As we enter the perennial winter hospital overcrowding crisis, exacerbated this year by health funding challenges, home care continues to be marginalised as a tool in combatting Delayed Transfers of Care (DTOC). There has also been a lack of focus on preventing hospital admissions by failing to tackle persistent home care waiting lists. Current proposals to force patients into the first nursing home with a bed available represents a kneejerk reaction that is detrimental to the patient’s autonomy and contrary to the Government’s stated ‘home first’ policy. In response to these challenges, Home and Community Care Ireland (HCCI) has prepared a set of policies to support timely discharge back to the home and increase sectoral capacity during Winter 2023/24.

1. Preventing Delayed Transfer of Care

On any given day, approx. 100 people (+/-25) are subjected to DTOC due to the lack of availability of a home care worker (HCW) to deliver a home care package. The well documented recruitment crisis plays a part in this, but the way home care is commissioned compounds this issue.

When a person is deemed fit for discharge, providing they have a home care package, the discharge team in the hospital is left to wait and hope that one of the home care providers has a home care worker who is available to support that person to leave hospital. This approach represents a strategic failure in hospital discharge planning. Given the costs of keeping someone in hospital (€7,203 per week1 ), the risk of physical deterioration, hospital acquired illness and the implications DTOC has for A&E overcrowding and elective procedures, it is crucial that home care providers are seen as partners in hospital discharge and are given the frameworks to strategically plan for hospital discharges.

Block Book Home Care Hours

Instead of the current ‘wait and hope’ for an available HCW approach, hospitals could purchase a block of home care hours in advance to ensure that there is HCW availability. Block booking hours in advance would enable home care providers to plan strategically and ensure supply. Hospitals have multiyear discharge data to inform the number of home care hours that are necessary to ensure timely discharge of patients and avoid wastage.

Pay for Continued Capacity

Currently, a home care provider immediately stops receiving payment for a home care package if a client stops or pauses their home support e.g., they enter hospital. Feedback from HCCI home care providers indicates that approximately 10% of home care hours are cancelled in any given week. This leads to providers rushing to reassign the HCW assigned to a cancelled package. This creates the situation where providers are in a constant flux in 2 trying to assign HCW to a package and with little ability to anticipate which packages might come through, and in what areas. This in turn leads to DTOC.

Paying for cancelled home support visits would bring stability for providers and free up HCWs to take on new packages. In addition to tackling DTOC, this measure would bring stability to HCWs and improve continuity of care for the person receiving home support.

There is precedent for this. During the pandemic, the HSE paid providers for their contracted hours, not hours delivered, to ensure capacity existed in the system. It meant providers could assure HCWs of their income during the period and, upon cancellation of a call, could update colleagues in the HSE about their additional capacity. This system would require no new funding. It would, of course, need additional audit and assurance requirements to ensure integrity.

Joint Planning and Information Sharing Between Hospitals and Providers

The 2018 Independent Expert Review of Delayed Discharges recommended that a joint planning forum between hospital and community leaders to support strategic discharge planning. To date, no attempts to develop a joint planning forum have included home care providers. Given that the independent sector delivers 61% of home support and was responsible for 84% of the 3.7 million increase in home support hours between 2018 and 2022, it is crucial that private and non-profit providers are fully integrated into discharge planning.

2. Short Term Measures to Increase Capacity in the Home Care Sector

In addition to the measures above which directly support timely hospital discharges, there are actions we can take to immediately increase the availability of HCWs in time for this winter.

Priority Garda Vetting for Home Care Workers

During the Covid-19 pandemic, Garda vetting for HCWs was expediated which led to an average turnaround of 2-3 working days. HCWs are no longer given priority Garda vetting status leading to a turnaround of between 2-4 weeks. This is delaying the onboarding of much needed HCWs. Reinstating priority Garda vetting so that HCWs are vetted within one week would greatly assist the onboarding of new HCWs.

Relax Working Limits in Social Welfare & Medical Cards

Navigating social welfare entitlement rules that limit working hours or income earned is a daily challenge for home care providers. Feedback from HCCI members, and reports from CDSWAG4 and the Commission on Taxation and Welfare, have identified social welfare rules (particularly Carers Allowance, Jobseekers and Medical Cards) as being disincentives to part time work. HCCI propose a temporary exemption to social welfare rules to allow 3HCWs work an additional 3 hours per week or earn equivalent income. Complementing this exemption would be a full review of social welfare rules to ensure they reflect modern realities of work and do not disincentive new HCWs from entering the workforce or existing HCWs from working additional hours during the busy winter season.

3. Tackling DTOC & Home Care Waiting Lists in the Medium to Long Term

While some progress has been made in addressing the recruitment crisis in home care, the pace of change has been too slow to meet demand. HCCI believes there has not been sufficient scrutiny of delays to home care reform, most noticeably around the implementation of the Statutory Home Support Scheme and the Cross Department Strategic Workforce Advisory Group on Home Carers. While it is not realistic to implement these policies in time for Winter 2023, significant progress can be made within the next 12-24 months which can alleviate hospital overcrowding and home care waiting lists into the future.

Implement CDSWAG

The 2022 CDSWAG report has several key recommendations to address the recruitment crisis in the home care sector. The report reflects the wide-ranging reforms that are necessary to attract more HCWs into the sector, but the rate of implementation has been slow. Only the payment of travel time, the living wage as a minimum rate of pay and the allowance of employment permits for HCWs has been implemented to date. The cross departmental nature of these reforms requires significant political backing to see them implemented. HCCI priority reforms are the indexation of the living wage, payment for mileage and reform of social welfare.

Develop a Career Structure for Home Care Workers

In addition to improving terms and conditions for HCWs, it is paramount that we develop a career structure that encourages and rewards upskilling and training. HCCI is pleased to be partnering with LHP Skillnet and RCSI to produce a report on career structures and competency frameworks for HCWs. We look forward to sharing the results of this report in the first half of 2024.

Streamline the Employment Permits and Employment Visa Process

The decision to remove home care workers from the ineligible skills list and allowing them to receive employment permits is welcome. Nevertheless, there is a convoluted process of applying for both an employment permit from the Department of Enterprise, Trade and Employment (DETE) and then an employment visa from the Department of Justice (DOJ). While much work has been done in streamlining the permit process through DETE, there remains considerable processing times for visas through the DOJ. There appears to be significant overlap in what the employers are asked to submit for the permits and the visas. Therefore, it stands to reason that these two processes could be streamlined into one, significantly reducing the bureaucracy and resulting processing times, allowing much needed home care workers to enter the workforce quicker.

For more information contact:
Jamie Farrelly
Policy & Communications Manager
jamiefarrelly@hcci.ie

Article Links

Hospital Performance: An Analysis of HSE Key Performance Indicator 2023.
2018 Independent Expert Review of Delayed Discharges
CDSWAG Report
Commission on Taxation and Welfare
HCCI briefing note on social welfare reform for more information
CDSWAG Progress Report October 2023