SlideShare a Scribd company logo
1 of 100
Download to read offline
Residential Provider
Expansion into Home and
Community-Based Services
Executive Summary	 2
Introduction	5
Nursing Homes
Alterszentrum Viktoria, Switzerland	 13
Feros Care, Australia	 19
Isabella Geriatric Care, United States	 31
Tabitha Health Care, United States	 42
Continuing Care Retirement Communities
BallyCara, Australia	 51
First Choice, United States	 60
Shepherd’s Care Foundation, Canada	 67
Well-Spring Continuing Care Retirement Community, United States	 77
Continuing Care at Home Programs
Cadbury Senior Living, United States	 87
Conclusion	96
Table of Contents
2 | Residential Provider Expansion into Home and Community-Based Services
A growing number of not-for-profit, residential providers of
aging services are developing new business lines in the area of
home and community-based services (HCBS). These services
include home health care, non-medical home care and adult
day care.
Few studies have examined the HCBS expansion process to
identify successful business models and marketing strategies,
or common challenges and lessons learned. With so many
residential providers entering the field of home and community-
based services, an elucidation of common themes, important
lessons and promising practices would greatly benefit the sector.
The Study
The International Association of Homes and Services for
the Ageing sought to fill this evidence gap by conducting a
qualitative study of not-for-profit residential service providers
that expanded to provide home and community-based services.
Researchers used the case study method, combined with an
analysis of emergent themes, to conduct this study. They sought
to include a diverse set of providers in the study in an effort
to identify emerging themes that transcended the differences
among providers of aging services. This method helped
researchers identify useful guidance that would apply to the
array of organizations in the sector.
The research team conducted structured phone interviews
with two representatives of each organization, usually the chief
executive officer and the vice president or director of the home
and community-based services program. The purpose of the
interviews was to understand the:
	 Program
	 Relevant policy context
	 Financial implications
	 Workforce
	 Organizational culture
	 Program outcomes
	 Perceived challenges
	 Perceived benefits
	 Lessons learned
The research team also conducted two-day site visits with two
organizations. One organization had a longstanding and well-
developed home and community-based services program and
the other was in the early stages of expanding into HCBS. The
site visits featured focus groups or telephone interviews with:
	 Home health and home care aides
	 Other frontline staff
	 Supervisors of frontline staff
	 Additional executives
	 Marketing, human resources and quality-assurance staff
The site visits allowed the research team to enrich the
perspectives developed during the phone interviews and
to focus more deeply on certain areas, including successful
strategies for staffing the new business lines and the financial
implications of the expansion.
Researchers wrote case studies describing each participating
provider. They also identified common themes that emerged
across these diverse organizations. An evaluation of the themes
led to the identification of guidelines that might be useful to
providers that are considering an expansion into home and
community-based services, or are in the early stages of such
an expansion. Each case study, as well as a discussion of the
emerging themes and lessons, is included in this report.
The Organizations
The research team completed case studies of five U.S. providers,
one Canadian provider, two Australian providers and one
European provider.
Executive Summary
Sodexo • IAHSA • LeadingAge | 3
Nursing Homes
Four organizations included in the study began as nursing
homes:
Alterszentrum Viktoria (Bern, Switzerland): Beginning as a
nursing home in 1995, Alterszentrum Viktoria began providing
home health care and limited non-medical home care to
members of the external community in 2011. The organization’s
small program currently serves 23 clients. Its predominant
source of reimbursement is mandated insurance.
Feros Care (Queensland, Australia): Established as an
operator of two nursing homes in the early 1990s, Feros Care
expanded into home and community-based services in 2002-
2003 and now delivers home health care, home care, telehealth,
companionship, and other services to approximately 5,000
clients per year. The Australian government’s Home Care
Packages Program comprises its main source of reimbursement
for home health and home care.
Isabella Geriatric Center (New York, USA): Founded as
a nursing home in 1875, the non-sectarian Isabella Geriatric
began expanding into home and community-based services in
1989. The organization now provides more than one million
service hours per year of home health care, home care, adult
day and other services. Isabella serves mainly low-income
clients. Its primary payer source for home health care is
Medicaid.
Tabitha Health Care (Nebraska, USA): Established as an
orphanage in 1886 and a nursing home in 1890, faith-based
Tabitha began providing home health care in 1966 and home
care in 1974. Each month, the organization delivers more than
10,000 service hours of home care and serves an average of 254
home health clients. Tabitha’s main source of reimbursement
for home health care is Medicare. Most of its home care
services are private pay.
Continuing Care Retirement Communities
Four organizations included in the study began as continuing
care retirement communities (CCRCs) or a CCRC-like entity,
and developed traditional home and community-based services
programs. They include:
BallyCara Village of Friends (Queensland, Australia):
BallyCara began in 1983 as a residential provider offering
successively higher levels of care, from independent living
to a nursing home. The organization expanded to home and
community-based services in 2013 and now provides an
average of 458 service hours to 200 external clients per month.
BallyCara’s funding sources are a mix of government-funded
and private pay.
First Choice (Virginia, USA): Founded by two faith-based
CCRCs in 2007, with a third partner joining the partnership in
2015, First Choice now provides more than 4,000 service hours
of home care per month and serves 65-70 home health clients
per day. First Choice was established through a partnership
among three providers that acquired an existing agency with a
client base. The agency’s primary funding sources are Medicare,
private insurance and private pay.
Shepherd’s Care Foundation (Alberta, Canada): Beginning
as a CCRC 45 years ago, faith-based Shepherd’s Care began
providing companionship, transportation services and other
home care services in September 2014. Older adults living
in the organization’s residential communities make up the
majority of home care clients. Shepherd’s Care structured its
home and community-based service lines within a separate,
for-profit corporate entity that now provides more than 1,500
service hours per month to approximately 40 clients. Its
main sources of reimbursement are currently private pay and
government contracts.
EXECUTIVE SUMMARY
4 | Residential Provider Expansion into Home and Community-Based Services
Well-Spring (North Carolina, USA): In addition to
operating a CCRC, Well-Spring provides home care and
adult day services to the external community. Each month,
the organization delivers more than 10,000 hours of home
care, approximately 1,000 of which are delivered outside the
CCRC. Well-Spring’s adult day program serves approximately
200 clients each month. The organization’s primary source
of reimbursement for home care is private pay. The adult day
program has multiple funding sources.
Continuing Care at Home
One organization included in the study began as a CCRC
and provides home and community-based services through a
“continuing care without walls” or “continuing care at home”
program.
Cadbury at Home (New Jersey, USA): Founded as a CCRC,
Cadbury established a continuing care at home program in
1998. The program provides a full range of services to its
200 members. Those services include home health care and
non-medical home care. The organization’s primary source of
reimbursement is private pay.
The expansion timeline for organizations in this study
ranges from more than 25 years (Tabitha Health Care and
Isabella Geriatric Center) to under one year (Shepherd’s
Care Foundation). This range of experience with home and
community-based services allowed researchers to glean insights
from individuals whose programs had a long track record of
success, and from individuals whose programs are currently in
the planning and early-implementation stages.
Common Themes: Highlights
An analysis of interview transcripts, notes and case studies
revealed several common themes among the organizations
regarding their experiences with the expansion process. Some
highlights of these themes are described below.
Reasons for expanding: When asked why they expanded
into home and community-based services, most organizations
cited a desire to fulfill their mission by serving more
community members, as well as a desire to grow their roster
of services in order to provide a continuum of care. Some
providers said they hoped to become a “one-stop shop” that
community-dwelling older adults and their adult children
would turn to for all of their aging services needs. Additionally,
some organizations said they were seeking additional revenue
streams to support their residential businesses.
Staffing: All organizations in the sample primarily hired
new frontline staff for their home and community-based
service lines, rather than redeploying frontline residential staff.
Organizations took this approach because the type of worker
who thrives in the home care environment tends to differ from
the type of worker who thrives in a residential setting. The
organizations often shared back-end support systems with the
residential services division.
Funding: Several organizations said they were seeking the
best balance between government and private funding. Home
and community-based service lines drew on private-pay clients
and had the potential to provide surplus revenue.
Challenges: Most providers said they faced tough
competition and found it difficult, at least at first, to distinguish
themselves from their competitors. Some organizations also
cited the difficulty of maintaining communication with the
workforce during the expansion process, especially regarding
the organization’s brand and high standards.
Benefits: Several providers noted that their home and
community-based service lines provided their organizations
with referrals to on-campus services. Most providers said they
derived pleasure from fulfilling their organization’s mission.
Organizations also reaped financial benefits from the expansion
into home and community-based services.
Lessons Learned and Promising
Practices: Highlights
Many of the lessons providers said they learned during the
expansion process concerned marketing. Several providers
emphasized the need to conduct in-depth market analysis
before expanding into home and community-based services.
Providers emphasized the importance of understanding the
needs and desires of the target community before designing the
HCBS business model.
Providers should consider how to distinguish their service
lines from the competition, according to study participants.
Several providers also noted that marketing strategies that are
successful for home and community-based services differ from
successful marketing practices for residential services. HCBS
marketing tends to be referral-based while residential care
marketing tends to depend on word-of-mouth. It is important to
understand these differences in advance.
Prior to launching a home and community-based service
program, it is important to develop a network that fosters
relationships with referral sources. Providers also should
develop a business strategy that aligns with the realities of the
market. Several providers noted the importance of educating
staff members, residents, boards of directors and consumers
about the value of HCBS programs.
Finding the “right” workers for the home setting is critical
to the success of HCBS programs. Providers emphasized the
importance of developing and supporting staff. Workers should
be empowered to identify client needs and provide services to
meet those needs.
Study participants discussed their strategies for expanding
to new services lines and geographical areas. Providers might
consider using contract staff and then hiring their own staff,
they suggest. Virtual offices can also enable organizations to
operate multiple satellite offices with minimal infrastructure.
EXECUTIVE SUMMARY
Sodexo • IAHSA • LeadingAge | 5
The International Association of Homes and Services for the
Ageing (IAHSA) and LeadingAge collaborated on a project to
examine why and how aging service providers transition from
a residential setting model into a home and community-based
services (HCBS) model, and to examine the operations of the
programs. Sodexo Institute for Quality of Daily Life, a research
partner of IAHSA, funded the project.
The research team performed a qualitative study of not-
for-profit residential providers. As part of this effort, the
team conducted 90- to 120-minute telephone interviews with
nine provider organizations in the United States, Canada,
Switzerland and Australia. The interviews typically were
conducted with the organization’s president/chief executive
officer and the vice president or director of the HCBS program.
These interviews covered the following topics:
	 Reason for expanding into home and community-based
services
	 History and description of the current program
	 Relevant policy context
	 Financial implications of the HCBS program
	 Workforce
	 Organizational culture
	 Program outcomes
	 Perceived challenges
	 Perceived benefits
	 Lessons learned through the experience
The research team also conducted two-day site visits to
two organizations: one organization in the United States had
a longstanding and well-developed HCBS program, and one
organization in Canada was in the early stages of expanding
into home and community-based services.
During each site visit, the research team held focus groups
with agency aides who directly provided care, other frontline
staff,1
and supervisors of frontline staff. The site visits also
included structured interviews with additional executives,
including the chief operating officer at one site and the chief
financial officer at the other; and the directors of marketing,
human resources and quality assurance. Researchers
sought to gain an in-depth understanding of the programs’
implementation, operations and impact.
Researchers wrote case studies describing each participating
provider, and then analyzed all transcripts and notes to
identify common themes that emerged across these diverse
organizations. An evaluation of these themes led to the
identification of guidelines that might be useful to providers
that are considering an expansion into home and community-
based services, or are in the early stages of such an expansion.
Each case study, as well as a discussion of the emerging themes
and lessons, is included in this report. Any errors in the study
report are the responsibility of the authors.
Background
Aging services providers are reinventing themselves by offering
home and community-based services to on-campus residents
and older adults living in the external community. These
organizations offer programs and services that reach beyond
the traditional, residential setting to meet consumer demands
and the economic realities of people who are aging in their own
homes. Demand for services like in-home care and adult day is
booming in many countries. Providers’ reasons for expansion
are varied and numerous, including meeting consumer
demands to age in place, reaching a greater percentage of the
older adult population, seeking new revenue streams in the
face of low occupancy rates, diversifying payer services, and
enhancing the organization’s brand.
Home and community-based services can be delivered to a
consumer at home or in a campus-based supportive living or
independent living setting. Operators have a variety of options
Introduction
6 | Residential Provider Expansion into Home and Community-Based Services
as they design an HCBS program. These programs can include,
but are not limited to:
	 Private duty (non-medical) home care: This service
provides assistance with activities of daily living or
instrumental activities of daily living, companionship
services, or specialized care. A non-licensed caregiver
usually provides the care. In some cases, a certified aide
provides care.
	 Home health care: This type of intermittent skilled care
requires more expertise than private duty care and more
regulatory oversight.
	 Continuing Care at Home: This package of long-term
services and supports is provided to adults who want the
security that a retirement community offers but want
to remain at home. This HCBS program differs from
the traditional home and community-based programs
that CCRCs deliver in the community. A continuing
care at home program takes the concept of the life
care contract and a bundle of services into the home.
Continuing care at home is not just a menu of services
that consumers purchase on an as-needed basis. Rather,
it is a comprehensive approach to providing a health and
wellness lifestyle to older adults in their homes.
Aging service providers follow different models when
designing the structure of their HCBS program. That program
can be a department within the retirement community, a
separate agency, or an affiliate of the retirement community.
The organization might also choose to provide home and
community-based services through multiple partners.
Government or private-pay reimbursement for different
services varies widely by region and by case.
Participating Providers
The research team completed case studies of four U.S.
providers, one Canadian provider, two Australian providers
and one Swiss provider. A fifth U.S. provider also participated
in the study, even though the organization does not offer a
traditional HCBS program. The provider delivers continuing
care at home, an emerging model that is described on page 87.
A brief description of each provider is presented below. More
detailed descriptions can be found in the individual case studies.
The organizations participating in this study differed in a
number of ways, including:
	 Nature of initial residential services
	 Design of the current HCBS line
	 Size of the workforce
	 Number of clients served
	 Number of years since the initial expansion
	 Location
	 Primary payer sources
	 Policy contexts and regulatory challenges encountered
Nursing Homes
Four organizations included in the study began as nursing homes.
Alterszentrum Viktoria in Berne, Switzerland was
established as a nursing home in 1995. It expanded to offer
home and community-based services to external clients in 2011.
Viktoria provides primarily home health (medical) care and
limited non-medical care to 23 clients in the community. Its
predominant source of reimbursement is government-mandated
insurance. The organization started a new program that is
housed within the parent organization.
Feros Care in Queensland, Australia is a standalone
organization that provides assisted or supportive living care
and nursing home care. Feros Care expanded into home and
community-based services in 2002-2003 and now delivers
personal care, home care, social care, allied health care,
wellness services and an extensive range of telehealth services
to 5,000 clients each year. Its main source of reimbursement
for home health and home care is the Australian government’s
Home Care Packages Program. The HCBS program delivers
services through a combination of new programs and strategic
partnerships. The program is housed within the parent
organization and has 245 service partners.
Sodexo • IAHSA • LeadingAge | 7
Isabella Geriatric Care in New York, United States is a non-
sectarian organization that has provided care for older adults
since 1875. Founded as a traditional nursing home, Isabella
now provides a continuum of services, including nursing
home care, moderately priced senior housing, adult day health
care, child day care, home care, certified home health care,
licensed home health care, short- and long-term rehabilitation,
Naturally Occurring Retirement Community (NORC) services,2
community-based care coordination, and other community
programs designed to help older adults remain healthy and
independent at home. Isabella began offering home and
community-based services in 1989. It delivers more than one
million service hours per year. Its primary payer sources are
Medicaid and managed care. Isabella started its own programs,
which are now part of overall organization.
Tabitha Health Care in Nebraska, United States started as a
nursing home in 1890. It has since expanded to offer older adults
a comprehensive line of services, including three nursing homes
for rehabilitation and long-term care, assisted living, affordable
senior housing, and a variety of home and community-based
services. These services include home health care, non-
medical home care, adult day services, Meals on Wheels, and
personalized services. Each month, Tabitha provides more than
10,000 home care service hours and serves an average of 254
home health clients. Its main source of reimbursement for home
health care is Medicare. Its main source of reimbursement
for private duty is private pay. Tabitha started a new program,
which is now part of the parent organization.
Continuing Care Retirement Communities
Four organizations included in the study began as continuing
care retirement communities (CCRCs)3
or a CCRC-like entity,
and developed traditional home and community-based service
programs.
BallyCara Village of Friends in Queensland, Australia is a
residential provider offering progressively higher levels of care,
including independent living, assisted living and nursing home
care. BallyCara established its first home and community-
based services program in October 2013. The organization
provides external clients with private duty care that includes
domestic assistance, home maintenance, transportation
and social support. BallyCara Community Care serves
approximately 200 clients across all its home care service lines
and averages 428 service hours each month. Its main funding
sources are government funding for home care, private pay
and government-allocated Home Care Packages, which it
currently delivers in partnership with other providers that
have been allocated funding by the Australian government.
The HCBS programs, which feature a combination of new
programs and strategic partnerships, are housed within the
parent organization.
First Choice in Virginia, United States is a home health
and home care agency jointly owned by three retirement
communities: Virginia Mennonite Retirement Community
(VMRC), Bridgewater Retirement Community and Sunnyside
Communities. VMRC and Bridgewater jointly purchased First
Choice in 2007. Sunnyside Communities joined the partnership
in 2015. First Choice provides home health and home care
services to people living on retirement community campuses
and in their own homes. The agency serves 65 to 70 home health
clients each day and provides 4,000 hours of home care services
each month. Its primary funding sources are Medicare, private
insurance and private pay.
Shepherd’s Care Foundation in Alberta, Canada was
founded in 1970 and is a faith-based retirement community
offering independent living, supportive living and nursing home
care on its campus. The organization serves more than 1,600
older adults who have low to moderate incomes. Shepherd’s Care
Foundation extended its service lines into home care in October
2014 and offers transportation and companionship services. The
agency delivers 1,500 service hours each month. Shepherd’s Care
at Home, a for-profit agency, is independent and separate from
Shepherd’s Care Foundation. Its main sources of reimbursement
are private pay and government contracts.
Well-Spring Retirement Community in North Carolina,
United States was established in 1993 by a coalition of nine
local churches. Well-Spring offers several different types of
home and community-based programs: the Program of All
Inclusive Care for the Elderly4
, adult day care, and home care.
The organization acquired an existing adult day provider
and started a new home care program. The adult day and
home care services have since combined and are under the
umbrella of Well-Spring. Well-Spring delivers more than 10,000
hours of home care per month, of which 1,000 are supplied
outside the Well-Spring CCRC. The adult day program serves
approximately 200 clients each month. The primary source
of reimbursement for home care is private pay. The adult day
program relies on a variety of funding sources.
Continuing Care at Home
One organization included in the study began as a CCRC
and provides home and community-based services through a
continuing care at home program.
Cadbury Senior Living in New Jersey and Delaware,
United States launched its Continuing Care at Home program
in 1998. Cadbury at Home, one of the first continuing care
at home programs in the United States, combines home care,
assisted living and nursing home care into a comprehensive
program that provides members with long-term services
and supports in the home and the opportunity to move onto
the CCRC campus as their health care needs change. The
program’s primary source of reimbursement is private pay. The
at-home program was created by Cadbury and is affiliated with
the parent organization.
INTRODUCTION
8 | Residential Provider Expansion into Home and Community-Based Services
Overview of Providers5
The timeline for expansion into home and community-based
services varied considerably for the eight providers with
traditional HCBS programs:
	 Over 25 years (Tabitha Home Health and Isabella Geriatric
Center)
	 Eight to 10 years (First Choice and Feros Care)
	 Three years or less (Viktoria, Well-Spring and Shepherd’s
Care).
Cadbury’s continuing care at home program has been in
existence almost 20 years.
Size of Program
Agencies reported the size of their program in different ways:
hours per month and number of clients per month or year.
Some agencies chose to report the number of service hours
instead of number of clients because of clients’ wide range of
service needs. For example, some clients only require a few
hours of service each month while others require more than 16
hours each day. The agencies felt the service hours provided a
more accurate portrayal of their size than the number of clients
served. This was particularly true for the private duty care.
	 All four providers who offered both home health and home
care had a substantial client base. Their service hours
ranged from 4,000 to 10,000 hours each month to one
million service hours each year.
	 Two out of the three providers delivering home care only
had a smaller client base. One agency averaged 428 service
hours each month while another delivered 1,500 service
hours per month. One agency delivered 10,000 service
hours per month to on-campus residents primarily. That
agency delivered approximately 1,000 hours per month to
off-campus clients.
	 The remaining home health care agency served
approximately 23 clients.
Type of Partnership
Organizations considered many factors when deciding whether
to house the home care/home health agency within the parent
corporation or establish it as a separate organization. The
factors—including financial, legal, expertise-related, and
branding-related issues—will be described more fully later in
this Introduction.
The majority of the providers have kept the home care/
home health agency as part of the parent organization. One
retirement community bought an existing agency to deliver
adult day services. This business will reside on the main
campus and house all of the organization’s HCBS programs,
including home care. While the parent company and the adult
day provider have separate boards of directors, they are legally
connected with each other.
Two home care providers function independently from the
parent organization. One home health/home care agency is
operated through a joint venture of three provider organizations
that purchased the agency. The other provider structured the
agency so it would be separate and independent from the parent
organization.
Reasons for Expansion
Residential providers diversified their service lines as a way
to fulfill the organization’s mission, reach a larger percentage
of the target population, create marketing opportunities and
referrals for a retirement community, develop a potential
revenue stream, and transform the organization into a “one-
stop shop.” Several providers cited more than one of these
reasons for expanding.
Mission: Skilled nursing home providers and aging-in-place
providers that offer a tiered approach to the aging process
by combining independent living, assisted living and skilled
nursing home care may not be able to reach all individuals.
In addition, some aging-in-place providers attract wealthier
clients and their care is not affordable to low- or modest-
income groups. By diversifying service lines, the organization
can potentially serve less-affluent clients and reach the most
vulnerable individuals in the community.
Expanded reach: As more people choose to remain at
home, organizations that provide only residential options
will be unable to reach a significant portion of the older adult
population, including older adults who are unlikely to use on-
campus services. Providing services in the community is an
opportunity to serve these individuals.
Retirement community feeder: When community-dwelling
older adults, or their family members, require higher levels of
care, they may consider moving to a residential care setting.
A home and community-based service line can serve as a
feeder into an organization’s other business lines by creating
brand awareness and connecting with consumers. When
those connections are made early in the aging process,
The eight agencies
with traditional
HCBS programs
offered a mix of
service types:
% provided private duty
or home care only
% provided both private
duty care and home
health care
provided home
health care only
38
50 1
INTRODUCTION
Sodexo • IAHSA • LeadingAge | 9
individuals and their family/support networks will think of the
organization when they need more services.
Potential revenue stream: A home and community-based
service line can supplement or support revenues from the
residential side of a business. The expansion into other services
lines also can attract different payer sources.
One-stop shop: A provider of aging services can be a “one-
stop shop” for individuals by providing a full continuum of
care, starting with services in a person’s home. The provider
can ensure that it helps people no matter where they live or
what level of care they need. In addition, campus residents can
receive high-quality home and community-based services from
a home care/home health agency that is affiliated with or a
department within the parent organization.
Workforce
Organizational environment: A strong workforce is a critical
component of any HCBS program. Staff members, particularly
the aides who provide direct care, are much more autonomous
and work with less supervision than their counterparts in the
residential setting. Aides in the home care setting also perform
a greater variety of tasks, have more responsibility to make
accurate and timely observations, and require flexibility.
Aides rarely report to the agency. Instead, they go directly to
the client’s home to provide care. It can be challenging for home
health and home care agencies to create camaraderie among
their employees. These workers have few opportunities to engage
and connect with each other. Special events, trainings and
meetings can give staff the opportunity to share information
and build connections with each other. A few providers
occasionally use these events to give staff from the HCBS and
residential programs the opportunity to interact with each other.
Hiring and orienting staff: Most providers did not staff the
HCBS program by redeploying staff from the organization’s
residential settings. Instead, they hired new staff with
experience in the home setting, including a vice president
or director of home and community-based with extensive
experience in the type of service lines included in the HCBS
program. A few providers held some type of orientation for
new staff. This generally included an introduction to the
organization. Supervisors in some organizations accompanied
new staff members on their first home visit and introduced the
aide to the client. One provider recommended using a “buddy
system” to allow a new aide to shadow an experienced aide a
few times before going out alone.
Training sessions: Almost all of the providers who offered
additional staff trainings held separate training sessions for
residential and home care aides. This decision was based on the
fact that home care and residential staff work in very different
work environments. Two providers conducted some form of
combined trainings. One provider held a joint orientation
for aides from both environments and separate in-service
trainings. Training sessions often included a mix of mandated
education for certified aides as well as additional trainings that
exceeded government requirements. Providers typically seek
input from aides when deciding on topics for trainings sessions,
which often address specific diseases or issues aides encounter
while caring for the organization’s clients.
Staff resources: Two providers with separate home care/
home health agencies did not share resources or staff with
the residential provider. Other providers often called on the
organization’s management team to run the daily operations
of the HCBS program. The residential and home care
businesses frequently shared back-end support functions,
including executive management, financial management,
human resources, billing, and information technology. This
arrangement helped to spread administrative costs over several
business lines. Some providers relied on a single marketing
team to promote their home-based and residential businesses.
Other providers had separate marketing teams because
marketing strategies for home-based and residential care are
so different.
Quality assurance and supervision: The quality of the HCBS
programs are monitored in a variety of ways, depending, in
part, on the source of funding. Home health care programs were
generally required to submit data on specified quality indicators
to the government. Some home health and home care providers
used their quality improvement committees to review that data
and make action plans to improve or change operations based
on the findings. Approximately half of the providers elicited
feedback from clients and family members to determine their
satisfaction with the services. Providers also supervised the
aides, although the level of supervision varied and aides and
supervisors typically had little interaction. Most providers had
a process in place to address clients’ complaints, although some
systems were more formal and sophisticated than other systems.
Outcomes
Few providers conducted formal evaluations of their programs
to determine their impact on consumers. Most of the providers
that measured outcomes conducted client and family member
surveys or solicited feedback to assess satisfaction with provided
services. Some providers have established committees or other
groups to review satisfaction data and develop action plans to
address areas of concern.
Organizations that offer home health care through
government funding have formal assessments and are measured
on select quality indicators. A few providers have initiated
efforts to track key measures through dashboards or scorecards.
Challenges
Providers experienced challenges in launching, operationalizing
and sustaining their HCBS programs. The key difficulties
reported by providers included:
Market competition: Organizations encounter competition
from other home care or home health providers serving the
same demographic group and geographic area. This can limit
the growth potential for agencies. In some regions, providers
who rely on government-funded services have found that
select entities have a large share of the market because they
INTRODUCTION
10 | Residential Provider Expansion into Home and Community-Based Services
are an official government provider or have a longstanding
relationship with the government. Providers emphasized the
importance of defining a niche for a program and identifying
features that distinguish the program from its competitors.
Financial: Most HCBS programs operated at a loss, at least
during their first year. Growth can be slow due to difficulties
associated with growing the program’s client base. Additionally,
providers struggled to establish the best balance between
private-pay and government-funded services.
Clients: Remaining solvent often involves balancing the case
mix of clients and their utilization of services. Home health
and home care aides reported challenges working with clients
who were noncompliant with the services listed on their care
plans, were combative or aggressive, or whose family members
expected that aides would provide services to them in addition
to the client.
Regulations: Providers experienced challenges with
regulations. A common regulation required organizations to
have a certificate of need to enter the market. The certificate of
need process requires approval from the state health planning
agency before an organization can begin any major capital
project, such as expansion into home health. As a result, the
government can limit the number licenses/certifications it
issues to service providers. Additional challenges included:
	 Inconsistency in the funding that a government issues to
different service providers
	 Strict regulations to create or fund HCBS programs
Staffing: Hiring and retaining the “right staff” for the home
care environment was challenging for several providers. The
home setting is different from the residential setting and
certain characteristics make individuals better suited for the
more autonomous setting. In addition, providers experienced
staffing shortages because they could not find staff with
adequate qualifications, or lacked sufficient staff when there
was increased demand for services.
Benefits
Continuum of care: Providing a multitude of services allows
the provider to support the individual through the continuum
of care. Clients can age as they wish and the organization can
adapt to client needs and the desire of consumers to stay at
home. The organization can provide care across service lines
and across the aging process.
Expanding market and mission: The addition of home and
community-based services is an opportunity to expand the
number of older adults an organization can serve and to reach a
greater percentage of the target population. An HCBS program
targets a different market composed of individuals who choose
not to live on a campus and prefer to age in the home. A
provider that serves a more affluent resident population can
use an HCBS program to serve individuals with more modest
incomes. The HCBS provider also can help consumers navigate
the system of long-term services and supports, and can reach a
variety of individuals through different service lines.
Relationships and marketing opportunities: Serving
people at home creates a relationship between the provider
and consumers early in the aging process. The retirement
community can build awareness of its on-campus options and
market its services. The client and family members can build
trust with the provider and can be comforted by the fact that
they can turn to the same organization over time. Clients, or
the members of their family/support networks, may become on-
campus residents when their care needs change and they require
higher levels of care.
Financial: HCBS programs have generated revenues and
positive financial gains for some providers. These revenues are
particularly beneficial when interest in retirement community
living is down. The additional service lines also have diversified
the revenue stream in some organizations. An organization’s
residential setting may be supported primarily by publicly
funded services. The HCBS program, which may rely more on
private funding, can augment and subsidize the public funding.
Lessons Learned
Providers offer several suggestions for residential service
providers that are considering or already expanding into home
and community-based services. These suggestions are based on
their experience launching and operating HCBS programs.
Prior to Launch
Market research: It is important to know the needs of the
community, and understand the competition, before launching
a program. Conduct extensive market research to understand
what services the community wants and how to most effectively
market to the target group. Identify organizations that already
Organizations encounter competition from other home care or home
health providers serving the same demographic group and geographic
area. This can limit the growth potential for agencies.
Serving people at home creates
a relationship between the
provider and consumers early
in the aging process.
INTRODUCTION
Sodexo • IAHSA • LeadingAge | 11
provide the services you want to offer and learn about their
successes and challenges. Understanding the market can lead to
greater program success. For example, one provider noted that
its superficial market analyses identified the services consumers
wanted, but not the services for which they were willing to pay.
This resulted in lower-than-expected rates of participation in a
transportation program.
Networks and partnerships: Establish a network prior to
launching the program. The network should include potential
referral sources and partners that will help you build the client
base. Build relationships with key referral sources, including
hospital discharge planners, physician practices or insurance
companies. Evaluate whether it is more beneficial to compete
with other providers in the community, or collaborate with
them to fill specific service gaps. Carefully review a prospective
partner’s business plan, philosophy, organizational cultures and
“business chemistry” to ensure compatibility.
Business strategy: Have a defined strategy in place before
starting your program. Test the business idea. Develop a solid
business plan and vision of how to operationalize the program.
The business plan should align with the realities of the market.
Education: Educate staff and residents about home care/
home health care and how it can benefit the organization,
workforce and community. Consider educating the board
of directors about the reasons and benefits for diversifying
service lines. Think about conducting informational sessions or
workshops to educate community members.
Staffing: Staff the home care/home health business with
people who have the right personalities and backgrounds to
launch and operate the program. These individuals should have
an understanding of home and community-based services,
particularly the service lines at your organization. They should
also be familiar with the different payment models. Ensure
that you care for your aides to engender loyalty among current
aides and attract the best aides through word-of-mouth
recommendations.
Program Operations
Expanding service lines and geography: When expanding
into new geographic areas, consider using contract staff that
will establish your brand by providing excellent service. Then
hire your own staff to ease management and communication
demands while further building your reputation. Establish
virtual offices to minimize the infrastructure needed to
expand. These strategies can help providers open multiple
satellite office and gain clientele.
Leadership patience: It takes time and energy to move
outside your core business and start a new service line, even
when partnering with an existing agency. The leadership team
will have to understand, grow and expand the new model of
care. Start with relatively few services and clients and gradually
build up your capabilities. Learn from your experiences and
growing pains.
Staff and systems development: Engage in a continual
process of staff and systems development. Recruit potential
hires well, offer them good initial training, and train them
throughout their tenure with the organization. Consider
creating career pathways to retain staff.
Understand the needs of consumers: Listen carefully to
clients and members of their family/support networks to ensure
that you understand their priorities. Learn what consumers
value most and be sure to provide it.
Marketing strategy: Employ a comprehensive strategy to
promote your services. Recognize that marketing the HCBS
program will require different strategies than marketing your
residential services. Consider reinforcing your brand identity
and distinguishing your services from the competition. In many
regions, it is critical to engage referral sources for your program.
You can accomplish this by meeting with referring agencies,
attending networking events, accepting speaking engagements,
and sponsoring celebrations and other organizational events.
One particularly successful organization stressed that
organizations need to distinguish their service lines and direct
their marketing to different groups of potential clients, while
maintaining the primacy and quality of the organization’s brand.
 
It is important to know the
needs of the community, and
understand the competition,
before launching a program.
Conduct extensive market
research to understand what
services the community wants
and how to most effectively
market to the target group.
INTRODUCTION
Nursing Homes
Sodexo • IAHSA • LeadingAge | 13
Introduction
Alterszentrum Viktoria was established in 1995 as a nursing
home. It offers residential care to protected group homes for
dementia patients, community nursing services, and medical
care. Alterszentrum Viktoria also has independent housing
with access to various services, as required. The organization
began providing primarily medical and limited non-medical
care to external clients in 2011 after making a strategic decision
to expand its services and its client base.
This study of Alterszentrum Viktoria’s expansion into
home and community-based services was conducted through
interviews with the organization’s director and a member of its
board of directors.
Policy Context
Switzerland is a confederation of 26 independent cantons (federal
states) that are distributed among the country’s four regions.
Alterszentrum Viktoria is located in the Canton of Bern.
Governance of Switzerland’s system of long-term services and
supports is highly decentralized and involves federal, cantonal
and communal governments. Primarily, cantonal governments
develop policies affecting older people and long-term care
services. Each canton has its own government and set of rules
for each sector of the health care system. However, cantons may
coordinate their actions at the regional or national level.
Swiss government policy has favored home care, over care in
nursing homes, for several years. The government is working
to ensure that individuals who require nursing home care can
stay in their own homes or apartments until the end of life and
will not be required to move to a special care unit. There are two
reasons why home care is preferred:
	 Delivering care services within the older person’s social
environment allows relatives, friends and neighbors to
continue providing informal care.
	 Home care reduces the pressure on nursing home beds and
leads to a more rational and economical use of those beds.
When nursing home beds are not available, older people
who cannot remain at home often are sent to the hospital,
even though they do not have a medical need to be there.
Insurance providers, not the government, pay almost all the
expenses associated with physician-approved, home-based
medical care. Care recipients pay a small percentage (10%) of
these expenses out of their own pockets. Reimbursement rates
for home-based medical care are consistent and do not fluctuate.
However, the tendency for insurance providers to reduce their
fees each year has resulted in lower prices for consumers, but
lower reimbursements for organizations that provide services to
those consumers.
Swiss providers considering an expansion into medical home
health care services must obtain a license after demonstrating
that they meet criteria established by the canton. License
holders must have the professional staff necessary to deliver
medical care. If a provider meets this requirement, it will be
approved, receive a license, and be free to open a home health
care agency. The government continues to monitor the agency
to ensure that it provides quality services.
Each canton has one government-sponsored home health care
agency. The government-sponsored home health care provider
in Bern is strong and has been operating for many years.
Private providers, including Alterszentrum Viktoria home
health care, compete with the government agency. This makes
it challenging, from a business point of view, to enter the home
health care market and obtain new clients.
Alterszentrum Viktoria
Bern, Switzerland | January 2015
Case Study
14 | Residential Provider Expansion into Home and Community-Based Services
On the regulatory side, however, the Canton of Bern has
few regulations for the home health care service sector. It is
relatively easy for providers to enter the market once they have
hired professional staff. If an agency has a license and maintains
standards of quality, it faces few problems from the canton. An
agency that wishes to provide non-medical care is not required
to obtain a license or to meet any government requirements.
This regulatory environment made it fairly easy for
Alterszentrum Viktoria to diversify its services.
Expansion into Home and Community-
Based Services
Alterszentrum Viktoria was established in 1995 as a nursing
home. The organization began offering primarily medical
and limited non-medical care to external clients in 2011.
Alterszentrum Viktoria’s diversification into home care was
driven primarily by government policies that provide stronger
support to home care services than to nursing home services.
Alterszentrum Viktoria’s management and board of directors
made the decision to provide services to the general public so
the organization could diversify its services and reach a larger
percentage of the older population. Management and board
were also seeking an opportunity to market the organization’s
other services to home care clients who might require higher
levels of care and services over time.
It is not uncommon for nursing home providers in
Switzerland to launch external home care services. Most (90%)
Swiss adults who require assistance live in their own homes.
Only a small percentage of these adults reside in nursing
homes. In this market environment, the survival of nursing
homes depends on their ability to offer services to external
clients. However, competition for these external clients is fierce.
Process for Launching the Program
When the Alterszentrum Viktoria board of directors approved
home and community-based services as a new service line,
it was making a strategic decision to grow the organization.
The government approved Alterszentrum Viktoria’s request to
provide home health care and provided the documentation that
the organization needed to deliver these services.
Alterszentrum Viktoria decided to focus primarily on offering
medical home care due to the great need—and high demand—
for these services in the community. State-mandated insurance
covers medical care services if a physician prescribes them.
Competition in the Marketplace
Alterszentrum Viktoria provides limited non-medical home
care and, at this time, is not interested in expanding its non-
medical care. Providing non-medical home care is much more
challenging than providing medical home care because state-
mandated insurance does not cover non-medical services and
providers do not need a license to enter the market.
Several factors increase competition among providers of non-
medical care services:
	 Many agencies offer non-medical care services.
	 Consumers must pay for non-medical services out of their
own pockets.
	 Clients often do not want to pay for the assistance they
receive.
Intense market competition also characterizes the medical
home health care market. Specifically:
	 Home health care providers face competition from many
private and government-owned agencies. As a result,
growing a client base is a slow process for most providers.
	 The market is open to any provider that obtains a license.
There are no mandated restrictions on the number of home
health care agencies that can deliver services in a specific
geographic area.
Description of the Program
Partnerships
Alterszentrum Viktoria provides its home health care
services in-house and does not partner with outside agencies,
although it does belong to an association representing not-
for-profit providers. The organization considered establishing
a partnership to lower its investment in software and staff
education. However, stiff competition made it difficult to
collaborate with outside agencies. In addition, partnerships
with outside entities are not common in Switzerland. Most
organizations believe that they can “do it better” on their own.
Having an in-house agency allows Alterszentrum Viktoria
to deliver home health care services to individuals in the
community and to bring these services to independent residents
who live on its campus. Alterszentrum Viktoria’s board of
directors is considering the possibility of converting the nursing
Alterszentrum Viktoria
Sodexo • IAHSA • LeadingAge | 15
1868
Guesthouse
called Viktoria
built.
1897
Expansion of
Viktoria sanatorium
into Viktoria hospital.
2008
Opening of day center.
1870
Viktoria is a sanatorium.
1991–95
Viktoria Hospital converted
to a nursing home.
2011
Founding of home
health care agency.
Timeline
Alterszentrum Viktoria
16 | Residential Provider Expansion into Home and Community-Based Services
home portion of its campus to independent apartments.
The organization would then bring at-home services to the
apartments. This option could help the organization reach more
clients and strengthen its home health care service agency.
Admission Criteria
Before an individual can receive medical home health care, a
physician must determine that he or she meets the criteria for
this care. Non-medical care does not require a doctor’s approval
and individuals do not have to meet eligibility requirements
before they can receive these services.
Services
Alterszentrum Viktoria offers a range of medical care services
to support older adults so they can stay in their own homes
for as long as possible. As a supplement to medical care, the
organization’s staff also provides limited non-medical services,
including meals, cleaning, transportation and shopping.
Alterszentrum Viktoria clients who require extensive non-
medical services must receive those services from a different
provider. The organization maintains a list of providers
in Bern that can deliver this type of care. Staff will make
recommendations to clients who need more services than
Alterszentrum Viktoria can provide.
Alterszentrum Viktoria staff members provide home health
care services for a minimum of 15 minutes. The organization
offers services from 7 a.m. to 11 p.m., on weekdays and
weekends. The agency does not provide overnight care, mostly
because it is too small to offer this type of coverage.
Clients
Alterszentrum Viktoria has been providing home and
community-based services for the past four years. It has been
difficult to expand the program’s client base due to competition
from other providers. As a result, the organization currently
serves only 23 individuals. Most clients (95%) receive medical
care. On average, Viktoria adds five to eight new clients each year.
Alterszentrum Viktoria was not able to provide demographic
information about its home health care clients. While the
organization collects data about residents living on its campus,
it does not currently gather information about clients living in
the community. The organization estimates that only about half
of its clients live alone and do not have family caregivers.
Quality Assurance
The Canton of Bern monitors the quality of Alterszentrum
Viktoria’s home health care services. Bern, like other cantons,
strictly supervises home health care providers and specifies
guidelines for provider quality and staff professionalism. At a
minimum, the canton conducts an annual, unannounced site
visit to assess the agency. During this annual assessment, the
home health care provider uses special instruments to measure
the quality of its services. Alterszentrum Viktoria does not track
quality measures outside of the government oversight process.
The government uses its funds as leverage when providers do
not fulfill regulatory requirements. If an agency does not meet
Sodexo • IAHSA • LeadingAge | 17
the canton’s standards, the canton will discontinue payment for
services and close down the provider.
When a client has a complaint about a home health care
agency, its staff or services, the complaint is first addressed
by the organization. If the organization is not successful in
resolving the issue, the complaint is then forwarded to a canton
office that is charged with handling complaints about home
health care services.
Since non-medical care services are private pay, the cantons
do not conduct oversight to ensure the quality of those services.
Instead, the private market controls quality and outcomes. It is
assumed that clients will select a different provider if an agency
does not meet a client’s quality standards.
Alterszentrum Viktoria’s home health care staff consists only
of nurses. There are no aides on staff. After the government
issues a license, it supervises home health care nurses in the
same way that it supervises nursing home nurses.
Workforce
Alterszentrum Viktoria’s home health care agency has two co-
directors and nine full-time nurses. The organization’s client-
base is not large enough to warrant additional staff. Home
health care nurses care for the same clients each week, when
possible, and work in the home environment, either on-campus
or off-campus. The home health care staff receives the same
benefits as residential care staff.
Alterszentrum Viktoria’s nursing home and home health
care agency have the same director and structure. However, the
residential and non-residential settings do not share nurses. All
home health care staff members are new hires. The organization
does not redeploy staff from elsewhere in the organization to
work in the home health care agency.
Other staff in the home health care agency, including human
resources, marketing, billing and information technology
(IT) staff, are shared with Alterszentrum Viktoria’s corporate
offices. This sharing has created challenges for the billing
staff, which needed additional training about the specialized
billing practices associated with home health care services.
The deployment of a new billing software for home health care
services will require additional support from the IT department.
All nurses at Alterszentrum Viktoria receive in-service
training and attend workshops directed by the head of the
nursing department. Nurses from residential care and home
health care are cross-trained. It can be taxing to bring these
two staff groups together for training due to the nurses’
attitudes toward the sector in which they do not work and
are not likely to work. Alterszentrum Viktoria is aware of the
differences between these two staff groups, and addresses those
differences during training workshop discussions.
Organizational Culture
The nursing home and home health care agency at Alterszentrum
Viktoria are not separate entities and the organizational culture
for home health care and residential care staff is the same, since
the newer home health care agency adopted Alterszentrum
Viktoria’s culture when the agency was created.
Workers from residential care and non-residential care have
opportunities to interact with each other and exchange ideas.
This can occur during formal meetings and the training/
workshops mentioned above. In addition, home health care and
nursing home staff members can meet and engage with each
other in a shared dining room.
This sharing of organizational culture is not typical in
Switzerland. In most organizations, home health care agencies
are separate from their parent organizations and have vastly
different cultures. These culture differences are due, in part,
to the political debate over home health care that is currently
taking place in Switzerland as the government increases its
support for home health care services while decreasing its
support for nursing home care. The debate extends to the
relative merits of the different models of care.
Alterszentrum Viktoria did not face any pushback from its
staff when it expanded its services. Many nursing homes in
Switzerland diversify into different service models, and home
health care is a common service model. Staff members had no
trouble accepting the expansion.
Financial Implications
Alterszentrum Viktoria’s home health care agency is based
on the organization’s campus, but it has its own building. The
diversification of the organization’s services involved an initial
investment in office space, equipment and staff.
The home health care agency has not yet broken even and
may find it difficult to generate adequate revenues until the
agency can expand its small client pool. This will be a challenge,
given the competition for home health care clients. For the time
being, other Alterszentrum Viktoria service lines can make up
for the losses incurred by the home health care business line.
Alterszentrum Viktoria’s management and board of directors
have considered discontinuing the home health care agency
because of slow growth and competition. However, they decided
to continue the agency’s operation because of its potential to
bring future customers to the organization’s residential care
services. For this reason, the continuation of home health care is
believed to be an advantage for the organization.
Perceived Challenges
Alterszentrum Viktoria’s home health care agency faces a
variety of perceived challenges:
	 Market competition with other providers makes it difficult
to grow and expand the home health care service business.
	 Competition from the official government-sponsored home
health care service provider is fierce. Private providers
must prove to clients that they are better, faster and have
higher quality than the government-sponsored home
health care agency.
	 A Swiss nursing shortage makes it difficult to find and hire
qualified personnel to provide medical care to people in
their homes. Non-professional staff members, including
aides, are easier to recruit and hire.
Alterszentrum Viktoria
18 | Residential Provider Expansion into Home and Community-Based Services
	 Alterszentrum Viktoria has found it difficult to make
a profit from its home health care business. The
organization’s management is unsure how long it will take
for this business to break even, if ever.
	 Lack of growth is the greatest barrier to the sustainability
of Alterszentrum Viktoria’s home health care program.
The organization has addressed this challenge by adopting
a comprehensive strategy to market its entire organization,
not just its home health care services. Alterszentrum
Viktoria advertises its other services—including concerts,
a day care center and a campus restaurant—in hopes that
these opportunities will help the organization connect
with prospective clients and create public awareness of its
home health care operation.
Perceived Benefits
Alterszentrum Viktoria executives believe that the benefits of
providing home health care services outweigh the challenges
associated with the expansion. Those benefits include the
following:
	 The ultimate benefit associated with home health care
services is the opportunities they create for Alterszentrum
Viktoria to gain future customers.
	 Alterszentrum Viktoria can now offer services along the
entire continuum of aging services, including independent
living, home health care, and special nursing services for
people with dementia.
	 Alterszentrum Viktoria has positioned home health care
as one of many points of entry into the organization and
a link to its nursing home. As the home health care staff
builds relationships with the public, the individuals they
encounter become potential customers who may eventually
move to the Alterszentrum Viktoria campus, either as
independent, assisted living or nursing home residents.
Outcomes
Alterszentrum Viktoria has not evaluated the impact of its
home health care service program. The board of directors is
discussing plans to conduct such an evaluation at a future date.
Lessons Learned
Providers considering diversifying their services face risks,
but the benefits can be substantial. Offering a variety of
services, and knowing the external environment, can help
an organization determine which services will lead to greater
success.
Alterszentrum Viktoria learned the hard way just how
important it is to understand the market before launching a
new business line. Viktoria did not research the market and just
“jumped into” the home health care business without knowing
its competitors. That experience convinced Alterszentrum
Viktoria that organizations should consider pre-development
market research before launching a new home health care
program. Such research would help an organization gain a
better understanding of its market and the expertise needed for
each new business line.
 
A Swiss nursing shortage makes it difficult to find and hire qualified
personnel to provide medical care to people in their homes.
The ultimate benefit associated
with home health care services
is the opportunities they create
for Alterszentrum Viktoria to gain
future customers.
Alterszentrum Viktoria
Sodexo • IAHSA • LeadingAge | 19
Introduction
Feros Care is a not-for-profit, non-sectarian, standalone
organization based in Coolangatta, Queensland, in the
Commonwealth of Australia. The organization provides a wide
range of aging-related services to older adults along Australia’s
eastern coast.
Feros Care provides services through three types of
programs:
	 Two low-care nursing homes6
	 One high-care nursing home7
	 Home and community-based service lines
The organization’s home and community-based service
lines include:
	 Nursing services
	 Personal care
	 Home care
	 Social care
	 Wellness services
	 An extensive range of telehealth services
	 Overnight and weekend respite care
	 Allied health care featuring community-based chronic
disease management and other services subsidized by
Australia’s Medicare program.
Policy Context
Australia is currently implementing a major reform of its aged
care systems. There are currently five major government-funded
home care programs. Feros Care has worked closely with all
of these programs to expand its home and community-based
service programs.
Feros Care
Coolangatta, Queensland, Australia | March 2015
Case Study
The Commonwealth Home Support Program (CHSP)
provides entry-level care for older adults who need government-
funded support to remain at home. These services operate on
a wellness model and may include a range of low-intensity
services like domestic assistance, personal and social care,
transportation and meals. CHSP is the largest government-
funded program in Australia.
The Home Care Packages Program serves individuals with
complex chronic conditions who are eligible for residential aged
care8
but are striving to age in the community. The program
allocates home health and community aged care “packages”
to older adults based on their level of need, as assessed by the
government’s Aged Care Assessment Team. Eligible older adults
receive one of four packages, which range from a relatively modest
level of support (Level 1) to a very high level of support (Level 4).
The packages cover a combination of clinical, personal and social
care that may include nursing care, personal care, allied health,
and domestic and social services. All levels of support include
an option for dementia care. Feros Care currently receives the
majority of its funding from the Home Care Packages Program.
The Veterans’ Community Nursing Program aids
individuals who have served in the armed forces. These
beneficiaries receive home health care, including nursing and
personal care. The program also covers the cost of care for
veterans’ spouses, widows and widowers.
The Veterans’ Home Care Program serves veterans, their
spouses, widows or widowers. Beneficiaries receive non-medical
home supportive care that is similar to the services provided
through CHSP.
The Allied Health Services Program provides a range of
health services in hospitals, community health centers, homes,
rehabilitation units and the community. Australia’s Medicare
and private reimbursement fund the program. Services include:
20 | Residential Provider Expansion into Home and Community-Based Services
	Physiotherapy
	Podiatry
	Dentistry
	Audiology
	 Occupational therapy
	 Social, mobility, pain management, fall-prevention and
disease management programs designed to support
healthy aging
Organizations like Feros Care face two primary complications
as they provide services and supports to older Australians:
consumer-directed care and government regulation.
	 Consumer-directed care: Australia began promoting
consumer-directed care in 2012 as part of its Living Longer
Living Better aged care reform legislation. Consumer-
directed care allows clients to choose their preferred
provider, thus giving older Australians more control over
their care and who provides it. The consumer-directed care
policy places additional administrative and cost burdens on
providers of aged care. For example, Feros Care and other
providers sometimes must enter into new partnerships with
local providers in order to honor clients’ choices.
	 Government regulation: Organizations providing
government-funded services are highly regulated and
must comply with strict funding agreements, guidelines,
external audits and external complaint mechanisms. In
contrast, there are almost no regulations governing the
provision of private-pay services. Most of the care that
Feros Care provides is at least partly government-funded.
Expansion into Home and Community-
Based Services
Feros Care was established in 1990 as a small, low-care nursing
home in Byron Shire, New South Wales. The organization has
followed a steady path of expansion since then, as the following
timeline illustrates.
1997: Feros Care added a high-care nursing home.
1999: Feros Care won funding to establish a small home-
care service providing 25 older adults in Bryon Shire with
community aged care packages. Providers of these packages
receive a certain amount of funding per day to provide a range
of services that support an older adult aging at home. Such
packages might include the following services:
	 One nurse visit per week for chronic disease management
	 Weekly shopping services
	 Transportation to therapy appointments three times each
week
	 Assistance with cooking and light housework for two
hours a day
2002-2003: The organization developed a plan to expand its
home and community-based services and began carrying out
the plan. Although the expansion proceeded slowly for the first
two years, the organization has grown by more than 20% per
year since 2005.
2005: The organization began offering home health care and
home care in the private-pay market.
2012: Feros Care purchased another community-owned
company operating a large nursing home.
2015: Feros Care currently provides a range of home and
community-based services through various government
programs and for private-paying clients. These services are
available in a 3,000-kilometer area along Australia’s East
Coast. The service area spans four states: New South Wales,
Queensland, Tasmania and Victoria.
Reasons for Expansion and Growth
Feros Care’s decision to expand its home and community-based
services was primarily market-driven. Although Feros Care was
operating at a surplus in the early 2000s, its leaders knew that
the organization would be vulnerable to competition due to its
small size and the fact that the Byron Shire area did not have a
large aging population.
Feros Care realized it would soon struggle to compete for
funding against providers in neighboring areas that had larger
populations and greater proportions of older adults. The
organization decided to expand its services and geographical
reach for the following reasons:
	 Expanding Feros Care’s home and community-
based services seemed less risky than expanding the
organization’s assisted living and nursing home operations.
Home and community-based services held two advantages
in comparison with residential care: a lack of adverse media
coverage and a much-reduced set of regulations.
	 An expansion into home and community-based services
would not be as capital-intensive as an expansion of
residential care. Feros Care would not need to build new
buildings or invest in new infrastructure.
	 The expansion would provide Feros Care with a much
larger potential market. Most (80%) of older adults in
Australia were receiving government-funded support
services in 2003, and the vast majority of those older adults
were still living in their homes.
Feros Care’s senior managers and board of directors made
the decision to expand into home and community-based
services as part of the organization’s strategic planning
deliberations. The expansion received little-to-no resistance
from staff members, who expressed excitement about Feros
Care’s vision for the future.
Feros Care
Sodexo • IAHSA • LeadingAge | 21
1990
Began as low-care
nursing home in
Byron Shire, New
South Wales.
1999
Received government funding
to provide home care to 25
older adults.
2005
Began offering private-
pay home care and
home health care.
2015
Provides a range of government-funded
and privately paid home health, home care
and other HCBS to older adults along the
3,000-km eastern coast of Australia.
1997
Added high-care nursing home.
2002
Began competing for home care and
home health care government funding
on wider scale.
2012
Purchased a company operating
a large nursing home.
Timeline
feros care
22 | Residential Provider Expansion into Home and Community-Based Services
Dependence on Government Programs
Initially, Feros Care provided only government-subsidized
home care. The availability of government packages has greatly
influenced organizational discussions regarding possible
expansion into the private-pay home care market.
In 2005, for example, the organization performed a market
analysis to gauge opportunities within the private-pay market.
At the time, long waiting lists for government-funded aged care
threatened to curtail the organization’s growth potential. Feros
Care viewed a private-pay expansion as a way to grow outside
its current market and region, and to become more competitive
with larger home care providers.
The organization began offering a few private-pay services in
2005. However, an extensive expansion into private-pay services
was put on hold when the government increased its funding for
aged care that same year. Essentially, the government’s decision
to increase its funding of aged care allowed Feros Care to grow
by winning more government packages.
Feros Care is once again considering an expansion of its
private-pay services. This latest discussion stems from a
government move in July 2014 to develop more stringent means
testing for the receipt of home care packages. The new rules
could make it cost-efficient for some consumers to purchase
Feros Care’s private services. As a result, the organization
expects the private-pay home care business to grow over the
next several years.
Ironically, the few private services Feros Care began offering
in 2005 allowed the organization to compete more effectively
for government packages. As Feros Care began offering services
in other regions, it learned that those services were often
superior to services offered by other providers. Feros Care’s
responsiveness, flexibility, staff values and philosophy of care
helped it build a strong reputation in these regions. As a result,
the organization became even more successful at acquiring
government contracts. This success spurred a positive feedback
cycle that helped Feros Care further improve and expand its
services, succeed during subsequent funding rounds, and then
improve and expand its services even more.
Description of the Program
Services Provided
Most of the home and community-based services that Feros
Care provides are delivered to older adults who receive
assistance through the Home Care Packages Program. To a
lesser extent, the organization provides services to older adults
covered by the Veterans’ Community Nursing, Veterans’ Home
Care, Commonwealth Home Support, and Allied Health
Services programs.
Feros Care provides non-medical and medical services through
these government programs and for its private-paying clients.
Non-medical services include:
	 Light housework
	Cooking
	 Lawn care
	 Pet care
	 Assistive and smart technologies
	 Moving services
Table 1. Services Provided by Feros Care
DOMESTIC CARE PERSONAL CARE & NURSING WELLNESS AND LIFESTYLE
Cleaning & Light Housework
Personal Laundry
Unaccompanied Shopping
Errands & Bill Paying
Accompanied Transport
Home-Cooked Meals
Home Maintenance
Lawn Mowing & Gardening
Pantry/Cupboard & Spring Cleaning
Moving Services
Pet Care
Internet Training & Support (banking,
shopping)
Technology (Robo-vac cleaners)
Personal Self Care (showering,
dressing, grooming, toileting)
Continence Management
Clinical Care
Palliative Care
Dietary Planning & Education
Mobility Assistance & Equipment
Communication Aides
Accompanied Medical Appointments
Foot Care & Nail Care
Life Link Personal Alarms
Lifelink Smart Home Monitoring (auto
night lighting, bed/chair/door sensors,
environmental alerts)
Hairdressing: Visiting Services
Beautician: Visiting Services
Companionship & Social Support
Accompanied Community Outings
Counseling & Chaplaincy Services
Maintaining Independence Program
Mobility Exercise Programs (Strong
Foundations & Forever Young)
Respite (in-home, day, residential)
Day Trips & Social Groups
Volunteer Activities
Falls Prevention & Re-ablement
Reminiscence, Hobbies, Crafts
Telehealth Vital Signs Monitoring
Internet training & Support (virtual
visiting & social connections)
Feros Care
Sodexo • IAHSA • LeadingAge | 23
	 Internet training and support
	 Personal care
	Companionship
	 Accompaniment to appointments
	 Counseling and chaplaincy services
	 Exercise programs
	 Respite care
	 Efforts to help older adults
participate in community outings
and wellness programs
Medical home care services include, but
are not limited to:
	 Continence management
	 Palliative care
	 Nutritional planning and education
	 Mobility assistance and home
retrofitting
	 Foot and nail care
	 Medical monitoring services offered
through telehealth programs
Feros Care provides around-the-clock
care when needed, and its Contact and
Referral Center is staffed at all hours.
While the organization does not offer
live-in staff placements, it does provide
nighttime and weekend care when clients
are discharged from the hospital and for
other needs. Feros Care regularly provides some services, such
as personal care and help with medications, to clients during
evening hours and on weekends.
See Table 1 for more details about Feros Care’s home health,
home care and community services.
Partnerships
Feros Care delivers services using a combination of its own
staff and service partners from the surrounding community.
When Feros Care expands into new regions, the organization
strategically engages service partners in those areas to deliver
direct care until it has a sufficient number of clients and
services. At that point, Feros Care begins recruiting its own
direct-care staff while maintaining its relationships with
local service partners. Feros Care calls on those partners for
assistance during times of high care volume.
In contrast, Feros Care does not contract for any care
coordination or case management services. Because care
coordinators play a major role in monitoring direct-care
provision and upholding its quality, Feros Care always fills
these positions with its own staff members. This is one way that
the organization works to ensure that its client assessment and
care planning activities meet the highest standards, and that its
service philosophy and the quality of its care are maintained.
Feros Care employs other strategies to ensure that it
maintains high standards of care. For example, Feros
Care signs formal service/brokerage agreements with all
organizations that work under contract to provide frontline staff
to its service lines. These agreements clearly spell out specific
service delivery expectations and requirements. Feros Care
also closely monitors client feedback and reported incidents
associated with contract providers. The organization does
not hesitate to discontinue partnerships due to differences in
corporate philosophies or inadequate care provision.
Feros Care has 245 service partners across all of its service
lines. The organization selects partners based on a number of
factors, including reputation, price, capabilities and flexibility.
Feros Care contracts with several franchisees associated with
larger home care organizations like Just Better Care and Home
Instead. The executives of these franchises tend to be small-
business owners who care deeply about maintaining good
relationships with other providers. These business owners help
Feros Care maintain its reliability, which is a source of pride for
the organization.
Australia’s implementation of consumer-directed care adds
to the complexity of contracting for services. Empowered to
choose the provider they want, consumers can select a local
cleaner to do their housework instead of the service provider
with which Feros Care has an agreement. In cases like this,
the consumer-directed care program requires that Feros
Care perform the necessary inquiries and develop a service
partnership with the provider preferred by the client.
Sources of Reimbursement
Feros Care receives Commonwealth reimbursement from the
Department of Social Services and the Department of Veterans
Affairs for the services it provides through the Home Care
Packages, Veterans’ Community Nursing, and Veterans’ Home
Care programs. Medicare, private insurance,9
and private-
pay clients pay for services provided under the Allied Health
Services program.
Feros Care
24 | Residential Provider Expansion into Home and Community-Based Services
Feros Care also receives some state funding for post-acute
care that is managed by state health departments. These
programs include Transitional Care; ComPacks, which
provides immediate access to short-term community services;
and programs for sub-acute care. State funding is generally for
short-term interventions designed to reduce the likelihood of
readmission.
Consumer Eligibility
In order to be eligible for government-funded programs,
Australians are required to participate in an independent
assessment, conducted either by telephone or in-person, or
both. Independent assessors include the Aged Care Assessment
Team for home care packages and the new Regional Assessment
Service Team for the Commonwealth Home Support Program.10
The approvals process for each major government program is
as follows:
Home Care Packages Program: Traditionally, a local Aged
Care Assessment Team determined an individual’s eligibility
for a home care package after conducting an in-person
assessment. This system changed on July 1, 2015. Now, clients
access the Aged Care Assessment Team through Australia’s
new My Aged Care Gateway, which makes an initial phone
assessment and then refers eligible individuals to the Aged Care
Assessment Team.
Commonwealth Home Support Program: Beginning July
1, 2015, the client calls the Commonwealth’s My Aged Care
Gateway for an initial phone assessment. Eligible individuals
are then referred to the Regional Assessment Service for an in-
home, face-to-face assessment. The assessors complete a goal-
oriented support plan and make the necessary service referrals
to the client’s preferred home support service providers.
Veterans’ Community Nursing Program: Clients must
receive a referral for an approved service from a doctor or
nurse. The amount of funding is based on the individual’s level
of need.
Veterans’ Home Care Program: A regional Veterans Home
Care Assessment Team determines the individual’s needs and
the level of support they may receive.
Allied Health Services Program: A doctor must approve
the client’s participation in this Medicare-funded system for
chronic disease management and other allied health services.
Private health providers have predetermined eligibility criteria.
Clients must access approved providers, including Feros Care.
Individuals can access all of these services regardless of their
financial means. However, retirees who are not receiving a full
pension may be required to make substantial co-payments.
There are no requirements for receipt of privately paid services,
other than ability to pay.
Provider Eligibility
Providers must apply for the right to provide services through
government-funded programs. There are no upper limits on the
number of clients a provider organization may accept through
the Commonwealth’s veterans’ programs.
In contrast, providers participating in the Home Care
Packages Program are awarded a license for a certain number
of packages. For example, they may be allocated packages for 50
clients at a given time.
Providers in the Commonwealth Home Support Program are
given a certain amount of money to provide a given number of
services. For example, providers may be allocated $100,000 in a
given year to provide 1,000 medical transport trips.
Feros Care Clientele
Feros Care provided this snapshot of its home and community-
based services clients:
	 The average age of clients is 82 years, and 59% are at least 80
years old.
	 Two-thirds of clients are female.
	 Most clients have at least one chronic condition.
	 One-quarter of clients are nursing home certifiable but are
living at home with assistance.
	 Three-quarters of clients are receiving lower level care to
help them maintain their independence.
	 Most clients have financial needs, and 85% are full
pensioners.
	 Less than half (44%) of clients live alone without a full-time
family caregiver.
Quality Assurance
Feros Care is committed to ensuring that it maintains high
quality standards, through its own efforts and the efforts of its
service partners. Quality is assured through four strategies.
1. 	 The Commonwealth’s Aged Care Quality Agency regularly
conducts on-site audits of government-funded community
care programs, and compares providers’ quality assurance
systems against a set of common standards.
2.	 Feros Care contracts with a standards-compliance
company called SAI Global for comprehensive quality
management of all its programs. Feros Care and SAI Global
track many measures, including the following:
	 Daily incident and hazard reporting
	 Systems of improvement
	 Workflow management
	 Customer feedback programs
	 Internal audit programs
	 Business excellence parameters
	 Response times
	 Adherence to policies and procedures
3.	 Feros Care employs a chief resolution officer who oversees
the resolution of all complaints to the organization’s
Customer Feedback Program.
4.	 Feros Care uses its care coordinators to oversee the work
performed by direct-care aides and to ensure that high
quality is maintained. Care coordinators integrate the
feedback they receive from clients with data collected
Feros Care
Sodexo • IAHSA • LeadingAge | 25
Feros Care
Clientele
A snapshot of Feros
Care’s home and
community-based
services clients
Average age of clients
are female clients
% of clients receiving
lower level care to help
maintain indepencence
% of clients who are
full pensioners (most have
financial needs)
% of clients who
live alone without a full-time
family caregiver
number of chronic conditions
for most clients (at least)
clients who are nursing
home certifiable, but live at
home with assistance
% at least 80 years old
82
2/3
75 85 44
1 1/4
59
Feros Care provided this snapshot of its home
and community-based services clients:
26 | Residential Provider Expansion into Home and Community-Based Services
through tracking of quality indicators. The coordinators
discuss issues with aides as they arise, and pass information
to supervisors. This information is included in daily
communication updates on services and clients, monthly
staff meetings, and performance reviews.
Marketing
Feros Care uses many venues to spread the word about its home
and community-based services. The organization employs a
comprehensive branding and marketing strategy that includes
Feros Care magazine, newspaper advertisements, local media
coverage, social media outreach, and participation in such
community events as expos, festivals and public celebrations.
The organization also employs a comprehensive strategy to
engage referral sources. These strategies include scheduled visits
with referring agencies; participation in networking events,
speaking engagements, celebrations and other events; and
maintenance of an extensive customer relations database.
Financial Implications
In 2005, Feros Care served 50 clients per year. In 2014, the
organization served approximately 4,000 clients, and it expects
to serve at least 6,000 clients in 2015, due to the advent of new
government-funded transportation and allied health services.
Client numbers could expand even further to 30,000 clients per
year due to the organization’s recent approval to operate the
Regional Assessment Service for the Commonwealth Home
Support Program (CHSP). However, services to some CHSP
clients may be provided only on a short-term basis.
Figure 1 presents Feros Care’s annual growth, beginning
in 2002-2003 when the organization began its expansion
into home and community-based services. Feros Care has
experienced double-digit growth during most years since home
and community-based services became its largest service line.
The first two years of Feros Care’s expansion into home and
community-based services (2003-2005) proved difficult, as the
organization struggled to find its niche in a field crowded with
many competitors. However, Feros Care’s growth has exceeded
20% per year for almost every year from 2006 until the present.
In 2003, the organization funded its community care services
with only $250,000. In contrast, current funding levels for
community care is $35 million. The new Regional Assessment
Service is likely to bring this growth level to $45 million in
2016.
The initial growth period did not require a large expansion
of the Feros Care staff. Prior to 2005, Feros Care hired a
part-time marketing assistant and a part-time writer who
was responsible for submitting applications for government
packages. The organization’s chief executive officer also spent
considerable time on marketing and budgeting efforts. Once
the organization began to obtain a significant number of
government contracts, however, these positions began paying
for themselves. The organization’s home and community-based
service program broke even in 2007.
Figure 1. Feros Care: Annual Growth
Since Expanding to Home and
Community-Based Services
0% 5% 10% 15% 20% 25% 30% 35%
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
2013-14
2014-15
Feros Care uses its care
coordinators to oversee the work
performed by direct-care aides
and to ensure that high quality
is maintained. Care coordinators
integrate the feedback they
receive from clients with data
collected through tracking of
quality indicators.
Feros Care
Sodexo • IAHSA • LeadingAge | 27
The bulk of Feros Care’s current revenues stem from the
services it provides to a quarter of its clients. That’s because
Feros Care receives most of its funding from the Home Care
Packages Program, despite the fact that the Commonwealth
Home Support Program (CHSP) is larger and serves more
of Australia’s older adults. Generally, the monetary value of
individual home care packages is much greater than the value of
packages provided through CHSP. For example, a typical CHSP
client might only be approved to receive $2,000 per year in
services, whereas typical home care packages range from $7,500
to $45,000 per year.
Workforce
Feros Care employed approximately 350 people in 2014. More
than 280 of these employees were care aides, and a majority
of these care aides worked in the organization’s home care
division.
Nurses comprised just over 5% of Feros Care staff in 2014
when Feros Care also used staff members to develop staff rosters
(6%) and coordinate services (8%). Allied health professionals,
who work in a Feros Care service line that is growing rapidly,
are expected to comprise 5% of the organization’s employees by
the end of 2015.
Feros Care expects its workforce profile to change over
the next year, although home care workers will continue to
comprise the majority of its staff. The organization expects to
see staff growth in three areas:
	 Allied health: The allied health line will soon be expanding
due to the increased use of specialists like physiotherapists
and occupational therapists in Feros Care’s restorative care
programs. These specialists operate a range of mobility,
strengthening, fall-prevention and wellness programs
designed to increase the independence of clients.
	 Telehealth: The number of telehealth nurses performing
chronic disease management is expected to increase
as Feros Care’s telehealth services continue their rapid
growth.
	 Information technology (IT): Feros Care will also be
expanding its IT staff to meet the growing needs for health
technology in clients’ homes.
Staff Benefits
Because Feros Care is a not-for-profit provider, its employees
can receive some of their income tax free. Feros Care also offers
employees:
	 Wellness programs11
	 Free gym memberships
	 In-house leadership programs
	 External education
	 An employee assistance program
	 Discounted mobile technologies
Feros Care employees do not receive health insurance
through their jobs because Australia has a public insurance
program.
Staff Recruitment and Training
Working in home care differs greatly from working in
a residential setting for aides at Feros Care and other
organizations.
Home care aides work alone primarily and perform a greater
variety of tasks for clients than aides in residential settings.
Home care aides have more responsibility to make accurate
and timely observations and to prudently make care decisions
on their own. They also have to be more flexible and versatile
than residential employees, since they are called on to provide
cleaning, cooking, social care and, in some cases, therapy
support in addition to traditional care tasks.
For these reasons, Feros Care generally does not redeploy
residential aides to home care unless those aides are very open
to working on their own and undertaking all the activities
required to support clients. Residential care aides may never
have performed activities like cooking and cleaning as part of
their prior professional responsibilities.
In addition to taking direct job inquiries, Feros Care partners
with jobs networks and registered training organizations to
identify the most qualified candidates. Once potential hires
have been identified, Feros Care conducts structured interviews
and tests applicants’ skills in such areas as technology and
observation, before making hiring decisions. Feros Care
has found that it is important to hire staff members who are
independent, are known to the organization, have experience,
and understand the expectations of the job.
Independence: Feros Care looks for staff members who are
self-starters and are comfortable working alone most of the
time. These staff members also need to be comfortable using
technology to stay connected with the organization and with
clients.
Known quantities: Feros Care places great importance on
hiring aides it knows and trusts. That’s why the organization
reduces its reliance on contracted services after it has settled
in a new region. And that is why Feros Care grooms its best
home care staff for management and supervisory positions,
rather than hiring staff from outside the organization or from
its residential services division. Feros Care also shares executive
and billing staff across its home and residential care divisions,
rather than hiring additional staff from outside the organization.
Feros Care places great importance
on hiring aides it knows and trusts.
That’s why the organization reduces
its reliance on contracted services
after it has settled in a new region.
Feros Care
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services
Residential Provider Expansion into Home and Community Based Services

More Related Content

What's hot

922_safki_pir_referrer_information_brochure
922_safki_pir_referrer_information_brochure922_safki_pir_referrer_information_brochure
922_safki_pir_referrer_information_brochure
Robert (Robbie) Thomas
 
Cardinal Health Community Report 2014
Cardinal Health Community Report 2014Cardinal Health Community Report 2014
Cardinal Health Community Report 2014
Nancy Radebaugh
 
Affordable care act NASW Annual Conference 2013
Affordable care act NASW Annual Conference 2013Affordable care act NASW Annual Conference 2013
Affordable care act NASW Annual Conference 2013
Janlee Wong
 
Michael Moran Resume
Michael Moran ResumeMichael Moran Resume
Michael Moran Resume
Michael Moran
 
2 Barnet LINk presentation 2011 Mathew Kendall
2 Barnet LINk presentation 2011 Mathew Kendall2 Barnet LINk presentation 2011 Mathew Kendall
2 Barnet LINk presentation 2011 Mathew Kendall
Flourishing
 
Project6_2016_LOWres (004)
Project6_2016_LOWres (004)Project6_2016_LOWres (004)
Project6_2016_LOWres (004)
Vicki Beere
 

What's hot (20)

Doingmentalhealth2015
Doingmentalhealth2015Doingmentalhealth2015
Doingmentalhealth2015
 
Overview_Brochure
Overview_BrochureOverview_Brochure
Overview_Brochure
 
922_safki_pir_referrer_information_brochure
922_safki_pir_referrer_information_brochure922_safki_pir_referrer_information_brochure
922_safki_pir_referrer_information_brochure
 
Cardinal Health Community Report 2014
Cardinal Health Community Report 2014Cardinal Health Community Report 2014
Cardinal Health Community Report 2014
 
Affordable care act NASW Annual Conference 2013
Affordable care act NASW Annual Conference 2013Affordable care act NASW Annual Conference 2013
Affordable care act NASW Annual Conference 2013
 
Medicaid Waiver: MI Choice Presentation
Medicaid Waiver: MI Choice Presentation Medicaid Waiver: MI Choice Presentation
Medicaid Waiver: MI Choice Presentation
 
PSH FINAL
PSH FINALPSH FINAL
PSH FINAL
 
Michael Moran Resume
Michael Moran ResumeMichael Moran Resume
Michael Moran Resume
 
AOF State Budget Overview and Highlight on Hunger Webinar
AOF State Budget Overview and Highlight on Hunger WebinarAOF State Budget Overview and Highlight on Hunger Webinar
AOF State Budget Overview and Highlight on Hunger Webinar
 
Long term care plus
Long term care  plusLong term care  plus
Long term care plus
 
Dental Access Now! Bringing Quality Dental Care to Every Community in Ohio
Dental Access Now! Bringing Quality Dental Care to Every Community in OhioDental Access Now! Bringing Quality Dental Care to Every Community in Ohio
Dental Access Now! Bringing Quality Dental Care to Every Community in Ohio
 
SCCAP_AR
SCCAP_ARSCCAP_AR
SCCAP_AR
 
2 Barnet LINk presentation 2011 Mathew Kendall
2 Barnet LINk presentation 2011 Mathew Kendall2 Barnet LINk presentation 2011 Mathew Kendall
2 Barnet LINk presentation 2011 Mathew Kendall
 
Understanding aca ambassadors
Understanding aca ambassadorsUnderstanding aca ambassadors
Understanding aca ambassadors
 
Position statement reablement
Position statement reablementPosition statement reablement
Position statement reablement
 
Ckhs community advocacy final
Ckhs community advocacy finalCkhs community advocacy final
Ckhs community advocacy final
 
Medica: A Health Plan Case Study
Medica: A Health Plan Case StudyMedica: A Health Plan Case Study
Medica: A Health Plan Case Study
 
Managed Long Term Care in Nursing Homes
Managed Long Term Care in Nursing HomesManaged Long Term Care in Nursing Homes
Managed Long Term Care in Nursing Homes
 
Project6_2016_LOWres (004)
Project6_2016_LOWres (004)Project6_2016_LOWres (004)
Project6_2016_LOWres (004)
 
Mid-Biennium Review Update
Mid-Biennium Review UpdateMid-Biennium Review Update
Mid-Biennium Review Update
 

Viewers also liked

Alistair Scott Tutorial Review Article
Alistair Scott Tutorial Review ArticleAlistair Scott Tutorial Review Article
Alistair Scott Tutorial Review Article
Alistair Scott
 

Viewers also liked (12)

Virtual architecture and the time machine — Feder Boitsov (Pixelated Realitie...
Virtual architecture and the time machine — Feder Boitsov (Pixelated Realitie...Virtual architecture and the time machine — Feder Boitsov (Pixelated Realitie...
Virtual architecture and the time machine — Feder Boitsov (Pixelated Realitie...
 
Understanding and Alleviating Caregiver Fear
Understanding and Alleviating Caregiver FearUnderstanding and Alleviating Caregiver Fear
Understanding and Alleviating Caregiver Fear
 
Ambulatory Networks
Ambulatory NetworksAmbulatory Networks
Ambulatory Networks
 
Buyfromseller
BuyfromsellerBuyfromseller
Buyfromseller
 
ЛИВАДЕ И ПАШЊАЦИ НАШЕГ ЗАВИЧАЈА
ЛИВАДЕ И ПАШЊАЦИ НАШЕГ ЗАВИЧАЈАЛИВАДЕ И ПАШЊАЦИ НАШЕГ ЗАВИЧАЈА
ЛИВАДЕ И ПАШЊАЦИ НАШЕГ ЗАВИЧАЈА
 
Revolutionising the Film Industry — Wendy Dent
Revolutionising the Film Industry — Wendy DentRevolutionising the Film Industry — Wendy Dent
Revolutionising the Film Industry — Wendy Dent
 
Startup WiseGuys
Startup WiseGuysStartup WiseGuys
Startup WiseGuys
 
How we have created a hardware entertaining project for a new market — Alexan...
How we have created a hardware entertaining project for a new market — Alexan...How we have created a hardware entertaining project for a new market — Alexan...
How we have created a hardware entertaining project for a new market — Alexan...
 
Buyfromseller
BuyfromsellerBuyfromseller
Buyfromseller
 
Reference Architectures for Fast Prototyping of IoT and Biomedical Solutions
Reference Architectures for Fast Prototyping of IoT and Biomedical SolutionsReference Architectures for Fast Prototyping of IoT and Biomedical Solutions
Reference Architectures for Fast Prototyping of IoT and Biomedical Solutions
 
Research on the curriculum of nursing courses
Research on the curriculum of nursing coursesResearch on the curriculum of nursing courses
Research on the curriculum of nursing courses
 
Alistair Scott Tutorial Review Article
Alistair Scott Tutorial Review ArticleAlistair Scott Tutorial Review Article
Alistair Scott Tutorial Review Article
 

Similar to Residential Provider Expansion into Home and Community Based Services

SOCW 6520 WK 5 responses Respond to the blog post of three.docx
SOCW 6520 WK 5 responses Respond to the blog post of three.docxSOCW 6520 WK 5 responses Respond to the blog post of three.docx
SOCW 6520 WK 5 responses Respond to the blog post of three.docx
rronald3
 
After reading the report on services in Georgia, write a short paper.docx
After reading the report on services in Georgia, write a short paper.docxAfter reading the report on services in Georgia, write a short paper.docx
After reading the report on services in Georgia, write a short paper.docx
ADDY50
 
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...
Altegra Health
 
MHDC Bridging_the_Gap_4_28_15_final
MHDC Bridging_the_Gap_4_28_15_final MHDC Bridging_the_Gap_4_28_15_final
MHDC Bridging_the_Gap_4_28_15_final
Amy MacNulty
 

Similar to Residential Provider Expansion into Home and Community Based Services (20)

System Innovation in California: The Impact of MHSA
System Innovation in California: The Impact of MHSASystem Innovation in California: The Impact of MHSA
System Innovation in California: The Impact of MHSA
 
SOCW 6520 WK 5 responses Respond to the blog post of three.docx
SOCW 6520 WK 5 responses Respond to the blog post of three.docxSOCW 6520 WK 5 responses Respond to the blog post of three.docx
SOCW 6520 WK 5 responses Respond to the blog post of three.docx
 
Advancing Team-Based Care:Dissolving the Walls: Clinic Community Connections
Advancing Team-Based Care:Dissolving the Walls: Clinic Community ConnectionsAdvancing Team-Based Care:Dissolving the Walls: Clinic Community Connections
Advancing Team-Based Care:Dissolving the Walls: Clinic Community Connections
 
After reading the report on services in Georgia, write a short paper.docx
After reading the report on services in Georgia, write a short paper.docxAfter reading the report on services in Georgia, write a short paper.docx
After reading the report on services in Georgia, write a short paper.docx
 
Better Together, Inc. Community Coalition Clinic
Better Together, Inc. Community Coalition ClinicBetter Together, Inc. Community Coalition Clinic
Better Together, Inc. Community Coalition Clinic
 
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...
Medicaid: An Edge of Your Seat View of Medicaid Risk Adjustment by Merrill Ha...
 
Reducing Health Disparities: The Journey of Brightpoint Health
Reducing Health Disparities: The Journey of Brightpoint HealthReducing Health Disparities: The Journey of Brightpoint Health
Reducing Health Disparities: The Journey of Brightpoint Health
 
Lessons Learned: The Government Healthcare Transformation Journey
Lessons Learned:  The Government Healthcare Transformation JourneyLessons Learned:  The Government Healthcare Transformation Journey
Lessons Learned: The Government Healthcare Transformation Journey
 
Medicaid 101 texas
Medicaid 101 texasMedicaid 101 texas
Medicaid 101 texas
 
Medicaid 101 texas
Medicaid 101 texasMedicaid 101 texas
Medicaid 101 texas
 
MHDC Bridging_the_Gap_4_28_15_final
MHDC Bridging_the_Gap_4_28_15_final MHDC Bridging_the_Gap_4_28_15_final
MHDC Bridging_the_Gap_4_28_15_final
 
Health as Housing
Health as HousingHealth as Housing
Health as Housing
 
Latino health forum 10.12.2017
Latino health forum  10.12.2017Latino health forum  10.12.2017
Latino health forum 10.12.2017
 
GenevieveRitchiePowerPoint.pptx
GenevieveRitchiePowerPoint.pptxGenevieveRitchiePowerPoint.pptx
GenevieveRitchiePowerPoint.pptx
 
Presentation.pptx
Presentation.pptxPresentation.pptx
Presentation.pptx
 
Presentation.pptx
Presentation.pptxPresentation.pptx
Presentation.pptx
 
Hasselman medicaid and pc
Hasselman medicaid and pcHasselman medicaid and pc
Hasselman medicaid and pc
 
NAMI California Conference 2009
NAMI California Conference 2009NAMI California Conference 2009
NAMI California Conference 2009
 
IESD case studies
IESD case studiesIESD case studies
IESD case studies
 
Laporan kunjungan ke Mind Australia
Laporan kunjungan ke Mind AustraliaLaporan kunjungan ke Mind Australia
Laporan kunjungan ke Mind Australia
 

More from Innovations2Solutions

More from Innovations2Solutions (20)

2017 Workplace Trends Report
2017 Workplace Trends Report2017 Workplace Trends Report
2017 Workplace Trends Report
 
2015 Workplace Food Insights
2015 Workplace Food Insights 2015 Workplace Food Insights
2015 Workplace Food Insights
 
Changing the Conversation From Cost to Value
Changing the Conversation From Cost to ValueChanging the Conversation From Cost to Value
Changing the Conversation From Cost to Value
 
Quality of life experiences no.4
Quality of life experiences no.4Quality of life experiences no.4
Quality of life experiences no.4
 
Quality of life experiences No.3
Quality of life experiences No.3Quality of life experiences No.3
Quality of life experiences No.3
 
Quality of life experiences No.2
Quality of life experiences No.2Quality of life experiences No.2
Quality of life experiences No.2
 
Quality of life experiences No.1
Quality of life experiences No.1Quality of life experiences No.1
Quality of life experiences No.1
 
Population Health Management: a new business model for a healthier workforce
Population Health Management: a new business model for a healthier workforcePopulation Health Management: a new business model for a healthier workforce
Population Health Management: a new business model for a healthier workforce
 
2016 association for community health improvement conference: summary of proc...
2016 association for community health improvement conference: summary of proc...2016 association for community health improvement conference: summary of proc...
2016 association for community health improvement conference: summary of proc...
 
2016 16th population health colloquium: summary of proceedings
2016 16th population health colloquium: summary of proceedings 2016 16th population health colloquium: summary of proceedings
2016 16th population health colloquium: summary of proceedings
 
Using big data in hospital fm to enhance employee productivity and quality of...
Using big data in hospital fm to enhance employee productivity and quality of...Using big data in hospital fm to enhance employee productivity and quality of...
Using big data in hospital fm to enhance employee productivity and quality of...
 
The quality of work life study - research brief
The quality of work life study - research briefThe quality of work life study - research brief
The quality of work life study - research brief
 
New facilities management model delivers dramatic results
New facilities management model delivers dramatic resultsNew facilities management model delivers dramatic results
New facilities management model delivers dramatic results
 
Improving patient quality of care with recognition and rewards
Improving patient quality of care with recognition and rewardsImproving patient quality of care with recognition and rewards
Improving patient quality of care with recognition and rewards
 
Hospital room service dining: organizational impact
Hospital room service dining: organizational impactHospital room service dining: organizational impact
Hospital room service dining: organizational impact
 
Evidence-based design: definition and application in the healthcare setting
Evidence-based design: definition and application in the healthcare setting Evidence-based design: definition and application in the healthcare setting
Evidence-based design: definition and application in the healthcare setting
 
Creating adaptable communities summary from Empowering Adaptable Communities ...
Creating adaptable communities summary from Empowering Adaptable Communities ...Creating adaptable communities summary from Empowering Adaptable Communities ...
Creating adaptable communities summary from Empowering Adaptable Communities ...
 
The Reciprocal Relationship of Higher Education Institutions and Their Commun...
The Reciprocal Relationship of Higher Education Institutions and Their Commun...The Reciprocal Relationship of Higher Education Institutions and Their Commun...
The Reciprocal Relationship of Higher Education Institutions and Their Commun...
 
Continuing the Journey of Alleviating Patient Fear: Post-Discharge
Continuing the Journey of Alleviating Patient Fear: Post-DischargeContinuing the Journey of Alleviating Patient Fear: Post-Discharge
Continuing the Journey of Alleviating Patient Fear: Post-Discharge
 
Stanford Healthcare Food Transformation Journey
Stanford Healthcare Food Transformation JourneyStanford Healthcare Food Transformation Journey
Stanford Healthcare Food Transformation Journey
 

Recently uploaded

☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in Windhoek...
☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in  Windhoek...☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in  Windhoek...
☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in Windhoek...
mikehavy0
 

Recently uploaded (10)

A case study on customer satisfaction towards First cry products.
A case study on customer satisfaction towards First cry products.A case study on customer satisfaction towards First cry products.
A case study on customer satisfaction towards First cry products.
 
Navigating Hypnotherapy Training: 7 Essential Considerations
Navigating Hypnotherapy Training: 7 Essential ConsiderationsNavigating Hypnotherapy Training: 7 Essential Considerations
Navigating Hypnotherapy Training: 7 Essential Considerations
 
How Can A Life Coach Help You Deal With Self-Limiting Beliefs
How Can A Life Coach Help You Deal With Self-Limiting BeliefsHow Can A Life Coach Help You Deal With Self-Limiting Beliefs
How Can A Life Coach Help You Deal With Self-Limiting Beliefs
 
_What are the Latest Trends in Interior Home Design for 2024.pdf
_What are the Latest Trends in Interior Home Design for 2024.pdf_What are the Latest Trends in Interior Home Design for 2024.pdf
_What are the Latest Trends in Interior Home Design for 2024.pdf
 
Tokyo Presentation Final (Release -2024-).pptx
Tokyo Presentation Final (Release -2024-).pptxTokyo Presentation Final (Release -2024-).pptx
Tokyo Presentation Final (Release -2024-).pptx
 
A Brief Introductory of Nuristan, By Ab.Hakim Hakimi .pdf
A Brief Introductory of Nuristan, By Ab.Hakim Hakimi .pdfA Brief Introductory of Nuristan, By Ab.Hakim Hakimi .pdf
A Brief Introductory of Nuristan, By Ab.Hakim Hakimi .pdf
 
Deloitte Gen Z Millennial Survey 2024_India_Full length report_.pdf
Deloitte Gen Z Millennial Survey 2024_India_Full length report_.pdfDeloitte Gen Z Millennial Survey 2024_India_Full length report_.pdf
Deloitte Gen Z Millennial Survey 2024_India_Full length report_.pdf
 
5cladba ADBBWorry-free after-sales, professional team, the safest and fastest...
5cladba ADBBWorry-free after-sales, professional team, the safest and fastest...5cladba ADBBWorry-free after-sales, professional team, the safest and fastest...
5cladba ADBBWorry-free after-sales, professional team, the safest and fastest...
 
☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in Windhoek...
☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in  Windhoek...☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in  Windhoek...
☎️Contact +27791653574. 💊💊for the availability of Abortion Pills in Windhoek...
 
PRINCESS OF DESIRE: MISADVENTURES OF A YOUNG GIRL
PRINCESS OF DESIRE:  MISADVENTURES OF A YOUNG GIRLPRINCESS OF DESIRE:  MISADVENTURES OF A YOUNG GIRL
PRINCESS OF DESIRE: MISADVENTURES OF A YOUNG GIRL
 

Residential Provider Expansion into Home and Community Based Services

  • 1. Residential Provider Expansion into Home and Community-Based Services
  • 2.
  • 3. Executive Summary 2 Introduction 5 Nursing Homes Alterszentrum Viktoria, Switzerland 13 Feros Care, Australia 19 Isabella Geriatric Care, United States 31 Tabitha Health Care, United States 42 Continuing Care Retirement Communities BallyCara, Australia 51 First Choice, United States 60 Shepherd’s Care Foundation, Canada 67 Well-Spring Continuing Care Retirement Community, United States 77 Continuing Care at Home Programs Cadbury Senior Living, United States 87 Conclusion 96 Table of Contents
  • 4. 2 | Residential Provider Expansion into Home and Community-Based Services A growing number of not-for-profit, residential providers of aging services are developing new business lines in the area of home and community-based services (HCBS). These services include home health care, non-medical home care and adult day care. Few studies have examined the HCBS expansion process to identify successful business models and marketing strategies, or common challenges and lessons learned. With so many residential providers entering the field of home and community- based services, an elucidation of common themes, important lessons and promising practices would greatly benefit the sector. The Study The International Association of Homes and Services for the Ageing sought to fill this evidence gap by conducting a qualitative study of not-for-profit residential service providers that expanded to provide home and community-based services. Researchers used the case study method, combined with an analysis of emergent themes, to conduct this study. They sought to include a diverse set of providers in the study in an effort to identify emerging themes that transcended the differences among providers of aging services. This method helped researchers identify useful guidance that would apply to the array of organizations in the sector. The research team conducted structured phone interviews with two representatives of each organization, usually the chief executive officer and the vice president or director of the home and community-based services program. The purpose of the interviews was to understand the:  Program  Relevant policy context  Financial implications  Workforce  Organizational culture  Program outcomes  Perceived challenges  Perceived benefits  Lessons learned The research team also conducted two-day site visits with two organizations. One organization had a longstanding and well- developed home and community-based services program and the other was in the early stages of expanding into HCBS. The site visits featured focus groups or telephone interviews with:  Home health and home care aides  Other frontline staff  Supervisors of frontline staff  Additional executives  Marketing, human resources and quality-assurance staff The site visits allowed the research team to enrich the perspectives developed during the phone interviews and to focus more deeply on certain areas, including successful strategies for staffing the new business lines and the financial implications of the expansion. Researchers wrote case studies describing each participating provider. They also identified common themes that emerged across these diverse organizations. An evaluation of the themes led to the identification of guidelines that might be useful to providers that are considering an expansion into home and community-based services, or are in the early stages of such an expansion. Each case study, as well as a discussion of the emerging themes and lessons, is included in this report. The Organizations The research team completed case studies of five U.S. providers, one Canadian provider, two Australian providers and one European provider. Executive Summary
  • 5. Sodexo • IAHSA • LeadingAge | 3 Nursing Homes Four organizations included in the study began as nursing homes: Alterszentrum Viktoria (Bern, Switzerland): Beginning as a nursing home in 1995, Alterszentrum Viktoria began providing home health care and limited non-medical home care to members of the external community in 2011. The organization’s small program currently serves 23 clients. Its predominant source of reimbursement is mandated insurance. Feros Care (Queensland, Australia): Established as an operator of two nursing homes in the early 1990s, Feros Care expanded into home and community-based services in 2002- 2003 and now delivers home health care, home care, telehealth, companionship, and other services to approximately 5,000 clients per year. The Australian government’s Home Care Packages Program comprises its main source of reimbursement for home health and home care. Isabella Geriatric Center (New York, USA): Founded as a nursing home in 1875, the non-sectarian Isabella Geriatric began expanding into home and community-based services in 1989. The organization now provides more than one million service hours per year of home health care, home care, adult day and other services. Isabella serves mainly low-income clients. Its primary payer source for home health care is Medicaid. Tabitha Health Care (Nebraska, USA): Established as an orphanage in 1886 and a nursing home in 1890, faith-based Tabitha began providing home health care in 1966 and home care in 1974. Each month, the organization delivers more than 10,000 service hours of home care and serves an average of 254 home health clients. Tabitha’s main source of reimbursement for home health care is Medicare. Most of its home care services are private pay. Continuing Care Retirement Communities Four organizations included in the study began as continuing care retirement communities (CCRCs) or a CCRC-like entity, and developed traditional home and community-based services programs. They include: BallyCara Village of Friends (Queensland, Australia): BallyCara began in 1983 as a residential provider offering successively higher levels of care, from independent living to a nursing home. The organization expanded to home and community-based services in 2013 and now provides an average of 458 service hours to 200 external clients per month. BallyCara’s funding sources are a mix of government-funded and private pay. First Choice (Virginia, USA): Founded by two faith-based CCRCs in 2007, with a third partner joining the partnership in 2015, First Choice now provides more than 4,000 service hours of home care per month and serves 65-70 home health clients per day. First Choice was established through a partnership among three providers that acquired an existing agency with a client base. The agency’s primary funding sources are Medicare, private insurance and private pay. Shepherd’s Care Foundation (Alberta, Canada): Beginning as a CCRC 45 years ago, faith-based Shepherd’s Care began providing companionship, transportation services and other home care services in September 2014. Older adults living in the organization’s residential communities make up the majority of home care clients. Shepherd’s Care structured its home and community-based service lines within a separate, for-profit corporate entity that now provides more than 1,500 service hours per month to approximately 40 clients. Its main sources of reimbursement are currently private pay and government contracts. EXECUTIVE SUMMARY
  • 6. 4 | Residential Provider Expansion into Home and Community-Based Services Well-Spring (North Carolina, USA): In addition to operating a CCRC, Well-Spring provides home care and adult day services to the external community. Each month, the organization delivers more than 10,000 hours of home care, approximately 1,000 of which are delivered outside the CCRC. Well-Spring’s adult day program serves approximately 200 clients each month. The organization’s primary source of reimbursement for home care is private pay. The adult day program has multiple funding sources. Continuing Care at Home One organization included in the study began as a CCRC and provides home and community-based services through a “continuing care without walls” or “continuing care at home” program. Cadbury at Home (New Jersey, USA): Founded as a CCRC, Cadbury established a continuing care at home program in 1998. The program provides a full range of services to its 200 members. Those services include home health care and non-medical home care. The organization’s primary source of reimbursement is private pay. The expansion timeline for organizations in this study ranges from more than 25 years (Tabitha Health Care and Isabella Geriatric Center) to under one year (Shepherd’s Care Foundation). This range of experience with home and community-based services allowed researchers to glean insights from individuals whose programs had a long track record of success, and from individuals whose programs are currently in the planning and early-implementation stages. Common Themes: Highlights An analysis of interview transcripts, notes and case studies revealed several common themes among the organizations regarding their experiences with the expansion process. Some highlights of these themes are described below. Reasons for expanding: When asked why they expanded into home and community-based services, most organizations cited a desire to fulfill their mission by serving more community members, as well as a desire to grow their roster of services in order to provide a continuum of care. Some providers said they hoped to become a “one-stop shop” that community-dwelling older adults and their adult children would turn to for all of their aging services needs. Additionally, some organizations said they were seeking additional revenue streams to support their residential businesses. Staffing: All organizations in the sample primarily hired new frontline staff for their home and community-based service lines, rather than redeploying frontline residential staff. Organizations took this approach because the type of worker who thrives in the home care environment tends to differ from the type of worker who thrives in a residential setting. The organizations often shared back-end support systems with the residential services division. Funding: Several organizations said they were seeking the best balance between government and private funding. Home and community-based service lines drew on private-pay clients and had the potential to provide surplus revenue. Challenges: Most providers said they faced tough competition and found it difficult, at least at first, to distinguish themselves from their competitors. Some organizations also cited the difficulty of maintaining communication with the workforce during the expansion process, especially regarding the organization’s brand and high standards. Benefits: Several providers noted that their home and community-based service lines provided their organizations with referrals to on-campus services. Most providers said they derived pleasure from fulfilling their organization’s mission. Organizations also reaped financial benefits from the expansion into home and community-based services. Lessons Learned and Promising Practices: Highlights Many of the lessons providers said they learned during the expansion process concerned marketing. Several providers emphasized the need to conduct in-depth market analysis before expanding into home and community-based services. Providers emphasized the importance of understanding the needs and desires of the target community before designing the HCBS business model. Providers should consider how to distinguish their service lines from the competition, according to study participants. Several providers also noted that marketing strategies that are successful for home and community-based services differ from successful marketing practices for residential services. HCBS marketing tends to be referral-based while residential care marketing tends to depend on word-of-mouth. It is important to understand these differences in advance. Prior to launching a home and community-based service program, it is important to develop a network that fosters relationships with referral sources. Providers also should develop a business strategy that aligns with the realities of the market. Several providers noted the importance of educating staff members, residents, boards of directors and consumers about the value of HCBS programs. Finding the “right” workers for the home setting is critical to the success of HCBS programs. Providers emphasized the importance of developing and supporting staff. Workers should be empowered to identify client needs and provide services to meet those needs. Study participants discussed their strategies for expanding to new services lines and geographical areas. Providers might consider using contract staff and then hiring their own staff, they suggest. Virtual offices can also enable organizations to operate multiple satellite offices with minimal infrastructure. EXECUTIVE SUMMARY
  • 7. Sodexo • IAHSA • LeadingAge | 5 The International Association of Homes and Services for the Ageing (IAHSA) and LeadingAge collaborated on a project to examine why and how aging service providers transition from a residential setting model into a home and community-based services (HCBS) model, and to examine the operations of the programs. Sodexo Institute for Quality of Daily Life, a research partner of IAHSA, funded the project. The research team performed a qualitative study of not- for-profit residential providers. As part of this effort, the team conducted 90- to 120-minute telephone interviews with nine provider organizations in the United States, Canada, Switzerland and Australia. The interviews typically were conducted with the organization’s president/chief executive officer and the vice president or director of the HCBS program. These interviews covered the following topics:  Reason for expanding into home and community-based services  History and description of the current program  Relevant policy context  Financial implications of the HCBS program  Workforce  Organizational culture  Program outcomes  Perceived challenges  Perceived benefits  Lessons learned through the experience The research team also conducted two-day site visits to two organizations: one organization in the United States had a longstanding and well-developed HCBS program, and one organization in Canada was in the early stages of expanding into home and community-based services. During each site visit, the research team held focus groups with agency aides who directly provided care, other frontline staff,1 and supervisors of frontline staff. The site visits also included structured interviews with additional executives, including the chief operating officer at one site and the chief financial officer at the other; and the directors of marketing, human resources and quality assurance. Researchers sought to gain an in-depth understanding of the programs’ implementation, operations and impact. Researchers wrote case studies describing each participating provider, and then analyzed all transcripts and notes to identify common themes that emerged across these diverse organizations. An evaluation of these themes led to the identification of guidelines that might be useful to providers that are considering an expansion into home and community- based services, or are in the early stages of such an expansion. Each case study, as well as a discussion of the emerging themes and lessons, is included in this report. Any errors in the study report are the responsibility of the authors. Background Aging services providers are reinventing themselves by offering home and community-based services to on-campus residents and older adults living in the external community. These organizations offer programs and services that reach beyond the traditional, residential setting to meet consumer demands and the economic realities of people who are aging in their own homes. Demand for services like in-home care and adult day is booming in many countries. Providers’ reasons for expansion are varied and numerous, including meeting consumer demands to age in place, reaching a greater percentage of the older adult population, seeking new revenue streams in the face of low occupancy rates, diversifying payer services, and enhancing the organization’s brand. Home and community-based services can be delivered to a consumer at home or in a campus-based supportive living or independent living setting. Operators have a variety of options Introduction
  • 8. 6 | Residential Provider Expansion into Home and Community-Based Services as they design an HCBS program. These programs can include, but are not limited to:  Private duty (non-medical) home care: This service provides assistance with activities of daily living or instrumental activities of daily living, companionship services, or specialized care. A non-licensed caregiver usually provides the care. In some cases, a certified aide provides care.  Home health care: This type of intermittent skilled care requires more expertise than private duty care and more regulatory oversight.  Continuing Care at Home: This package of long-term services and supports is provided to adults who want the security that a retirement community offers but want to remain at home. This HCBS program differs from the traditional home and community-based programs that CCRCs deliver in the community. A continuing care at home program takes the concept of the life care contract and a bundle of services into the home. Continuing care at home is not just a menu of services that consumers purchase on an as-needed basis. Rather, it is a comprehensive approach to providing a health and wellness lifestyle to older adults in their homes. Aging service providers follow different models when designing the structure of their HCBS program. That program can be a department within the retirement community, a separate agency, or an affiliate of the retirement community. The organization might also choose to provide home and community-based services through multiple partners. Government or private-pay reimbursement for different services varies widely by region and by case. Participating Providers The research team completed case studies of four U.S. providers, one Canadian provider, two Australian providers and one Swiss provider. A fifth U.S. provider also participated in the study, even though the organization does not offer a traditional HCBS program. The provider delivers continuing care at home, an emerging model that is described on page 87. A brief description of each provider is presented below. More detailed descriptions can be found in the individual case studies. The organizations participating in this study differed in a number of ways, including:  Nature of initial residential services  Design of the current HCBS line  Size of the workforce  Number of clients served  Number of years since the initial expansion  Location  Primary payer sources  Policy contexts and regulatory challenges encountered Nursing Homes Four organizations included in the study began as nursing homes. Alterszentrum Viktoria in Berne, Switzerland was established as a nursing home in 1995. It expanded to offer home and community-based services to external clients in 2011. Viktoria provides primarily home health (medical) care and limited non-medical care to 23 clients in the community. Its predominant source of reimbursement is government-mandated insurance. The organization started a new program that is housed within the parent organization. Feros Care in Queensland, Australia is a standalone organization that provides assisted or supportive living care and nursing home care. Feros Care expanded into home and community-based services in 2002-2003 and now delivers personal care, home care, social care, allied health care, wellness services and an extensive range of telehealth services to 5,000 clients each year. Its main source of reimbursement for home health and home care is the Australian government’s Home Care Packages Program. The HCBS program delivers services through a combination of new programs and strategic partnerships. The program is housed within the parent organization and has 245 service partners.
  • 9. Sodexo • IAHSA • LeadingAge | 7 Isabella Geriatric Care in New York, United States is a non- sectarian organization that has provided care for older adults since 1875. Founded as a traditional nursing home, Isabella now provides a continuum of services, including nursing home care, moderately priced senior housing, adult day health care, child day care, home care, certified home health care, licensed home health care, short- and long-term rehabilitation, Naturally Occurring Retirement Community (NORC) services,2 community-based care coordination, and other community programs designed to help older adults remain healthy and independent at home. Isabella began offering home and community-based services in 1989. It delivers more than one million service hours per year. Its primary payer sources are Medicaid and managed care. Isabella started its own programs, which are now part of overall organization. Tabitha Health Care in Nebraska, United States started as a nursing home in 1890. It has since expanded to offer older adults a comprehensive line of services, including three nursing homes for rehabilitation and long-term care, assisted living, affordable senior housing, and a variety of home and community-based services. These services include home health care, non- medical home care, adult day services, Meals on Wheels, and personalized services. Each month, Tabitha provides more than 10,000 home care service hours and serves an average of 254 home health clients. Its main source of reimbursement for home health care is Medicare. Its main source of reimbursement for private duty is private pay. Tabitha started a new program, which is now part of the parent organization. Continuing Care Retirement Communities Four organizations included in the study began as continuing care retirement communities (CCRCs)3 or a CCRC-like entity, and developed traditional home and community-based service programs. BallyCara Village of Friends in Queensland, Australia is a residential provider offering progressively higher levels of care, including independent living, assisted living and nursing home care. BallyCara established its first home and community- based services program in October 2013. The organization provides external clients with private duty care that includes domestic assistance, home maintenance, transportation and social support. BallyCara Community Care serves approximately 200 clients across all its home care service lines and averages 428 service hours each month. Its main funding sources are government funding for home care, private pay and government-allocated Home Care Packages, which it currently delivers in partnership with other providers that have been allocated funding by the Australian government. The HCBS programs, which feature a combination of new programs and strategic partnerships, are housed within the parent organization. First Choice in Virginia, United States is a home health and home care agency jointly owned by three retirement communities: Virginia Mennonite Retirement Community (VMRC), Bridgewater Retirement Community and Sunnyside Communities. VMRC and Bridgewater jointly purchased First Choice in 2007. Sunnyside Communities joined the partnership in 2015. First Choice provides home health and home care services to people living on retirement community campuses and in their own homes. The agency serves 65 to 70 home health clients each day and provides 4,000 hours of home care services each month. Its primary funding sources are Medicare, private insurance and private pay. Shepherd’s Care Foundation in Alberta, Canada was founded in 1970 and is a faith-based retirement community offering independent living, supportive living and nursing home care on its campus. The organization serves more than 1,600 older adults who have low to moderate incomes. Shepherd’s Care Foundation extended its service lines into home care in October 2014 and offers transportation and companionship services. The agency delivers 1,500 service hours each month. Shepherd’s Care at Home, a for-profit agency, is independent and separate from Shepherd’s Care Foundation. Its main sources of reimbursement are private pay and government contracts. Well-Spring Retirement Community in North Carolina, United States was established in 1993 by a coalition of nine local churches. Well-Spring offers several different types of home and community-based programs: the Program of All Inclusive Care for the Elderly4 , adult day care, and home care. The organization acquired an existing adult day provider and started a new home care program. The adult day and home care services have since combined and are under the umbrella of Well-Spring. Well-Spring delivers more than 10,000 hours of home care per month, of which 1,000 are supplied outside the Well-Spring CCRC. The adult day program serves approximately 200 clients each month. The primary source of reimbursement for home care is private pay. The adult day program relies on a variety of funding sources. Continuing Care at Home One organization included in the study began as a CCRC and provides home and community-based services through a continuing care at home program. Cadbury Senior Living in New Jersey and Delaware, United States launched its Continuing Care at Home program in 1998. Cadbury at Home, one of the first continuing care at home programs in the United States, combines home care, assisted living and nursing home care into a comprehensive program that provides members with long-term services and supports in the home and the opportunity to move onto the CCRC campus as their health care needs change. The program’s primary source of reimbursement is private pay. The at-home program was created by Cadbury and is affiliated with the parent organization. INTRODUCTION
  • 10. 8 | Residential Provider Expansion into Home and Community-Based Services Overview of Providers5 The timeline for expansion into home and community-based services varied considerably for the eight providers with traditional HCBS programs:  Over 25 years (Tabitha Home Health and Isabella Geriatric Center)  Eight to 10 years (First Choice and Feros Care)  Three years or less (Viktoria, Well-Spring and Shepherd’s Care). Cadbury’s continuing care at home program has been in existence almost 20 years. Size of Program Agencies reported the size of their program in different ways: hours per month and number of clients per month or year. Some agencies chose to report the number of service hours instead of number of clients because of clients’ wide range of service needs. For example, some clients only require a few hours of service each month while others require more than 16 hours each day. The agencies felt the service hours provided a more accurate portrayal of their size than the number of clients served. This was particularly true for the private duty care.  All four providers who offered both home health and home care had a substantial client base. Their service hours ranged from 4,000 to 10,000 hours each month to one million service hours each year.  Two out of the three providers delivering home care only had a smaller client base. One agency averaged 428 service hours each month while another delivered 1,500 service hours per month. One agency delivered 10,000 service hours per month to on-campus residents primarily. That agency delivered approximately 1,000 hours per month to off-campus clients.  The remaining home health care agency served approximately 23 clients. Type of Partnership Organizations considered many factors when deciding whether to house the home care/home health agency within the parent corporation or establish it as a separate organization. The factors—including financial, legal, expertise-related, and branding-related issues—will be described more fully later in this Introduction. The majority of the providers have kept the home care/ home health agency as part of the parent organization. One retirement community bought an existing agency to deliver adult day services. This business will reside on the main campus and house all of the organization’s HCBS programs, including home care. While the parent company and the adult day provider have separate boards of directors, they are legally connected with each other. Two home care providers function independently from the parent organization. One home health/home care agency is operated through a joint venture of three provider organizations that purchased the agency. The other provider structured the agency so it would be separate and independent from the parent organization. Reasons for Expansion Residential providers diversified their service lines as a way to fulfill the organization’s mission, reach a larger percentage of the target population, create marketing opportunities and referrals for a retirement community, develop a potential revenue stream, and transform the organization into a “one- stop shop.” Several providers cited more than one of these reasons for expanding. Mission: Skilled nursing home providers and aging-in-place providers that offer a tiered approach to the aging process by combining independent living, assisted living and skilled nursing home care may not be able to reach all individuals. In addition, some aging-in-place providers attract wealthier clients and their care is not affordable to low- or modest- income groups. By diversifying service lines, the organization can potentially serve less-affluent clients and reach the most vulnerable individuals in the community. Expanded reach: As more people choose to remain at home, organizations that provide only residential options will be unable to reach a significant portion of the older adult population, including older adults who are unlikely to use on- campus services. Providing services in the community is an opportunity to serve these individuals. Retirement community feeder: When community-dwelling older adults, or their family members, require higher levels of care, they may consider moving to a residential care setting. A home and community-based service line can serve as a feeder into an organization’s other business lines by creating brand awareness and connecting with consumers. When those connections are made early in the aging process, The eight agencies with traditional HCBS programs offered a mix of service types: % provided private duty or home care only % provided both private duty care and home health care provided home health care only 38 50 1 INTRODUCTION
  • 11. Sodexo • IAHSA • LeadingAge | 9 individuals and their family/support networks will think of the organization when they need more services. Potential revenue stream: A home and community-based service line can supplement or support revenues from the residential side of a business. The expansion into other services lines also can attract different payer sources. One-stop shop: A provider of aging services can be a “one- stop shop” for individuals by providing a full continuum of care, starting with services in a person’s home. The provider can ensure that it helps people no matter where they live or what level of care they need. In addition, campus residents can receive high-quality home and community-based services from a home care/home health agency that is affiliated with or a department within the parent organization. Workforce Organizational environment: A strong workforce is a critical component of any HCBS program. Staff members, particularly the aides who provide direct care, are much more autonomous and work with less supervision than their counterparts in the residential setting. Aides in the home care setting also perform a greater variety of tasks, have more responsibility to make accurate and timely observations, and require flexibility. Aides rarely report to the agency. Instead, they go directly to the client’s home to provide care. It can be challenging for home health and home care agencies to create camaraderie among their employees. These workers have few opportunities to engage and connect with each other. Special events, trainings and meetings can give staff the opportunity to share information and build connections with each other. A few providers occasionally use these events to give staff from the HCBS and residential programs the opportunity to interact with each other. Hiring and orienting staff: Most providers did not staff the HCBS program by redeploying staff from the organization’s residential settings. Instead, they hired new staff with experience in the home setting, including a vice president or director of home and community-based with extensive experience in the type of service lines included in the HCBS program. A few providers held some type of orientation for new staff. This generally included an introduction to the organization. Supervisors in some organizations accompanied new staff members on their first home visit and introduced the aide to the client. One provider recommended using a “buddy system” to allow a new aide to shadow an experienced aide a few times before going out alone. Training sessions: Almost all of the providers who offered additional staff trainings held separate training sessions for residential and home care aides. This decision was based on the fact that home care and residential staff work in very different work environments. Two providers conducted some form of combined trainings. One provider held a joint orientation for aides from both environments and separate in-service trainings. Training sessions often included a mix of mandated education for certified aides as well as additional trainings that exceeded government requirements. Providers typically seek input from aides when deciding on topics for trainings sessions, which often address specific diseases or issues aides encounter while caring for the organization’s clients. Staff resources: Two providers with separate home care/ home health agencies did not share resources or staff with the residential provider. Other providers often called on the organization’s management team to run the daily operations of the HCBS program. The residential and home care businesses frequently shared back-end support functions, including executive management, financial management, human resources, billing, and information technology. This arrangement helped to spread administrative costs over several business lines. Some providers relied on a single marketing team to promote their home-based and residential businesses. Other providers had separate marketing teams because marketing strategies for home-based and residential care are so different. Quality assurance and supervision: The quality of the HCBS programs are monitored in a variety of ways, depending, in part, on the source of funding. Home health care programs were generally required to submit data on specified quality indicators to the government. Some home health and home care providers used their quality improvement committees to review that data and make action plans to improve or change operations based on the findings. Approximately half of the providers elicited feedback from clients and family members to determine their satisfaction with the services. Providers also supervised the aides, although the level of supervision varied and aides and supervisors typically had little interaction. Most providers had a process in place to address clients’ complaints, although some systems were more formal and sophisticated than other systems. Outcomes Few providers conducted formal evaluations of their programs to determine their impact on consumers. Most of the providers that measured outcomes conducted client and family member surveys or solicited feedback to assess satisfaction with provided services. Some providers have established committees or other groups to review satisfaction data and develop action plans to address areas of concern. Organizations that offer home health care through government funding have formal assessments and are measured on select quality indicators. A few providers have initiated efforts to track key measures through dashboards or scorecards. Challenges Providers experienced challenges in launching, operationalizing and sustaining their HCBS programs. The key difficulties reported by providers included: Market competition: Organizations encounter competition from other home care or home health providers serving the same demographic group and geographic area. This can limit the growth potential for agencies. In some regions, providers who rely on government-funded services have found that select entities have a large share of the market because they INTRODUCTION
  • 12. 10 | Residential Provider Expansion into Home and Community-Based Services are an official government provider or have a longstanding relationship with the government. Providers emphasized the importance of defining a niche for a program and identifying features that distinguish the program from its competitors. Financial: Most HCBS programs operated at a loss, at least during their first year. Growth can be slow due to difficulties associated with growing the program’s client base. Additionally, providers struggled to establish the best balance between private-pay and government-funded services. Clients: Remaining solvent often involves balancing the case mix of clients and their utilization of services. Home health and home care aides reported challenges working with clients who were noncompliant with the services listed on their care plans, were combative or aggressive, or whose family members expected that aides would provide services to them in addition to the client. Regulations: Providers experienced challenges with regulations. A common regulation required organizations to have a certificate of need to enter the market. The certificate of need process requires approval from the state health planning agency before an organization can begin any major capital project, such as expansion into home health. As a result, the government can limit the number licenses/certifications it issues to service providers. Additional challenges included:  Inconsistency in the funding that a government issues to different service providers  Strict regulations to create or fund HCBS programs Staffing: Hiring and retaining the “right staff” for the home care environment was challenging for several providers. The home setting is different from the residential setting and certain characteristics make individuals better suited for the more autonomous setting. In addition, providers experienced staffing shortages because they could not find staff with adequate qualifications, or lacked sufficient staff when there was increased demand for services. Benefits Continuum of care: Providing a multitude of services allows the provider to support the individual through the continuum of care. Clients can age as they wish and the organization can adapt to client needs and the desire of consumers to stay at home. The organization can provide care across service lines and across the aging process. Expanding market and mission: The addition of home and community-based services is an opportunity to expand the number of older adults an organization can serve and to reach a greater percentage of the target population. An HCBS program targets a different market composed of individuals who choose not to live on a campus and prefer to age in the home. A provider that serves a more affluent resident population can use an HCBS program to serve individuals with more modest incomes. The HCBS provider also can help consumers navigate the system of long-term services and supports, and can reach a variety of individuals through different service lines. Relationships and marketing opportunities: Serving people at home creates a relationship between the provider and consumers early in the aging process. The retirement community can build awareness of its on-campus options and market its services. The client and family members can build trust with the provider and can be comforted by the fact that they can turn to the same organization over time. Clients, or the members of their family/support networks, may become on- campus residents when their care needs change and they require higher levels of care. Financial: HCBS programs have generated revenues and positive financial gains for some providers. These revenues are particularly beneficial when interest in retirement community living is down. The additional service lines also have diversified the revenue stream in some organizations. An organization’s residential setting may be supported primarily by publicly funded services. The HCBS program, which may rely more on private funding, can augment and subsidize the public funding. Lessons Learned Providers offer several suggestions for residential service providers that are considering or already expanding into home and community-based services. These suggestions are based on their experience launching and operating HCBS programs. Prior to Launch Market research: It is important to know the needs of the community, and understand the competition, before launching a program. Conduct extensive market research to understand what services the community wants and how to most effectively market to the target group. Identify organizations that already Organizations encounter competition from other home care or home health providers serving the same demographic group and geographic area. This can limit the growth potential for agencies. Serving people at home creates a relationship between the provider and consumers early in the aging process. INTRODUCTION
  • 13. Sodexo • IAHSA • LeadingAge | 11 provide the services you want to offer and learn about their successes and challenges. Understanding the market can lead to greater program success. For example, one provider noted that its superficial market analyses identified the services consumers wanted, but not the services for which they were willing to pay. This resulted in lower-than-expected rates of participation in a transportation program. Networks and partnerships: Establish a network prior to launching the program. The network should include potential referral sources and partners that will help you build the client base. Build relationships with key referral sources, including hospital discharge planners, physician practices or insurance companies. Evaluate whether it is more beneficial to compete with other providers in the community, or collaborate with them to fill specific service gaps. Carefully review a prospective partner’s business plan, philosophy, organizational cultures and “business chemistry” to ensure compatibility. Business strategy: Have a defined strategy in place before starting your program. Test the business idea. Develop a solid business plan and vision of how to operationalize the program. The business plan should align with the realities of the market. Education: Educate staff and residents about home care/ home health care and how it can benefit the organization, workforce and community. Consider educating the board of directors about the reasons and benefits for diversifying service lines. Think about conducting informational sessions or workshops to educate community members. Staffing: Staff the home care/home health business with people who have the right personalities and backgrounds to launch and operate the program. These individuals should have an understanding of home and community-based services, particularly the service lines at your organization. They should also be familiar with the different payment models. Ensure that you care for your aides to engender loyalty among current aides and attract the best aides through word-of-mouth recommendations. Program Operations Expanding service lines and geography: When expanding into new geographic areas, consider using contract staff that will establish your brand by providing excellent service. Then hire your own staff to ease management and communication demands while further building your reputation. Establish virtual offices to minimize the infrastructure needed to expand. These strategies can help providers open multiple satellite office and gain clientele. Leadership patience: It takes time and energy to move outside your core business and start a new service line, even when partnering with an existing agency. The leadership team will have to understand, grow and expand the new model of care. Start with relatively few services and clients and gradually build up your capabilities. Learn from your experiences and growing pains. Staff and systems development: Engage in a continual process of staff and systems development. Recruit potential hires well, offer them good initial training, and train them throughout their tenure with the organization. Consider creating career pathways to retain staff. Understand the needs of consumers: Listen carefully to clients and members of their family/support networks to ensure that you understand their priorities. Learn what consumers value most and be sure to provide it. Marketing strategy: Employ a comprehensive strategy to promote your services. Recognize that marketing the HCBS program will require different strategies than marketing your residential services. Consider reinforcing your brand identity and distinguishing your services from the competition. In many regions, it is critical to engage referral sources for your program. You can accomplish this by meeting with referring agencies, attending networking events, accepting speaking engagements, and sponsoring celebrations and other organizational events. One particularly successful organization stressed that organizations need to distinguish their service lines and direct their marketing to different groups of potential clients, while maintaining the primacy and quality of the organization’s brand.   It is important to know the needs of the community, and understand the competition, before launching a program. Conduct extensive market research to understand what services the community wants and how to most effectively market to the target group. INTRODUCTION
  • 15. Sodexo • IAHSA • LeadingAge | 13 Introduction Alterszentrum Viktoria was established in 1995 as a nursing home. It offers residential care to protected group homes for dementia patients, community nursing services, and medical care. Alterszentrum Viktoria also has independent housing with access to various services, as required. The organization began providing primarily medical and limited non-medical care to external clients in 2011 after making a strategic decision to expand its services and its client base. This study of Alterszentrum Viktoria’s expansion into home and community-based services was conducted through interviews with the organization’s director and a member of its board of directors. Policy Context Switzerland is a confederation of 26 independent cantons (federal states) that are distributed among the country’s four regions. Alterszentrum Viktoria is located in the Canton of Bern. Governance of Switzerland’s system of long-term services and supports is highly decentralized and involves federal, cantonal and communal governments. Primarily, cantonal governments develop policies affecting older people and long-term care services. Each canton has its own government and set of rules for each sector of the health care system. However, cantons may coordinate their actions at the regional or national level. Swiss government policy has favored home care, over care in nursing homes, for several years. The government is working to ensure that individuals who require nursing home care can stay in their own homes or apartments until the end of life and will not be required to move to a special care unit. There are two reasons why home care is preferred:  Delivering care services within the older person’s social environment allows relatives, friends and neighbors to continue providing informal care.  Home care reduces the pressure on nursing home beds and leads to a more rational and economical use of those beds. When nursing home beds are not available, older people who cannot remain at home often are sent to the hospital, even though they do not have a medical need to be there. Insurance providers, not the government, pay almost all the expenses associated with physician-approved, home-based medical care. Care recipients pay a small percentage (10%) of these expenses out of their own pockets. Reimbursement rates for home-based medical care are consistent and do not fluctuate. However, the tendency for insurance providers to reduce their fees each year has resulted in lower prices for consumers, but lower reimbursements for organizations that provide services to those consumers. Swiss providers considering an expansion into medical home health care services must obtain a license after demonstrating that they meet criteria established by the canton. License holders must have the professional staff necessary to deliver medical care. If a provider meets this requirement, it will be approved, receive a license, and be free to open a home health care agency. The government continues to monitor the agency to ensure that it provides quality services. Each canton has one government-sponsored home health care agency. The government-sponsored home health care provider in Bern is strong and has been operating for many years. Private providers, including Alterszentrum Viktoria home health care, compete with the government agency. This makes it challenging, from a business point of view, to enter the home health care market and obtain new clients. Alterszentrum Viktoria Bern, Switzerland | January 2015 Case Study
  • 16. 14 | Residential Provider Expansion into Home and Community-Based Services On the regulatory side, however, the Canton of Bern has few regulations for the home health care service sector. It is relatively easy for providers to enter the market once they have hired professional staff. If an agency has a license and maintains standards of quality, it faces few problems from the canton. An agency that wishes to provide non-medical care is not required to obtain a license or to meet any government requirements. This regulatory environment made it fairly easy for Alterszentrum Viktoria to diversify its services. Expansion into Home and Community- Based Services Alterszentrum Viktoria was established in 1995 as a nursing home. The organization began offering primarily medical and limited non-medical care to external clients in 2011. Alterszentrum Viktoria’s diversification into home care was driven primarily by government policies that provide stronger support to home care services than to nursing home services. Alterszentrum Viktoria’s management and board of directors made the decision to provide services to the general public so the organization could diversify its services and reach a larger percentage of the older population. Management and board were also seeking an opportunity to market the organization’s other services to home care clients who might require higher levels of care and services over time. It is not uncommon for nursing home providers in Switzerland to launch external home care services. Most (90%) Swiss adults who require assistance live in their own homes. Only a small percentage of these adults reside in nursing homes. In this market environment, the survival of nursing homes depends on their ability to offer services to external clients. However, competition for these external clients is fierce. Process for Launching the Program When the Alterszentrum Viktoria board of directors approved home and community-based services as a new service line, it was making a strategic decision to grow the organization. The government approved Alterszentrum Viktoria’s request to provide home health care and provided the documentation that the organization needed to deliver these services. Alterszentrum Viktoria decided to focus primarily on offering medical home care due to the great need—and high demand— for these services in the community. State-mandated insurance covers medical care services if a physician prescribes them. Competition in the Marketplace Alterszentrum Viktoria provides limited non-medical home care and, at this time, is not interested in expanding its non- medical care. Providing non-medical home care is much more challenging than providing medical home care because state- mandated insurance does not cover non-medical services and providers do not need a license to enter the market. Several factors increase competition among providers of non- medical care services:  Many agencies offer non-medical care services.  Consumers must pay for non-medical services out of their own pockets.  Clients often do not want to pay for the assistance they receive. Intense market competition also characterizes the medical home health care market. Specifically:  Home health care providers face competition from many private and government-owned agencies. As a result, growing a client base is a slow process for most providers.  The market is open to any provider that obtains a license. There are no mandated restrictions on the number of home health care agencies that can deliver services in a specific geographic area. Description of the Program Partnerships Alterszentrum Viktoria provides its home health care services in-house and does not partner with outside agencies, although it does belong to an association representing not- for-profit providers. The organization considered establishing a partnership to lower its investment in software and staff education. However, stiff competition made it difficult to collaborate with outside agencies. In addition, partnerships with outside entities are not common in Switzerland. Most organizations believe that they can “do it better” on their own. Having an in-house agency allows Alterszentrum Viktoria to deliver home health care services to individuals in the community and to bring these services to independent residents who live on its campus. Alterszentrum Viktoria’s board of directors is considering the possibility of converting the nursing Alterszentrum Viktoria
  • 17. Sodexo • IAHSA • LeadingAge | 15 1868 Guesthouse called Viktoria built. 1897 Expansion of Viktoria sanatorium into Viktoria hospital. 2008 Opening of day center. 1870 Viktoria is a sanatorium. 1991–95 Viktoria Hospital converted to a nursing home. 2011 Founding of home health care agency. Timeline Alterszentrum Viktoria
  • 18. 16 | Residential Provider Expansion into Home and Community-Based Services home portion of its campus to independent apartments. The organization would then bring at-home services to the apartments. This option could help the organization reach more clients and strengthen its home health care service agency. Admission Criteria Before an individual can receive medical home health care, a physician must determine that he or she meets the criteria for this care. Non-medical care does not require a doctor’s approval and individuals do not have to meet eligibility requirements before they can receive these services. Services Alterszentrum Viktoria offers a range of medical care services to support older adults so they can stay in their own homes for as long as possible. As a supplement to medical care, the organization’s staff also provides limited non-medical services, including meals, cleaning, transportation and shopping. Alterszentrum Viktoria clients who require extensive non- medical services must receive those services from a different provider. The organization maintains a list of providers in Bern that can deliver this type of care. Staff will make recommendations to clients who need more services than Alterszentrum Viktoria can provide. Alterszentrum Viktoria staff members provide home health care services for a minimum of 15 minutes. The organization offers services from 7 a.m. to 11 p.m., on weekdays and weekends. The agency does not provide overnight care, mostly because it is too small to offer this type of coverage. Clients Alterszentrum Viktoria has been providing home and community-based services for the past four years. It has been difficult to expand the program’s client base due to competition from other providers. As a result, the organization currently serves only 23 individuals. Most clients (95%) receive medical care. On average, Viktoria adds five to eight new clients each year. Alterszentrum Viktoria was not able to provide demographic information about its home health care clients. While the organization collects data about residents living on its campus, it does not currently gather information about clients living in the community. The organization estimates that only about half of its clients live alone and do not have family caregivers. Quality Assurance The Canton of Bern monitors the quality of Alterszentrum Viktoria’s home health care services. Bern, like other cantons, strictly supervises home health care providers and specifies guidelines for provider quality and staff professionalism. At a minimum, the canton conducts an annual, unannounced site visit to assess the agency. During this annual assessment, the home health care provider uses special instruments to measure the quality of its services. Alterszentrum Viktoria does not track quality measures outside of the government oversight process. The government uses its funds as leverage when providers do not fulfill regulatory requirements. If an agency does not meet
  • 19. Sodexo • IAHSA • LeadingAge | 17 the canton’s standards, the canton will discontinue payment for services and close down the provider. When a client has a complaint about a home health care agency, its staff or services, the complaint is first addressed by the organization. If the organization is not successful in resolving the issue, the complaint is then forwarded to a canton office that is charged with handling complaints about home health care services. Since non-medical care services are private pay, the cantons do not conduct oversight to ensure the quality of those services. Instead, the private market controls quality and outcomes. It is assumed that clients will select a different provider if an agency does not meet a client’s quality standards. Alterszentrum Viktoria’s home health care staff consists only of nurses. There are no aides on staff. After the government issues a license, it supervises home health care nurses in the same way that it supervises nursing home nurses. Workforce Alterszentrum Viktoria’s home health care agency has two co- directors and nine full-time nurses. The organization’s client- base is not large enough to warrant additional staff. Home health care nurses care for the same clients each week, when possible, and work in the home environment, either on-campus or off-campus. The home health care staff receives the same benefits as residential care staff. Alterszentrum Viktoria’s nursing home and home health care agency have the same director and structure. However, the residential and non-residential settings do not share nurses. All home health care staff members are new hires. The organization does not redeploy staff from elsewhere in the organization to work in the home health care agency. Other staff in the home health care agency, including human resources, marketing, billing and information technology (IT) staff, are shared with Alterszentrum Viktoria’s corporate offices. This sharing has created challenges for the billing staff, which needed additional training about the specialized billing practices associated with home health care services. The deployment of a new billing software for home health care services will require additional support from the IT department. All nurses at Alterszentrum Viktoria receive in-service training and attend workshops directed by the head of the nursing department. Nurses from residential care and home health care are cross-trained. It can be taxing to bring these two staff groups together for training due to the nurses’ attitudes toward the sector in which they do not work and are not likely to work. Alterszentrum Viktoria is aware of the differences between these two staff groups, and addresses those differences during training workshop discussions. Organizational Culture The nursing home and home health care agency at Alterszentrum Viktoria are not separate entities and the organizational culture for home health care and residential care staff is the same, since the newer home health care agency adopted Alterszentrum Viktoria’s culture when the agency was created. Workers from residential care and non-residential care have opportunities to interact with each other and exchange ideas. This can occur during formal meetings and the training/ workshops mentioned above. In addition, home health care and nursing home staff members can meet and engage with each other in a shared dining room. This sharing of organizational culture is not typical in Switzerland. In most organizations, home health care agencies are separate from their parent organizations and have vastly different cultures. These culture differences are due, in part, to the political debate over home health care that is currently taking place in Switzerland as the government increases its support for home health care services while decreasing its support for nursing home care. The debate extends to the relative merits of the different models of care. Alterszentrum Viktoria did not face any pushback from its staff when it expanded its services. Many nursing homes in Switzerland diversify into different service models, and home health care is a common service model. Staff members had no trouble accepting the expansion. Financial Implications Alterszentrum Viktoria’s home health care agency is based on the organization’s campus, but it has its own building. The diversification of the organization’s services involved an initial investment in office space, equipment and staff. The home health care agency has not yet broken even and may find it difficult to generate adequate revenues until the agency can expand its small client pool. This will be a challenge, given the competition for home health care clients. For the time being, other Alterszentrum Viktoria service lines can make up for the losses incurred by the home health care business line. Alterszentrum Viktoria’s management and board of directors have considered discontinuing the home health care agency because of slow growth and competition. However, they decided to continue the agency’s operation because of its potential to bring future customers to the organization’s residential care services. For this reason, the continuation of home health care is believed to be an advantage for the organization. Perceived Challenges Alterszentrum Viktoria’s home health care agency faces a variety of perceived challenges:  Market competition with other providers makes it difficult to grow and expand the home health care service business.  Competition from the official government-sponsored home health care service provider is fierce. Private providers must prove to clients that they are better, faster and have higher quality than the government-sponsored home health care agency.  A Swiss nursing shortage makes it difficult to find and hire qualified personnel to provide medical care to people in their homes. Non-professional staff members, including aides, are easier to recruit and hire. Alterszentrum Viktoria
  • 20. 18 | Residential Provider Expansion into Home and Community-Based Services  Alterszentrum Viktoria has found it difficult to make a profit from its home health care business. The organization’s management is unsure how long it will take for this business to break even, if ever.  Lack of growth is the greatest barrier to the sustainability of Alterszentrum Viktoria’s home health care program. The organization has addressed this challenge by adopting a comprehensive strategy to market its entire organization, not just its home health care services. Alterszentrum Viktoria advertises its other services—including concerts, a day care center and a campus restaurant—in hopes that these opportunities will help the organization connect with prospective clients and create public awareness of its home health care operation. Perceived Benefits Alterszentrum Viktoria executives believe that the benefits of providing home health care services outweigh the challenges associated with the expansion. Those benefits include the following:  The ultimate benefit associated with home health care services is the opportunities they create for Alterszentrum Viktoria to gain future customers.  Alterszentrum Viktoria can now offer services along the entire continuum of aging services, including independent living, home health care, and special nursing services for people with dementia.  Alterszentrum Viktoria has positioned home health care as one of many points of entry into the organization and a link to its nursing home. As the home health care staff builds relationships with the public, the individuals they encounter become potential customers who may eventually move to the Alterszentrum Viktoria campus, either as independent, assisted living or nursing home residents. Outcomes Alterszentrum Viktoria has not evaluated the impact of its home health care service program. The board of directors is discussing plans to conduct such an evaluation at a future date. Lessons Learned Providers considering diversifying their services face risks, but the benefits can be substantial. Offering a variety of services, and knowing the external environment, can help an organization determine which services will lead to greater success. Alterszentrum Viktoria learned the hard way just how important it is to understand the market before launching a new business line. Viktoria did not research the market and just “jumped into” the home health care business without knowing its competitors. That experience convinced Alterszentrum Viktoria that organizations should consider pre-development market research before launching a new home health care program. Such research would help an organization gain a better understanding of its market and the expertise needed for each new business line.   A Swiss nursing shortage makes it difficult to find and hire qualified personnel to provide medical care to people in their homes. The ultimate benefit associated with home health care services is the opportunities they create for Alterszentrum Viktoria to gain future customers. Alterszentrum Viktoria
  • 21. Sodexo • IAHSA • LeadingAge | 19 Introduction Feros Care is a not-for-profit, non-sectarian, standalone organization based in Coolangatta, Queensland, in the Commonwealth of Australia. The organization provides a wide range of aging-related services to older adults along Australia’s eastern coast. Feros Care provides services through three types of programs:  Two low-care nursing homes6  One high-care nursing home7  Home and community-based service lines The organization’s home and community-based service lines include:  Nursing services  Personal care  Home care  Social care  Wellness services  An extensive range of telehealth services  Overnight and weekend respite care  Allied health care featuring community-based chronic disease management and other services subsidized by Australia’s Medicare program. Policy Context Australia is currently implementing a major reform of its aged care systems. There are currently five major government-funded home care programs. Feros Care has worked closely with all of these programs to expand its home and community-based service programs. Feros Care Coolangatta, Queensland, Australia | March 2015 Case Study The Commonwealth Home Support Program (CHSP) provides entry-level care for older adults who need government- funded support to remain at home. These services operate on a wellness model and may include a range of low-intensity services like domestic assistance, personal and social care, transportation and meals. CHSP is the largest government- funded program in Australia. The Home Care Packages Program serves individuals with complex chronic conditions who are eligible for residential aged care8 but are striving to age in the community. The program allocates home health and community aged care “packages” to older adults based on their level of need, as assessed by the government’s Aged Care Assessment Team. Eligible older adults receive one of four packages, which range from a relatively modest level of support (Level 1) to a very high level of support (Level 4). The packages cover a combination of clinical, personal and social care that may include nursing care, personal care, allied health, and domestic and social services. All levels of support include an option for dementia care. Feros Care currently receives the majority of its funding from the Home Care Packages Program. The Veterans’ Community Nursing Program aids individuals who have served in the armed forces. These beneficiaries receive home health care, including nursing and personal care. The program also covers the cost of care for veterans’ spouses, widows and widowers. The Veterans’ Home Care Program serves veterans, their spouses, widows or widowers. Beneficiaries receive non-medical home supportive care that is similar to the services provided through CHSP. The Allied Health Services Program provides a range of health services in hospitals, community health centers, homes, rehabilitation units and the community. Australia’s Medicare and private reimbursement fund the program. Services include:
  • 22. 20 | Residential Provider Expansion into Home and Community-Based Services  Physiotherapy  Podiatry  Dentistry  Audiology  Occupational therapy  Social, mobility, pain management, fall-prevention and disease management programs designed to support healthy aging Organizations like Feros Care face two primary complications as they provide services and supports to older Australians: consumer-directed care and government regulation.  Consumer-directed care: Australia began promoting consumer-directed care in 2012 as part of its Living Longer Living Better aged care reform legislation. Consumer- directed care allows clients to choose their preferred provider, thus giving older Australians more control over their care and who provides it. The consumer-directed care policy places additional administrative and cost burdens on providers of aged care. For example, Feros Care and other providers sometimes must enter into new partnerships with local providers in order to honor clients’ choices.  Government regulation: Organizations providing government-funded services are highly regulated and must comply with strict funding agreements, guidelines, external audits and external complaint mechanisms. In contrast, there are almost no regulations governing the provision of private-pay services. Most of the care that Feros Care provides is at least partly government-funded. Expansion into Home and Community- Based Services Feros Care was established in 1990 as a small, low-care nursing home in Byron Shire, New South Wales. The organization has followed a steady path of expansion since then, as the following timeline illustrates. 1997: Feros Care added a high-care nursing home. 1999: Feros Care won funding to establish a small home- care service providing 25 older adults in Bryon Shire with community aged care packages. Providers of these packages receive a certain amount of funding per day to provide a range of services that support an older adult aging at home. Such packages might include the following services:  One nurse visit per week for chronic disease management  Weekly shopping services  Transportation to therapy appointments three times each week  Assistance with cooking and light housework for two hours a day 2002-2003: The organization developed a plan to expand its home and community-based services and began carrying out the plan. Although the expansion proceeded slowly for the first two years, the organization has grown by more than 20% per year since 2005. 2005: The organization began offering home health care and home care in the private-pay market. 2012: Feros Care purchased another community-owned company operating a large nursing home. 2015: Feros Care currently provides a range of home and community-based services through various government programs and for private-paying clients. These services are available in a 3,000-kilometer area along Australia’s East Coast. The service area spans four states: New South Wales, Queensland, Tasmania and Victoria. Reasons for Expansion and Growth Feros Care’s decision to expand its home and community-based services was primarily market-driven. Although Feros Care was operating at a surplus in the early 2000s, its leaders knew that the organization would be vulnerable to competition due to its small size and the fact that the Byron Shire area did not have a large aging population. Feros Care realized it would soon struggle to compete for funding against providers in neighboring areas that had larger populations and greater proportions of older adults. The organization decided to expand its services and geographical reach for the following reasons:  Expanding Feros Care’s home and community- based services seemed less risky than expanding the organization’s assisted living and nursing home operations. Home and community-based services held two advantages in comparison with residential care: a lack of adverse media coverage and a much-reduced set of regulations.  An expansion into home and community-based services would not be as capital-intensive as an expansion of residential care. Feros Care would not need to build new buildings or invest in new infrastructure.  The expansion would provide Feros Care with a much larger potential market. Most (80%) of older adults in Australia were receiving government-funded support services in 2003, and the vast majority of those older adults were still living in their homes. Feros Care’s senior managers and board of directors made the decision to expand into home and community-based services as part of the organization’s strategic planning deliberations. The expansion received little-to-no resistance from staff members, who expressed excitement about Feros Care’s vision for the future. Feros Care
  • 23. Sodexo • IAHSA • LeadingAge | 21 1990 Began as low-care nursing home in Byron Shire, New South Wales. 1999 Received government funding to provide home care to 25 older adults. 2005 Began offering private- pay home care and home health care. 2015 Provides a range of government-funded and privately paid home health, home care and other HCBS to older adults along the 3,000-km eastern coast of Australia. 1997 Added high-care nursing home. 2002 Began competing for home care and home health care government funding on wider scale. 2012 Purchased a company operating a large nursing home. Timeline feros care
  • 24. 22 | Residential Provider Expansion into Home and Community-Based Services Dependence on Government Programs Initially, Feros Care provided only government-subsidized home care. The availability of government packages has greatly influenced organizational discussions regarding possible expansion into the private-pay home care market. In 2005, for example, the organization performed a market analysis to gauge opportunities within the private-pay market. At the time, long waiting lists for government-funded aged care threatened to curtail the organization’s growth potential. Feros Care viewed a private-pay expansion as a way to grow outside its current market and region, and to become more competitive with larger home care providers. The organization began offering a few private-pay services in 2005. However, an extensive expansion into private-pay services was put on hold when the government increased its funding for aged care that same year. Essentially, the government’s decision to increase its funding of aged care allowed Feros Care to grow by winning more government packages. Feros Care is once again considering an expansion of its private-pay services. This latest discussion stems from a government move in July 2014 to develop more stringent means testing for the receipt of home care packages. The new rules could make it cost-efficient for some consumers to purchase Feros Care’s private services. As a result, the organization expects the private-pay home care business to grow over the next several years. Ironically, the few private services Feros Care began offering in 2005 allowed the organization to compete more effectively for government packages. As Feros Care began offering services in other regions, it learned that those services were often superior to services offered by other providers. Feros Care’s responsiveness, flexibility, staff values and philosophy of care helped it build a strong reputation in these regions. As a result, the organization became even more successful at acquiring government contracts. This success spurred a positive feedback cycle that helped Feros Care further improve and expand its services, succeed during subsequent funding rounds, and then improve and expand its services even more. Description of the Program Services Provided Most of the home and community-based services that Feros Care provides are delivered to older adults who receive assistance through the Home Care Packages Program. To a lesser extent, the organization provides services to older adults covered by the Veterans’ Community Nursing, Veterans’ Home Care, Commonwealth Home Support, and Allied Health Services programs. Feros Care provides non-medical and medical services through these government programs and for its private-paying clients. Non-medical services include:  Light housework  Cooking  Lawn care  Pet care  Assistive and smart technologies  Moving services Table 1. Services Provided by Feros Care DOMESTIC CARE PERSONAL CARE & NURSING WELLNESS AND LIFESTYLE Cleaning & Light Housework Personal Laundry Unaccompanied Shopping Errands & Bill Paying Accompanied Transport Home-Cooked Meals Home Maintenance Lawn Mowing & Gardening Pantry/Cupboard & Spring Cleaning Moving Services Pet Care Internet Training & Support (banking, shopping) Technology (Robo-vac cleaners) Personal Self Care (showering, dressing, grooming, toileting) Continence Management Clinical Care Palliative Care Dietary Planning & Education Mobility Assistance & Equipment Communication Aides Accompanied Medical Appointments Foot Care & Nail Care Life Link Personal Alarms Lifelink Smart Home Monitoring (auto night lighting, bed/chair/door sensors, environmental alerts) Hairdressing: Visiting Services Beautician: Visiting Services Companionship & Social Support Accompanied Community Outings Counseling & Chaplaincy Services Maintaining Independence Program Mobility Exercise Programs (Strong Foundations & Forever Young) Respite (in-home, day, residential) Day Trips & Social Groups Volunteer Activities Falls Prevention & Re-ablement Reminiscence, Hobbies, Crafts Telehealth Vital Signs Monitoring Internet training & Support (virtual visiting & social connections) Feros Care
  • 25. Sodexo • IAHSA • LeadingAge | 23  Internet training and support  Personal care  Companionship  Accompaniment to appointments  Counseling and chaplaincy services  Exercise programs  Respite care  Efforts to help older adults participate in community outings and wellness programs Medical home care services include, but are not limited to:  Continence management  Palliative care  Nutritional planning and education  Mobility assistance and home retrofitting  Foot and nail care  Medical monitoring services offered through telehealth programs Feros Care provides around-the-clock care when needed, and its Contact and Referral Center is staffed at all hours. While the organization does not offer live-in staff placements, it does provide nighttime and weekend care when clients are discharged from the hospital and for other needs. Feros Care regularly provides some services, such as personal care and help with medications, to clients during evening hours and on weekends. See Table 1 for more details about Feros Care’s home health, home care and community services. Partnerships Feros Care delivers services using a combination of its own staff and service partners from the surrounding community. When Feros Care expands into new regions, the organization strategically engages service partners in those areas to deliver direct care until it has a sufficient number of clients and services. At that point, Feros Care begins recruiting its own direct-care staff while maintaining its relationships with local service partners. Feros Care calls on those partners for assistance during times of high care volume. In contrast, Feros Care does not contract for any care coordination or case management services. Because care coordinators play a major role in monitoring direct-care provision and upholding its quality, Feros Care always fills these positions with its own staff members. This is one way that the organization works to ensure that its client assessment and care planning activities meet the highest standards, and that its service philosophy and the quality of its care are maintained. Feros Care employs other strategies to ensure that it maintains high standards of care. For example, Feros Care signs formal service/brokerage agreements with all organizations that work under contract to provide frontline staff to its service lines. These agreements clearly spell out specific service delivery expectations and requirements. Feros Care also closely monitors client feedback and reported incidents associated with contract providers. The organization does not hesitate to discontinue partnerships due to differences in corporate philosophies or inadequate care provision. Feros Care has 245 service partners across all of its service lines. The organization selects partners based on a number of factors, including reputation, price, capabilities and flexibility. Feros Care contracts with several franchisees associated with larger home care organizations like Just Better Care and Home Instead. The executives of these franchises tend to be small- business owners who care deeply about maintaining good relationships with other providers. These business owners help Feros Care maintain its reliability, which is a source of pride for the organization. Australia’s implementation of consumer-directed care adds to the complexity of contracting for services. Empowered to choose the provider they want, consumers can select a local cleaner to do their housework instead of the service provider with which Feros Care has an agreement. In cases like this, the consumer-directed care program requires that Feros Care perform the necessary inquiries and develop a service partnership with the provider preferred by the client. Sources of Reimbursement Feros Care receives Commonwealth reimbursement from the Department of Social Services and the Department of Veterans Affairs for the services it provides through the Home Care Packages, Veterans’ Community Nursing, and Veterans’ Home Care programs. Medicare, private insurance,9 and private- pay clients pay for services provided under the Allied Health Services program. Feros Care
  • 26. 24 | Residential Provider Expansion into Home and Community-Based Services Feros Care also receives some state funding for post-acute care that is managed by state health departments. These programs include Transitional Care; ComPacks, which provides immediate access to short-term community services; and programs for sub-acute care. State funding is generally for short-term interventions designed to reduce the likelihood of readmission. Consumer Eligibility In order to be eligible for government-funded programs, Australians are required to participate in an independent assessment, conducted either by telephone or in-person, or both. Independent assessors include the Aged Care Assessment Team for home care packages and the new Regional Assessment Service Team for the Commonwealth Home Support Program.10 The approvals process for each major government program is as follows: Home Care Packages Program: Traditionally, a local Aged Care Assessment Team determined an individual’s eligibility for a home care package after conducting an in-person assessment. This system changed on July 1, 2015. Now, clients access the Aged Care Assessment Team through Australia’s new My Aged Care Gateway, which makes an initial phone assessment and then refers eligible individuals to the Aged Care Assessment Team. Commonwealth Home Support Program: Beginning July 1, 2015, the client calls the Commonwealth’s My Aged Care Gateway for an initial phone assessment. Eligible individuals are then referred to the Regional Assessment Service for an in- home, face-to-face assessment. The assessors complete a goal- oriented support plan and make the necessary service referrals to the client’s preferred home support service providers. Veterans’ Community Nursing Program: Clients must receive a referral for an approved service from a doctor or nurse. The amount of funding is based on the individual’s level of need. Veterans’ Home Care Program: A regional Veterans Home Care Assessment Team determines the individual’s needs and the level of support they may receive. Allied Health Services Program: A doctor must approve the client’s participation in this Medicare-funded system for chronic disease management and other allied health services. Private health providers have predetermined eligibility criteria. Clients must access approved providers, including Feros Care. Individuals can access all of these services regardless of their financial means. However, retirees who are not receiving a full pension may be required to make substantial co-payments. There are no requirements for receipt of privately paid services, other than ability to pay. Provider Eligibility Providers must apply for the right to provide services through government-funded programs. There are no upper limits on the number of clients a provider organization may accept through the Commonwealth’s veterans’ programs. In contrast, providers participating in the Home Care Packages Program are awarded a license for a certain number of packages. For example, they may be allocated packages for 50 clients at a given time. Providers in the Commonwealth Home Support Program are given a certain amount of money to provide a given number of services. For example, providers may be allocated $100,000 in a given year to provide 1,000 medical transport trips. Feros Care Clientele Feros Care provided this snapshot of its home and community- based services clients:  The average age of clients is 82 years, and 59% are at least 80 years old.  Two-thirds of clients are female.  Most clients have at least one chronic condition.  One-quarter of clients are nursing home certifiable but are living at home with assistance.  Three-quarters of clients are receiving lower level care to help them maintain their independence.  Most clients have financial needs, and 85% are full pensioners.  Less than half (44%) of clients live alone without a full-time family caregiver. Quality Assurance Feros Care is committed to ensuring that it maintains high quality standards, through its own efforts and the efforts of its service partners. Quality is assured through four strategies. 1. The Commonwealth’s Aged Care Quality Agency regularly conducts on-site audits of government-funded community care programs, and compares providers’ quality assurance systems against a set of common standards. 2. Feros Care contracts with a standards-compliance company called SAI Global for comprehensive quality management of all its programs. Feros Care and SAI Global track many measures, including the following:  Daily incident and hazard reporting  Systems of improvement  Workflow management  Customer feedback programs  Internal audit programs  Business excellence parameters  Response times  Adherence to policies and procedures 3. Feros Care employs a chief resolution officer who oversees the resolution of all complaints to the organization’s Customer Feedback Program. 4. Feros Care uses its care coordinators to oversee the work performed by direct-care aides and to ensure that high quality is maintained. Care coordinators integrate the feedback they receive from clients with data collected Feros Care
  • 27. Sodexo • IAHSA • LeadingAge | 25 Feros Care Clientele A snapshot of Feros Care’s home and community-based services clients Average age of clients are female clients % of clients receiving lower level care to help maintain indepencence % of clients who are full pensioners (most have financial needs) % of clients who live alone without a full-time family caregiver number of chronic conditions for most clients (at least) clients who are nursing home certifiable, but live at home with assistance % at least 80 years old 82 2/3 75 85 44 1 1/4 59 Feros Care provided this snapshot of its home and community-based services clients:
  • 28. 26 | Residential Provider Expansion into Home and Community-Based Services through tracking of quality indicators. The coordinators discuss issues with aides as they arise, and pass information to supervisors. This information is included in daily communication updates on services and clients, monthly staff meetings, and performance reviews. Marketing Feros Care uses many venues to spread the word about its home and community-based services. The organization employs a comprehensive branding and marketing strategy that includes Feros Care magazine, newspaper advertisements, local media coverage, social media outreach, and participation in such community events as expos, festivals and public celebrations. The organization also employs a comprehensive strategy to engage referral sources. These strategies include scheduled visits with referring agencies; participation in networking events, speaking engagements, celebrations and other events; and maintenance of an extensive customer relations database. Financial Implications In 2005, Feros Care served 50 clients per year. In 2014, the organization served approximately 4,000 clients, and it expects to serve at least 6,000 clients in 2015, due to the advent of new government-funded transportation and allied health services. Client numbers could expand even further to 30,000 clients per year due to the organization’s recent approval to operate the Regional Assessment Service for the Commonwealth Home Support Program (CHSP). However, services to some CHSP clients may be provided only on a short-term basis. Figure 1 presents Feros Care’s annual growth, beginning in 2002-2003 when the organization began its expansion into home and community-based services. Feros Care has experienced double-digit growth during most years since home and community-based services became its largest service line. The first two years of Feros Care’s expansion into home and community-based services (2003-2005) proved difficult, as the organization struggled to find its niche in a field crowded with many competitors. However, Feros Care’s growth has exceeded 20% per year for almost every year from 2006 until the present. In 2003, the organization funded its community care services with only $250,000. In contrast, current funding levels for community care is $35 million. The new Regional Assessment Service is likely to bring this growth level to $45 million in 2016. The initial growth period did not require a large expansion of the Feros Care staff. Prior to 2005, Feros Care hired a part-time marketing assistant and a part-time writer who was responsible for submitting applications for government packages. The organization’s chief executive officer also spent considerable time on marketing and budgeting efforts. Once the organization began to obtain a significant number of government contracts, however, these positions began paying for themselves. The organization’s home and community-based service program broke even in 2007. Figure 1. Feros Care: Annual Growth Since Expanding to Home and Community-Based Services 0% 5% 10% 15% 20% 25% 30% 35% 2002-03 2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 2009-10 2010-11 2011-12 2012-13 2013-14 2014-15 Feros Care uses its care coordinators to oversee the work performed by direct-care aides and to ensure that high quality is maintained. Care coordinators integrate the feedback they receive from clients with data collected through tracking of quality indicators. Feros Care
  • 29. Sodexo • IAHSA • LeadingAge | 27 The bulk of Feros Care’s current revenues stem from the services it provides to a quarter of its clients. That’s because Feros Care receives most of its funding from the Home Care Packages Program, despite the fact that the Commonwealth Home Support Program (CHSP) is larger and serves more of Australia’s older adults. Generally, the monetary value of individual home care packages is much greater than the value of packages provided through CHSP. For example, a typical CHSP client might only be approved to receive $2,000 per year in services, whereas typical home care packages range from $7,500 to $45,000 per year. Workforce Feros Care employed approximately 350 people in 2014. More than 280 of these employees were care aides, and a majority of these care aides worked in the organization’s home care division. Nurses comprised just over 5% of Feros Care staff in 2014 when Feros Care also used staff members to develop staff rosters (6%) and coordinate services (8%). Allied health professionals, who work in a Feros Care service line that is growing rapidly, are expected to comprise 5% of the organization’s employees by the end of 2015. Feros Care expects its workforce profile to change over the next year, although home care workers will continue to comprise the majority of its staff. The organization expects to see staff growth in three areas:  Allied health: The allied health line will soon be expanding due to the increased use of specialists like physiotherapists and occupational therapists in Feros Care’s restorative care programs. These specialists operate a range of mobility, strengthening, fall-prevention and wellness programs designed to increase the independence of clients.  Telehealth: The number of telehealth nurses performing chronic disease management is expected to increase as Feros Care’s telehealth services continue their rapid growth.  Information technology (IT): Feros Care will also be expanding its IT staff to meet the growing needs for health technology in clients’ homes. Staff Benefits Because Feros Care is a not-for-profit provider, its employees can receive some of their income tax free. Feros Care also offers employees:  Wellness programs11  Free gym memberships  In-house leadership programs  External education  An employee assistance program  Discounted mobile technologies Feros Care employees do not receive health insurance through their jobs because Australia has a public insurance program. Staff Recruitment and Training Working in home care differs greatly from working in a residential setting for aides at Feros Care and other organizations. Home care aides work alone primarily and perform a greater variety of tasks for clients than aides in residential settings. Home care aides have more responsibility to make accurate and timely observations and to prudently make care decisions on their own. They also have to be more flexible and versatile than residential employees, since they are called on to provide cleaning, cooking, social care and, in some cases, therapy support in addition to traditional care tasks. For these reasons, Feros Care generally does not redeploy residential aides to home care unless those aides are very open to working on their own and undertaking all the activities required to support clients. Residential care aides may never have performed activities like cooking and cleaning as part of their prior professional responsibilities. In addition to taking direct job inquiries, Feros Care partners with jobs networks and registered training organizations to identify the most qualified candidates. Once potential hires have been identified, Feros Care conducts structured interviews and tests applicants’ skills in such areas as technology and observation, before making hiring decisions. Feros Care has found that it is important to hire staff members who are independent, are known to the organization, have experience, and understand the expectations of the job. Independence: Feros Care looks for staff members who are self-starters and are comfortable working alone most of the time. These staff members also need to be comfortable using technology to stay connected with the organization and with clients. Known quantities: Feros Care places great importance on hiring aides it knows and trusts. That’s why the organization reduces its reliance on contracted services after it has settled in a new region. And that is why Feros Care grooms its best home care staff for management and supervisory positions, rather than hiring staff from outside the organization or from its residential services division. Feros Care also shares executive and billing staff across its home and residential care divisions, rather than hiring additional staff from outside the organization. Feros Care places great importance on hiring aides it knows and trusts. That’s why the organization reduces its reliance on contracted services after it has settled in a new region. Feros Care