Influencing Caregiving

Staffing Crisis Influencing Caregiving

Fifty-Three Million Caregivers    

   The “National Data on Caregivers” show approximately fifty-three million adult caregivers in the United States.  Between 2015 and 2021, the United States saw a 21% increase in adults providing unpaid care to their family members. Why such a significant increase? One reason suspected is the shortage of individuals entering the job market interested in healthcare as a career option. With the decrease in available healthcare workers, a staffing crisis occurred, negatively influencing caregiving.

Baby Boomers  vs. Generation “X”

   Why the sudden staffing crisis in healthcare? Human Resources Departments have warned management for years that it was coming. The culture change influencing caregiving rapidly left its mark as a change occurred between generations “baby boomer” and “X.”  Think about the significant change in thinking during that time frame and how it impacted how everyone acted.  

  • We had a population explosion at the end of the war resulting in many baby boomers. As the offspring of a post-war generation that lived through the depression and the stark years of war, they learned to work for success to achieve dreams their fathers never had.  Parents encouraged them to make the world a better place, and they were determined to show they would never let the world be destroyed as it was during the big wars. So their sons and daughters joined the peace corps, helped in free clinics, and made personal sacrifices for the good of others by the hundreds.
  • When the baby boomers had children, they gave them everything money could buy.  The “things” were to make up for the time they spent away from the children pursuing personal goals. The result was a generation of children who felt entitled but neglected and had difficulty with interpersonal relationships.


Generations Made Different Choices

The Next Generation Likes Technology

     Based on the above differences, the generations drifted toward different career choices. Generation “X” selected careers in information technology (independent, high-paying, technical). At the same time, baby boomers leaned toward jobs in service industries involving people interaction. The jobs often provided a much-needed service to the community but unfortunately do not pay well or receive recognition for the value they provide.

       As a result, the service industries faced a crisis due to a significant deficit in healthcare professional training institutions. Therefore, as the baby boomers retired, trained generation “X” replacements were difficult to recruit.

Healthcare Industry Plans for Staffing Crisis

     The healthcare industry began planning ways to address the potential shortage of healthcare professionals.  One way they considered as a possible solution involved discharging patients home earlier in their recovery process. The healthcare industry promoted the idea that “home was better” because it was less germ-intensive.

     In a hospital, all germs come in and out daily, whereas, in a home, the patient exposure stays confined to family and guests.   Furthermore, at-home care is provided on a 1:1 basis rather than by staff shared with 6-8 other patients.   

Survey Supports Quicker Response Times

     According to survey results, quicker response times and greater patient satisfaction in a more comfortable living space lead them to say patients should be discharged home. Furthermore, it freed up a hospital room for the next patient.

     The benefit of an early discharge also meant an increase in their revenue stream by decreasing inpatient days for the diagnostic codes used for reimbursement by third-party payors.

 Caregivers Not Included in the Planning

     While the government’s plan to move hospital care to homes has many benefits for the healthcare industry, they forgot to incorporate a process for preparing and supporting families to take over the care transferred to them. Their plan enhances home health agency training and resources, but those individuals visit for 30-60 minutes once a week or day and go home.  Who helps out the family after that? 

     The complexity of home care has become greater each year, but help for families has not kept up with the change. Resources remain inadequate, training remains minimal or absent, and regulations instead of helping get in the way of resolving the issues.

What is Influencing Caregiving for the Future?

    Baby Boomers are Growing Old

    In 2010 13% of the US population was 65 years or older. The 2018 United States Census Bureau report showed that as soon as 2035, older adults would exceed children in the US.  With the aging population, the demand for healthcare services becomes critical.  The rapid aging of such a large group is particularly concerning because the generations coming of age responsible for their care are not choosing to enter healthcare careers. Who will take care of all these people if there is a shortage of doctors and nurses?  The first thought is family members, but my second thought is a blank.  The family is falling apart. The loyalty to family to care for one another no longer exists. Therefore, the government’s plan to rely on family to care for the ill discharged home may not work in the long run (but that’s a topic for another day).


    In 2014 Congress passed IMPACT (Improving Medicare Post-Acute Care Transformation Act of 2014).  IMPACT brought about major changes in how home health agencies, long-term care, rehab facilities, and hospitals interacted. For example, they are now all graded on the same measures of success. That means that companies must now send reports regularly to one government agency telling them how well they did on certain things.

Part of adapting to caregiving involves being prepared for the unexpected such as falls. Planning ahead for what to do when a fall occurs and you're alone to deal with the crisis helps to keep the panic down when it happens for real.
Part of adapting to caregiving involves being prepared for the unexpected such as falls. Planning ahead for what to do when a fall occurs and you’re alone to deal with the crisis helps to keep the panic down if it happens.
Meaningful Measures

     Each company must report on certain types of events (called Meaningful Measures) such as:

  • how many new wounds patients obtained while under their care,
  • how many new infections patients acquired, the number of unexpected deaths that occurred,
  • the number of falls that happened.

      Medicare provides payment to the company based on the scores received on those reports. Besides paying facilities based on their quality of care defined by their Meanful Measures scores, there is also a proposal to implement new models of care that require hospitals and home health agencies to partner in receiving payments for care. For example, in 2020, Patient-Driven Groupings became effective matching the payment to the individual patient’s needs. In addition, home health value-based purchasing (HHVBP), another new government program set for implementation nationwide in 2022, provides reimbursement to home health agencies based on the quality of care they provide.

Likely Impact on Patient Care

     What does that mean for families, though? On the surface, you would think that means that agencies would provide better care. However, having been in healthcare for almost 30 years, what it means is that the agencies will focus all their resources only on making sure they do well on those measurements. As a result, staffing will decrease in other areas, and care overall declines because the focus becomes a documentation of care rather than the care itself.  When care becomes tied to money, quality almost always suffers.


Changes in Health Care Services Had a Great Impact on Caregiving Need

Many children care for parents from afar or assist them through oversight measures.
Many children care for parents from afar or assist them through oversight measures.

     Another reason we have seen an increase in family caregivers is because states have pushed the responsibility to provide services for low-income and special-needs families to local governments. However, requiring the local governments to provide the services did not include the funding to make it happen. As a result, many families no longer receive services. They either cannot afford to pay the copay or shared cost for services, or if the locality does not provide the service, they cannot drive the distance to where it is now available.

Consumer Directed-Services

     Service companies continue to struggle with finding solutions to this issue.  Consumer-Directed Services is one way Medicaid helps those eligible access care options when services are not readily available. More is available about that topic under the Medicaid pages.


    Directed Services are not a true solution for this dilemma because they also have limited funding. Under Directed Services, the family can find a neighbor or family member to pay to provide the care needed. Medicaid is supposed to pay the family member for doing the agency’s job who used to provide the care but is no longer available.

Limited or No Funding

     Unfortunately, with the cut in funding at the local level, Directed Services no longer has money available in many circumstances to pay for assisted care. The result is either using personal funds until the money in the bank runs out or do without the service.

Eric's wedding
Stages of life – birth/family, marriage, retirement. All with caregiving challenges and special needs.

Care at Home Options

Compare Home Health Agencies

     To protect yourself and your family, check to see how well various agencies are scoring on their measurements compared to one another by going to the Home Health Compare website ( Using this website, you can select the highest quality home health agencies providing skilled care for your area. 

Hospital at Home Model

     Another model being considered for the future by many hospitals and currently being evaluated by Johns Hopkins as an option is “Hospital at Home.”  This model is used in other countries to treat patients who are not acutely ill at home. In many ways, it’s what we just did during COVID. The advantage of encouraging early discharge from the hospital to their home is that patients are less likely to fall, develop delirium, or decline their functional abilities.

     The disadvantage for the family is that they provide all the care. None of the care is paid for by Medicare. Some third-party insurance carriers may pay for it; most won’t.  Therefore, the burden is on the family to miss work to stay home to provide the care. The program provides huge clinical savings for the government and healthcare industry and significantly increases the hardship for caregivers.

Where is Support for Caregivers?

     In conclusion, the healthcare trends are moving toward sending patients home with more complex care needs and expecting more from families in providing care in the home. The burden of care is likely to become greater and more complex over time; however, nowhere do I hear plans to provide family caregivers with financial support or resources to relieve their burden to take on these additional challenges.   

Caregivers frequently face financial hardship due to paying for supplies and medications not covered by insurance and for missing or leaving the workforce to provide care for their family member.
Caregivers frequently face financial hardship due to paying for supplies and medications not covered by insurance and for missing or leaving the workforce to provide care for their family member.