Staff Recruitment & Retention in 2021 and Beyond

The United States—like the world—is aging, a product of fluctuating birthrates and increasing life expectancy. According to the U.S. Census Bureau, about 17 percent of the U.S. population today, approximately 56.1 million people, are aged 65 and older. This percentage is steadily increasing, by at least 2.5% per year since 2012. Over the next 10 years the 65+ senior population is projected to increase by about 30 percent—to more than 73 million by 2030.

Even before the COVID-19 pandemic, the home healthcare industry was facing the increasing challenges these statistics represent. Elderly people are more likely to suffer from chronic diseases and to have greater and more complex healthcare needs. Even independent seniors can require assistance after an acute care stay, with the onset or progression of dementia, or as aging limits functionality. The realities of aging mean that almost 70 percent of older adults will require some level of support or long term care during their lifetime.

More older adults are choosing to “age in place”

“Aging in place” refers to older adults continuing to live at home for as long as possible as they age. The term has been around for several years, and the concept for even longer. Most older adults would prefer to age in place—as many as 90 percent, according to a 2017 article by the American Association of Retired Persons (AARP)—putting home health agencies (HHAs) at the forefront of the growth in healthcare services and technology.

COVID-19 has made aging in place more than a preference; staying home is now a safety issue, as well. According to The Atlantic’s COVID Tracking Project, 121,000 long-term care residents have died as a result of COVID-19. Fewer than one percent of America’s population lives in long-term care facilities, “but as of December 24, 2020, this tiny fraction of the country accounts for 38 percent of US COVID-19 deaths.”

According to a survey from health care research and consulting firm Transcend Strategy Group, “over 50% of family members are now more likely to choose in-home care for their loved ones than they were prior to the coronavirus.” Stan Massey, a partner at Transcend Strategy, said that “65% of respondents agreed that COVID-19 had completely changed their perception about the best way to care for aging seniors.”

Recruitment is challenging in a competitive workforce market

Not surprisingly, as the population ages over the coming decades and more seniors opt to age in place, health care is projected to be among the fastest growing job markets. According to LeadingAge, “the nation will need 2.5 million workers of all different types by 2030 to keep up with the growth of America’s aging population.” The Bureau of Labor Statistics predicts that more than half of these new health care jobs will comprise personal care aides, home health aides, and registered nurses. Analysis has shown that both the supply-demand and skills gaps will be high.

A qualified and quality direct care employee base is essential to a safe work environment, to quality patient care and patient satisfaction, and to overall agency success. Finding qualified employees has been one of the biggest staffing concerns for the home health and hospice industries for years.

LeadingAge says that worker recruitment and retention are ongoing challenges for a number of reasons: “The reality is that jobs in aging services are highly skilled and complex, a fact not recognized in pay scales or reimbursement rates. In addition, work in these settings is physically and emotionally demanding.”

A tighter labor market means an increasingly competitive workforce environment, and competition is not limited to the home health and hospice industries. Rising minimum wages are further fueling the competition, drawing qualified candidates away from health care altogether. The challenge is, and increasingly will be, how to attract qualified, quality staff in such a competitive environment, and how to keep them once you have them. Competitive wages are obviously key, but getting—and staying—competitive will be an ongoing challenge for hospice and HHAs as Medicaid and Medicare reimbursements fail to keep pace with rising minimum wages.

COVID-19 adds to staffing concerns

COVID-19 has only intensified the challenge of recruiting and retaining quality clinicians and staff. In addition to the inevitable staffing shortages due to an aging—and aging in place—population, the Centers for Disease Control (CDC) warned that the COVID-19 pandemic would likely result in staffing shortages “due to HCP exposures, illness, or [the] need to care for family members at home.”

Exacerbating the crisis is the fact that a staffing shortage itself is a self-perpetuating problem. According to the American Association of Colleges of Nursing (AACN), insufficient staffing raises the stress level of nurses and impacts job satisfaction, thereby driving many nurses to leave the profession.

With or without staffing shortages, COVID-19 has only added to the stress as frontline home health workers face fears for the health and safety of their at-risk patients, and for their own health and safety as well. One study found frontline healthcare workers at 12 times the risk for contracting COVID-19 compared to the general public, and those healthcare workers who do get COVID seem to be hit harder than others who contract the disease.

Compounding this fear are exhaustion, burnout, and a shortage in personal protective equipment (PPE)—especially N95 masks—that has been an issue since the beginning of the pandemic. “[H]ealthcare workers are already being asked to put themselves at risk and do an incredibly difficult job,” Marla Lahat told Healthline last April. “We’re now having trouble supporting them with personal protective equipment.” Lahat is executive director of Home Care Partners in Washington, DC. “It’s already a difficult job,” she added. “It’s now even more difficult.”

Recruitment and Retention During the COVID-19 Pandemic

COVID-related staffing shortages are a reality for most home health and hospice providers, and protecting and maximizing the current workforce is an emergent priority. “We already had a very, very critical shortage of certified home care workers nationwide,” Lahat said.

Health policy journal Health Affairs says that community healthcare settings such as hospice and home health present special challenges. “These settings serve high-risk populations and are highly dependent on health workers…There must be a focus on prevention, early identification and response, and maintenance of care, which will require intentional support for the health workers in these settings.”

The unique roles of HHAs and hospice during the COVID public health emergency (PHE) have not gone unrecognized, even if the necessary assistance has fallen a bit short. At the state level, flexible scope of practice and licensing requirements have helped ensure that current health workers can keep practicing.

At the federal level, the Centers for Medicare and Medicaid Services (CMS) has released an unprecedented array of temporary new rules and waivers to help the U.S. healthcare system respond to the COVID-19 pandemic. Waivers regarding the increased use of telehealth services have been among the most anticipated and critical. While agencies have found these telehealth waivers somewhat helpful in their efforts to protect frontline staff and minimize the risk of infection, the lack of reimbursement for HHA telehealth services has limited their effectiveness.

There are other CMS waivers that have been helpful for home health and hospice agencies facing COVID-related staffing shortages, allowing them more flexibility in visit scheduling and staff deployment. These include temporary waivers regarding:

• Initial Assessments: HHAs are allowed to perform Medicare-covered initial assessments and determine patients’ homebound status remotely or by record review.
• Initial and Comprehensive Assessments: Occupational Therapists (OTs), Physical Therapists (PTs), and Speech Language Pathologists (SLPs) are allowed to perform initial and comprehensive assessments for all patients receiving therapy services as part of the plan of care, regardless of whether or not the service establishes eligibility for the patient to be receiving home care. (Rehabilitation therapies are not permitted to perform assessments in nursing only cases.)
• Onsite Visits for HHA and Hospice Aide Supervision: HHA nurses or other professionals are not required to conduct an onsite visit every two weeks for aide evaluation.
• Training and Assessment of HHA and Hospice Aides: A registered nurse or other skilled professional is not required to make an annual onsite supervisory visit for each aide that provides services on behalf of the agency. (All postponed onsite assessments must be completed by authorized professionals no later than 60 days after expiration of the PHE.)
• Ordering Medicaid Home Health Services and Equipment: non-physician practitioners are allowed to order medical equipment; supplies and appliances; home health nursing and aide services; and PT, OT, SLP and audiology services (in accordance with state scope of practice laws).

Protecting your staff and maintaining staffing levels may be top priority, but they are not enough to address the staffing crisis many agencies are experiencing with the current PHE. According to Health Affairs, new licensing and credentialing flexibilities have enabled more healthcare professionals to enter the workforce, including “the recruitment of retirees and other non-active workers to transition back into clinical practice on a temporary basis; transition of final year, health care students into practice; and rapid, targeted training to bring new health workers into practice.”  

Recruitment and Retention in the Post-COVID World

COVID-19 vaccine distribution is well underway, and it seems probable that the COVID-19 pandemic will be over by mid to late 2021. At that point, emergent COVID-related staffing issues should be resolving, and agencies will be able to assess the lasting fallout from the longest, deadliest PHE in a hundred years.

One thing we know: staffing issues are not going away; they will likely only get worse. Luckily, some of the best recruitment tools are also the best tools for retention.

Six Things to Help Your Agency Attract Quality Candidates

1. Know who you’re looking for

Look at your successful current employees and try to figure out why they are successful. In The Rowan Report article Retaining and Growing the Direct Care Workforce, Darcey Trescone advises: “Collect, store, and then mine the data you collect on your current employees to better understand who would make great candidates to add to your agency. Understanding where your best candidates come from will help drive investment into the right recruitment channels.”

Candidates who are great fits for your agency are more likely to consider your agency a great fit for themselves.

2. Know and define who you are as an agency

You are competing for qualified candidates so it’s important to distinguish yourself from the competition. This goes beyond branding, however. It is about an honest positioning of your agency’s mission and culture. Your mission should define what you stand for and must reflect your agency’s commitment to the community you serve.

Make sure your employees are knowledgeable and supportive of your mission. According to Forbes, “connection to the mission is commonly linked to why any given employee wanted to work for the company in the first place. Nurture those reasons and unite them with the company mission.

3. Be proactive

Using social media and recruiting websites is a necessary first step, but you can’t just wait for people to find you. Recruitment in a competitive workforce market requires proactive and directed action. Many agencies are looking to retirees to help fill the staffing gap, hiring back known high performers in part-time or specialized roles.

• Provide as much information to prospective candidates as you can regarding available shifts and locations. Matching your needs to those of your prospective candidates can save time and effort in the recruitment process.
• Encourage your successful and satisfied employees to spread the word, and find a way to acknowledge those who do. Consider rewarding employees who help with recruitment efforts. According to Healthcare at Home, referrals are your “best source for the highest retention candidates.”
• Seek out new graduates of training programs and certification courses. You’ll have the advantage if you’re the first person to contact them. Trescone notes: “The #1 reason cited by caregivers for accepting a job? It was the first job offered to them.”
• Get a first visit scheduled for new hires as soon as possible—ideally, before they finish orientation, Trescone adises. “If it takes two weeks to schedule a new caregiver, by then they may have accepted a job somewhere more responsive.”
• Consider starting your own training program or certification course.

4. Be competitive, however you can

Direct care recruitment has always been challenging for hospice and HHAs, and compensation is one of the biggest factors––and one of the hardest to address. Trescone notes that the skills required of direct care employees are not yet recognized in reimbursement rates, and inadequate reimbursement rates translate to lower salaries. “The unfairness of a low wage for a physically and emotionally demanding role is what keeps the numbers of available workers low.”

Offering a competitive wage/salary is obviously the goal, but you should be competitive in any and every way you can. A good benefits package is a powerful draw, and some agencies have begun offering substantial signing bonuses for home health care nurses. Also consider:

• Flexible scheduling
• Employee Stock Ownership Plans (ESOP)
• More frequent or flexible pay days

5. Market your agency

• Be visible: Online visibility and a social media presence are requisite. Make sure your website reflects your mission and culture.
• Be focused: When you know who you’re looking for, make sure you understand the diverse demographics of your ideal candidates. Trescone advises you should “be upfront about why your agency is the best place for candidates by addressing what you know their concerns to be… Create specific messages, and utilize relevant channels for those segments of your audience as appropriate.”
• Be honest and credible: Remember that word of mouth from dissatisfied employees can quickly dispel any positive image you may be marketing.

6. Stay technologically current

As the world changes, consumers and businesses are becoming more technologically savvy. The home healthcare industry particularly must integrate and utilize new technologies in order to cut costs, maximize resources, enhance productivity, and remain competitive. Tech-savvy candidates (and most of them are) will be drawn to tech-savvy agencies.

Seven Ways to Keep Quality Employees Once You Have Them

Once you’ve hired someone, the next challenge is keeping them—never an easy thing in a competitive workforce market. In his January 6 article, Four Home Care Agencies Solve Expensive “Bad Hire” Problem, Tim Rowan notes that retention failure can cost agencies as much as $4500 per incident.

Having an employee retention strategy is critical, says Trescone. Job satisfaction is obviously paramount, but staffing retention “is about building trust and loyalty with your direct care workforce…In general, workers crave engagement, support, and growth for themselves and the company they work for.”

It all comes down to the work environment, which can include everything from staffing levels to staff support. According to MedPage Today, improving the workplace environment can not only reduce staff turnover, but lower costs and improve patient outcomes as well.  

1. Focus on your mission of quality care

As mentioned above, your agency mission can be a strong recruitment tool. It is also critical to staff retention. Forbes says that promoting your mission to employees can increase their day-to-day engagement and promote a positive work culture. “Mission-driven workers are 54 percent more likely to stay for five years at a company and 30 percent more likely to grow into high performers than those who arrive at work with only their paycheck as the motivator…Companies that cultivate a strong work culture driven by deep engagement and meaningful work find success, beat the competition and retain and attract high-performing talent.”

2. Be honest, and follow through

Authenticity and transparency build trust, according to Forbes. Communicate both employee-specific and agency-wide goals to your staff. Be honest about your expectations, and about the consequences of meeting—or not meeting—them.

Honor the commitments you make to new hires regarding wages or salaries, shifts and locations, and day-to-day work requirements. If you can’t follow through on a previous commitment, make sure you communicate the reason why honestly and as soon as possible.

In short, if your agency follows through on promises and meets expectations, your employees are more likely to do the same.

3. Support the individual needs and circumstances of your employees

A 2014 study on why nurses leave the profession cited “lack of support” as a significant issue. Respondents described “their manager’s lack of support, unsupportive relationships within their work group, and a health-care system putting business principles before care” as factors resulting in job dissatisfaction and nurse turnover.

Even before the pandemic, one of the biggest factors affecting staff retention were staffing levels themselves. Inadequate staffing increases employee stress levels and accelerates burnout. It is a vicious and seemingly endless cycle, but a supportive company culture can go a long way toward mitigating the stress and burnout that can cost your agency quality employees.

• Solicit and acknowledge employee input into quality care policies and procedures.
• Be responsive to employee issues and complaints.
• Be as flexible as possible with scheduling to accommodate individual needs, preferences, and emergencies.
• Establish or strengthen your agency’s employee support network.

4. Recognize and reward good work

Rewards and recognition are crucial to staff retention. “You don’t have to have big recognition programs…It’s about [employees] feeling cared for just like we care for our clients,” said Stacey Buechler, director of employee experience at Omaha, Nebraska-based Right at Home.

5. Offer opportunities for professional growth

Opportunities for education, leadership, and advancement can attract motivated workers, and keep them engaged and invested for the long-term. Focusing on quality and training can pay off in retention as well as recruitment by helping to foster a more involved and invested employee base. Consider:

• Offering advanced training and employee/professional development opportunities
• Covering the cost of relevant continuing education (CE) and continuing nursing education (CNE)
• Covering the cost of relevant certifications
• Offering compensation incentives for professional growth and development

Staff education can pay back in more than job satisfaction. It can also assure that your agency has the skills necessary to meet the increasingly specialized care needs of your patient population.

6. Stay technologically current

Just as being a tech-savvy agency can help attract quality tech-savvy candidates, the lack of current and appropriate technology can negatively impact your retention efforts.

• A quality EMR is a must for any agency looking to reduce the documentation and quality assurance burdens of its clinical staff.
• Technological advances such as remote patient monitoring and other telehealth services can extend workforce capacities and enable the safe continuation of services for at-risk patients and/or clinicians. Telehealth services enable more timely and efficient intervention by allowing caregivers and providers to identify real issues and potential concerns earlier.
• Technological advancements in the recruitment process itself could allow an agency to assess a candidate’s potential as a caregiver early on. Rowan reports on the new human resources application called MiliMot, which may offer new and valuable insight into potential applicants–-even before the interview. One home care company piloted the application in several agencies across three states. The franchises experienced increases of up to 30 percent in both 30- and 90-day retention rates, saving the agencies thousands of dollars in recruitment, orientation, and training.

7. Get creative

Agencies will need to get more creative about attracting and keeping quality employees. Buechler believes that wages aren’t always the most powerful motivator. Her agency teams up with a large network of area businesses, allowing her to offer meaningful everyday discounts to her staff. As workforce competition continues to heat up, unique benefit offerings such as these may be necessary to attract and retain qualified hospice and home health care employees.

Staffing issues are probably here to stay

In response to the Patient-Driven Groupings Model (PDGM) and the COVID-19 pandemic, Home Health Care News predicts that the “home health industry may ultimately shrink in terms of raw number of agencies, but the overall size of the market is very likely to expand at a faster-than-anticipated pace.”

The challenges of staff recruitment and retention have increased through the current PHE, and the realities of our aging population mean those challenges won’t be going away anytime soon. Agencies should begin now to address the long-standing staffing issues that are sure to remain a top priority in the post-pandemic world.

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