour, how much can you really get to know about them and what they need?” said Wheeler, who has also come to know James’ niece and regularly checks in with her. “With some of the people I go to, it gets to the point where you know them so well that when they hurt, you hurt.”

Remsen doubts that many agencies — for-profit or non-profit — will keep workers long enough to develop such caregiver-client ties if they have to lower hourly wages to be able to break even under Medicaid rates.

“We have people who have worked here for more than 20 years,” Remsen said. “Our salaries are not the highest in the industry and they are not the lowest. They stay with us because of the relationships we’ve built with them and with the community.”

Whether the Legislature comes to the rescue, Wessel said he thought that enough agencies or for-profit companies might soon begin refusing Medicaid clients that it will be hard for an insurance company to find home care for a client it is trying to keep at home — rather than footing the bill for a nursing home.

“Sooner or later, the rates are going to have to go up because there is going to be an access problem,” Wessel said. “The question is whether there will be any non-profits left when that happens.”