Advocates Call for Policy Change to Support Hospice, Home-Based Direct Care Workforce

The coronavirus pandemic has shed a brighter light on issues plaguing hospice and palliative care industries, with widespread staffing shortages at the forefront of provider’s minds. Some stakeholders say policy change at a federal level is needed for hospice providers to build and sustain a healthy workforce in the face of growing demand amid a global pandemic, particularly when it comes to direct care workers. 

COVID-19 helped to expose policy issues associated with growing demand for direct care workers, starting with cracks in providers’ ability to support employees during a global pandemic, according to Marian Grant, senior regulatory advisor at the Coalition to Transform Advanced Care (C-TAC). The term “direct care workers” typically refers to certified nursing assistants, personal care providers and home health aides.

“You can’t have delivery models if you don’t have people to deliver them,” said Grant during C-TAC’s National Policy Forum. “Since COVID we’ve become much more aware of some of the policy issues with this [direct care] workforce, like what could go wrong with a situation where people don’t get paid time off in the middle of a global pandemic. To be a direct care worker, this is dangerous work. There are a lot of opportunities to support this workforce better.”


More patients than ever are seeking hospice and palliative care, and the industry in time may not have enough trained clinicians to take care of them. More than 35% of hospice leaders surveyed by Hospice News and Homecare Homebase earlier this year cited staffing shortages as a top concern for their organizations, along with regaining access to patients in facilities.

The direct care workforce is predominantly women of color, and many of them come from disadvantaged communities working multiple jobs, according to Grant. These employees, unable to work from home, were frequently at risk of contracting the virus or possibly spreading it to patients and families. Some found it difficult to take paid time off to care for their own sick loved ones, Grant said.

A number of hospices stepped up employee support with expanded paid time off policies and other benefits, but some in the industry have called for more employee support, with a contingent calling for change in federal policy. Recognizing growing demand for home-based health care services, providers are building out staff recruitment and retention programs.


According to Grant, more consistency and standardization is necessary for direct care worker credentials and job requirements. This includes ensuring that job descriptions are sufficiently broad and encompass the “raw wood” of community-based health care workers.

Credentialing requirements for direct care workers can vary from state to state, according to Sarah Slocum, deputy director of the Altarum’s Center for Eldercare Improvement, which provides research and consulting services for senior and serious illness care providers. Based in Ann Arbor, Mich., Altarum is a nonprofit research and consulting organization aimed at helping health care providers reach at-risk and disenfranchised populations.

“There are some federal standards, although they’re widely recognized to be insufficient: 75 hours of initial training plus 16 hours of clinical practice,” Slocum said. “The same applies to Medicare funded home health aides. That’s one segment of the workforce [where] at least there is some requirement, but lots of the long-term supports and services that happen in residential settings across our country are done by other kinds of workers that don’t fit either of those categories.”

The prevalence of COVID-19 infections in nursing homes and other acute-care referral sources has created a stronger impetus to move patients out of facilities and into the home, and policymakers have taken some steps to foster this trend. The U.S. Centers for Medicaid & Medicare Services (CMS) allocated $165 million to states that participate in its Money Follows the Person (MFP) program designed to help Medicaid recipients transition from receiving care in facility-based settings to home- and community-based services.

Participation in the MFP program as of Sept. 2020 stood at 33 states across the country and the District of Columbia. The CMS website indicates that hospice, home health care, durable medical equipment, personal care, caregiver training, case management and other services fall under the designation home- and community-based services. Many of these services when provided in the long term are covered by Medicaid, in which credentialing rules are often determined by each individual state.

“We may want to start thinking more about what we can do in Medicaid policy,” Slocum said. “Establishing [training and credentialing standards] at a federal level would be a huge step to saying if you’re going to use Medicaid money for this type of care, here are some basic requirements.”

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