Successful Supportive Care: Personnel, Pricing, and Salaries

Home Health Care Managed Practices - 2000
By Judith B. Clinco, R.N,

Building a successful supportive-care service is a matter of hard work, industry knowledge, marketing skill, and much more. At the core of any successful senior service, though, is the caregiver. Without a screened, trained, qualified workforce, the supportive senior care service will fail. This article outlines many of the staff-management strategies the author has developed, refined, and applied in her own service. It also discusses ways to make marketing do double duty as a re-cruiting tool for both clients and care-givers.

Introduction
There's no secret to growing a successful supportive-care service. All you have to do is consistently deliver an unwaveringly high standard of senior care services. When satisfied customers tell their friends and family members, you get referrals. Unhappy customers will talk too, but they won't help you get referrals.

Your business is built on your caregivers. Everything that happens in your senior service comes down to this: you need to place in every client's home the best-trained and best-supported caregiver you possibly can. Anything less is a gift to your competition and a disservice to your senior clients.

You'll find two kinds of employees in the labor pool. Experienced health care workers have built a track record you can verify and hiring them can reduce your up-front training costs. They're hard to find, however, especially in the tight labor market we are now experiencing. Entry-level employees may have informal caregiver experience—usually obtained by raising a family or by caring for a relative, friend, or neighbor; or they may have no caregiving experience whatsoever. You can build a thriving senior service with any of these workers. Successful staffing relies on wise recruiting, aggressive and empowering training, and appropriate compensation. Add supervision, scheduling, marketing, regulatory compliance, financial planning, street smarts, and luck, and your service should do well. Without a solid staff, though, all your other work will be wasted. For that reason, I'll focus my comments on staffing issues.

It All Starts with Recruiting

Where do you look for adult care workers? Often the best places to recruit prospective employees are also the best places to find new clients or their families.

My first choice is newspaper advertising. Create a directory of local publications and update it periodically. Be sure to include the target audience and distribution area for each publication. This information helps me tailor my message to the readership, since some publications are more likely to be read by prospective employees and others by prospective clients. I’ve also created a strong, easy-to-recognize logo. A good logo helps build brand identity; it is well worth the investment of having it designed professionally.

Another way to make contact with employees and senior clients is to become known as an authority on adult home care topics. I'm always on the lookout for opportunities to contribute articles, opinion pieces, and letters to newspapers and other publications. As an adult home care professional you have expert knowledge about elder care, business management, and other subjects of great interest to many people. The exposure is priceless. If you're not sure your writing is acceptable for publication, a freelance writer or editor can help shape your message.
Flyers are another good way to find senior care workers. Create a professional-looking flyer—don't forget that logo!—and distribute it wherever people congregate. Likely distribution points include houses of worship, colleges and universities, bulletin boards in libraries and supermarkets, laundry rooms at apartment complexes and mobile-home parks, and windshields at mall parking lots. You might also design doorknob hangers to distribute at adult apartment complexes.

Advertising in the yellow pages should be a central element of your marketing and recruiting strategy. My adult care service does a great deal of marketing in the community, but many of our referrals come straight from the yellow pages. We run identical quarter-page ads in two sections—"Nurses" and "Home Health Services." This dual-advertising approach is more expensive than a single placement, but I'm not willing to take the risk that prospective senior clients will miss my ad. Our advertisements are printed in black and white only, so they really stand out in the yellow pages, and they always mention that we have job opportunities as well as senior services to offer.

Personal contact is important too. I’ve had buttons made that say “Ask Me About Home Care.” People stop me in the grocery store—or the mall or wherever I wear the button—and ask me about it. Of course I’m more than happy to answer their questions.

My adult care service also uses folded business cards rather than standard cards. Along with the usual contact information we include a summary of our senior services. These cards are more expensive than standard cards, but well worth it. Many people don’t understand what adult home care is, or what our senior services can mean to them or someone they know. Sometimes a brief summary is the best way to open the dialogue.

We’ve also used direct mail advertising; advertising on radio, broadcast television, and cable television, and cable television; and a sandwich sign outside the office. If you want your message to be heard, repeat it as often and on as many channels as you can.

Public speaking engagements are another way to leverage your time by simultaneously marketing your senior services and finding new employees. Ask your Chamber of Commerce for a list of clubs, houses of worship, social organizations, and other groups that that may be open to you. Consider speaking at trade schools, community colleges, nursing schools, job fairs and job training programs, and social-service and civic organizations. When marketing supportive senior care, always mention employee recruitment, and always have printed materials to distribute.

Finally there are referrals. My adult care service gives bonuses to current employees for bringing in recruits. We also stay in contact with nursing home personnel departments; often they can recommend valued employees who are departing for personal reasons. Be sure to track every referral so you can tell where your business is coming from and help identify areas you may be missing.

Selecting the Best

The goal of your recruiting program should be to find the most cost-effective way to choose successful caregivers. My adult care service uses a multi-level approach.

First, we have a telephone based pre-selection process. In all recruiting materials we direct potential applicants to one dedicated phone number. Callers hear a 60-second description of the work, followed by an invitation to leave a phone number. Some choose not to; for those who do, when we return the call we answer questions and decide whether to schedule an interview.

Once in the office, potential applicants read our vision statement, our mission statement, and our statement of values. We confirm our requirements for employment, making it clear that employees must have reliable transportation with current liability insurance, which we periodically confirm, and an acceptable driving record, a copy of which the candidate obtains from the state motor ve-hicle department.

In addition to having a telephone, our caregivers are required to carry a pager during business hours when they are not on an assignment. It does the adult care service no good to take a big job and then send a dozen caregivers to the home the first week. If someone calls with a referral for a 24-hour case, we ask for half an hour to arrange for an appropriate caregiver and then we start calling pagers. Pagers have made huge difference to our scheduling coordinators, making it easy for them to contact employees who are between placements. We tell care-givers to turn off their pagers when they are working in a client's home. To help employees meet this requirement we've arranged with a pager company to supply pagers at a discounted rate. The service pays for the first two months of service; after that, the pager company bills the employee directly.

Other requirements for employment include CPR certification, a tuberculosis test, and no felony convictions. The candidate must be a U.S. citizen or have a visa with the right to work, and must be able to work one weekend a month (we pay time-and-a-half for any time over 40 hours a week).

The application form includes the candidate's permission for a drug test. At this point we don't actually perform drug testing, but its important applicants know we might. Some leave the office rather than give permission for a drug test. The application also asks for personal and professional references and makes it clear that we will conduct an investigative background check to confirm that the candidate has no felony convictions. As with the possibility of drug testing, this is an opportunity for candidates to deselect themselves. We do check references by phone, and request a written follow-up for the employee’s file. We conduct a Curry Screen psychologi-cal profile to help gauge the applicant’s reliability and work ethic.

Finally we evaluate the application. Are there gaps or questionable inconsistencies in the work history? Has the applicant had frequent changes in employment or home address? None of these items are “deal-breakers,” but they should trigger a closer look.

Next comes the interview. We watch for personal presentation, grooming, and hygiene. Does the applicant have the right attitude—the right philosophy? We clarify any questions that arise from information on the application form, review our requirements for employment, and make certain the applicant will be available the hours we need. To avoid accusations of discrimination, my service has developed standard interview questions and scoring; we are an equal-opportunity employer.

We also assess the candidate’s personal-care skills in four areas: measuring vital signs, including blood pressure; chair-to-bed and bed-to-chair transfers; bathing, shaving, and dental hygiene; and range of exercises. For personal assistants (PAs) and certified nurse’s aides (CNAs), we administer a written test. If the applicant doesn’t pass the test but is otherwise qualified, we generally offer a lower-level position or training in the future.

New hires take their first step into our service family during an initial orientation. This is when we issue a temporary name badge and a copy of our employee handbook. The session is also a good time to reaffirm the adult care service’s philosophy and values, review the employee’s responsibilities, and stress important service policies. We can also see if the employee arrives on time and understands the uniform/dress policy.

In-house mentoring helps bring new employees up to speed. Every staff member is encouraged to show support for new employees and to be available to give information and guidance. Experienced CNAs are available by phone and the care manager—an RN—makes a site visit at the client’s home during the caregiver’s first two weeks on the job. The message we want to give is, “You’re a part of this company. We’re on your side.”

During the last week of each month, all new hires are scheduled for a four-hour meeting. During this second orientation session they view a set of training videos demonstrating core skills. The videos cover home-management skills (finding nothing appropriate on the market, we created these videos in-house), dealing with death and dying, and building stronger communication skills. This session is also a time to discuss problems and concerns and answer questions.

Training

Having an ongoing training program is essential. There's a lot caregivers need to know in order to deal safely and efficiently with the challenges they face on the job. An ongoing training program can help with staff retention, too; it shows your caregivers that you value them and are willing to invest in their professional growth. Well-trained workers are less like to injure themselves or a client, as well.

Three options are available.

•You can create your own curriculum and administer it yourself, buy and administer a curriculum developed by someone else, or contract for training through an outside organization.

Developing our own training program has allowed my adult care service to control the content of the courses—as well as the philosophy embodied within them—and to innovate where no materials exist that fit our needs. This ap-proach works best for us; on the down side, a training program developed in-house takes a great deal of time and can be expensive. For that reason some agencies may find it more economical to look elsewhere for mate-rials or a complete package.

Who pays for tuition? Here, too, are three options. The service can pay all tuition, the cost can be split with the employee, or the employee can pay all tuition. At my ser-vice, we pay tuition for who stay with us for at least a year.
Another set of options centers on the question of pay while in training. Some agencies choose to pay full wages, some provide a training stipend, and some offer no pay during training. At my service we do not reim-burse for training time. We pay full wages for an annual 12 hours of mandatory continuing education. Employees are free to attend additional training as well, but on their own time.

Another component of our educational program is mandatory annual back-safety training. It's expensive to offer this, but one bad injury will cost you whole lot of money. Last year Workmen's Compensation gave my service a $30,000 rebate because we have great safety performance in a very high-risk area. You might consider offering advanced training as a way of helping your caregivers grow in their careers. Care of seniors who are mentally ill or have Alzheimer’s patients, care of dying people and hospice issues, restorative care, and holistic care are all valuable additions to the continuing-education syllabus.

Supervision

It takes diligent supervision to keep a senior care service and its caregivers on track. At my service, we supervise both on the job and in the office. On-the-job supervision is handled by an RN that visits in the client’s home. The first visit is scheduled during the first two weeks of the new caregiver’s placement and quarterly thereafter. While the caregiver’s primary job site is the client’s home, there are a number of occasions when a visit to the home office is necessary. These include the mandatory team conference we schedule for every client, our annual 12 hours of continuing education, and annual skill-testing sessions. We also have employees come to the office to collect their paychecks, which gives them a chance to socialize with their peers and the office staff.

Employees are evaluated after three months and annually thereafter. Service policy holds every employee responsible for helping maintain a high standard of qual-ity in all aspects of service and business. All employees should feel comfortable in reporting any violations of company policy. Infractions of policy and procedure are dealt with immediately. The point of view that “We’re here to train and develop our staff and to ensure their success” is built into correction and coaching efforts. We make every effort to avoid giving the “You’re bad and wrong” message.

Appreciate Your Home Care Aides

To make certain our wages are competitive, we regularly poll other adult care agencies in the area to determine their wages and prices. We also determine our cost of doing business and the profit margin we’d like to see. From this information we can calculate our wage struc-ture—making sure to include room for raises for performance and seniority—and our price structure.

Wages are only part of the compensation package; benefits complete the picture. My adult care service enjoys a 72% retention rate for employees who have been with us more than six months. This is ample evidence of the value of benefits. Health insurance is our chief benefit. We offer an HMO plan to employees who work more than 32 hours a week. The plan costs $119 a month per individual; the service covers part of that cost on a sliding scale based on longevity. After three months on the job, we pay 20% of the first-year premiums. That goes to 25% the second year and tops out at 50% after five years. This has been an effective device for boosting retention, particularly for older women—say between the ages of 55 and 65—who are not eligible for Medicare. Family coverage at a discounted rate is also available through us, though we don’t actually provide that cover-age. The 32-hour minimum for health plan participation helps us keep people working for us full-time rather than splitting their time with another service. We also offer a group dental plan and optical plan, for which the em-ployee pays the premium.

Another part of the benefit package is the employee assistance counseling program. Offered by an outside firm, the program costs the service about two dollars per employee per month. We feel it’s important that our employees have access to confidential counseling, because if their own lives aren’t working, they’re not there work-ing for us. Our schedulers and nurses are trained to encourage caregivers to seek counseling when the need comes up.
After a year, our employees are eligible for a week’s paid vacation, prorated according to the number of hours and weeks they’ve worked during the year. Occasionally we will give cash in lieu of vacation time, but we really prefer that the workers take the time off. It’s important for their own well being.

Other benefits include employee-paid access to af-fordable group insurance through an AFLEX policy covering short-term disability, long-term care, and cancer. Credit union membership, which we can offer at no cost to the service, is another benefit. We also pay time-and-a-half for working on holidays, and we give one day of bereavement pay when there’s been a death in the employee’s immediate family.

Little things mean a lot too. We celebrate on a personal level with birthday cards, a party, presents during the holidays, and “employee of the month” recognition in the service’s monthly newsletter. Every payday features a catered brunch.

Recently, I heard about a service where the RN carries a coupon book during supervisory visits to clients’ homes. The nurse gives a coupon for a treat; for example, a free car wash or frozen yogurt or dry cleaning as an instant reward for caregivers who are doing out-standing work. What a great idea!

Employees who refer a client get 2% of the gross income from that client. This is a new incentive for us; it means that employees who refer a 24-hour case can add $2,500, paid quarterly, to their annual income. Some strings are attached: the bonus continues only as long as the employee remains continuously employed and the senior client remains in our program. We have a special training session for employees to show how the program works and how to speak about our services appropriately and professionally.

Marketing

Of course there’s more to business success than recruiting and retaining good staff. Marketing your adult care services is another area where innovation and energy can bring in big rewards. Every marketing effort we make is intended to help bring in both new clients and new employees.

Word of mouth is the cornerstone of my marketing plan. It isn’t really marketing at all, but it has the power to amplify—or limit—everything else I do. Consistently delivering quality services will build your reputation and your business.

In practical terms this means that success is based on people trusting you. Be sure to fulfill all promises to all your customers—senior clients, families, employees, referral sources, the professional community, and vendors. Stay in touch. Set up a database of all your contacts and keep it current. Maintain a high standard of professional conduct and empower your employees to embody it. Make it clear that this is expected from every person who represents your service.

To encourage senior clients to tell their friends about my adult care service, we give them a gift certificate for four hours of service for each successful referral. To encourage repeat business, we also give them a gift certificate when they no longer require our services.

Invest in your image. If you want to project an image of competence and good service, spend the money for professional logo design and professional graphic de-sign for all printed materials. Don't forget the Internet; having a well-designed, well-maintained web site is an increasingly important tool for marketing and recruiting.
Always remember—your marketing should be aimed at recruiting new employees and finding new clients. Make your business grow from both ends.

The Bottom Line

These guidelines represent the basis of my approach to running a successful supportive-care service.

• The quality of your senior care services depends on the quality of your caregivers.
• Respect, appreciate, support, and back up the dedicated people who improve the lives of your senior clients.
• If you do things right, your senior clients and your community will build your business for you.

Summation/Questions from the Floor

The summary of this article/presentation is best presented in the format of her presentation closure. This is devoted to responding to the audience. Much of Judith Clinco's presentation was devoted to answering questions from the audience. Below is a selection of typical questions that arise during a presentation on this topic and responses given by Clinco.

Question: If a client needs both homemaking and personal care services, do you send two people?

Answer: No. We send only one person. Who we send de-pends on the needs of the client. One reason we created the PA level of care is to let us offer a more economical service option for people who are shopping for hands-on care in the yellow pages but don't need a medically trained caregiver. Other agencies were offering CNAs to fill this need. The PA performs homemaker duties and assists with personal hygiene, which is often all a frail elder needs. Just a helping hand—assistance and safety in the bathroom, getting in and out of the car, and so on.

Question: How is the PA different from a CNA?

Answer: My adult care services offers three levels of caregiver: the homemaker companion, the PA, and the CNA. All our caregivers do housekeeping—we have a holistic model, where we care for the client, the family, and environment as a unit. The CNA has more training than the PA. In Arizona, 75 hours of training is required to become a CNA aide. Since we pioneered the PA niche, we established its 40-hour training standard, too. CNAs are qualified to care for a client who is coming home after a hospitalization. We also send a CNA when the client is dying at home or when long-term care insurance is providing the care. CNAs can work in hospitals and nurs-ing homes as well as home care agencies. With extra train-ing a CNA can care for two clients at once, or for a client with cognitive impairments. For this care we charge an ex-tra dollar an hour and pay the caregiver accordingly. The PA provides an economical alternative for a cli-ent who needs some hands-on care—principally help with hygiene and transfers—but not the medical support a CNA can provide. We charge $1.80 less per hour to pro-vide PA services, and we pay $1.25 less. About 30% of our clients get a PA; the rest require services of a CNA.

Question: What are the insurance considerations when you have employees using their own cars to transport clients or run errands for them?

Answer: Clients sign an automobile waiver in which they agree not to hold the adult care service liable if they should be injured while riding in a caregiver’s car. The waiver might not hold up in court, but it does provide a measure of protection for the service. We also have employee nonowned auto insurance, a benefit of being a member of the Home Care Aide Association of America. This policy protects the corporation if there is an accident and one of the parties to the accident is not insured.

Question: Do your caregivers work for other agencies as well?

Answer: We have 140 home care aides; at least half work only for us. We can’t guarantee full-time employ-ment, but at least 40 of those are consistently working full time.

Question: How do you get your employees to pay for pagers?

Answer: We just say it’s a condition of working for us, and they’re either willing to step into the condition or they don’t work for us. It’s the same thing with the car—you must have reliable transportation and current insurance to work for my service. Of course we compensate them for the use of their car for business, at 30 cents a mile.

Question: Are you employees on call?

Answer: No. That's why they carry pagers. When they're between assignments they're free to come and go, but we need to be able to contact them when a placement comes up. They do have to be available to work their choice of one weekend a month.

Question: What happens to a full-time employee's health insurance when the employee is between assignments?

Answer: We'll continue the employee's coverage for the week or two it might take to arrange another placement.

Question: You said you have 140 people on staff. How does that translate into hours of service?

Answer: We deliver about $50,000 worth of senior services a week. That's about 3,800 hours of adult care per week. Most senior clients get three or four-hour blocks of time, but some receive only two hours once a week or an hour seven days a week. The Department of Labor requires you to pay travel time when you move employees around from one short shift to the next, so these small blocks are not efficient for the service. As the industry grows I think you'll see more and more people who want short hours; it's going to be up to us an industry to meet that need and still get full staff utilization. Maybe we’ll develop scheduling formulas where we offer specific blocks of time at certain times—where we can say, “If you want a two-hour block, these are the times we can offer you.” Up to now it’s been entirely consumer-driven. Mothers with school-age children are a good source of part-time caregivers for the 10 am to 2 pm shift. They want to work when the kids are at school, be home when the kids are, and won’t become discouraged because you can’t find them full-time placements.

Question: Is it your goal to keep your caregivers working 40 hours a week?

Answer: No. Our goal is to work our staffers to their fullest capacity. We don’t want our people to work more than 40 hours a week because, by law, we’d have to start paying them time and a half. Maybe as an industry we could lobby to change this, because we’re running a 24-hour senior services business and could use more flexibility in scheduling. Hospitals, fire departments, and police departments are limited to 80 hours in a 2-week period before having to pay overtime; that would be appropriate for supportive care, too.

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