The pandemic altered the nature and dynamics of the healthcare industry. The Zacks Medical – Outpatient and Home Healthcare industry bore the brunt of lower outpatient clinic visits and struggled to provide quality care with respect to home healthcare due to the risk of exposure to the virus as well as the record level of staffing shortages. In recent times, although the severity of the infection has declined, there has been a circulation of a mixture of respiratory viruses per a recently-published data published by the Centers for Disease Control and Prevention. Apart from the respiratory ailments, the U.S. healthcare system is also currently being bothered by the recent increasing threat of spread of the antimicrobial resistant fungus — Candida auris (C. auris) — in healthcare facilities. Another concern plaguing the U.S. healthcare system is the persistent cost inflation and supply-chain constraints. These are consistently pushing up the operating costs of the healthcare industry, thereby lowering the margins of industry players.
On a positive note, rising dependence on telehealth and artificial intelligence (AI) is likely to help the industry thrive in the near term. Chemed Corporation CHE, Addus HomeCare Corporation ADUS, RadNet, Inc. RDNT and The Pennant Group, Inc. PNTG are likely to gain from the prospects.
Industry Description
The industry comprises companies that offer ambulatory care in an outpatient setting or at home. These companies use advanced medical technologies for diagnosis, observation, consultation, treatment and rehabilitation services. The industry participants also include operators of HMO medical centers, kidney dialysis centers, freestanding ambulatory surgical units, emergency centers and other outpatient care centers. Some of the companies in this space have been at the forefront of the COVID-19 pandemic response since 2020 by expanding access to laboratory insights to enable people to lead healthier and safer lives through both molecular diagnostic and antibody serology tests. These tests help in the diagnosis of COVID-19 and the identification of immune response to the virus.
Major Trends Shaping the Future of the Outpatient and Home Healthcare Industry
Cost Effectiveness: The primary advantage of outpatient clinics is cost-effectiveness. Outpatient medical care clinics do not retain patients for long hours (overnight) or charge exorbitantly. Notably, modern-day outpatient clinics offer a broad spectrum of treatment and diagnostic options and even minor surgical procedures. Financial incentives like health plans and government program payment policies supporting services in lower-cost care settings have also been driving outpatient care. In fact, this is the primary reason why middle-class Americans, making up more than 62{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the total population, prefer outpatient clinic visits.
Participating in Alternative Payment Models: It only seems reasonable for outpatient clinics to shift from fee-for-service (FFS) to alternative payment models (APM) with shared savings, risk, bundled payments or population-based payments. With value-based models of care steadily emerging as the future of healthcare, this shift is an ongoing parallel trend. FFS will be crucial to care organizations as a benchmark by which providers can assess alternative payment models. By obtaining the payment schedule from payers and comparing it to the organization’s FFS reimbursements from the same payer, providers can ascertain APM that would be financially the most advantageous to its operation.
AI’s Dominant Role: AI has been a roaring success in healthcare. It is no wonder that it has taken the outpatient and home healthcare space by storm. Outpatient companies prefer bots and automated techniques for managing health information. With the help of AI, hospitals have been achieving better outcomes, with patients receiving more efficient and personalized care. The outpatient industry has been generating huge profits from Electronic Health Records, Revenue Cycle Management, eLabs and ePrescriptions.
In recent times, healthcare facilities are experimenting with software designed to help doctors automatically generate notes from conversations with patients. Microsoft, in its official blog, has confirmed that it (along with Nuance) is introducing a solution — Dragon Ambient eXperience (DAX) Express. It is an automated clinical documentation application integrated into the workflow that combines proven conversational and ambient AI with advanced reasoning and natural language capabilities of OpenAI’s GPT-4.
Increased Dependence on Telehealth: The pandemic resulted in a decline in outpatient clinic visits. Home healthcare providers struggled to offer quality care due to the risk of exposure to the virus. Though the impact of the pandemic has been far-reaching, it has accelerated healthcare innovation. Visits to outpatient clinics have been witnessing a noticeable rebound, with the majority of people being vaccinated. But there are patients who want to be cautious and are resorting to telehealth. Meanwhile, home healthcare can gain from the benefits provided by Medicare (and several other payers) that comprises a broad range of services that can be delivered in a patient’s home, including post-operative and chronic wound care, rehabilitation, and physical therapy. These services serve as lifelines for vulnerable patients, including the Medicare population, suffering from complications arising from COVID-19. Moreover, home healthcare has seen a surge in the utilization of the telehealth platform in response to the pandemic.
A notable trend that has been emerging in this respect is the increasing popularity of the hybrid mode of treatment. As there are certain chronic health conditions, which cannot be identified over a telephone or video call, patients are embracing the hybrid mode of seeking treatments from their physicians in these cases.
Prominent Role of Remote Patient Monitoring: Remote patient monitoring (RPM) has been gradually gaining ground since the pandemic. During that phase, it was difficult to keep a watch on non-COVID patients in the hospital care setting as hospital capacities were brimming with COVID-19 patients. Thus, non-critical patients were increasingly being provided with healthcare in the comfort of their homes while being remotely monitored by their care providers. Even with the return to normalcy, patients are increasingly preferring to be monitored from their homes via RPM devices. This is also boosting home healthcare services as vulnerable patients can be safely and adequately cared from the home setting instead of hospital settings, where the risk of COVID-19 or other infections persists.
Zacks Industry Rank
The Zacks Medical – Outpatient and Home Healthcare industry falls within the broader Zacks Medical sector. It carries a Zacks Industry Rank #156, which places it in the bottom 38{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of nearly 250 Zacks industries.
The group’s Zacks Industry Rank, which is basically the average of the Zacks Rank of all the member stocks, indicates bleak near-term prospects. Our research shows that the top 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the Zacks-ranked industries outperforms the bottom 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} by a factor of more than 2 to 1.
Before we present a few outpatient home health stocks that you may want to consider for your portfolio, let’s take a look at the industry’s recent stock-market performance and valuation picture.
Industry’s Stock Market Performance
The industry has underperformed both its sector and the Zacks S&P 500 composite in the past year.
The industry has declined 22.8{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} over this period compared with the S&P 500’s decline of 13.9{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The broader sector has declined 17.8{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} in the same time frame.
One Year Price Performance
Image Source: Zacks Investment Research
Industry’s Current Valuation
On the basis of the forward 12-month price-to-earnings (P/E), which is commonly used for valuing medical stocks, the industry is currently trading at 27.5X compared with the S&P 500’s 17.7X and the sector’s 21.6X.
Over the last five years, the industry has traded as high as 31.5X and as low as 16.8X, with the median being at 21.7X, as the charts below show.
Price-to-Earnings Forward Twelve Months (F12M)
Image Source: Zacks Investment Research
Price-to-Earnings Forward Twelve Months (F12M)
Image Source: Zacks Investment Research
4 Promising Outpatient and Home Healthcare Stocks
Chemed: The company operates through two wholly owned subsidiaries — VITAS Healthcare Corporation (a renowned provider of end-of-life care) and Roto-Rooter (a well-known commercial and residential plumbing and drain cleaning services provider). Chemed announced its fourth-quarter 2022 results last month, wherein it registered an uptick in its overall revenues. It also recorded robust reported sales in its Roto-Rooter business, wherein the total Roto-Rooter branch commercial revenues improved 8.7{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} from last year on a 5.5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} increase in drain cleaning revenues, a 13.8{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} rise in commercial plumbing, 5.1{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} growth in excavation revenues and a 27.3{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} hike in commercial water restoration revenues. CHE carries a Zacks Rank of 2 (Buy). You can see the complete list of today’s Zacks #1 Rank (Strong Buy) stocks here.
Price and Consensus: CHE
Image Source: Zacks Investment Research
For this company, the Zacks Consensus Estimate for 2023 revenues suggests growth of 4.7{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The same for earnings indicates an increase of 5.6{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The company’s return on equity (ROE) of 41.5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} compares favorably with the industry’s 6.4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
Addus HomeCare: Its services and operating model address a number of crucial needs across the healthcare continuum. Last month, Addus HomeCare announced its fourth-quarter 2022 results, where it registered a solid uptick in its net service revenues. Management confirmed that its personal care revenues (accounting for 74.2{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of overall revenue) improved year over year on a same-store basis, reflecting steady volume growth trends. Home health revenues, which included the operations of Armada Home Health and Summit Home Health acquired in 2021, and the addition of Apple Home Healthcare operations effective Oct 1, 2022, were also up year over year on a same-store basis. ADUS carries a Zacks Rank of 2.
Price and Consensus: ADUS
Image Source: Zacks Investment Research
For this company, the Zacks Consensus Estimate for 2023 revenues suggests growth of 8.2{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The same for earnings indicates an increase of 9.4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The company’s ROE of 8.6{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} compares favorably with the industry’s 6.4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
RadNet: It is a renowned provider of fixed-site outpatient diagnostic imaging services through a network of owned and/or operated outpatient imaging centers. Last month, RadNet announced its fourth-quarter 2022 results, where it registered a solid uptick in its net revenues, both including and excluding revenues from the AI reporting segment. The company’s aggregate procedural volumes and same-center procedural volumes also increased year over year in the reported quarter. On the back of its performance in the fourth quarter of 2022, management is optimistic about its financial position and operating model, which has presented RadNet with targeted opportunities to expand its business, particularly through the construction of new centers to meet growing demand and utilization in strategic markets. RDNT carries a Zacks Rank of 2.
Price and Consensus: RDNT
Image Source: Zacks Investment Research
For this Los Angeles, CA-based company, the Zacks Consensus Estimate for 2023 revenues suggests growth of 9.6{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The same for earnings indicates an increase of 70{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The company’s P/CF ratio of 6.6 compares favorably with the industry’s 9.4.
The Pennant Group: It is the parent company of the Pennant group of affiliated home health, hospice and senior living companies. This month, The Pennant Group completed the acquisition of operations of Robins Landing at New Berlin, WI and Robins Landing at Brookfield, WI. Last month, it reported its fourth-quarter 2022 results, where it witnessed solid improvement in its overall top line. Its Home Health and Hospice Services segment recorded a robust uptick in revenues, whereas the company also recorded strength in its total home health admissions and total Medicare home health admissions. The uptick in total hospice admissions, Senior Living Services segment and Same store Senior Living Services segment for the fourth quarter was also impressive. PNTG carries a Zacks Rank of 2.
Price and Consensus: PNTG
Image Source: Zacks Investment Research
For this Eagle, ID-based company, the Zacks Consensus Estimate for 2023 revenues suggests growth of 8.4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The same for earnings indicates an increase of 24.6{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}. The company’s ROE of 12.4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} compares favorably with the industry’s 6.4{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
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Current residence product sales have gone down continually each individual thirty day period for an full calendar year now. Stock has also been at historic lows. Even though today’s facts might be good information for the market, it comes versus a clean backdrop of financial institution collapse and standard recession stress.
Robert Padilla and his wife Patricia have been on the lookout for a house to get in Santa Fe, New Mexico, for about a calendar year.
“It’s just the two of us, but we have family that we’d like they arrive down to visit us,” Padilla mentioned. “So we needed a a few bed room, two bathtub.”
But there hasn’t been much to seem at in their cost vary — which is about $350,000. Padilla is effective as a stability guard for general public educational institutions. The properties they’ve observed have been disappointing.
“The roofs are leaking,” he claimed. “They’ve experienced animals dwelling in there. chickens. I necessarily mean we just cannot do that.”
If home loan rates had been lower, Padilla states they’d be equipped to glimpse at nicer residences. Rates have appear down from their substantial of a lot more than 7{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} past November. But with premiums about 6.5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, getting is out of get to for many residence buyers.
It is all a little bit of a unfavorable suggestions loop amongst buyers and sellers, claims Selma Hepp, main economist at CoreLogic.
“Both sides assume it is a negative time to acquire and it is a negative time to market,” Hepp said. “And so both of those are sitting down on the sidelines.”
According to her, this trend has been worsening. “Both attribute it to better mortgage loan charges,” Hepp explained.
And now there’s the uncertainty of a banking disaster to element in. “A whole lot of the expectation is that home finance loan charges may perhaps once more go up, and that we will see a tightening of lending ailments,” she claimed.
Hepp also details to shopper sentiment staying minimal as an obstacle. Logan Mohtashami, a guide analyst for HousingWire, agrees.
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Evangelou stated she is cautiously optimistic mainly because contract signings rose noticeably for the 2nd straight month and which is a fantastic indicator for home revenue. But like quite a few analysts and would-be household customers and sellers — she’s keeping her breath for the federal reserve’s up coming shift.
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These developers (clockwise from top left) Geneva Heyward, Catt Small, Charles McGregor, Xalavier Nelson Jr. and Neil Jones discuss how they are putting their stamp on the industry.
Geneva Heyward, Catt Small, Charles McGregor, Xalavier Nelson Jr., Neil Jones, filo/Getty Images
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Geneva Heyward, Catt Small, Charles McGregor, Xalavier Nelson Jr., Neil Jones, filo/Getty Images
These developers (clockwise from top left) Geneva Heyward, Catt Small, Charles McGregor, Xalavier Nelson Jr. and Neil Jones discuss how they are putting their stamp on the industry.
Geneva Heyward, Catt Small, Charles McGregor, Xalavier Nelson Jr., Neil Jones, filo/Getty Images
In many ways, it all started with Jerry Lawson.
The trailblazing engineer helped lead the team that developed the first home video gaming system with interchangeable cartridges, which opened up a whole new world of playing games at home in the 1970s.
The move paved the way for future systems like Atari and Super Nintendo, and by the time Lawson died in 2011, his legacy was imprinted on the video game industry.
It was rare to see Black engineers working in tech decades ago, but Lawson wasn’t alone. Ed Smith was another Black engineer who reimagined consoles in the early days of at-home gaming, working on the very first hybrid video game/personal computer, called The Imagination Machine.
These two pioneers showed that Black people have a place in the multibillion-dollar video game industry. And yet, while the industry employs hundreds of thousands of people around the world, Black people are in the minority. Of the respondents to a 2021 survey from the International Game Developers Association, only 5{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} were Black while close to 80{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} were white — suggesting the enormous gap that exists in the industry.
Surveys from past years show that the number of developers who are Black has grown – albeit slowly – and particularly in the indie video game space.
We talk to five people who are forging their own path, and bringing their unique experience to the world of video games.
Xalavier Nelson Jr.
Founder of Strange Scaffold, studio head writer and video game developer
El Paso, Texas
Nelson Jr. started writing about video games from a young age.
Xalavier Nelson Jr.
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Xalavier Nelson Jr.
The first video game he ever played: Nelson says that there is photographic evidence of the first video game he ever played. “One of the earliest pictures that exists of me is of me sitting on my dad’s lap holding an unplugged controller while he was holding a plugged-in controller, and me thinking that he was playing with me. I think it might have been something like Crash Bandicoot. But I know the first conscious memory of a video game that I’ve had was on the Dreamcast back in the ’90s.”
Games Nelson is currently playing:
Marvel’s Midnight Suns
Silent Hill 2
Fortnite
The video games journalist to developer pipeline: “When I was 12 years old, I was reading an article about Duke Nukem Forever, a kind of infamously panned video game, and it mentioned that game journalists got games for free,” he said. “That is the only job that makes sense for a child in this world.”
Nelson was intrigued by this and concocted a bold plan. “So thanks to the power of the internet, at 12 years old, I pretended to be an adult and I got my first job.” For six years, Nelson wrote for well known industry outlets like PC Gamer and Polygon. Before he was even old enough to vote, he had gained a lot of insight into the video game industry and not all of it was good. The industry showed itself to be grueling and draining, and Nelson decided he no longer wanted to be associated with it. But he says that he wanted to at least try to make a video game himself before closing that chapter of his life.
“The problem is, I loved it,” he said. “I found a deep joy and satisfaction in the process of making a video game.”
The first video game he created: Nelson created an interactive fiction adventure game called All Hail the Spider God. “You would click on highlighted words and some of them led to unexpected choices or descriptions. The narrative was about choosing indirectly what type of person you become through the circumstances of the surreal world that you exist within.” Nelson would go on to work on games like Space Warlord Organ Trading Simulator, a virtual stock ticker and auction interface where the player buys and sells human organs, and An Airport For Aliens Currently Run By Dogs, which is exactly what it sounds like. Nelson’s joy for developing video games led him to start up his own studio in 2019 called Strange Scaffold.
A screenshot of Space Warlord Organ Trading Simulator.
Xalavier Nelson Jr.
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Xalavier Nelson Jr.
Challenges within the industry as a Black developer: “I think the problem that the games industry faces with Black people is twofold,” Nelson said. “The first is giving people their first opportunity, because they haven’t done it already. The inability to create space for people to start their journey in the first place is a terminal illness which is currently strangling the games industry.” Nelson said the industry is struggling to hire developers at a senior level because juniors weren’t being trained in years past.
“The second major factor is that once people are in, what you’re looking at for all the people who are Black who have survived, is that they’re survivors. They have existed in toxic environments. They are flowers in the desert. If you bring in a group of 10 people and one survives and becomes a standout, it is not an acclamation of your recruitment efforts, it is an indictment that this one star exists because you failed to preserve the other nine.”
A screenshot from An Airport For Aliens Currently Run By Dogs.
Xalavier Nelson Jr.
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Xalavier Nelson Jr.
His favorite part of being a video game developer: “My favorite part of working on games these days is direction. It is really hard to have a focused direction for a project with precision that also actively incorporates collaborators and creates processes and inherent contexts where the human beings that work on the project also feel recognized, seen, and able to live healthy lives while building a game. But walking on that tightrope and doing that with intentionality and responsibility is what makes me feel alive. So, every day I get to wake up and feel like I was doing exactly what I was built to do.”
Catt Small
Video game developer and product designer
Brooklyn, New York
Small started to learn how to program when she was 10 years old.
Catt Small
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Catt Small
The first video game she ever played: “The first game that I played that’s like a really memorable experience for me would have to be Sonic the Hedgehog on the Sega Genesis. I grew up playing games of all kinds, so not just video games but also board games, and gaming has always been a part of my life.”
Learning how to code: “When I was 10, I actually started to learn how to program so I could make my own dress-up dolls, and eventually I learned that you could make games as well. I had a tutorial for the dress-up doll program that I was able to read, it was updated in like 1999 and I think I looked at it in like the year 2000.”
Small met others interested in programming and video games through online forums. “We did collaborate, which was really fun. So I got to learn how to make art for these dress-up doll games that we were creating, and we would kind of trade art back and forth and figure out how to build everybody’s work into one cohesive experience, which was really fun.”
Games Small is currently playing:
Splatoon 3 (she says “It’s my life basically!”)
Say NO! More
Space Warlord Organ Trading Simulator
The first video game she created: Small’s first video game was inspired by growing up in the Bronx. The game is called Train Jumper. “It was all about running to catch the train and kicking people out of the way. The point was to get there within 30 seconds. That was so fun because it was what I always wished that I could do in real life, but you know, you can’t exactly bump into people and shove them on your way to the train because that’s very rude. But I just loved being able to get my frustration out in the form of this game.”
A screenshot from Train Jumper.
Catt Small
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Catt Small
Making a bigger impact through her games: One of the other games Small has developed is called SweetXheart. Players act as Kara, a 19-year-old girl from the Bronx who attends an art college and interns at a tech company – very similar to Small’s life in her early 20s. Players go to work, school and interact with people in Kara’s life. It’s a slice of life game that showcases what life can be like for a Black woman. “There was parts in this game about harassment because being a black woman in New York City, you experience a fair amount of street harassment. A man actually told me that he was not going to harass women or catcall women anymore after playing the game.”
A screenshot from SweetXheart.
Catt Small
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Catt Small
Organizing the Game Devs of Color Expo: Co-founded by Small and Chris Algoo in 2016, the Game Devs of Color Expo is a space for developers of color to meet one another and showcase their work. Several events have been held over the years, some in partnership with major gaming companies like Xbox, Nintendo and Oculus. Besides bringing developers of color together, Small says the expo helps to break down the barriers that people of color may face when trying to get into the industry. “We are actively giving people money to make their video games.” Since 2019, the Game Devs of Color Expo has given more than $360,000 to game developers of color.
Advice she has for those who want to get into the video game industry: “Find your people, because your community is going to be the thing that gives you energy to keep going, and your community is going to be what inspires you and helps you to keep pushing to learn and grow.”
Geneva Heyward
Video game developer
Brooklyn, New York
Heyward’s parents helped pave the way for a life in video games.
Geneva Heyward
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Geneva Heyward
The first video game they ever played: “Because my dad had a lot of computers lying around, he let me go on them and play games on Disney. We haven’t been able to find this photo, but there’s a photo of me when I was like three playing the Lilo & Stitch sandwich stacker game.” Heyward says that their parents are big nerds and have been playing games for as long as they can remember. “My mom got us a GameCube when I was young because I have a sibling who’s one year younger and we played a lot together. I have two other siblings as well, so games have been just a thing me and my family have used all the time.”
Games Heyward is currently playing:
Splatoon 3
Fire Emblem Engage
Super Lesbian Animal RPG
Figuring out how to make video games: As a high schooler, Heyward applied for a free NYU arts program that had classes in video game design that students could attend on the weekend. “I didn’t really think I’d get into it, but I got it. There is when I learned that you didn’t have to have a goofy amount of money to make games at home. You didn’t have to have all the expensive programs and there were free ones.” Heyward had already thought about perhaps becoming an animator, but now they realized being a video game developer could be in the cards. “Creating games was something that I just knew I wasn’t gonna get tired of like how I did with animation.”
A screenshot from the game ValiDate.
Geneva Heyward
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Geneva Heyward
Bringing ideas to life in the form of video games: “I got to work on this game called ValiDate, which is a game about people in Jersey City dating and trying to navigate through their mid 20s.” Heyward focused on the programming aspect of the game. “I think the writers did a really great job, and I think we need more video games with Black and queer people and trans people in them.” One of the more recent projects Heyward worked on is called Treachery in Beatdown City – which they say combines politics with a good ole’ fashioned “beat ’em up” style of game. “You are trying to rescue the president who’s been kidnapped by ninjas. You’re going through New York and running into all of these weird people who are being racists and homophobes – awful people – but you get to beat them up!” Heyward says the game includes cutscenes with those characters who end up apologizing for their behavior.
Being young and Black and trying to get into the video game industry: “I feel like on the more indie side [of games] there’s a lot more diversity and collaborating with people online. The game industry … it is diverse but the problem is that the people who get the most money are just the cishet, white dudes.” Heyward says that they do a lot of networking to make connections in the industry and it makes them realize they aren’t alone.
A screenshot from Treachery in Beatdown City.
Geneva Heyward
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Geneva Heyward
Advice for prospective Black video game developers: “There are scholarships, there are lots of programs that usually offer lessons for free. I know there’s Code Coven, I know Black Voices in Gaming is a thing, I know the Game Devs of Color Expo is a thing. You do not have to go through everything alone. There are communities out there that can help.” Heyward also points out that while they did get a degree in game design from NYU, they say a degree isn’t the only way to get into the industry. “What matters is your experience and your knowledge working on games. Your portfolio can speak for itself.”
Charles McGregor
Founder of Tribe Games and a video game developer
Minneapolis–Saint Paul, Minnesota
McGregor’s dad taught both him and his brother how to code when they were kids.
Charles McGregor
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Charles McGregor
The first video game he ever played: “I was three years old when I first started playing video games, and that’s because my dad is really into video games. So when we were growing up, he had a Super Nintendo that we were able to play. Some of the earliest games that I do remember playing were games like Super Mario World and Donkey Kong Country.”
Games McGregor is currently playing:
Wonderbox: The Adventure Maker
God of War Ragnarök
Valorant
Deciding to make video games a part of his life: McGregor remembers when he was in elementary school that he came across an article in a magazine about a young girl who had started her own bakery business. McGregor thought to himself maybe he could do that but with video games. “My dad is also a computer scientist, so I went to my dad and I was like, do you think that you could possibly teach me how to make video games?” From there, McGregor says his dad taught both him and his brother how to code when they were kids. That set the stage for McGregor, and his brother, eventually growing up to be video game developers.
A screenshot from the game HyperDot.
Charles McGregor
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Charles McGregor
The first video game he created: McGregor says there were a lot of video game projects he would start working on, but wouldn’t finish. It was in college that he decided to make a video game for a media arts club he was part of. “I finished a really quick, small prototype of a twin stick shooter. If you’re familiar with Geometry Wars, or I’d normally say it’s like Asteroids except you can move and shoot using the two sticks unlike a controller.” Making that game was a lot of fun for McGregor, so he decided to turn the prototype into a complete game. “It’s only going to take me two weeks! ” McGregor remembers thinking to himself at the time. “It took me two months, but I actually got to the end of the finish line and I released Glitch In The System. That really just changed the game, it just opened so many different doors and motivated me to be like, oh, this is what it’s like to actually finish a game.” After that, over the course of two years, McGregor finished eight different video game projects.
Being “the only”: In college, McGregor noticed he tended to be the only Black person in his computer science classes. “Because I live in Minnesota, I have this expectation of being like, oh yeah, of course I’m just gonna be the only Black person around.” That was the norm for McGregor. “It wasn’t until I went to more industry events where I started to see other Black people.” That, McGregor said, isn’t something he realized he needed. “When you are immersed in an environment where you’re no longer the minority person, that is something that it feels like you’re breathing a sigh of relief. You’re able to talk about things and relate to people.”
A screenshot from the game HyperDot.
Charles McGregor
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Charles McGregor
Putting the Black in gaming: “The games that you create don’t have to be extremely super pro Black, something where it’s like, ‘Oh, this is clearly just made for Black people,'” McGregor says. “I’m known for a game about a dot.” That game is called HyperDot, it’s an action arcade type of game where the player is trying to dodge everything coming at them. While it may be a game about shapes, McGregor says that there are some cultural references in the game. “I like ’80s and ’90s hip hop. So there’s actually a couple of references to Eric B. & Rakim. There’s a level [in HyperDot] called ‘Know The Ledge’ and if you lose in that level, you’ll get an achievement that says you didn’t know the ledge, referencing one of their songs. There’s just a lot of subtle hints.”
Neil Jones (aka Aerial Knight)
Indie video game developer
Detroit, Michigan
Jones says most of what he knows today about video game development he taught himself.
Neil Jones
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Neil Jones
The first video game he ever played: Jones’ grandma, who raised him, is the one who got him into video games. “My favorite thing was after she would get done, you know, working and cooking and all that stuff, she would just want to play Bejeweled. I would sit there and watch her and then she would give me the controller, and I’d try to beat her score. And we’d go back and forth.”
Games Jones is currently playing:
Super Space Club
MARVEL SNAP
EL PASO, NIGHTMARE
Getting into video game development: “In high school they really forced you to kind of pick your entire future and I didn’t know. I fell for those commercials that said, ‘Hey, you wanna make video games, kid?’ That’s the only thing I could imagine me being happy doing.” Jones ended up going to a for-profit school to learn more about video game development. He says that he learned a lot about 3D modeling and the different kinds of software that could be used to make a game, but most of what he knows today about video game development he taught himself.
A screenshot from the game Never Yield.
Neil Jones
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Neil Jones
A screenshot from the game Never Yield.
Neil Jones
What life is like as a video game developer: “You sit down and you code or you do art. In the larger scheme of things any developers have to deal with is not only sitting down and making the game, making sure the game is fun, but we have to worry about what other games are similar to our game. How can we stand out? How can you market the game? You have to make marketing materials. You have to do the sound effects in music.” Jones says that indie developers like himself end up doing everything on their own without the help of a larger team at times. “It’s not just one or two things, it’s all aspects. I really burnt myself out on the game that I launched, I only slept two hours a day. It was very stressful, but, you know, I’m really proud of it.”
The first game he developed: Jones’ video game, Never Yield, is akin to runner games like Temple Run. The difference between Never Yield and other runner games, Jones says, is that this game has a narrative. Set in a futuristic Tokyo-style Detroit, the main character of the game is Wally, who is trying to escape enemies after finding his family’s lost treasurer that grants him special abilities. “This one has cutscenes. The player interacts with their environment. It has a lot of freedom of movement.” Jones also worked with a friend doing a full original soundtrack for the video game. “We had rappers come in, singers come in and record over that. That’s not really something you see a lot of in games, especially indie games.” Never Yield was Jones’ way of proving himself as a developer. “I’ve been trying to get into the game industry for so long. Let me make my own thing. If I’m never going to make it into the game industry, let me make a perfect example of — this is what they’re rejecting.”
A screenshot from Never Yield.
Neil Jones
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Neil Jones
The barriers of entry into the video game industry for Black people: Jones has pointed out a lot of issues with the video game industry when it comes to the way Black developers are regarded. Many companies pledged to do better when it comes to diversity and inclusion in the 2020 post-George Floyd era. Jones is seeing more people of color get their foot in the door, but he says that skilled developers like him should be further along in their careers if companies had hired Black people in the first place years ago. “I don’t think we’ll ever be able to fix the original sin of these massive studios who have hired people over the last 20 years actively not hiring Black people. We can never make up for the lost time.” Jones says that it’s great more Black people are joining the industry, as well as that there is more racial and gender representation in games, but he says the industry still has a long way to go.
Passing the torch: Despite the barriers, Jones encourages Black people to get into the video game industry, especially kids. At an event over the summer where Jones showcased Never Yield for people to play, he ended up speaking with a lot of Black families whose children were interested in video games but didn’t want their kids to think all they had to do was play games and they’d make loads of money. “I kind of just told them there’s a lot of different jobs in gaming — community managers to project managers. He doesn’t have to be a master at coding or be a master artist to kind of get into this.” Jones says that he doesn’t really like to give advice to people because everyone’s journey is so different. “People say that, you know, the journey that I took was inspirational, and I never saw it like that until I talked to all those kids and those families.” What he does tell people is to find your own voice and space, and just do what you like the most.
Ebony Ross-Peel, of Waterbury, wasn’t paid for two months for two weeks of her work as a personal care aide. It led her to be evicted and lose her car because she couldn’t pay for her car insurance. “They want quality of life from us for their clients. That’s what I want,” she said. “But where’s my quality of life?” Yehyun Kim / ctmirror.org
Editor’s Note: This is the first report in a four-part series about Connecticut’s aging population and the challenges in finding ways to care for people.
This week: The country’s aging population is expected to more than double. Connecticut’s network of supports is struggling.
Next week: Nursing homes face a reckoning as they deal with fewer residents, a change in pay and plans to ‘right size’ the industry.
Upcoming: As more people choose home and community options over institutional care, will access to services be equal for all?
Upcoming: More people are aging in place. But the state’s home care industry operates with little oversight.
Connecticut’s elder care system is at a precipice.
Nursing homes, for decades the final destination for many older adults and people with disabilities, are being squeezed at both ends as state officials increase oversight of the industry while funneling millions intoprograms that aim to keep residents in their homes and communities.
The state’s aging nursing facilities, beset by staffing problems, outdated infrastructure and dwindling financial support, are facing an identity crisis. Occupancy, which plunged steeply during the pandemic, has yet to fully recover. Complaints about the quality of care in some homes are escalating, as arequestions about how owners spend taxpayer money.Connecticut policymakers no longer envision nursing homes as the primary option for elder care but as a recourse only for those with medical needs that can’t be managed at home.
At the same time, the state’s lofty goals for boosting the number of people aging at home have hit roadblocks.
Connecticut launched a vast network of programs in recent decades designed to prevent unneeded nursing home admissions and increase the flow of people from facilities back to the community. State officials use terms such as “right-sizing” and “rebalancing” when contemplating the future of long-term care, with the objective of reducing the number of nursing homes.
By 2040, state leaders expect a nearly 30{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} increase in the number of long-term care residents on Medicaid who remain in their homes, and they’ve committed more than $1 billion annually to that cause.
But a year-long review by The Connecticut Mirror that encompassed interviews with state officials, elder care advocates, legislators, nursing home leaders and union representatives has found the intricate web of resources supporting those ambitions is fraying.
Private agencies and the state are struggling to recruit enough workers to care for this expanding population. Residents complain of difficulty navigating a convoluted home care system that operates with little oversight. A dearth of affordable housing and a lengthy process for accessing Medicaid are undercutting efforts. And Connecticut lacks a streamlined process for hospital discharges to the community, as it has with nursing homes.
The stakes are extraordinarily high. The nation’s 85-and-older population is expected to more than double by 2040. And Connecticut shoulders a disproportionate number of older adults. The state ranks 4th-highest nationally for its share of people in that age group.
“We’re in a care crisis, a housing crisis and a nursing home crisis. We’re at a dire point now,” said Rep. Michelle Cook, D-Torrington, a member of the legislature’s Human Services Committee. “There is a rapidly aging community. A vital part of our state’s future is how we navigate this.
“We have a moral and ethical obligation to take care of people.”
“I don’t think enough people are paying attention to this,” said Sen. Cathy Osten, D-Sprague, co-chair of the Appropriations Committee and an influential member of the Nursing Home and Assisted Living Oversight Working Group. “The things we pay attention to concern the next generation, what we are doing for children, and we certainly should do things for children. But we need to put as much into services for seniors as we are putting into services for young people.”
Advocates, lawmakers and elder care experts say there is an urgent need for better strategies to attract and retain a workforce that will aid Connecticut’s aging and disabled population, to ease the cumbersome process of navigating the home care system, to speed up Medicaid enrollment, and to address peripheral problems like housing that have an outsized impact on how and where people age.
“We need to address this in a big way, or we’re not going to have the workers and the physical infrastructure to care for an older population,” said Anna Doroghazi, associate state director of advocacy and outreach for the AARP in Connecticut. “We can’t just react to what the need is now.”
“We have to meet the immediate need but also to anticipate what that’s going to be years from now, when we will have more people over the age of 60 than under 18,” she said. “We’ve never had that. We don’t know what that world looks like. But we do know that it’s on its way and we have to rethink a lot of things.”
Anna Doroghazi, right, policy and advocacy director for the AARP, and Heidi Carlson, a grant officer at Goodwin University, try out exercise equipment during a tour of South Meadows River Trail that AARP funded to make the trail more accessible. Doroghazi said better coordination is necessary to make information accessible for people who need it. “There are three different state agencies involved with regulating different pieces of home care, and they don’t really talk to each other,” she said. “So when people want information, they’re not sure where to go.” Yehyun Kim / ctmirror.org
Problems mount in nursing homes
For decades, the bulk of the state’s long-term care spending went toward institutional settings like nursing homes. But just before the pandemic began, that trend shifted considerably.
In 2018, for the first time ever, the state spent more Medicaid funds on home and community-based services than on institutional care, 53{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to 47{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}, state data show. By 2022, it had spent 58{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of its Medicaid long-term care money on home services, versus 42{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} for nursing homes and other facilities.
Although the spread of COVID accelerated that swing, a migration from institutionalized care to home services had been underway for years. In 2009, 65{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} of the state’s long-term care Medicaid expenditures went to nursing homes. By 2017, that number had dropped to 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b}.
Nursing home occupancy fell steeply during the early months of the pandemic. Hovering around 88{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} statewide before the first reported case of COVID, it plunged to 71{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} by July 2020.
As of February 2023, it had climbed to 83{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} but still hadn’t reached pre-pandemic levels.
Facility operators have sought $193 million more from the state to sustain struggling buildings. State officials balked at the request, and lawmakers raised questions about how several infusions of money during the pandemic were spent.
“We’re concerned about quality,” said Matthew Barrett, president and CEO of the Connecticut Association of Health Care Facilities. “As we move to the other side of the pandemic, especially as it relates to high Medicaid facilities and serving low-income communities, there is evidence that they continue to be under-resourced, and without proper focus and attention, we’ll continue to see slippage.”
People send me pictures and videos of their loved ones in nursing homes with their bed sores and whatnot. It’s horrific.
Rep. Jane Garibay, D-Windsor, co-chair of the Aging Committee
Nursing home owners say they are having extraordinary difficulty recruiting and retaining workers, and many facilities are understaffed. From February 2020 to December 2022, the nursing home industry lost 210,000 jobs nationally, and staffing tumbled to levels not seen since 1994, officials with the American Health Care Association and National Center for Assisted Living said.
And in recent years, complaints about care in nursing homes have increased. In 2017, the Office of the State’s Long-Term Care Ombudsman logged 3,090 grievances from nursing home residents and their loved ones. Last year, it received 4,278.
Complaints range from lack of access to care, typically from understaffing, to meals arriving late and cold, problems with heating and air conditioning, trash piling up and residents missing daily activities.
During the last quarter, the health department issued four “immediate jeopardy” findings in Connecticut. In general, there has been an increase in those orders, at least partially due to staffing issues in nursing homes, Barbara Cass, chief of the department’s health care quality and safety branch, said at a public meetingrecently.
The findings indicate that violations in a nursing home caused or were likely to cause serious harm or death to a resident.
The problems have stirred debate at the Capitol.
“People send me pictures and videos of their loved ones in nursing homes with their bed sores and whatnot. It’s horrific,” said Rep. Jane Garibay, a Democrat from Windsor who is co-chair of the Aging Committee. “Here we are discussing if we can afford to put in air conditioning for seniors when the majority of our animal shelters have air conditioning. We have to change the way we think.
“When someone says, ‘I went to see my father. He got up in the morning, and they didn’t answer his bell so they could assist him to the bathroom. After three hours, he went in his bed and they served him lunch in that state without cleaning him,’ people will say, ‘Oh, that’s awful.’ But there’s just not the outrage. I get outraged.”
Lawmakers have introduced bills during the 2023 legislative session to raise the mandatory minimum staffing hours in nursing homes, to require more transparency in how facility operators spend state money, to mandate that owners provide air conditioning in resident rooms, and to prompt broader disclosures about private equity investment in long-term care, among other proposals.
State officials are also trying to “right size” the nursing home industry by scaling back the number of beds — and, eventually, facilities — to align with current demand. Lawmakers are weighing a measure that would slash funding for buildings whose occupancy drops below 90{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} over a 12-month period.
“Essentially, we no longer want to pay for excess beds,” Andrea Barton-Reeves, the state’s social services commissioner, said at a public hearing in February.
A push for home care, a lack of direction
Home care services are ideal for both residents and the state. Most people prefer to age at home, and it costs less for the state to fund a Medicaid recipient in home care than in a nursing home.
But difficulty navigating the system has left many people feeling lost. For people already at home, the confusion can cause delays in getting care. For those in nursing homes who want to move back to the community, it can mean extra time sitting in institutional settings waiting for services to line up.
One issue is the absence of an updated home care worker registry. People on the state’s Medicaid program seeking care at home receive a binder with printed pages containing the names and contact information of potential employees.
But several residents have said the paper registry, produced by the state’s payroll agency, does not have up-to-date information for employees. Some people reported spending weeks calling candidates, only to be told they no longer work in the field, they could not take on additional clients, they did not live within a reasonable commuting distance or, in cases of people with special needs, they did not have the right skills.
Workers have complained about providing updated contact information but never seeing it reflected in the registry.
“There is a paper list. The reports we tend to hear about it are that it’s not up to date and it often does not reflect who’s actually looking for work,” said Diedre Murch, home care director with SEIU 1199 New England, the state’s largest health care workers union. “I’ve heard consumers talk about having to go through dozens of workers just to find someone who’s looking for another client. People tell me they live in Stamford and get names of employees from Manchester.
“Some of the workers say, ‘Oh my God, I’ve given my updated contact information 40 times and they still have my bad phone number on the directory.’ I hear a whole constellation of problems.”
Alan Coker, left, and his personal care aide, Jackie Katibian, leave after grocery shopping. Coker had several strokes and back surgery and receives help from two personal care aides for daily tasks. Yehyun Kim / ctmirror.org
Coker watches a comedy show that he loves. “We have happy lives now,” he said. He is happy that he can take a walk, meet his family and go grocery shopping whenever he wants to, which wasn’t possible at a nursing home. Yehyun Kim / ctmirror.org
Coker’s to-do list hangs on the wall. He is passionate about Bible education and joined an online school to enhance his teaching skills. Coker thinks he wouldn’t have been able to do that at a nursing home. Yehyun Kim / ctmirror.org
Jackie Katibian, one of Alan Coker’s personal care aides, cleans his house, does the laundry and drives him to doctor’s appointments. “If I don’t have PCAs, I can’t stay home. That’s part of the condition for me to be on my own,” Coker said. Yehyun Kim / ctmirror.org
Katibian, right, takes a short break after cleaning the bathroom. It took a lot of effort for Coker to hire personal care aides after staying at a nursing home for 10 months. “They just gave me a notebook and said you got to hire somebody … I really didn’t know what I was doing,” Coker said. “I would have appreciated if I had some guidance and some hands-on assistance.” Yehyun Kim / ctmirror.org
Coker’s house is covered with photos of his loved ones, including social workers who helped him leave a nursing home and live independently with assistance. “There’s no reason to stay in a nursing home when you can get back on your feet,” Coker said. “If you put somebody in, you’re going to put me in a nursing home to die.” Yehyun Kim / ctmirror.org
After receiving care in a nursing home for 10 months, Alan Coker, 65, wanted to transition back to a home. Through a state program called Money Follows the Person, Coker set out to hire aides who could help him prepare meals, clean, run errands and shuttle him to doctor appointments.
But the process proved difficult. During an initial visit with an employee from the state’s payroll company, Coker said he was able to ask questions, but the answers weren’t especially helpful in picking a home care aide. After calling several candidates and conducting interviews, Coker spent more than a month in the nursing home waiting for paperwork to be processed.
“I was getting worried because I couldn’t leave the nursing home until I was able to find somebody,” said Coker, who lives in Manchester.
He wishes he had received more guidance and information about the system up front.
“I was given a notebook and told a checklist of employment information and questions you can ask — ‘You can ask for references, you can do this, you can do that.’ But there was no help from there,” Coker said. “Mistakes could be prevented or done away with if there was more initial assistance given. They’re basically throwing the consumer and the new personal care aides right into the fire.”
Mairead Painter, the state’s long-term care ombudsman, and others have recommended developing an electronic database with worker information that can be updated regularly.
“It is so antiquated, the way it’s done,” she said. “It needs to be electronic. There needs to be a database where someone can click and see — ‘I’m still working’ or ‘I’m not working,’ instead of literally this thing of paper. Everything should be computerized.”
Officials at the social services department said they plan to issue a request for proposals to hire a company that could develop an electronic database, though they did not give a target date for when the request would be issued or when the project would be completed. It would be funded with state and federal money.
The revolving door of home care workers is hard on some people and disrupts continuity of care. And trouble navigating the system means residents are going through a burdensome hiring process repeatedly.
Sharon Thorstenson, of Southington, gets her hair colored by her niece Megan Murphy. It was the first time getting her hair cut since 2017, having stayed home most of the time during the pandemic partially because of her compromised immune system. Yehyun Kim / ctmirror.org
Sharon Thorstenson, second from right, spends time with her relatives at their home after not having seen them for a long time. Yehyun Kim / ctmirror.org
Sharon Thorstenson, 58, began needing care in 2017 after a tick bite left her with a disability. She made a volley of calls to potential workers before landing a person who was right for her.
“Initially, I want to say I probably made 30 phone calls,” said Thorstenson, a Southington resident.
“It was very challenging, because there was so much thrown at you. And they really didn’t walk you through the program. You pretty much were given a binder with legal forms and things like that. There were so many things, and I wish there was more guidance from the agencies so it wasn’t so time-consuming and frustrating.”
To make matters worse, problems with compensation from the payroll agency and other issues meant workers kept quitting. From 2017 to 2021, her first years of home care, Thorstenson estimates she hired 28 different aides. Aside from disrupting her care, the exits were painful because she formed relationships with workers, only to have them leave over and over again.
“It breaks my heart,” Thorstenson said. “It’s kind of like grieving, because you’re losing somebody.”
‘Massive need’ for increased workforce
Home care is a fast-growing field in Connecticut. In 2011, there were nearly 21,000 home health and personal care aides working in the state. By 2021, there were about 38,000.
But the industry experiences staggering turnover, and the population it serves is expected to grow substantially. That has raised alarms for officials in the long-term care sector.
Turnover is 30{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} to 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} a year in the 11,000-member unionized workforce of personal care aides that serves residents on Medicaid. Low wages, problems getting paid on time and, until recently, a lack of paid time off have hampered efforts to keep workers in the industry.
Even at private sector agencies where benefits are better, some employers report an annual turnover of 50{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} or more.
“The biggest challenge — and it’s getting worse — is workforce availability,” said Julie Robison, professor of medicine at the UConn Center on Aging. “There is a massive need for an increased workforce in institutional settings but even more so in the community. You have lots of demand, and you have organizers who are willing to help set up plans for people. But just getting the day-to-day workers on the ground has been extremely challenging.
“The wages are low, the benefits are spotty, and it’s really hard work. Some people are just made for it and are so good at it. They should have a living wage.”
“It’s a real struggle,” added Painter. “We have many, many more older adults and individuals who may have care needs than we do the population of people who want to do that work.”
This is still not a living wage in Connecticut.
Diedre Murch, home care director with SEIU 1199 New England
Until recently, the personal care aides represented by 1199 SEIU in Connecticut made an average salary of $16.25 per hour, or $33,800 annually. After more than a year of rallies and bargaining, the union reached a new agreement with the state that raised pay to $17.75 an hour in 2022. For many members, it increased again to $18.25 this year.
“Our members are excited about the raises, but it’s clear this is still not a living wage in Connecticut,” said Murch, the 1199 home care director. “A living wage is north of $20 an hour. Even at $17.75, if you work full time, you’re making $36,000 a year. So it’s still a real struggle.”
In a 2022 union survey, roughly one-thirdof the personal care aides reported being behind on their rent or mortgage payments during the last year. Forty-two percent said they had paid late fees or were referred to a collection agency for unpaid bills, andmore than one in five received a shutoff notice for utilities or had their utilities turned off during the past year.
Thirty-seven percent of the aides said they rely on food stamps, and a thirdcould not afford groceries or did not have enough food to feed their families over the last year. Seventy-two percent reported using some form of state assistance.
Halfof the PCAs reported taking unpaid days off during the last six months due to illness or quarantine. For years, the workers did not have regular paid time off (federal programs during the pandemic provided some relief, as did the recently enacted paid leave law). Under the terms of the new union contract, full-time aides were granted five paid days off, though union leaders say that benefit is on hold until the state hires a new payroll agent.
“There’s still a long way to go,” said Murch. “It’s not like illness neatly confines itself to five days a year.”
Aside from low wages and scant benefits, many personal care aides have complained about late payment or non-payment from an agency hired by the state to manage payroll. The unreliability of the agency, Allied Community Resources, to pay employees promptly has caused some workers to leave the industry, union officials and employees said.
For those living paycheck to paycheck, the consequences are worse. Some workers have been evicted from their homes or faced the threat of eviction.
Ross-Peel calls a state office to reinstate her food stamps. She raises a 2-year-old son as a single mom and sometimes has had to choose between buying diapers or clothes. Yehyun Kim / ctmirror.org
Ebony Ross-Peel, 27, took on a new home care client in July 2022, her only one at the time. After two weeks of work, Ross-Peel had not received payment.
She and union leaders sent urgent pleas to the state and its payroll agent about the missed compensation. Confusion over paperwork was blamed for the problem.
But the late paycheck caused Ross-Peel, who has a 2-year-old son, to be evicted from her home.
In an email she sent to union leaders and the state on Aug. 18, Ross-Peel pressed for answers.
“So am I going to be receiving payment today or tomorrow? Because I had to let my son stay with my mom last night and sleep in my car,” she wrote. “I just need to know what I am doing tonight.”
“I shouldn’t have to go through this amount of stress over not getting paid for work,” she said in an August interview. “I just don’t understand it. I have never been through something like this in my life.”
Ross-Peel eventually was paid, but she left the field not long after.
“I most certainly do not want to work in home care anymore,” she said. “You give so much and you get so little out of it.”
Murch said many aides have complained about nonpayment or late payment. In 2022, the union received 1,653 grievances against Allied from personal care aides over payment problems. It has received 622 so far this year, she said.
She remembered one worker who went as long as 12 weeks without compensation.
“I can’t even talk about this without getting emotional,” Murch said. “I have been texting with a worker who is being evicted because Allied didn’t process her new hire paperwork. … I wish I didn’t hear these stories ever, but I wish I didn’t hear them every single week.”
Don Waddell, executive director of Allied, said all kinds of issues can cause problems with payment. For example, he said, if a client is discharged home from the hospital and begins receiving services, the company can’t pay a worker until it knows the client’s discharge date.
“We have rules and rules that we have to check before we actually make the payment,” he said. “We just can’t pay anything that comes to our office.”
In a joint statement, Waddell and Allied CEO Leigh Gallivan Mahoney added: “Our staff work extremely hard to clear up issues with employers and providers and are dedicated to processing the payroll … as quickly as possible,” they said. “We know how critical it is for them to receive their pay every week.
“We have also introduced multiple ways for employers and their providers to report payment issues, all to streamline the problem-solving necessary for managing such a complex system. One of these areas is our website, which has an integrated problem-resolution form and online chat.”
State officials said they are aware of the payroll problems and put out a request for proposals to hire a new company to manage payments.
“The RFP process has concluded, and the state is in active contract negotiations with the selected vendor,” said Jalmar De Dios, a spokesman for the Department of Social Services. “The contract, which will include specific service level agreements, will start when negotiations are complete.”
State officials did not provide an estimate for when the new company would begin work.
“The goal [with the new vendor] is 100{1668a97e7bfe6d80c144078b89af180f360665b4ea188e6054b2f93f7302966b} payment on time, which we don’t have right now for a lot of different reasons,” said Dawn Lambert, co-leader of the Community Options Unit at the social services department. “There is a history of corrective action with Allied. We are aware of some performance targets not being met and have put in place corrective action over the years.”
But that hasn’t stopped the issue from recurring, even recently.
Union leaders said that even when a new company takes over, the state should provide better oversight to ensure payroll problems don’t keep happening.
“Sadly, the state has been slow on this,” said Pedro Zayas, a spokesman for 1199 SEIU. “Hopefully, the new payroll agency will make good for these members. We don’t expect perfect payroll, we know it’s thousands of workers, but we need good customer service.”
Challenges abound
Aside from an unwieldy system and cratering workforce, the state faces other barriers as it tries to encourage more people to age at home.
Lengthy wait times for accessing Medicaid, the lack of a streamlined process for hospital discharges to the community and challenges with housing also pose obstacles.
Medicaid, the primary funder of long-term care services, has a long approval process, sometimes as many as 90 days for verifying eligibility, state officials said. For people who need elder care urgently, the system can unintentionally steer them toward nursing homes.
“Nursing homes will typically admit an individual pending Medicaid eligibility determination because they are generally able to bear the cost of providing services until they are eventually paid, or even to withstand a total loss if they are never paid,” officials with the AARP noted in a 2021 report. “In contrast, agencies that provide home and community-based care typically cannot afford to start services without the certainty of being paid right away.”
“The time period between applying and final approval of Medicaid eligibility can be particularly perilous and stressful for individuals who urgently need long term services but have limited resources,” the authors wrote. “To avoid a nursing home admission, they must either rely on family caregivers or privately pay for home-based services, all the while navigating a complex, fragmented system of providers.”
Advocates have urged the state to consider “presumptive eligibility” as a way to help more people avoid institutionalized care.
I most certainly do not want to work in home care anymore. You give so much and you get so little out of it.
Ebony Ross-Peel
Under the program, case managers and social workers can use screening tools and basic financial information to determine if a person is qualified for Medicaid and temporarily provide services, the AARP noted.
“To say, ‘Go sort it out for 90 days at home while we do the paperwork’ — some people can’t go 90 days without services. If they can, it might be because they have a friend or daughter or son who can take on a lot of that care, which also comes at a cost,” said Doroghazi, the AARP advocacy director. “There’s a big ripple effect, so presumptive eligibility is something that would be helpful.”
At least seven states already offer it. Five of them — Michigan, Washington, Ohio, Vermont and Rhode Island — adopted policies that allow for presumptive eligibility. Two states, California and Indiana, are offering it under a temporary Medicaid amendment.
In Connecticut, lawmakers introduced a bill in 2021 that would have established a presumptive eligibility program for certain home care applicants, but the measure never made it out of the Human Services Committee.
The program poses a risk. If a person ultimately is found ineligible for Medicaid, the financial burden of the services falls on the state or is shared with home care providers.
“It’s really about underwriting it upfront,” said Lambert at the social services department. “We’re going to assume that you’re going to qualify, and we’re going to pay your claims as if you qualify. And then we’re going to go through the [eligibility] process.
“If we’re right, we’ll go back and claim all of that money appropriately to Medicaid. But if the state’s not right, it’s going to continue to fund that, which could be expensive.”
Despite that, advocates say the state should consider the potential savings in averting unnecessary nursing home care.
“On average, states can provide care for approximately three individuals at home for the cost of one in a nursing home,” AARP officials wrote in the 2021 report. “Washington state officials determined that each client in their ‘fast-track’ presumptive eligibility program saves Medicaid an average of $1,964 a month by helping individuals access community services instead of institutional care.”
Affordable housing is critical, and we don’t have it. We cannot get people out [of institutions] because they can’t live in their community of origin. It’s so expensive.
Mairead Painter, long-term care ombudsman
As Connecticut tries to keep more older residents at home, it also must explore better options for hospital discharges to the community, advocates say.
The hospital discharge process often shuffles older adults and people with disabilities to nursing homes because those facilities already have the infrastructure to care for them and can ensure a smooth transition.
“Ownership structures, in some cases, lend themselves to going from hospitals to nursing homes because they have the same management. A big health care system might have its own rehab center and nursing homes,” Doroghazi said. “It’s an easier lift for case managers and care planners.”
The Connecticut Hospital Association acknowledged that hospital discharges to the community are rife with challenges but said patient releases of any kind can be difficult.
“A lack of available home care services, due to the present health care workforce shortage, is impacting the staffing of home and community-based care programs and agencies, and delays in securing the necessary durable medical equipment to meet needs … can create further challenges,” said Nicole Rall, a spokesperson for the organization.
Residents who would prefer to be discharged to the community might not know they have that as an option, Doroghazi said. And hospital discharges to the home can be more difficult because there is no streamlined process for accessing community support systems. Low-income residents who need care immediately after their hospital stay may be steered toward a nursing home, because those facilities can accept people while they are waiting to be approved for Medicaid.
But discharging people to nursing homes increases their risk of remaining there. Data show nearly two-thirdsof all Medicaid participants who enter nursing facilities are still there after six months, according to a state study of long-term care needs.
“Thus, for vulnerable populations, entry into a nursing facility can often lead to permanent institutionalization and loss of community ties and individual freedom of choice,” the report’s authors wrote.
Transitions from nursing homes back to the community are also complicated by a lack of affordable housing.
If a Medicaid recipient is looking for an apartment, it must be within the state’s maximum allowable rent, which varies depending on the town of residence and the number of bedrooms. It also must suit the person’s needs; someone who relies on a wheelchair must have a wheelchair-accessible unit.
Finding safe, affordable housing has proven difficult for many aging residents and people with disabilities.
“Affordable housing is critical, and we don’t have it,” said Painter, the long-term care ombudsman. “We cannot get people out [of institutions] because they can’t live in their community of origin. It’s so expensive.
“If you want to live in your community of origin and you live anywhere [in Fairfield County], for example, you really can’t find housing for most people unless you’re going to put them in horrible housing.”
The state study also cites affordable housing as a key impediment to home-based care.
“Finding adequate housing can be more challenging than developing the array of services needed to assist consumers,” its authors noted.
Weighing solutions
State officials say they are working on solutions to help ease the migration from nursing homes to home care.
For people seeking long-term care, they have launched a website, myplacect.org, with information about the process and what services are available.
Organizers say they plan to add podcasts and other elements to the site “to reach a broad range of audiences.” But advocates contend that the website still has a low profile, and a state study recommends increasing its readership.
The state also plans to build an electronic registry of home care workers that will be updated regularly.
“An RFP has been drafted and is near finalization and will then move through the final approval processes before issuance,” De Dios, the social services department spokesman, said.
In the meantime, the state Department of Developmental Services will put some worker contact information on its website to help connect people in its programs with personal care aides.
Painter has suggested the addition of a mobile app where consumers can search for prospective home health aides on their phones.
In the coming months, state employees will begin testing screening tools that could be used in a presumptive eligibility program, though no funding is lined up to launch the initiative.
“We have screening tools, we have an interview tool, and we’ve done training on them,” Lambert said. “We’ve worked with other states on the development of those tools.”
But to offer presumptive eligibility, Connecticut will need to set aside money to fund care for people awaiting Medicaid approval. Officials at the social services department said they did not know of any immediate plans to do that.
“It would have to be money appropriated by the state, because the state would be at risk,” Lambert said. “I’m hopeful of continuing the discussion.”
The study on long-term care lays out recommendations to prepare for the ballooning aging population.
To expand the home care workforce, it suggests recruiting employees who have left the nursing home industry. It also recommends boosting the profile of myplacect.org, increasing the number of physicians’ offices, hospitals and other locations that provide information on long-term care options, and creating an educational campaign for hospital social workers and discharge planners to improve awareness of home care services.
“Given the aging demographic, there is an urgent need for systemic reform,” the authors wrote.
The state’s health czar agrees.
“The country as a whole is undergoing a shift in demographics,” said Deidre Gifford, senior adviser to the governor on health and human services and executive director of the state Office of Health Strategy. “The population of the country is aging, and people are wanting to age in place. We need to adapt our health care system to align with those changing demographics.”
Legislators say that in the coming years, a wide-ranging bill or set of proposals is needed to address these issues in a broader way.
“The plan is not there,” said Garibay, co-chair of the Aging Committee. “We see the problem coming, but right now we’re just trying to plug the dike with patches. We need to have an overall plan, and we have to work together.”
CT Mirror staff writer Katy Golvala contributed to this story.
Incapacity advocates welcomed a proposal by Gov. Phil Murphy this week to expend $165 million much more to address the staffing crisis plaguing team households and day systems for people today with disabilities in New Jersey.
The $53 billion spending budget blueprint unveiled by Murphy on Tuesday contains money to increase hourly pay, keep professionals and inspire new personnel to enter a subject that can help care for 24,500 people with developmental disabilities in the point out.
Advocates stated the more funding is sorely essential in a group that was strike tough by the pandemic and an market that has confronted a steep labor lack in current several years.
“For all of the neighborhood solutions, anyone will get an enhance, and that is actually critical,” mentioned Catherine Chin, executive director of the Alliance for the Betterment of Citizens with Disabilities, a trade group representing 64 group property providers in New Jersey.
“If we could get will increase every yr, a charge-of-residing adjustment, that could create lasting reform, and it will empower us to construct a far better process for the persons that we serve,” Chin stated.
If point out lawmakers approve Murphy’s budget, it will give a thing in “all of the areas” Chin’s group experienced lobbied for, she claimed.
Murphy’s proposal involves $31.3 million for ongoing wage improves for direct help professionals, the aides who assistance make everyday lifestyle possible for people residing in team residences. The increase would indicate an supplemental $1.25 per hour for the aides, whose recent median wage is $19.11 an hour, in accordance to the condition.
The shortage of aides has been a prolonged-standing good quality-of-life challenge for the individuals who count on them for all the things from social functions to cooking, bathing and transportation, in accordance to the disability advocates. In the restricted labor market of the latest many years, one particular in five DSP positions often go unfilled, according to marketplace surveys.
One more $10.4 million would be set apart for group house managers. The cash is an try to tackle turnover so workforce “remain in this vital career,” spending plan files state.
The price range features an added $36 million, to be matched by federal funds, to enhance spend prices for expert services provided during day courses, like all those for occupational remedy.
There are also plans to spend $86.8 million in federal cash to further more “shore up the workforce,” where turnover has been extreme, in accordance to the funds blueprint. The condition Division of Developmental Disabilities would deliver the revenue for recruitment and retention payments, college student financial loan redemption, coaching subsidies and related packages.
“It will also include things like neighborhood-dependent treatment employees in fields such as behavioral well being care, private-responsibility nursing, utilized behavioral examination and compound-use ailment cure,” reported Tom Hester, a spokesman for the state Section of Human Services, which oversees the plans.
The disability community was “encouraged by the governor’s proposed finances, as it includes new funding to help needs raised by people today with intellectual and developmental disabilities and their family members,” claimed Mercedes Witowsky, govt director of the New Jersey Council on Developmental Disabilities, a federally appointed advisory panel.
Chin, of the marketplace alliance, explained the proposal would “totally” improve group residences.
“It will still be challenging, but it stabilizes us superior,” she claimed, adding, “The point that the state of New Jersey, the governor and the Legislature are having to pay attention and are attentive to this business speaks to not only households and individuals who get the products and services, but the men and women who do the job in that field. It says to them this is essential, this is valued by our governing administration.”
Gene Myers covers disability and psychological well being for NorthJersey.com and the United states Nowadays Network. For unrestricted accessibility to the most significant news from your neighborhood neighborhood, remember to subscribe or activate your digital account these days.
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