Infection prevention efforts aren't exclusive to COVID and must be made a priority to keep vulnerable patients safe.
The public health emergency (PHE) declaration for COVID-19 ended in May, along with the waivers, flexibilities, and additional funding it enabled. While more attention is being paid to infection prevention efforts in skilled nursing facilities and now home health, there is still much work and education to be done to ensure the safety of residents and patients alike.
Here are recent HealthLeaders stories featuring conversations with Devin Jopp, CEO of the Association for Professionals in Infection Control and Epidemiology, raising awareness for the need for solid infection prevention processes.
Conversations around infection prevention increased over the course of the pandemic, but Jopp explained that it isn't exclusive to COVID. Hospitals, skilled nursing facilities, and home health agencies alike should either have a combination of infection prevention methods in place, staff trained in infection prevention, or at least one full-time infection control specialist on staff.
Compounding the problem is that like the rest of healthcare, there aren't enough specialists to accommodate the need, nor are there many students pursuing that career pathway.
Infection Prevention Efforts in Home Health—Part 1 and Part 2
As more people prefer to receive care in their home, the home healthcare sector is experiencing substantial growth. However, according to Jopp, there are minimal infection prevention practices in place, if any.
Whether it's home health or hospital at home, the lack of oversight and difficult logistics of maintaining a clean, pathogen-free environment for patients in their own home presents a challenge and puts the patient's health at risk.
Jopp provides some recommendations on how to make infection prevention a priority throughout the healthcare continuum, as well as how to address the shortage of infection preventionists.
The specialized and clinical home care provider appointed Paul Mastrapa to succeed former CEO Jennifer Sheets in July.
With 30 years of experience in home care and the home health sector, Paul Mastrapa is in familiar territory as president and CEO of Interim HealthCare and its parent company, Caring Brands International.
Interim HealthCare, a provider offering specialized and clinical home care, announced Mastrapa’s appointment as CEO in July. He succeeds former president and CEO, Jennifer Sheets.
Prior to his appointment, Mastrapa served as CEO of Help at Home, a home care provider, and president and CEO of Option Care, the leading national provider of alternate site infusion services.
He knew early in his career that home care and home health were to be his focus.
"I have the benefit of seeing healthcare longitudinally, and I think that helps give me a lot of perspective," he told HealthLeaders.
Much of what is currently happening in healthcare, calls for reform and increased oversight in different areas, has previously occurred, and it's important that workers and stakeholders advocate for the changes they want to see, according to Mastrapa.
Especially, he noted, with such a high portion of the industry receiving reimbursements from the government.
"[We] know [we] need to make sure that [we're] advocating effectively and educating policymakers about the benefit of the services that [we] provide," he said.
Mastrapa also emphasized the importance of an organization's ability to innovate and scale as it grows—particularly large providers such as Interim HealthCare. Considering the growing demand for aging services and the current reforms organizations and healthcare workers alike are advocating for, having those factors as part of organizational culture is crucial.
"Every organization has wonderful caregivers that do the work they do for personal and noble reasons," he said. Early in his career, he added, he learned that organizations could use that purpose-driven mindset to drive strategies, goals, and outcomes and foster a culture that encourages that.
Now a month into his tenure as CEO, Mastrapa has been spending time in the field with franchises, internal support center staff, and company-owned locations getting acquainted with the different areas of Interim HealthCare. Even as a C-suite executive, he doesn't shy away from learning new things.
"There's a lot of innovation happening in the marketplace. Value based care, I think, is a very large, systemic shift that's changing the relationship between providers and payers," he said. "The system really needs to lean into the way these organizations access patients, provide care, drive their services forward."
"It's becoming less about what you do and more about the impact of what you do, which determines your success."
Mastrapa believes that healthcare is at an inflection point, with technological innovations such as artificial intelligence (AI) and its potential to enable organizations to be more efficient with their workforce, alleviating the strain of the workforce shortage.
Going forward, some of his goals include assessing Interim HealthCare's capabilities against market demands to define a future strategy to accelerate growth.
"I'm very carefully working with the leadership team on where we're headed to drive clear focus, alignment, and investment to help us get there," he said. "Which is what I've tried to do with every organization I've touched."
Facilities negotiated the staffing minimum, but finding staff remains an issue.
A staffing mandate for Pennsylvania nursing homes went into effect in July, and facilities are already feeling the strain.
Former Gov. Tom Wolf proposed a staffing requirement of 4.1 PPD (per patient day) for the state's nursing homes. Many facilities called the proposal untenable, so Wolf's administration struck a compromise: a minimum staffing requirement of 2.87 PPD, in exchange for a $300 million increase in Medicaid funding.
This compromise came with additional accountabilities, said Garry Pezzano, president and CEO of the Pennsylvania chapter of LeadingAge, a community of nonprofit, mission-driven aging services providers.
"One of the accountabilities being that 70% of the Medicaid [funding] spent in skilled nursing facilities would go directly to the bedside," he told HealthLeaders. "And then there was also some very specific staffing ratios that were put into place."
While the compromised staffing ratio decreased from 4.1 PPD to 2.87 PPD, this would be only for the first year—2023, with the mandate going into effect July 1. For the second year—which would be 2024— the PPD will go up to 3.2 PPD, unless another Medicaid increase is approved for that year's budget.
Each sector of healthcare has been affected by the workforce shortage, with aging services like skilled nursing facilities and home health providers struggling even more. A staffing mandate, Pezzano said, is the last thing they need right now.
After polling LeadingAge Pennsylvania's skilled nursing facility members—about 150 in total—34% said they have beds on hold, meaning that they have a certain number of beds available but can't admit residents because they don't have enough staff.
About 55% of members said they were having to turn away hospital transfers. The average length of stay in Pennsylvania's hospitals is increasing by one and two days, according to Pezzano.
"[That’s] significant because it's not the least-restrictive placement for the resident and it's more costly for an older person to be in acute care," he said.
"That means they're not getting the rehabilitation they need. They're not getting the socialization they need and they're not getting the mobility that they need. Then, it's more costly, so it becomes an access issue."
Some 83% of members are using temporary nurses from staffing agencies, which are notoriously expensive. In addition to the mandate compromise, the state's nursing homes were successful in getting legislators to place quality measures over agency staffing, namely by requiring them to register with the state.
However, no changes were made to the pay rates that staffing agencies can charge.
As for how facilities are managing operations with the mandate now in effect, Pezzano said it varies by location. In some areas of the state, they're able to hire the staff they need, and some member facilities have said that they're seeing staff who previously left return to the facility.
"What a mandate does is it treats everyone the same, and not all providers are the same in regard to even their physical space, or their ability to find staff, and most importantly, the acuity of their patients," Pezzano said.
"When you lose that flexibility as a clinical operator, as a clinical team, it kind of forces you into a situation that you know is ultimately going to impact your ability to care for patients."
HealthLeaders has previously reported on the anticipated influx of older adults needing some type of aging service by 2030. With the persisting workforce shortage, strain of staffing minimums, and lack of young healthcare workers interested in working in the post-acute space, there's pressure on skilled nursing facilities to provide the care that people will need.
LeadingAge Pennsylvania began an initiative called Long Term Services and Supports (LTSS) Evolved, where they've begun looking at ways to create more efficiencies in practice by affecting antiquated and more cumbersome legislative health policies. They're also involved in state efforts, urging Gov. Josh Shapiro to create an office of health workforce innovations and reform, and looking at immigration reform to see how foreign workers can bolster their workforce.
"We're stepping through this at the moment, but we continue to look at these disruptors and forward-looking ways of solving the workforce crisis because there are not enough people," Pezzano said.
"You're not going to get enough people and there literally is not enough money to throw at it,” he said. “Staffing mandates that are unfunded and unsupported are just making the situation worse."
Aspen Park and Lewiston Transitional Care, both Cascadia Healthcare facilities, were recognized for meeting the rigorous standards of the organization's national quality award program.
"This recognition is a testament to the dedication, compassion, and the tireless efforts over the years by these incredible providers," Cathy Bergland, AHCA/NCAL's national quality award board chair, said in a statement.
"They all deserve to be celebrated for their unwavering focus on delivering high-quality care and outcomes for their residents and staff."
To receive the Gold award, a long-term care facility needs to have previously received the Bronze and Silver awards for commitment to quality and achievement in quality, respectively, which takes several years. Applicants for these awards must adhere to the core values and criteria of the Baldridge Performance Excellence Program, an organizational improvement tool that targets leadership, customer and workforce satisfaction, clinical outcomes, and other factors.
This year’s honorees for the Bronze and Silver awards were recognized earlier in the summer, with 399 providers receiving the Bronze award and 72 receiving the Silver award.
"Congratulations to this year's extraordinary providers for achieving exceptional performance and care outcomes for their residents and staff," Mark Parkinson, president and CEO of AHCA/NCAL, said in a statement.
"Their dedication and commitment to the Quality Award journey to become the best in the nation is inspiring. I am so proud of our members for their hard work and ongoing progress in delivering high-quality care."
Gold, Silver, and Bronze honorees will be presented their awards during Delivering Solutions 23, AHCA/NCAL's annual Convention and Expo, October 1-4, 2023, in Denver, Colorado.
Lack of interest from young professionals stems from lack of exposure.
For Tammy Schmitz, what began with a nudge from her father turned into a nursing career spanning three decades and being named Interim HealthCare's 2023 Nurse of the Year.
In 1989, Schmitz had been working as a bartender when, after a conversation with her father, she began to think about other career options. Some of her customers had wives who were nurses, and speaking with them gave her the push she needed to enroll in a licensed practical nurse (LPN) program.
Years later, having accumulated a wealth of experience in the field and earning her nursing degree, Schmitz joined Interim HealthCare of Lima, Ohio, a home healthcare agency, in 2019 as an RN case manager, right at the onset of the COVID-19 pandemic.
"I was very lucky as an LPN back then," she said. "I could do quite a bit and gather knowledge and build confidence. Then I went back for my bachelor's degree and took off from there to where I am today."
In the aftermath of the pandemic, and aligning with the nation's growing elderly population, healthcare has seen more patients preferring to receive care at home, rather than going into a doctor's office. Yet, due to a workforce shortage exacerbated by the pandemic, there aren't enough nurses, aides, and caregivers to accommodate the demand for services.
The issue goes beyond home health and home care, with all healthcare sectors struggling to hire and retain staff, Schmitz said. When it comes to finding and recruiting young talent, they have little to no interest in working with older populations, which she attributes to a lack of exposure.
As a nursing student, she had the opportunity to work with different populations during her clinical rotations which helped her figure out which patient populations she worked best with. She found that obstetrics and pediatrics weren't for her, but she did discover a preference for working in geriatrics.
"You had all sorts of different age groups in the hospital, so we were exposed for quite a while," she said. "We had nursing home rotations, hospital rotations; we really got a well-rounded education with the school I was at."
Another hinderance to younger healthcare professionals not choosing to work with older patients is ageism—discriminating against older people due to negative and inaccurate stereotypes.
To correct these misconceptions and get future healthcare professionals interested in working with older patients, Schmitz suggested normalizing interactions with older adults from when they're young.
"I think what it takes is just starting people when they're younger, interacting with some of the older generation just so they start getting more comfortable with them," she said.
Nicole Haney talks about a key strategy for growing her home care service line.
Nicole Haney was inspired to open an adult day center when her grandfather began struggling with Alzheimer's and her family had a difficult time finding consistent caregivers. "I couldn't set the expectation or the standard of the care that he was receiving, and so I just decided we're going to do the day center and he can come here, and we'll take care of him too," she said.
Haney is the owner of Papa's Place Adult Day Center in Reed City, Michigan, and is a featured speaker at the Decision Health Private Duty National Conference & Expo, November 12–14, 2023, in Las Vegas. Haney will speak on the topic of "Leadership Primer: Shift Your Mindset, Step Back, and Watch Your Agency Grow."
Haney recently talked with HealthLeaders about the growth strategy at Papa’s Place. Figuring out the services Papa’s Place could consistently provide was a key part of this strategy and as it maintained that consistency, its reputation and business benefited.
Papa's Place Adult Day Center opened its doors in 2018. Haney previously worked in administrative hospice roles, giving her the experience and knowledge of the post-acute sector, along with staffing and client management.
While her vision for Papa's Place didn't initially include home care, the COVID-19 pandemic forced the business to pivot, and the facility began offering limited home care services.
"We really had no choice but to transition into home care if we wanted to stay in business," Haney said. “We made a quick pivot and jumped into home care. That’s where the business took off.”
HealthLeaders: How did your clientele transition with you from the adult day center model to the home care model?
Haney: “Most of Papa's Place clients are based in Northern Michigan—a rural, low-income area. The majority of our referrals come from Medicaid waiver case managers—about 95%. At first, we had to figure out how to make Medicaid profitable, especially in this industry. There really is not, honestly, a huge private pay market for what we do in the 11 counties that we serve for home care. So, [we have] been being very strategic with our margins and understanding where our limitations lie. We didn't start off providing home care on the weekends because that's the hardest to staff. We still don't provide overnight care because we cannot consistently provide that. However, we serve between 50 and 60 home care clients per day.
We don’t have a huge marketing budget. We had to be strategic on what we could be consistent with, and by being consistent, we were able to build our reputation.
It literally made the difference for us. Everything that we've built has been organic. It's been about figuring out what our right fit is—what our right fit client is, and what our right fit staff is, because without those two, one area is going to lack if they're not both consistently monitored and nurtured.
It comes down to your organic message and your consistent ability, and if you make all the promises in the world and you can't follow through on them, then, in this industry, [people are] going to move on to the next one that's available to do that.”
HL: Has your consistency helped your relationships with not just your clients, but your caregivers as well?
Haney: “We're very transparent with our staff. We tell them as much as we want to be a right fit for our clients, we also want to be a right fit for them and a right fit for us.
That transparent communication starts from day one, and people will know before they walk in the door what their job is, what their pay scale is, what the expectation is.
I think that it can, and will, make the difference for other agencies on whether they get caregivers to apply and follow through with investing as an employee in their company because it really is about making sure that you have happy staff. Because without happy staff, they're not going to want to serve and provide consistent quality care to the clients.”
Hear more from Nicole Haney as she presents at the Decision Health Private Duty National Conference & Expo in November. Be sure to register for this event!
The report identified recruitment, workforce well-being, and advocacy as common struggles.
As the home care and home health markets continue to grow, agencies and franchises alike are struggling to keep up with the demand for services due to the caregiver and nurse shortage.
A recent industry report by the National Association for Home Care and Hospice called the shortage a "crisis," and offered actionable recommendations for leaders, providers, and agencies.
The report identified the following as common issues agencies struggle with:
Workforce well-being: The welfare of caregivers must be made a central part of the organization's culture.
Recruitment, training, and retention: Agencies must broaden their search for workers, commit to providing thorough onboarding and training, and show those with longer-term goals the career paths available to them.
Transparency and visibility: Members of the home care space must contribute and amplify the conversation around services and care that are able to be provided in the home, including raising awareness about affordability.
Policy and advocacy: Leaders in the home care space must also advocate for legislators to address funding, legislation to support family caregivers, Medicaid and Medicare rate increases, and immigration reform.
While the following are actions for the home care and home health sector to consider as a whole, the report states that these are also actions individual agencies can take:
Attracting and Retaining Caregivers
Instead of in-person trainings, the report recommends virtual training to make onboarding easier and faster.
Peer mentoring can be helpful for new hires in their first 90 days with an agency, reducing turnover.
Replace weekly or biweekly pay with daily or on-demand access to earned pay.
Education, Career Paths, and Elevating the Profession
Work with local nursing programs to support teaching and working in home-based care.
Promote the image of home-based care via social media.
Define and support career paths for home-based care and invest in resources to support career advancement.
Advocacy and Supporting Legislation
Oppose further Medicare rate cuts by the Centers for Medicare & Medicaid Services.
Support legislation like the Credit for Caring Act and Home Care for Seniors Act, advocate for the passage of the Better Care Better Jobs legislation to increase accessibility to home care services, and improve caregivers' wages.
Join the American Hospital Association and other healthcare provider groups to support the refiling and passage of a revised Health Care Workforce Resilience Act, which would create a path for immigrant nurses and physicians to access previously unused visas.
While the Biden administration has proposed a federal staffing mandate, New York state implemented theirs last year.
Staffing mandates have been touted as the answer to concerns about the quality of care provided in the nation's nursing homes. However, many facilities are unable to recruit sufficient staff to comply with the mandate.
While a federal staffing mandate has yet to be decided, some states have implemented staffing mandates of their own.
On January 1, 2022, the state of New York's staffing mandate went into effect requiring the following: a minimum daily average of 3.5 hours of nurse and certified nurse aide (CNA) care per resident per day (HPRD); a minimum of 2.2 HPRD provided by CNAs; and a minimum of 1.1 HPRD provided by a licensed practical nurse (LPN) or RN. The remaining 0.2 HPRD can be provided by an RN, LPN, or CNA.
"Member facilities have been struggling to hire staff prior to the pandemic because of New York state's low Medicaid rate," Jim Clyne, president of the New York chapter of LeadingAge, a community of nonprofit, mission-driven aging service providers, told HealthLeaders.
Until 2023, members have seen the Medicaid rate increase by only 1%, and that Medicaid pays for more than 72% of the days care is provided, he said.
Because of its low rates and Medicaid being such a large payer, which affect facilities’ ability to recruit and retain staff, member facilities are having to lower their occupancy. According to Clyne, there are currently 6,000 more unstaffed nursing home beds in New York than in 2019.
For the first quarter of 2022, Gov. Kathy Hochul waived penalties for facilities unable to maintain the necessary number of staff due to the workforce shortage, declaring it a healthcare staffing emergency. In April, with the declaration still in place, penalties began going into effect.
While the Department of Health has not released details on how penalties are assessed, they can be as much as $2,000 a day.
Staffing mandates have been criticized for their "one-size-fits-all" approach, and Clyne maintains that all nursing homes are not the same; that they have different staffing needs.
"A nursing home serving medically fragile children needs staffing that is completely different than one serving a geriatric population," he said. "Even with the geriatric population, ventilator-dependent residents are very different from dementia residents.
"Certainly, if the national mandate used additional staffing titles beyond the three nursing titles used in New York, there would be a greater recognition of the full range of services being provided to residents."
Devin Jopp discusses home health's current lack of lack of infection prevention oversight.
Editor's note: This is the second part of a two-part series. Read part one here.
HealthLeaders continues the conversation with Devin Jopp, CEO of the Association for Professionals in Infection Control and Epidemiology (APIC) about the need for infection control oversight in the home health setting.
As more individuals prefer to receive care in their home and older adults opt to age in place, home healthcare has seen substantial growth in the aftermath of the pandemic. Here is part two of HealthLeaders' interview with Jopp.
The following transcript has been edited for clarity and brevity.
HealthLeaders: How can we make infection prevention efforts a priority in healthcare overall?
Devin Jopp: We should be investing in our public health infrastructure. We should be building a pipeline for infection prevention and infection preventionist (IP) training and putting new infrastructure in place.
We should make sure we have surveillance systems in long-term care facilities, and IPs in long-term care facilities. All these pieces still aren't there, and I don't think there's the bandwidth politically to push some of these things, but we've got to dig deep and find the will to do the right thing and make these investments, because otherwise we're just going to be sitting ducks for the next infection, and it will come.
On the other hand, we're talking about pushing new models of care, like hospital at home or advancing home health. How are we going to do that when we can't even get the other components of what we're doing situated?
HL: How should healthcare professionals handle the gap in perspective when it comes to explaining these issues to legislators?
Jopp: The general politics of the acute-care and long-term-care lobby are very sophisticated. There's a lot of money in it, there's a lot of established players in it, so it's a lot harder for the home health organizations to get the same level of attention in the broader ecosystem.
There are education barriers around helping Congress understand that. We've got to educate legislators around that.
HL: It's been recommended that skilled nursing facilities have at least a full-time infection prevention officer on staff full-time. Would you recommend the same for home health agencies?
Jopp: APIC is coming up with a new staffing ratios calculator this year that's going to start by looking at different segments. Initially we will focus on acute, long-term care, and ambulatory, which looks at a whole bunch of resources and then determines what's the optimal number of infection preventionists you should have on staff.
We don't have one yet for home health, but we do have a white paper that will come out at the end of this year on infection prevention and control in home health, hospital, and hospice that will have some thoughts and ideas around what needs to happen in this space.
I think, if you are a home health agency, you absolutely need to have an infection preventionist on staff—at least one to help provide guidance. But after that, it depends how many homes you might have and how often people are doing rounding.
The Biden administration's proposed staffing mandate could cause more harm than good to struggling facilities.
Post-pandemic, the Biden administration has increased efforts to hold the nation's skilled nursing facilities (SNFs) accountable for the quality of care they provide. Such efforts have included potentially implementing a staffing mandate, which many facilities have been vocal in objecting.
In the letter, Mark Parkinson, president and CEO of AHCA/NCAL, acknowledged the impact the pandemic had on the healthcare sector and its workforce, as well as the need for improvements in the long-term care space.
"However," he added, "meaningful change will not happen through unrealistic requirements and enforcement, but through collaboration and innovation."
In the letter, available on the organization's website, AHCA/NCAL offer four policy proposals to help address the quality of care in nursing homes:
Publicly report customer satisfaction: Add a customer satisfaction measure to the Five-Star rating system and Care Compare data from the Centers for Medicare and Medicaid Services.
Build the long-term care workforce: Implement the efforts outlined in the Care for Our Seniors Act workforce proposal to supply, attract, and retain workers in long-term care by leveraging federal, state, and academic entities.
Improve the special focus facility program: Begin incorporating evidence-based performance improvement approaches designed to help the facility improve quality care of residents they serve and successfully graduate from the program.
Enhance CMS SNF value-based purchasing program: Add a measure about adopting systems of care related to high performance, as defined by the U.S. Department of Commerce Malcolm Baldridge Framework, which would drive systemic quality improvement.
"We understand that the original intent of proposing additional federal staffing requirements is to enhance care," Parkinson wrote. "However, given the current and forthcoming caregiver shortage, we do not believe a federal staffing mandate will be feasible nor will it yield the intended outcome of improving care."