Mark Burns, Executive Director of Homebridge: Innovative Retention Strategies in Home Care

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development, and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

According to the Centers for Medicare and Medicaid Services, home care expenditures are expected to increase 73% between 2020 and 2028, and job openings for home health workers are expected to grow faster than for any other occupation over the next decade. But where will all of these workers come from, especially when there’s an existing shortage?

Well, we’re going to explore solutions to that problem today with Mark Burns, Executive Director of Homebridge, which provides both in-home supportive services to San Francisco County as well as statewide training in California for home health workers. Mark’s career spans several decades in the nonprofit and for-profit sectors at companies including Charles Schwab, JPMorgan Chase, and Citigroup. He also serves on several nonprofit boards, including the California Collaborative for Long-Term Services and Supports.

Thanks so much for joining us today, Mark.

Mark Burns: It’s lovely to be here, Van. Thanks for having me.

Van: Absolutely. Well, Mark, I’m really troubled by the workforce challenges in this space.

Do you think it will be possible to fill all of these expected job openings in home health care over the next decade, and what will happen to us if we can’t?

Mark: Well, I fear that we’re only looking at the tip of the iceberg. We are hiring more than thirty new home care professionals every month, and we have just as many who are moving on into other jobs. To get to those thirty home care professionals that we onboard, we’re screening and interviewing hundreds of people. It’s a super competitive job market. Home care professional work is very difficult to do. It can be very low paying in most instances. There are a lot of competitive job opportunities in this space.

I think that what we have to do is really look at some new immigration policies in order to attract a new group of workers for the caregiving economy. I think it’s not just home care, it’s childcare, it’s this whole large slice of caregiving that is short of workforce right now. I think one of the other things that we’re going to talk about today is probably creating more opportunity and job mobility for people so that these become sustainable career opportunities with advancement and skill development.

What happens if we don’t? I think we’re already beginning to see what happens. In my own corner of the world, we are short probably 100 full-time caregivers. As a result of that, we’re creating waiting lists. People who are in significant need of care are not getting it. We’re having to triage and take people who have more intensive personal care needs, who have more significant disabilities. But that means that people who have daily care needs are going without and we’re seeing this across the board across the state of California.

Van: And Mark, I would imagine that if you’re going without the care, then you’re going to end up having much more serious diseases and other medical issues that would then impact the cost of the healthcare system as well, right?

Mark: I think we know that people who receive the right level of care at home have far less impact on the healthcare system. They have far better health outcomes. They go to go to the doctor less for emergency needs. They go to the emergency room less. And so conversely,

when people are not getting the right level of care at home, people are showing up in emergency rooms. They’re having poorer health outcomes.

In a certain sector of the client base — people who have more behavioral health disorders that are impacting their daily ability to care for themselves — you’re going to have more people becoming unhoused. People who aren’t able to maintain clean environments because of hoarding and cluttering disorder, people who encounter lease violations because of their conditions, and then they basically slip off the radar because people who are in home care already are semi off the radar of healthcare. I think a lot of the people who we see becoming homeless in California are people who aren’t receiving regular steady care in the community that could keep them more stable at home.

Van: Well, thank you, Mark, for laying out for us the landscape of how one area of workforce shortage impacts so many other areas of our society. Now, Mark, tell us a little bit more about Homebridge and the agency’s role in the provision of in-home care and supportive services.

Mark: Back in the 1970s and 80s, about half the California counties had a home care agency

model of In-Home Support Services (IHSS), and it was provided predominantly by one large national healthcare company. The quality of care was suffering under that program, and the costs of the program were increasing rapidly. So, a group of nonprofits in San Francisco began advocating with the city for increased quality of care for the very fragile people who were referred over to this agency model of care, as differentiated from the independent provider model where people can hire and manage their own worker. In that model, 80% of the clients of the IHSS program in the state have a family member who’s caring for them, so it’s very in-house. But as the program shifts away from that and they’re more independent, a lot of folks have trouble hiring and maintaining a worker.

So, that’s the population that we focus on in San Francisco. One of the basic tenets of our nonprofit was that providers needed to have specific skill training in order to be able to best manage folks who were living in the home. And in the home care world, as you well know, there’s very little professional training that goes on. There’s no certification level. There’s no skill testing. Folks go out and do this work really without the support that comes from having professional skills, and so we built an agency model that was based in skilling and supporting a caregiver.

We eventually applied for the contract in San Francisco, and we’ve held that contract since 1995. We currently care for about 1,000 complexly diagnosed clients who are living predominantly by themselves, most of them living in single-room occupancy hotels. They don’t have family members they are connected to who are caring for them. They don’t have a circle of support. So, we assign a worker and a case manager to them and we make sure that they’re stable in receiving services at home in the community so that they don’t have the negative health outcomes that we started talking about. They don’t end up in the emergency room as much as they were before they come to Homebridge. They don’t end up going into the nursing home.

In fact, on the contrary, we actually help a lot of folks transition out of the nursing home into the community. These are people who don’t need to have that skilled nursing level of support, but who basically are being — and this is true across California — warehoused in skilled nursing facilities because they can’t maintain the regular support that would keep them at home.

Van: So, Mark, when there’s a discussion about value-based care or preventive care, is Homebridge more positioned in that area? Is that how its model works?

Mark: Yes. Folks come to us through a referral from the County IHSS program. They are assessed as not being able to hire and manage their own worker. They’re then offered Homebridge as an opportunity. They don’t have to. It’s not a requirement. But I don’t think anyone’s actually turned down Homebridge so far in the past. Then we provide them with all the wraparound support as if they were hiring and managing their own worker. We pick workers according to their specific needs or to their cultural backgrounds, possibly their food requirements or language requirements. We provide them with a level of case management that makes sure that they’re connecting to all the other services that they need, such as food delivery, that they’re keeping their medical appointments. So, we act as sort of a care coordinator for them.

I would say it is value-based and preventative because in most of these instances, folks are pretty much capable of making it to doctor appointments and managing medication. What we’re talking about for us, is a group of people who struggle with some of that. Often, our population has a behavioral health diagnosis along with their physical disability. They often have active substance use. They have advancing dementia, other memory issues. They have other psychosocial behavioral challenges that just complicate their ability to stay home. They can maintain at a regular level. Generally, these folks are not so significantly diagnosed that they require intensive medical interventions at home.

We do have low levels of paramedical service that are allowed in the IHSS program, and we do have folks who have significant physical needs, but it doesn’t require that they actually be in a skilled nursing facility. They’re not so medically fragile that they have to be in that high level of a medical environment. As we often say, there’s so much more freedom of choice at home: being able to pick what you have for dinner; being able to watch what you want to watch on TV; being able to go to bed and get up when you want to; those are all freedoms that we take for granted when we’re living in the community that you lose when you’re going into institutional care systems.

Van: Well, Mark, this is such important work in terms of the domain of care and hard work, too. So, thank you for the work that you do every day. You recently launched a major new statewide training program as part of the California Department of Social Services’ Career Pathways program and, of course, Futuro Health is proud to be a partner in that effort. Can you tell us more about this training program and Homebridge’s role in it?

Mark: Sure. And, of course, it’s lovely to have met you through Career Pathways, and we’re thrilled we’re getting ready to launch a big piece of our initiative together over the coming weeks. So, Career Pathways is a legislated $200 million stream of funding — one-time funding, initially — that comes down through the Build Back Better program from the Biden administration. In California, we chose to dedicate this to training in-home caregivers across a range of government-funded programs, predominantly through the In-Home Supportive Services program, but also through some of the other home and community-based service efforts.

There are more than 600,000 caregivers across the state of California who have this opportunity to participate in Career Pathways as a training program. This is paid training, which is really one of the rarest things. Having training available in general is fairly rare for this population, but having paid training is almost unheard of. And that’s, I guess, one of the real problems in this overall workforce space is that there isn’t training or paid training available to folks. So, we’re thrilled.

We’re providing a very large portion of the content for this program along with several other providers. We will, in the course of the eighteen months that we’re in this program, deliver more than 8,000 virtual trainer-led classes of up to thirty individuals each. That means a potential reach of more than a quarter million people in the population.

We also, in conjunction with you, are going to be delivering nearly 100 asynchronous self-directed training modules that we hope are going to give people a lot more choice in how they access this information. We’re also actually doing some in-person stuff around the state.  We’re doing sort of pop-up training in various markets to try and reach some of the in-person skill training that’s required, where you actually have to be present to do the assessments and show the demonstrations.

So, it’s a very, very large program. It’s a very large piece of funding through California Department of Social Services underneath the IHSS program, and I think we’re all super excited. We actually launched our first classes in January.

Van: Oh, this is going to be exciting work. Now, you mentioned that this is an area that has had a history of a lack of training. So, tell me a little bit more about the friction. I mean, paid training, boy…I could imagine that would be very well received, but it isn’t necessarily right, Mark? I mean, who are all the different stakeholders that you have to think through in terms of removing friction to training?

Mark: Well, I think that there are some real systemic challenges to in-home care at large. It’s

not something that’s generally covered by most insurance plans. Most large healthcare organizations don’t have in-home care programs. The best they have are home health that delivers specific nursing care in very small increments to folks. But most folks who need regular

in-home care sometimes need thirty hours a month or more. Thirty hours is about a minimum, so about four or five hours a week, ongoing regular care. There are spot needs for folks who have had total joint replacements where you might be able to come in for a couple

of weeks and assist somebody. But for most folks who have progressive disability and permanent disability, the need for home care doesn’t go away.

It’s an expensive proposition in general and in California, it has been a Medi-Cal entitlement program, but it has not been mandated to be part of other health insurance. So, folks in Medi-Cal can get this and there are about 500,000 people in the state’s IHSS program who receive this today. It’s a big economy. It’s $18 billion a year in California in just the wages that are paid. Then the other side of that is the private industry that people have to tap into. There are private home care agencies everywhere and these are very much cottage industries. Frankly, they make money by charging you $50 per hour for someone they pay $15 per hour to, and that’s how that model works.

So, there’s no incentive on either side of this program to spend additional money on training expenses or the wages required for training expenses. The people who do this work quite often have two or three jobs, so going to an extra training in the evening or on a Saturday is not something that they really can afford to do or that they have incentive to do unless there’s something in it for them. Are they getting a degree? No. Are they getting a higher rate of pay? No. Are they getting paid for it? Well, in this instance, they are.

We’ve done a lot of research at Homebridge about how caregivers feel about training. They want training. They feel validated. They feel that they’re being acknowledged that the skills that they have and the skills that they need to learn in order to do their job make them professionals. It’s one of the reasons we just retitled our jobs from home care providers to home care professionals at Homebridge because people know innately that they are adding a great deal of value that is of a professional scale that helps with people’s wellness, that helps them stay stable in the community and that gives them longevity, but there’s no system of validation for that. The Career Pathways program is actually beginning to provide that on a very large scale, and I think it’s a very exciting entry for California into trying to address the value of home care in the overall healthcare wellness landscape.

Van: Extract for me some of the best practices that you have experimented with and now are incorporating in the career pathways that you’re developing.

Mark: So, for us, this exploration into workforce began several years ago when there was a rapid increase in the minimum wage in San Francisco County. Suddenly, we lost about a third of our workforce in the course of the year and that happened because there were lots of other

great job opportunities at this price point and in this space. We had to become a very different type of employer, and we’re still working to become a very different type of employer which has become a very large sector of who we are.

We often have internal conversations about the conflict between trying to be a service delivery organization, a training organization and a workforce organization. We did a lot of background research and we decided that there were a couple of different things that we wanted to build into this employment side of our program, which used to be a single wage and there was no benefit to your having thirty years of experience or zero experience. None of that was in our workforce model. Today, we have four different tiers of home care professionals. We have an entry level where you come in, you learn basic domestic tasks and how the business runs. Tier two, you learn personal care, more complex issues. Tier three, you learn paramedical services and behavioral complexities. And in tier four — we have several tracks that we’re beginning to develop — but generally, tier four is conceived of as a bridge between becoming a frontline home care professional and being something higher than that.

So, first and foremost, we’ve been pursuing a bridge into healthcare. We have an in-house CNA program that we’ve been developing — we’re graduating our first CNAs, outplacing our first CNAs into higher paying jobs — and there’s lots of fascinating, interesting data around this. We’re working on a similar track to help folks become community wellness coaches. We’re working on a behavioral track. And, out of our pool of about thirty care supervisors who oversee our workforce of caregivers, about half of those care supervisors came from our caregiver pool. So, we have our own internal ladders and some folks have even moved up into management.

Frankly, I like the vision of an agency down the road where many or most of the management structure have come from the caregiver pool because it gives folks great career opportunity. They bring skills and knowledge of the community and the work into their job that is invaluable. So, that sort of career ladder, I think, is absolutely a best practice. I would humbly say that we are very much on the leading edge of doing that these days.

You know, a lot of people in the home care industry look at us and say, why would you eat your own population? Why would you show them the door? Why would you help them move on? I think our theory is that we will attract more people as new hires who come here for careers. We’re still working through what some of that looks like. We’re also finding that we’re having to do a tremendous amount of workforce development support in the early stages of the job that we didn’t used to have to do. So, for a lot of folks, there’s a lot less job readiness in this tier. There are a lot of barriers that we have to work to remove.

We have these morning reports where people are calling out, and I was watching how many people were calling out because childcare was closed today for various reasons. These economies intersect. People who do this type of work often do childcare work, and the lack of childcare and employer-funded childcare or government funded childcare in our country is really devastating to the entry level workforce. So many parents have to stay home. This is a topic with so many members of my family — the balance between paying for childcare or having a career — and we see it in our workforce. It’s a major impact for us. So, I’d love to be able to find a way to actually supply childcare to our workforce. That’s, I think, another best practice for folks who are embedding childcare into their work, into their employee assistance programs.

Coming back to the best practice topic, we’re building out a lot of ancillary programs. We do a lot around transportation funding already. We are looking at food insecurity. As I mentioned, we’re looking at childcare. We’re looking at emergency housing assistance or loan programs. We do have people who come into these jobs who are unhoused — living in their cars or living with relatives because they’ve lost a lease because of not having stable income. It’s not at all uncommon in the entry level workforce out there today.

Van: Well, I really want to applaud the work that you’re doing to stabilize the household. All of these strategies that you’re using combine so that somebody can actually go to work, right?

Mark: As you well know, more than 75% of the people in this workforce are women of color. They are often single heads of household and they’re often trying to balance childcare with their attempt to work and support their families. So, you can’t ignore this or you lose an entire sector of the workforce. And you’re also not lifting people up. I mean, one of the great things about doing this work is that you can attempt to be many things to many people. You can be something for the clients that helps them at home. You can also be something for your workforce that helps them find career, job stability, sustainability, respect for their family. There are a lot of great things about it if you can make it work.

Van: Mark, in terms of moving from entry to tier one to tier two to tier three and four, there’s wage gains accompanying all of these training levels and performance levels?

Mark: Yes, there are. We started out with this sort of very simple formula. We had to talk our funder into this — the City and County of San Francisco — and they have been a wonderful partner to us. If they’re listening, thank you again for everything that you’ve done. They’ve worked with our Office of Economic and Workforce Development, which does workforce support programs, and so they’ve collaborated throughout this entire introduction of what we call our STEPS program — Skills Training Employment Pathways program — to try and determine what is the right entry wage, and what are the right gaps. We started out, I think, with a 50 cent

per hour gap between each of these skills, and we thought that the pathway was going to be longer.

I’ll tell you that in January, we just introduced an entirely new and fairly aggressive wage structure where our new hires start at $22. But after 120 days of intensive training and supports shadowing in the community — access to trainers who come out into the community to help them review skills that they’ve learned in the classroom, things like this, and barrier removal assistance as well — they can move to the Home Care Professional 2 level at $25 an hour.

We also are mirroring what’s going on in the Career Pathways program where if you take a certain combination of classes, you earn bonuses up to about $3,500 over the course of nine months. We are mimicking about $2,500 in six months and we’re using those as incentives if you get through your first two weeks of training, if you’re on the job for thirty days…pretty typical workforce stuff. But again, we’re trying to infuse cash upfront as incentive payments for folks who probably are trying to transition into stable employment, and so it’s very helpful to them. So, we now are going $22, $25, $26, and $27. And then we actually have an on-call tier where some people can earn up to $29 an hour. I am aiming for a $30 an hour base wage,

which is frankly about the midpoint of most institutional CNA positions in San Francisco.

We struggle to know what to compare this job to. Caring for complexly diagnosed people with paramedical needs in the community is not at all dissimilar from caring for institutionalized

patients in a high medically supported setting like a hospital. So, we’re sort of equating these two jobs and thinking that people — after they do this type of community work — it’s a great transition for them to go into a CNA program as a higher-level CNA, and then probably aspire to be an LVN, a licensed vocational nurse. So, it’s an upward path for folks who want that.

Van: I’m just really enjoying hearing about how you crafted these smart retention strategies to the combination of all of these ancillary supports that you’re providing the worker, but also the training path and the wage gains as well as the bonuses. These are very smart elements to combine in order to create an effective workforce development program. I was thinking about our podcast the other day because I saw an advertisement for Starbucks. It said $19.50 as a starting wage. So, in order for the healthcare workforce to compete, we’ve got to figure out some very creative strategies as well.

Mark: It’s a very competitive job market. People yell and scream about, “You’re going to pay how much? Why are you paying so much? People aren’t even showing up for work and you’re

giving them this type of pay.” I mean, there’s just a lot that goes on emotionally in this space because it has moved so rapidly and the competition is so significant. For me, I think some of the competitive job markets are that you can go be a security officer for somebody like the San Francisco airport for $29 to $30 an hour where you get to wear a nice uniform, you don’t have to go into someone’s living space, you don’t have to deal with someone’s personal body care… a much more pleasant work environment for the same pay. You can go to work in a lot of retail places. Like you just said, for $20 an hour, you can go to work in a nice retail establishment and deal with customers all day instead of dealing with very different work environments. So, you’ve got to be competitive and that’s the problem people are having across the board.

Again, looking at my morning emails, I’m watching a lot of people getting referred to us because, although they don’t need our level of support and care, they can’t find other caregivers in the community. So, people who can successfully hire and manage a workforce in this space are in very high demand because it’s super tough work to do. There aren’t enough people applying for these jobs.

Van: Well, thank you for your leadership of Homebridge and your broader leadership in policy conversations. Mark, why don’t we close up by giving you an opportunity to make any comments about the future of care and things that we should note or be trying to get ahead of?

Mark: Well, the good news is that I think California understands the problem at a very large level.  We’ve been trying for years to integrate community-based home care into the healthcare system, and that’s where we have to go. I think our healthcare providers understand that community-based care is a critical part of wellness that reduces acute care costs.  I also think we’re going to see, in the next couple of years, a lot of studies that come out and say having a higher, more expensive, more complex level of community-based care pays for itself. And that’s always the problem in government, right, is what pays for itself? So, the good news is that I think we know what the problem is and we have a general idea about how to solve it which is by better coordinating care between community-based care organizations and institutional healthcare systems.

But then you get into the bad news. The bad news is that space is super political, right? The healthcare system, the Department of Public Health system and the Department of Social Services system are not designed to integrate. In fact, they compete with each other in lots of different places, which is why people are so confused about so many different benefits. I think healthcare, while it’s trying to talk wellness, is actually becoming more acute. It’s becoming more financially specific. It’s becoming more symptom management oriented.

Community care is trying to step up into this space, but there’s just not the type of money that healthcare has, and part of this becomes a money game. There’s a desire to pay for this training, but is there long-term money for paid training? I think the answer to that is no, there’s not long-term money. Who is going to pay for training as a long-term opportunity is an unknown question.  At the end of Career Pathways, I expect that there will be training funding that will continue, but will the incentive to be paid for that continue? And who will that be? I don’t think the state thinks it should be them, and I don’t think counties think it should be them.

Will workers take training that is available free, but not paid? Or will they do what they need to do, and that is go work in another job during that time period in their life? So, I think there’s some big systemic problems that we really have to solve that go all the way up to the governor’s office and to the highest levels of state and county government that are just systemic issues that have to be figured out in order for us to be able to progress better.

Then I think there’s the immigration question. Where are the next level of workers coming from? We need caregivers in the tens of thousands.  I could hire 100 to 150 people tomorrow and put them to work. You magnify that across the state of California, and you look at the number of people who are suffering because they don’t get care today. We need to take some significant policy shifts in order to bring in a new group of workers who will be attracted to these jobs.

Van: Well, Mark, no doubt the challenges you’ve outlined are mimicked across all of our state borders and across the country. I’ve learned so much from spending time with you today. Thank you so much for joining us!

Mark: It’s been my pleasure. Thanks for having me.

Van: Absolutely. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.