LeadingAge Magazine · July/August 2016 • Volume 06 • Number 04

As home and personal care services grow, the challenges of workforce management remain significant. Recruiting for relatively low-wage jobs, finding and retaining candidates interested in emotionally and physically demanding work and training them are 3 important concerns. And when sources of funding do not keep up with regulatory requirements, it can be difficult to compensate caregivers appropriately. Here is a look at how 3 organizations manage workforce challenges in home and community-based services.


atHome with Western Home, launched in 2013, is a private-pay home health service owned by Western Home Communities, life plan community founded 104 years ago in Cedar Falls, IA. atHome offers services to about 100 clients with 60 FTE employees, and is a significant part of Western Home Communities’ services.

Despite the fact that atHome pays well, staffing is a challenge, according to Director of Health Services Briana Hilmer, R.N.

“We offer really great benefits—we’re in the top 10-20% of employers in the area,” says Hilmer. Even so, atHome began to compare the costs of turnover to the costs of effective recruiting and training. With a variety of initiatives, atHome reduced its turnover by 20% in the first 5 months of 2016.

“We introduced a year-long training program focused on communication, mentoring, and better relationships with supervisors, especially given the millennials in our workforce,” says Matt Garcia, chief business development and process improvement officer. Training also includes an in-house CNA class called “Prepare to Care.”

In addition to training, says Garcia, atHome “is realistic about the needs of the employment pool, and designs incentives accordingly.” In addition to flexible hours, gift cards show appreciation for the care employees offer clients. Rather than a sign-on bonus, atHome offers a more effective award for perfect attendance.

“Employees have user-friendly electronic tablets to facilitate communication about hours and for occasional switching of assignments,” says Hilmer. “This is particularly useful for student employees. And nurses and staff are on call after hours when a caregiver has a question.”

For recruiting, “we are learning to use Facebook,” says Garcia, “and have had success with job fairs and open interview days at our headquarters. Word of mouth works well—sometimes the people we hire know about us because we took care of their own parents.” While small local newspapers can be useful in recruiting, atHome has decreased advertising in larger newspapers.

The nearby University of Northern Iowa and Hawkeye Community College are excellent recruiting sources. About 80% of atHome’s employees are college or nursing students. The 1-2 hour blocks of time for home care are suited to the student schedule, and most stay until they graduate.

AtHome is careful to match the employee to the job, starting with the interview. “Less than 5% leave because they don’t like the job,” says Garcia.

“Some of our staff are caregivers by nature, parents for example, and this fills a void for them. Others have retired from full-time jobs and are looking for some flexible work hours. This is a nice balance with our student employees.”

Garcia expects atHome services to grow. One assisted living community already budgets 20% of its residents on the Medicaid HCBS program, and 10% to15% of clients now receive Medicaid assistance.
“Every day the country acquires another 10,000 boomers,” says Garcia. “We’re not a big fancy organization, but we are committed to caring inside and out. It’s not easy but it’s needed.”


Western Michigan’s Porter Hills is a large retirement community with multiple campuses, home care and a hospice partnership. Leigh Baker, director of home health, says that Porter Hills’ home services include both regulated services and non-certified private-duty home care, transportation, and other support for home care and assisted living. Porter Hills’ HCBS revenue is about 50% of its total and is expected to be more than 65% in the next 5-10 years.

“Home care is low-paying and physically and emotionally demanding,” says Baker. “It’s hard to find qualified staff, including people who enjoy caring for others. So we have asked ourselves how to make the job easier and more enjoyable.”

Baker cited typical turnover of up to 65%, compared to Porter Hills’ rate of 14% in the second quarter of 2016. Thirty percent of employees are full time, a high rate for the industry, according to Baker. “We strongly believe low turnover has a direct impact on the quality of care we deliver and we see that proven in our high customer approval rating of 92%.”

Revenue from Porter Hills’ private duty services help to finance benefits like job enrichment, training and employee recognition.

“We offer medical, dental, 401(k) accounts, paid time off, flex spending and mileage reimbursement,” says Baker. “Staying connected with field staff is challenging, so we offer a holiday open house and a summer picnic to boost engagement, and during the holidays, we give a small Christmas bonus based on hours worked.”

Community-based employees also benefit from job enrichment and ongoing training, including a “Gracious Training” program in customer service. Employees are encouraged to come in any time to talk about client care and concerns. Rather than time sheets, they use a phone to check in, and can log in to see their schedule and send notes and queries. These tools make the job easier and more enjoyable, says Baker.

Employee recognition is also an important part of retention. “It’s not about expensive cards or gifts,” says Baker, “but about what’s written on a thank-you card, or said in a phone call. Even a ‘You’re a great caregiver’ pin can make a difference. After one such gift, an employee called in tears to say, “In 20 years nobody’s done anything this nice for me.”

To recruit, Porter Hills “tries to go everywhere,” says Erika Jager, manager of private duty services. Sources include an unemployment agency, community aging and senior centers, job fairs, Craig’s list, Indeed.com and Porter Hills’ own job listings. Facebook has been an occasional source.

Porter Hills also offers open interview days, with a kiosk set up at headquarters to facilitate completing an application. Continuing education programs and ESL classes have also proved useful for recruitment. “We want to be innovative,” says Jager, “and to think about cultures where personal care is especially valued.”


Ascentria Care Alliance, a member agency of Lutheran Services in America, began its In-Home Care program 12 years ago. It is now one of the 2 largest providers for New Hampshire’s Choices for Independence Program.

In-Home Care is Ascentria’s largest service, with about 430 clients served by 380 direct-care professionals (for a total of 163 FTEs). It offers 5 other service lines, such as support for families and the chronically ill, interpretation and translation, and transportation. Ann Dancy, vice president of operations for New Hampshire, says Ascentria hopes to grow 5-10% in 2016. “Our real challenge is finding direct support workers.”

Perhaps Ascentria’s chief recruiting obstacle is lack of funding, since, given its mission, private-pay clients are not a substantial source of revenue.

“Our reimbursement rates are so low,” says Dancy, that we aren’t yet able to offer a step program for compensation and promotion.”

Other pressures on funding include required health care coverage for employees working 30 hours or more per week, and high worker’s compensation rates for employees going into homes. “Our funding was not designed to pay for these things, even though they are important benefits.”

Ascentria already meets the Home Care Worker Rule standards, but is negotiating the challenge of full vs. part-time work. “We chose not to hold work to 29 hours, keeping in mind that family caregivers may need to work longer than 30 hours.”

Ascentria’s training coordinator provides in-person training to all new staff. In addition, the agency uses an online training program, Relias, for a range of topics. Ascentria also uses DVDs and paper versions of training as needed. Each fall there is a full day of in-person training for all staff.

Ascentria “tries to be very creative in the recruitment of new staff,” says Dancy, such as contact with family and friends of clients. Newspaper advertising is less valuable, while online recruiting has increased. Recruitment bonuses are also offered. When asked about the challenge of minimum wage increases, Dancy says that she hoped these will be offset by an increase in reimbursement rates. “It’s tough when entry-level jobs in other sectors are able to pay more than we do for home care professionals.”

LeadingAge Thrive provides resources to help members better serve seniors and their communities. The 7 major topic areas in Thrive include questions designed to stimulate discussion among your leadership team and board of directors. Thrive also includes resources such as white papers, articles, tools, presentations and business intelligence.

Under the “Quality” section of Thrive, see the resources connected to these questions:

  • What quality metrics define and differentiate our services?
  • How do we use quality measurement for continuous process improvement?
  • Are we implementing IT systems that facilitate care coordination and ease transitions of care for older adults?
  • Do we utilize your data and quality reports to differentiate your services to potential referral sources?

Under the “Workforce and Leadership Development” section of Thrive, see the resources connected to these questions:

  • Do we have a comprehensive orientation program for new employees across all staff levels and settings?
  • Do we conduct employee satisfaction and engagement surveys, provide employee feedback, and use the data to make organizational decisions?
  • Do we use evidence-based management best practices (e.g., supervisory training, open communication, empowerment of frontline staff, self-managed work teams, peer mentoring and support) to set organizational priorities, solve problems, improve the working conditions and the quality of the job and minimize turnover and instability in the workplace?
  • Do we offer competitive compensation and benefits for staff at all levels and across all settings?
  • Do we provide specific opportunities to develop the leadership skills and core competencies of staff for future success?
  • Do we have a comprehensive cultural competence strategy to support healthy staff-to-staff and staff-to-resident/client relationships and quality service delivery?
  • Do we have in place a comprehensive employee orientation program
  • Do we conduct performance evaluations to provide employee feedback and improve performance?

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