Ann Painter has been in the home health care sector for at least two decades, and with Delaware’s aging population, it may be having its moment soon.
“I’ve waited for the day that care could be delivered at home, and the day has come,” said Painter, senior vice president of ChristianaCare HomeHealth & Community Services. “The home environment is so comfortable for patients, and you find they’re more comfortable speaking to you. I’d say there’s been tremendous growth, and we expect it to continue at least through 2040, and what’s triggering it is patients would prefer to be home whenever they can.”
For example, ChristianaCare recently discharged a 30-year-old patient who was in a serious car crash. After staying in the hospital for a week and leaving his wife at home with their children, he opted into the HomeHealth program. After seeing nurses and physical therapists at home, he was able to return to work this month.
“That’s not the only way patients come to us. We have some who see their providers for a recurring condition that leads to a referral, or rehab centers and skilled nursing facilities. We do serve all patients, but we do have quite a few older ones,” Painter said.
Beebe Healthcare, which has run a home health program since 1985, has seen a similar trend. Right now, its daily census is roughly 300 patients, all under the care of a doctor and unable to leave the house. All patients need to have a skilled reason to have a nurse or therapist come to their home.
“The demand is great because of the aging population we serve. Patients become debilitated very quickly even from a three-day hospital stay,” Beebe Home Health Services Administrator Regina Moody said. “We consistently serve more patients in Sussex County year over year. “The challenges vary from family to family, but certainly, serving patients in rural areas, the connectivity to our computer system can be a challenge as well as social determinants of health that face our community.”
The First State continues to rank among the oldest states in the country, with a 54% jump in residents 65 and older between 2010 and 2020. It sits as the sixth oldest state, with 17% of its population 65 and older, according to the 2020 U.S. Census. But with this boom and more Baby Boomers getting older, Delaware has work to do to meet the growing demand, including adding new facilities to the market as well as a trained workforce to meet it.15
Cheryl Heiks, executive director of the Delaware Health Care Facilities Association, which represents the state’s long-term care facilities, noted that the state isn’t alone in this problem. The National Investment Center for Seniors Housing & Care projects that there will be a need for 156,000 senior housing units by next year – and 806,000 units by 2030.
In Delaware, the landscape is a little more complicated. Because the state is so small, it already forces the existing facilities to compete from a limited pool of candidates for at-home and facility-based care. Medicare often doesn’t cover long-term services. Medicaid-paid long-term care at home services have long waiting lists, and nursing home stays are often covered in the short-term. Reimbursement rates for either program also haven’t been raised in 15 years.
“Skilled nursing facilities are very highly regulated, and it’s hard to do that work and retain staff if the rates haven’t increased either and we have a very small workforce. That’s our biggest problem in Delaware,” Heiks said. “We’ve done a great job in recruiting people to move to Delaware. But the hardest part is the needs for health care are rising dramatically to meet the aging population. The number of people doing the job is declining.”
Rebuilding Talent
Nursing homes nationwide are down 250,000 workers since the COVID-19 pandemic started, according to the American Health Care Association and National Center for Assisted Living. Burnout has accelerated people leaving health care while others are aging out, and rebounding to the same workforce level may happen by 2026.
In Delaware, the number of licensed nursing home administrators dropped from 177 to 166 between 2022 and 2023. Fourteen are eligible for retirement, according to figures prepared by the Delaware Health Force. But the number of adult and gerontology nurse practitioners and certified specialists is growing, with at least 144 new licenses recognized last year.
However, 1,031 nurse practitioners hit retirement age in 2023. The data does not account for certified nurse assistants (CNAs), which Heiks said are very scarce right now.
“The competition for people who pursue that career path is tough because there’s a lot of need in health care right now,” she said. “Sometimes people in this environment need help getting dressed or a shower, and it takes an individual who has that interest.”
Another obstacle is salaries were historically low for the sector. According to the state labor data, the average salary for a nursing assistant is $36,670. But as the market has pushed wages up, Heiks said that salaries for some positions for an entry job in health care have since doubled. Some of those raises came from the state’s share of American Rescue Plan Act funding.
Rebuilding the workforce for long-term care facilities is critical as the state continues to age. With more retirees from Pennsylvania, New York and New Jersey flocking to enjoy Delaware’s beaches and favorable tax climate, it will put pressure on existing health care needs. For years, hospital systems have been working to head this off by expanding primary care offices and hybrid-model emergency facilities in Sussex County.
“Broadly, we do need to enhance our infrastructure to meet the need. We do rely on our assisted living facilities, just like we do other post-acute facilities, to help aid our patients to recover faster and not have long stays in our hospitals,” Delaware Healthcare Association President and CEO Brian Frazee said. “We have prided ourselves on opening opportunities to offer more skill training to get them to try new positions that may be in higher demand.”
Innovation
Looking ahead, the COVID-19 pandemic has solidified a trend that’s also been underway for a decade. Many older adults want to stay in their homes as they age. A 2022 AARP survey shows that 77% of adults aged 50 and older want to remain in their homes for the long term.
The national average home health aide cost about $5,148 in 2021, assuming an aide works 44 hours a week, according to Genworth’s Cost of Care 2021 survey. It’s still less than the cost of a private room at a nursing room ($9,034) or a one-bedroom apartment at an assisted living facility ($5,995).
For Painter, bringing health care professionals into the home opens up possibilities in taking patient care to the next level.
“You also learn more about the challenges they could be facing in recovery, and that can help develop a better care plan,” she said. “They may be having difficulties adhering to medication or not eating the right foods. That’s information that can all be shared with the care team.”
ChristianaCare’s HomeHealth program started in 1922 and has 800 caregivers who made over 160,000 home visits all over the state, driving roughly a million miles. ChristianaCare also offers tuition reimbursement for its clinicians to upskill and continue to progress their careers. But soft skills are still critically important, Painter added.
“In general in health care you have to have warmth and empathy for patients and colleagues, and at HomeHealth, you have to enjoy meeting people. You’re doing it every day and you have to be willing to accept people who live differently than you,” she said.
Painter joined ChristianaCare eight years ago because she was impressed with their innovative approach to the program. Months ago, ChristianaCare launched robotic technology in HomeHealth, to give patients reminders on medication, exercises and when clinicians are scheduled for a visit. It could also give caregivers – like family members – the ability to see and talk to the patient remotely.
“We believe that this robotic technology will really help patients and families age in place,” she said. “It will also give caregivers the ability to see if their loved one is well while they’re at work or away. If they’re not, it gives them the ability to act relatively quickly.”
ChristianaCare HomeHealth’s patients skew mostly older, but Painter says that the state’s largest health care system sees opportunities to expand the program into new demographics, such as young adults or patients with pre-existing conditions. And with the potential of a growing patient base, the need to grow the workforce has become a more pressing issue.
“We’re all aware of the challenges that come with nurses and home health aides, but we’ve anticipated it and worked to meet that challenge,” she said. “We have also developed a residency program where a candidate with the right soft skills can go to our tech schools, tuition-free, to become a [CNA] or aide. We’ve also developed a new graduate nurse program to bring in candidates and train them, as well as a fellowship for those who haven’t done acute care.”
But while the demand in home care is growing and driving the market, it still leaves challenges in long-term care as a whole. Heiks noted that there weren’t many home care services that work 24/7 like facilities that have medical staff on hand.
“I do think our trusted local educators need to embrace this industry and help solve the problem. Where students get the training and experience is where they frequently end up – and long term care is not always offered in training,” Heiks said. “Delaware hospitals and home care systems need to work together because the need is only going to grow.”
