Congress Mulls Bill to Bulk Up Direct Care Hospice, Home Health Workforce

A bill recently introduced in the U.S. House of Representatives would grant federal funds to home-based providers for the recruitment, retention and advancement of direct care workers, including hospices. The bill could be an important vehicle for policy change at a federal level in support of a growing need for these workers in hospice.

Stakeholders have pushed for federal action to bolster the hospice and palliative care workforce amid ongoing shortages. Providers have contended with staff burnout, clinician retirement, higher turnover stemming from the pandemic, and a general lack of personnel trained to provide hospice care. Members of several industry organizations have called on Congress to establish federal grants for health care professional training as demand for their services continues to rise. Among other positions, hospices are in need of direct care workers such as home health and personal care aides, nursing assistants and other types of care providers.

The bill could offer financial backing for hospices working to replenish their ranks as staffing shortages continue to plague the industry, according to Davis Baird, director of government affairs for hospice at the National Association for Home Care & Hospice (NAHC). However, initiatives like these may only be a drop in the ocean compared to providers’ needs.

“Efforts to support [hospice] organizations’ innovative recruitment, retention and advancement programs are important and can highlight best practices that could be spread,” Baird told Hospice News. “But time-limited grant programs without sustainable increases in payment rates will likely not address the systemic challenges facing these industries.”

More than 35% of hospice leaders surveyed by Hospice News earlier this year cited staffing shortages as a top concern for their organizations, along with regaining access to patients in facilities. If enacted, the H.R. 2999 bill would become the Direct Creation, Advancement, and Retention of Employment Opportunity Act, or the Direct CARE Opportunity Act, aimed at addressing a growing need to support these workers.

If approved by the House, the bill would proceed to the Senate where no companion bills on this issue have been introduced to date. The legislation would create a $300 million grant program within the U.S. Department of Health & Human Services (HHS) to support direct care worker recruitment and retention, offering federal dollars to at least 15 entities. Eligible entities would include state governments, nonprofits that meet certain criteria, tribal organization and apprenticeship programs, among others.

The bill’s goals include implementation of models to make direct care work more attractive, including training, mentoring and career paths, as well as to better ensure that aging and seriously ill populations have access to much needed home-based care.

Nearly 20 million adults in the United States require assistance completing self-care and other daily tasks due to physical, cognitive, developmental or behavioral conditions, according to research from the senior care advocacy group PHI. This includes 17 million living in the community, 1.5 million residing in nursing homes and almost 1 million in residential care. PHI projected that the number of people needing this type of assistance will rise in coming decades as the 65 and older population increases dramatically.

The aging population jumped by 30% to 47.8 million in 2015, up from 36.6 million in 2005, according to HHS. Current projections estimate that this number will reach 98 million by 2060. By 2024, an additional 5.2 million direct care workers will be needed across all care settings, according to a report shared with Hospice News from the U.S. Committee on Education and Labor, which is considering the bill.

The committee’s chairman and bill sponsor Rep. Robert Scott (Dem-Va) called for Congress to “invest in the workforce that cares for millions of people every day,” by creating greater economic opportunities for them. The Direct CARE Opportunity Act works to address the need “for a prepared, well-trained and empowered direct care workforce now and for the future.”

Hospice entities could receive grants to support their existing initiatives already in place without creating new or separate programs, said Baird.

Cosponsored by Rep. Susan Wild (D-Penn.), Rep. Susie Lee (D-Nev.) and Rep. Suzanne Bonamici (D-Ore.), the bill indicates a push in the right direction of growing recognition to expand care into the home and provide sustainable employment avenues for direct care workers, according to Mollie Gurian, director of hospice, palliative and home health policy for senior care association LeadingAge.

“This bill is one that would have some potential viability because of [Education and Labor Committee Chairman] Scott’s involvement in it, and his committee’s involvement in the drafting,” Gurian told Hospice News. “The fact that the chairman of the committee put his name on it and did the work with his professional staff on this particular piece of legislation shows a potential path forward for this bill when we talk about workforce priorities and any policies going into future legislation coming up.”

Direct care workers are a huge part of expanding care into the community, and this bill could be a primary vehicle through which more legislation focusing on the workforce could be driven, according to Gurian.

As part of the American Jobs Plan, President Biden called on Congress to direct $400 billion toward home-based care, with much of that funding allocated toward improving low-wage caregiving and home care worker jobs often held by women and people of color. Biden’s plan seeks to increase the home care workforce, including hospice workers providing care in the home, by 1.5 million people in a $2 trillion infrastructure proposal to create jobs and substantially increase funding for home- and community-based services, Hospice News’ sister site Home Health Care News reported.

Direct care workers are a huge part of that, and they were disproportionately impacted by the pandemic and need higher wages and better working conditions. They tend to come from populations that were just disproportionately impacted by the pandemic, whether that be women of color or immigrants, according to Gurian.

The median wage for direct care workers was $12.27 per hour in 2018, according to PHI. Wages tended to be even lower in rural areas. Nearly half of direct care workers live in low-income households, with 15% below the poverty line. Close to 50% of the direct care workforce rely on some type of public assistance to supplement their wages, PHI reported. Contributing factors include low wages, variable work hours and little access to workplace benefits.

Even if the grant program makes it through Congress, providers will struggle to improve pay and working conditions for direct care employees without higher reimbursement from government payers.

“Without a commensurate increase in the government reimbursement rates for Medicaid and Medicare programs that pay for the bulk of these kinds of services, it will be difficult for the organizations that employ these workers to retain them given the low current rates,” Baird told Hospice News.