Residential Provider
Expansion into Home and
Community-Based Services
TABLE OF CONTENTS
Executive Summary
2
Introduction5
Nursing Homes
Alterszentrum Viktoria, Switzerland
13
Feros Care, Australia
19
Isabella Geriatric Care, United States
31
Tabitha Health Care, United States
42
Continuing Care Retirement Communities
BallyCara, Australia
51
First Choice, United States
60
Shepherd’s Care Foundation, Canada
67
Well-Spring Continuing Care Retirement Community, United States
77
Continuing Care at Home Programs
Cadbury Senior Living, United States
87
Conclusion96
EXECUTIVE SUMMARY
A growing number of not-for-profit, residential providers of
aging services are developing new business lines in the area of
home and community-based services (HCBS). These services
include home health care, non-medical home care and adult
day care.
Few studies have examined the HCBS expansion process to
identify successful business models and marketing strategies,
or common challenges and lessons learned. With so many
residential providers entering the field of home and communitybased services, an elucidation of common themes, important
lessons and promising practices would greatly benefit the sector.
The Study
The International Association of Homes and Services for
the Ageing sought to fill this evidence gap by conducting a
qualitative study of not-for-profit residential service providers
that expanded to provide home and community-based services.
Researchers used the case study method, combined with an
analysis of emergent themes, to conduct this study. They sought
to include a diverse set of providers in the study in an effort
to identify emerging themes that transcended the differences
among providers of aging services. This method helped
researchers identify useful guidance that would apply to the
array of organizations in the sector.
The research team conducted structured phone interviews
with two representatives of each organization, usually the chief
executive officer and the vice president or director of the home
and community-based services program. The purpose of the
interviews was to understand the:

Program
Relevant policy context
 Financial implications
 Workforce
 Organizational culture

2 | Residential Provider Expansion into Home and Community-Based Services

Program outcomes
Perceived challenges
 Perceived benefits
 Lessons learned

The research team also conducted two-day site visits with two
organizations. One organization had a longstanding and welldeveloped home and community-based services program and
the other was in the early stages of expanding into HCBS. The
site visits featured focus groups or telephone interviews with:

Home health and home care aides
Other frontline staff
 Supervisors of frontline staff
 Additional executives
 Marketing, human resources and quality-assurance staff

The site visits allowed the research team to enrich the
perspectives developed during the phone interviews and
to focus more deeply on certain areas, including successful
strategies for staffing the new business lines and the financial
implications of the expansion.
Researchers wrote case studies describing each participating
provider. They also identified common themes that emerged
across these diverse organizations. An evaluation of the themes
led to the identification of guidelines that might be useful to
providers that are considering an expansion into home and
community-based services, or are in the early stages of such
an expansion. Each case study, as well as a discussion of the
emerging themes and lessons, is included in this report.
The Organizations
The research team completed case studies of five U.S. providers,
one Canadian provider, two Australian providers and one
European provider.
EXECUTIVE SUMMARY
Nursing Homes
Four organizations included in the study began as nursing
homes:
Alterszentrum Viktoria (Bern, Switzerland): Beginning as a
nursing home in 1995, Alterszentrum Viktoria began providing
home health care and limited non-medical home care to
members of the external community in 2011. The organization’s
small program currently serves 23 clients. Its predominant
source of reimbursement is mandated insurance.
Feros Care (Queensland, Australia): Established as an
operator of two nursing homes in the early 1990s, Feros Care
expanded into home and community-based services in 20022003 and now delivers home health care, home care, telehealth,
companionship, and other services to approximately 5,000
clients per year. The Australian government’s Home Care
Packages Program comprises its main source of reimbursement
for home health and home care.
Isabella Geriatric Center (New York, USA): Founded as
a nursing home in 1875, the non-sectarian Isabella Geriatric
began expanding into home and community-based services in
1989. The organization now provides more than one million
service hours per year of home health care, home care, adult
day and other services. Isabella serves mainly low-income
clients. Its primary payer source for home health care is
Medicaid.
Tabitha Health Care (Nebraska, USA): Established as an
orphanage in 1886 and a nursing home in 1890, faith-based
Tabitha began providing home health care in 1966 and home
care in 1974. Each month, the organization delivers more than
10,000 service hours of home care and serves an average of 254
home health clients. Tabitha’s main source of reimbursement
for home health care is Medicare. Most of its home care
services are private pay.
Continuing Care Retirement Communities
Four organizations included in the study began as continuing
care retirement communities (CCRCs) or a CCRC-like entity,
and developed traditional home and community-based services
programs. They include:
BallyCara Village of Friends (Queensland, Australia):
BallyCara began in 1983 as a residential provider offering
successively higher levels of care, from independent living
to a nursing home. The organization expanded to home and
community-based services in 2013 and now provides an
average of 458 service hours to 200 external clients per month.
BallyCara’s funding sources are a mix of government-funded
and private pay.
First Choice (Virginia, USA): Founded by two faith-based
CCRCs in 2007, with a third partner joining the partnership in
2015, First Choice now provides more than 4,000 service hours
of home care per month and serves 65-70 home health clients
per day. First Choice was established through a partnership
among three providers that acquired an existing agency with a
client base. The agency’s primary funding sources are Medicare,
private insurance and private pay.
Shepherd’s Care Foundation (Alberta, Canada): Beginning
as a CCRC 45 years ago, faith-based Shepherd’s Care began
providing companionship, transportation services and other
home care services in September 2014. Older adults living
in the organization’s residential communities make up the
majority of home care clients. Shepherd’s Care structured its
home and community-based service lines within a separate,
for-profit corporate entity that now provides more than 1,500
service hours per month to approximately 40 clients. Its
main sources of reimbursement are currently private pay and
government contracts.
Sodexo • IAHSA • LeadingAge | 3
EXECUTIVE SUMMARY
Well-Spring (North Carolina, USA): In addition to
operating a CCRC, Well-Spring provides home care and
adult day services to the external community. Each month,
the organization delivers more than 10,000 hours of home
care, approximately 1,000 of which are delivered outside the
CCRC. Well-Spring’s adult day program serves approximately
200 clients each month. The organization’s primary source
of reimbursement for home care is private pay. The adult day
program has multiple funding sources.
Continuing Care at Home
One organization included in the study began as a CCRC
and provides home and community-based services through a
“continuing care without walls” or “continuing care at home”
program.
Cadbury at Home (New Jersey, USA): Founded as a CCRC,
Cadbury established a continuing care at home program in
1998. The program provides a full range of services to its
200 members. Those services include home health care and
non-medical home care. The organization’s primary source of
reimbursement is private pay.
The expansion timeline for organizations in this study
ranges from more than 25 years (Tabitha Health Care and
Isabella Geriatric Center) to under one year (Shepherd’s
Care Foundation). This range of experience with home and
community-based services allowed researchers to glean insights
from individuals whose programs had a long track record of
success, and from individuals whose programs are currently in
the planning and early-implementation stages.
Common Themes: Highlights
An analysis of interview transcripts, notes and case studies
revealed several common themes among the organizations
regarding their experiences with the expansion process. Some
highlights of these themes are described below.
Reasons for expanding: When asked why they expanded
into home and community-based services, most organizations
cited a desire to fulfill their mission by serving more
community members, as well as a desire to grow their roster
of services in order to provide a continuum of care. Some
providers said they hoped to become a “one-stop shop” that
community-dwelling older adults and their adult children
would turn to for all of their aging services needs. Additionally,
some organizations said they were seeking additional revenue
streams to support their residential businesses.
Staffing: All organizations in the sample primarily hired
new frontline staff for their home and community-based
service lines, rather than redeploying frontline residential staff.
Organizations took this approach because the type of worker
who thrives in the home care environment tends to differ from
the type of worker who thrives in a residential setting. The
organizations often shared back-end support systems with the
residential services division.
4 | Residential Provider Expansion into Home and Community-Based Services
Funding: Several organizations said they were seeking the
best balance between government and private funding. Home
and community-based service lines drew on private-pay clients
and had the potential to provide surplus revenue.
Challenges: Most providers said they faced tough
competition and found it difficult, at least at first, to distinguish
themselves from their competitors. Some organizations also
cited the difficulty of maintaining communication with the
workforce during the expansion process, especially regarding
the organization’s brand and high standards.
Benefits: Several providers noted that their home and
community-based service lines provided their organizations
with referrals to on-campus services. Most providers said they
derived pleasure from fulfilling their organization’s mission.
Organizations also reaped financial benefits from the expansion
into home and community-based services.
Lessons Learned and Promising
Practices: Highlights
Many of the lessons providers said they learned during the
expansion process concerned marketing. Several providers
emphasized the need to conduct in-depth market analysis
before expanding into home and community-based services.
Providers emphasized the importance of understanding the
needs and desires of the target community before designing the
HCBS business model.
Providers should consider how to distinguish their service
lines from the competition, according to study participants.
Several providers also noted that marketing strategies that are
successful for home and community-based services differ from
successful marketing practices for residential services. HCBS
marketing tends to be referral-based while residential care
marketing tends to depend on word-of-mouth. It is important to
understand these differences in advance.
Prior to launching a home and community-based service
program, it is important to develop a network that fosters
relationships with referral sources. Providers also should
develop a business strategy that aligns with the realities of the
market. Several providers noted the importance of educating
staff members, residents, boards of directors and consumers
about the value of HCBS programs.
Finding the “right” workers for the home setting is critical
to the success of HCBS programs. Providers emphasized the
importance of developing and supporting staff. Workers should
be empowered to identify client needs and provide services to
meet those needs.
Study participants discussed their strategies for expanding
to new services lines and geographical areas. Providers might
consider using contract staff and then hiring their own staff,
they suggest. Virtual offices can also enable organizations to
operate multiple satellite offices with minimal infrastructure.
INTRODUCTION
The International Association of Homes and Services for the
Ageing (IAHSA) and LeadingAge collaborated on a project to
examine why and how aging service providers transition from
a residential setting model into a home and community-based
services (HCBS) model, and to examine the operations of the
programs. Sodexo Institute for Quality of Daily Life, a research
partner of IAHSA, funded the project.
The research team performed a qualitative study of notfor-profit residential providers. As part of this effort, the
team conducted 90- to 120-minute telephone interviews with
nine provider organizations in the United States, Canada,
Switzerland and Australia. The interviews typically were
conducted with the organization’s president/chief executive
officer and the vice president or director of the HCBS program.
These interviews covered the following topics:










Reason for expanding into home and community-based
services
History and description of the current program
Relevant policy context
Financial implications of the HCBS program
Workforce
Organizational culture
Program outcomes
Perceived challenges
Perceived benefits
Lessons learned through the experience
The research team also conducted two-day site visits to
two organizations: one organization in the United States had
a longstanding and well-developed HCBS program, and one
organization in Canada was in the early stages of expanding
into home and community-based services.
During each site visit, the research team held focus groups
with agency aides who directly provided care, other frontline
staff,1 and supervisors of frontline staff. The site visits also
included structured interviews with additional executives,
including the chief operating officer at one site and the chief
financial officer at the other; and the directors of marketing,
human resources and quality assurance. Researchers
sought to gain an in-depth understanding of the programs’
implementation, operations and impact.
Researchers wrote case studies describing each participating
provider, and then analyzed all transcripts and notes to
identify common themes that emerged across these diverse
organizations. An evaluation of these themes led to the
identification of guidelines that might be useful to providers
that are considering an expansion into home and communitybased services, or are in the early stages of such an expansion.
Each case study, as well as a discussion of the emerging themes
and lessons, is included in this report. Any errors in the study
report are the responsibility of the authors.
Background
Aging services providers are reinventing themselves by offering
home and community-based services to on-campus residents
and older adults living in the external community. These
organizations offer programs and services that reach beyond
the traditional, residential setting to meet consumer demands
and the economic realities of people who are aging in their own
homes. Demand for services like in-home care and adult day is
booming in many countries. Providers’ reasons for expansion
are varied and numerous, including meeting consumer
demands to age in place, reaching a greater percentage of the
older adult population, seeking new revenue streams in the
face of low occupancy rates, diversifying payer services, and
enhancing the organization’s brand.
Home and community-based services can be delivered to a
consumer at home or in a campus-based supportive living or
independent living setting. Operators have a variety of options
Sodexo • IAHSA • LeadingAge | 5
as they design an HCBS program. These programs can include,
but are not limited to:
Private duty (non-medical) home care: This service
provides assistance with activities of daily living or
instrumental activities of daily living, companionship
services, or specialized care. A non-licensed caregiver
usually provides the care. In some cases, a certified aide
provides care.
 Home health care: This type of intermittent skilled care
requires more expertise than private duty care and more
regulatory oversight.
 Continuing Care at Home: This package of long-term
services and supports is provided to adults who want the
security that a retirement community offers but want
to remain at home. This HCBS program differs from
the traditional home and community-based programs
that CCRCs deliver in the community. A continuing
care at home program takes the concept of the life
care contract and a bundle of services into the home.
Continuing care at home is not just a menu of services
that consumers purchase on an as-needed basis. Rather,
it is a comprehensive approach to providing a health and
wellness lifestyle to older adults in their homes.

Aging service providers follow different models when
designing the structure of their HCBS program. That program
can be a department within the retirement community, a
separate agency, or an affiliate of the retirement community.
The organization might also choose to provide home and
community-based services through multiple partners.
Government or private-pay reimbursement for different
services varies widely by region and by case.
Participating Providers
The research team completed case studies of four U.S.
providers, one Canadian provider, two Australian providers
and one Swiss provider. A fifth U.S. provider also participated
in the study, even though the organization does not offer a
6 | Residential Provider Expansion into Home and Community-Based Services
traditional HCBS program. The provider delivers continuing
care at home, an emerging model that is described on page 87.
A brief description of each provider is presented below. More
detailed descriptions can be found in the individual case studies.
The organizations participating in this study differed in a
number of ways, including:








Nature of initial residential services
Design of the current HCBS line
Size of the workforce
Number of clients served
Number of years since the initial expansion
Location
Primary payer sources
Policy contexts and regulatory challenges encountered
Nursing Homes
Four organizations included in the study began as nursing homes.
Alterszentrum Viktoria in Berne, Switzerland was
established as a nursing home in 1995. It expanded to offer
home and community-based services to external clients in 2011.
Viktoria provides primarily home health (medical) care and
limited non-medical care to 23 clients in the community. Its
predominant source of reimbursement is government-mandated
insurance. The organization started a new program that is
housed within the parent organization.
Feros Care in Queensland, Australia is a standalone
organization that provides assisted or supportive living care
and nursing home care. Feros Care expanded into home and
community-based services in 2002-2003 and now delivers
personal care, home care, social care, allied health care,
wellness services and an extensive range of telehealth services
to 5,000 clients each year. Its main source of reimbursement
for home health and home care is the Australian government’s
Home Care Packages Program. The HCBS program delivers
services through a combination of new programs and strategic
partnerships. The program is housed within the parent
organization and has 245 service partners.
INTRODUCTION
Isabella Geriatric Care in New York, United States is a nonsectarian organization that has provided care for older adults
since 1875. Founded as a traditional nursing home, Isabella
now provides a continuum of services, including nursing
home care, moderately priced senior housing, adult day health
care, child day care, home care, certified home health care,
licensed home health care, short- and long-term rehabilitation,
Naturally Occurring Retirement Community (NORC) services,2
community-based care coordination, and other community
programs designed to help older adults remain healthy and
independent at home. Isabella began offering home and
community-based services in 1989. It delivers more than one
million service hours per year. Its primary payer sources are
Medicaid and managed care. Isabella started its own programs,
which are now part of overall organization.
Tabitha Health Care in Nebraska, United States started as a
nursing home in 1890. It has since expanded to offer older adults
a comprehensive line of services, including three nursing homes
for rehabilitation and long-term care, assisted living, affordable
senior housing, and a variety of home and community-based
services. These services include home health care, nonmedical home care, adult day services, Meals on Wheels, and
personalized services. Each month, Tabitha provides more than
10,000 home care service hours and serves an average of 254
home health clients. Its main source of reimbursement for home
health care is Medicare. Its main source of reimbursement
for private duty is private pay. Tabitha started a new program,
which is now part of the parent organization.
Continuing Care Retirement Communities
Four organizations included in the study began as continuing
care retirement communities (CCRCs)3 or a CCRC-like entity,
and developed traditional home and community-based service
programs.
BallyCara Village of Friends in Queensland, Australia is a
residential provider offering progressively higher levels of care,
including independent living, assisted living and nursing home
care. BallyCara established its first home and communitybased services program in October 2013. The organization
provides external clients with private duty care that includes
domestic assistance, home maintenance, transportation
and social support. BallyCara Community Care serves
approximately 200 clients across all its home care service lines
and averages 428 service hours each month. Its main funding
sources are government funding for home care, private pay
and government-allocated Home Care Packages, which it
currently delivers in partnership with other providers that
have been allocated funding by the Australian government.
The HCBS programs, which feature a combination of new
programs and strategic partnerships, are housed within the
parent organization.
First Choice in Virginia, United States is a home health
and home care agency jointly owned by three retirement
communities: Virginia Mennonite Retirement Community
(VMRC), Bridgewater Retirement Community and Sunnyside
Communities. VMRC and Bridgewater jointly purchased First
Choice in 2007. Sunnyside Communities joined the partnership
in 2015. First Choice provides home health and home care
services to people living on retirement community campuses
and in their own homes. The agency serves 65 to 70 home health
clients each day and provides 4,000 hours of home care services
each month. Its primary funding sources are Medicare, private
insurance and private pay.
Shepherd’s Care Foundation in Alberta, Canada was
founded in 1970 and is a faith-based retirement community
offering independent living, supportive living and nursing home
care on its campus. The organization serves more than 1,600
older adults who have low to moderate incomes. Shepherd’s Care
Foundation extended its service lines into home care in October
2014 and offers transportation and companionship services. The
agency delivers 1,500 service hours each month. Shepherd’s Care
at Home, a for-profit agency, is independent and separate from
Shepherd’s Care Foundation. Its main sources of reimbursement
are private pay and government contracts.
Well-Spring Retirement Community in North Carolina,
United States was established in 1993 by a coalition of nine
local churches. Well-Spring offers several different types of
home and community-based programs: the Program of All
Inclusive Care for the Elderly4, adult day care, and home care.
The organization acquired an existing adult day provider
and started a new home care program. The adult day and
home care services have since combined and are under the
umbrella of Well-Spring. Well-Spring delivers more than 10,000
hours of home care per month, of which 1,000 are supplied
outside the Well-Spring CCRC. The adult day program serves
approximately 200 clients each month. The primary source
of reimbursement for home care is private pay. The adult day
program relies on a variety of funding sources.
Continuing Care at Home
One organization included in the study began as a CCRC
and provides home and community-based services through a
continuing care at home program.
Cadbury Senior Living in New Jersey and Delaware,
United States launched its Continuing Care at Home program
in 1998. Cadbury at Home, one of the first continuing care
at home programs in the United States, combines home care,
assisted living and nursing home care into a comprehensive
program that provides members with long-term services
and supports in the home and the opportunity to move onto
the CCRC campus as their health care needs change. The
program’s primary source of reimbursement is private pay. The
at-home program was created by Cadbury and is affiliated with
the parent organization.
Sodexo • IAHSA • LeadingAge | 7
INTRODUCTION
Overview of Providers5
The timeline for expansion into home and community-based
services varied considerably for the eight providers with
traditional HCBS programs:

Over 25 years (Tabitha Home Health and Isabella Geriatric
Center)
 Eight to 10 years (First Choice and Feros Care)
 Three years or less (Viktoria, Well-Spring and Shepherd’s
Care).
Cadbury’s continuing care at home program has been in
existence almost 20 years.
Size of Program
Agencies reported the size of their program in different ways:
hours per month and number of clients per month or year.
Some agencies chose to report the number of service hours
instead of number of clients because of clients’ wide range of
service needs. For example, some clients only require a few
hours of service each month while others require more than 16
hours each day. The agencies felt the service hours provided a
more accurate portrayal of their size than the number of clients
served. This was particularly true for the private duty care.

All four providers who offered both home health and home
care had a substantial client base. Their service hours
ranged from 4,000 to 10,000 hours each month to one
million service hours each year.
 Two out of the three providers delivering home care only
had a smaller client base. One agency averaged 428 service
hours each month while another delivered 1,500 service
hours per month. One agency delivered 10,000 service
hours per month to on-campus residents primarily. That
agency delivered approximately 1,000 hours per month to
off-campus clients.
 The remaining home health care agency served
approximately 23 clients.
Type of Partnership
Organizations considered many factors when deciding whether
to house the home care/home health agency within the parent
corporation or establish it as a separate organization. The
factors—including financial, legal, expertise-related, and
branding-related issues—will be described more fully later in
this Introduction.
The majority of the providers have kept the home care/
home health agency as part of the parent organization. One
retirement community bought an existing agency to deliver
adult day services. This business will reside on the main
campus and house all of the organization’s HCBS programs,
including home care. While the parent company and the adult
day provider have separate boards of directors, they are legally
connected with each other.
Two home care providers function independently from the
parent organization. One home health/home care agency is
8 | Residential Provider Expansion into Home and Community-Based Services
The eight agencies
with traditional
HCBS programs
offered a mix of
service types:
50
% provided both private
duty care and home
health care
38
% provided private duty
or home care only
1
provided home
health care only
operated through a joint venture of three provider organizations
that purchased the agency. The other provider structured the
agency so it would be separate and independent from the parent
organization.
Reasons for Expansion
Residential providers diversified their service lines as a way
to fulfill the organization’s mission, reach a larger percentage
of the target population, create marketing opportunities and
referrals for a retirement community, develop a potential
revenue stream, and transform the organization into a “onestop shop.” Several providers cited more than one of these
reasons for expanding.
Mission: Skilled nursing home providers and aging-in-place
providers that offer a tiered approach to the aging process
by combining independent living, assisted living and skilled
nursing home care may not be able to reach all individuals.
In addition, some aging-in-place providers attract wealthier
clients and their care is not affordable to low- or modestincome groups. By diversifying service lines, the organization
can potentially serve less-affluent clients and reach the most
vulnerable individuals in the community.
Expanded reach: As more people choose to remain at
home, organizations that provide only residential options
will be unable to reach a significant portion of the older adult
population, including older adults who are unlikely to use oncampus services. Providing services in the community is an
opportunity to serve these individuals.
Retirement community feeder: When community-dwelling
older adults, or their family members, require higher levels of
care, they may consider moving to a residential care setting.
A home and community-based service line can serve as a
feeder into an organization’s other business lines by creating
brand awareness and connecting with consumers. When
those connections are made early in the aging process,
INTRODUCTION
individuals and their family/support networks will think of the
organization when they need more services.
Potential revenue stream: A home and community-based
service line can supplement or support revenues from the
residential side of a business. The expansion into other services
lines also can attract different payer sources.
One-stop shop: A provider of aging services can be a “onestop shop” for individuals by providing a full continuum of
care, starting with services in a person’s home. The provider
can ensure that it helps people no matter where they live or
what level of care they need. In addition, campus residents can
receive high-quality home and community-based services from
a home care/home health agency that is affiliated with or a
department within the parent organization.
Workforce
Organizational environment: A strong workforce is a critical
component of any HCBS program. Staff members, particularly
the aides who provide direct care, are much more autonomous
and work with less supervision than their counterparts in the
residential setting. Aides in the home care setting also perform
a greater variety of tasks, have more responsibility to make
accurate and timely observations, and require flexibility.
Aides rarely report to the agency. Instead, they go directly to
the client’s home to provide care. It can be challenging for home
health and home care agencies to create camaraderie among
their employees. These workers have few opportunities to engage
and connect with each other. Special events, trainings and
meetings can give staff the opportunity to share information
and build connections with each other. A few providers
occasionally use these events to give staff from the HCBS and
residential programs the opportunity to interact with each other.
Hiring and orienting staff: Most providers did not staff the
HCBS program by redeploying staff from the organization’s
residential settings. Instead, they hired new staff with
experience in the home setting, including a vice president
or director of home and community-based with extensive
experience in the type of service lines included in the HCBS
program. A few providers held some type of orientation for
new staff. This generally included an introduction to the
organization. Supervisors in some organizations accompanied
new staff members on their first home visit and introduced the
aide to the client. One provider recommended using a “buddy
system” to allow a new aide to shadow an experienced aide a
few times before going out alone.
Training sessions: Almost all of the providers who offered
additional staff trainings held separate training sessions for
residential and home care aides. This decision was based on the
fact that home care and residential staff work in very different
work environments. Two providers conducted some form of
combined trainings. One provider held a joint orientation
for aides from both environments and separate in-service
trainings. Training sessions often included a mix of mandated
education for certified aides as well as additional trainings that
exceeded government requirements. Providers typically seek
input from aides when deciding on topics for trainings sessions,
which often address specific diseases or issues aides encounter
while caring for the organization’s clients.
Staff resources: Two providers with separate home care/
home health agencies did not share resources or staff with
the residential provider. Other providers often called on the
organization’s management team to run the daily operations
of the HCBS program. The residential and home care
businesses frequently shared back-end support functions,
including executive management, financial management,
human resources, billing, and information technology. This
arrangement helped to spread administrative costs over several
business lines. Some providers relied on a single marketing
team to promote their home-based and residential businesses.
Other providers had separate marketing teams because
marketing strategies for home-based and residential care are
so different.
Quality assurance and supervision: The quality of the HCBS
programs are monitored in a variety of ways, depending, in
part, on the source of funding. Home health care programs were
generally required to submit data on specified quality indicators
to the government. Some home health and home care providers
used their quality improvement committees to review that data
and make action plans to improve or change operations based
on the findings. Approximately half of the providers elicited
feedback from clients and family members to determine their
satisfaction with the services. Providers also supervised the
aides, although the level of supervision varied and aides and
supervisors typically had little interaction. Most providers had
a process in place to address clients’ complaints, although some
systems were more formal and sophisticated than other systems.
Outcomes
Few providers conducted formal evaluations of their programs
to determine their impact on consumers. Most of the providers
that measured outcomes conducted client and family member
surveys or solicited feedback to assess satisfaction with provided
services. Some providers have established committees or other
groups to review satisfaction data and develop action plans to
address areas of concern.
Organizations that offer home health care through
government funding have formal assessments and are measured
on select quality indicators. A few providers have initiated
efforts to track key measures through dashboards or scorecards.
Challenges
Providers experienced challenges in launching, operationalizing
and sustaining their HCBS programs. The key difficulties
reported by providers included:
Market competition: Organizations encounter competition
from other home care or home health providers serving the
same demographic group and geographic area. This can limit
the growth potential for agencies. In some regions, providers
who rely on government-funded services have found that
select entities have a large share of the market because they
Sodexo • IAHSA • LeadingAge | 9
INTRODUCTION
Organizations encounter competition from other home care or home
health providers serving the same demographic group and geographic
area. This can limit the growth potential for agencies.
are an official government provider or have a longstanding
relationship with the government. Providers emphasized the
importance of defining a niche for a program and identifying
features that distinguish the program from its competitors.
Financial: Most HCBS programs operated at a loss, at least
during their first year. Growth can be slow due to difficulties
associated with growing the program’s client base. Additionally,
providers struggled to establish the best balance between
private-pay and government-funded services.
Clients: Remaining solvent often involves balancing the case
mix of clients and their utilization of services. Home health
and home care aides reported challenges working with clients
who were noncompliant with the services listed on their care
plans, were combative or aggressive, or whose family members
expected that aides would provide services to them in addition
to the client.
Regulations: Providers experienced challenges with
regulations. A common regulation required organizations to
have a certificate of need to enter the market. The certificate of
need process requires approval from the state health planning
agency before an organization can begin any major capital
project, such as expansion into home health. As a result, the
government can limit the number licenses/certifications it
issues to service providers. Additional challenges included:

Inconsistency in the funding that a government issues to
different service providers
 Strict regulations to create or fund HCBS programs
Staffing: Hiring and retaining the “right staff” for the home
care environment was challenging for several providers. The
home setting is different from the residential setting and
certain characteristics make individuals better suited for the
more autonomous setting. In addition, providers experienced
staffing shortages because they could not find staff with
adequate qualifications, or lacked sufficient staff when there
was increased demand for services.
Benefits
Continuum of care: Providing a multitude of services allows
the provider to support the individual through the continuum
of care. Clients can age as they wish and the organization can
adapt to client needs and the desire of consumers to stay at
home. The organization can provide care across service lines
and across the aging process.
Expanding market and mission: The addition of home and
community-based services is an opportunity to expand the
number of older adults an organization can serve and to reach a
10 | Residential Provider Expansion into Home and Community-Based Services
greater percentage of the target population. An HCBS program
targets a different market composed of individuals who choose
not to live on a campus and prefer to age in the home. A
provider that serves a more affluent resident population can
use an HCBS program to serve individuals with more modest
incomes. The HCBS provider also can help consumers navigate
the system of long-term services and supports, and can reach a
variety of individuals through different service lines.
Relationships and marketing opportunities: Serving
people at home creates a relationship between the provider
and consumers early in the aging process. The retirement
community can build awareness of its on-campus options and
market its services. The client and family members can build
trust with the provider and can be comforted by the fact that
they can turn to the same organization over time. Clients, or
the members of their family/support networks, may become oncampus residents when their care needs change and they require
higher levels of care.
Serving people at home creates
a relationship between the
provider and consumers early
in the aging process.
Financial: HCBS programs have generated revenues and
positive financial gains for some providers. These revenues are
particularly beneficial when interest in retirement community
living is down. The additional service lines also have diversified
the revenue stream in some organizations. An organization’s
residential setting may be supported primarily by publicly
funded services. The HCBS program, which may rely more on
private funding, can augment and subsidize the public funding.
Lessons Learned
Providers offer several suggestions for residential service
providers that are considering or already expanding into home
and community-based services. These suggestions are based on
their experience launching and operating HCBS programs.
Prior to Launch
Market research: It is important to know the needs of the
community, and understand the competition, before launching
a program. Conduct extensive market research to understand
what services the community wants and how to most effectively
market to the target group. Identify organizations that already
INTRODUCTION
provide the services you want to offer and learn about their
successes and challenges. Understanding the market can lead to
greater program success. For example, one provider noted that
its superficial market analyses identified the services consumers
wanted, but not the services for which they were willing to pay.
This resulted in lower-than-expected rates of participation in a
transportation program.
Networks and partnerships: Establish a network prior to
launching the program. The network should include potential
referral sources and partners that will help you build the client
base. Build relationships with key referral sources, including
hospital discharge planners, physician practices or insurance
companies. Evaluate whether it is more beneficial to compete
with other providers in the community, or collaborate with
them to fill specific service gaps. Carefully review a prospective
partner’s business plan, philosophy, organizational cultures and
“business chemistry” to ensure compatibility.
Business strategy: Have a defined strategy in place before
starting your program. Test the business idea. Develop a solid
business plan and vision of how to operationalize the program.
The business plan should align with the realities of the market.
Education: Educate staff and residents about home care/
home health care and how it can benefit the organization,
workforce and community. Consider educating the board
of directors about the reasons and benefits for diversifying
service lines. Think about conducting informational sessions or
workshops to educate community members.
Staffing: Staff the home care/home health business with
people who have the right personalities and backgrounds to
launch and operate the program. These individuals should have
an understanding of home and community-based services,
particularly the service lines at your organization. They should
also be familiar with the different payment models. Ensure
that you care for your aides to engender loyalty among current
aides and attract the best aides through word-of-mouth
recommendations.
Program Operations
Expanding service lines and geography: When expanding
into new geographic areas, consider using contract staff that
will establish your brand by providing excellent service. Then
hire your own staff to ease management and communication
demands while further building your reputation. Establish
virtual offices to minimize the infrastructure needed to
expand. These strategies can help providers open multiple
satellite office and gain clientele.
Leadership patience: It takes time and energy to move
outside your core business and start a new service line, even
when partnering with an existing agency. The leadership team
will have to understand, grow and expand the new model of
care. Start with relatively few services and clients and gradually
build up your capabilities. Learn from your experiences and
growing pains.
Staff and systems development: Engage in a continual
process of staff and systems development. Recruit potential
hires well, offer them good initial training, and train them
throughout their tenure with the organization. Consider
creating career pathways to retain staff.
Understand the needs of consumers: Listen carefully to
clients and members of their family/support networks to ensure
that you understand their priorities. Learn what consumers
value most and be sure to provide it.
Marketing strategy: Employ a comprehensive strategy to
promote your services. Recognize that marketing the HCBS
program will require different strategies than marketing your
residential services. Consider reinforcing your brand identity
and distinguishing your services from the competition. In many
regions, it is critical to engage referral sources for your program.
You can accomplish this by meeting with referring agencies,
attending networking events, accepting speaking engagements,
and sponsoring celebrations and other organizational events.
One particularly successful organization stressed that
organizations need to distinguish their service lines and direct
their marketing to different groups of potential clients, while
maintaining the primacy and quality of the organization’s brand.
It is important to know the
needs of the community, and
understand the competition,
before launching a program.
Conduct extensive market
research to understand what
services the community wants
and how to most effectively
market to the target group.
Sodexo • IAHSA • LeadingAge | 11
NURSING HOMES
Case Study
ALTERSZENTRUM VIKTORIA
BERN, SWITZERLAND | January 2015
Introduction
Alterszentrum Viktoria was established in 1995 as a nursing
home. It offers residential care to protected group homes for
dementia patients, community nursing services, and medical
care. Alterszentrum Viktoria also has independent housing
with access to various services, as required. The organization
began providing primarily medical and limited non-medical
care to external clients in 2011 after making a strategic decision
to expand its services and its client base.
This study of Alterszentrum Viktoria’s expansion into
home and community-based services was conducted through
interviews with the organization’s director and a member of its
board of directors.
Policy Context
Switzerland is a confederation of 26 independent cantons (federal
states) that are distributed among the country’s four regions.
Alterszentrum Viktoria is located in the Canton of Bern.
Governance of Switzerland’s system of long-term services and
supports is highly decentralized and involves federal, cantonal
and communal governments. Primarily, cantonal governments
develop policies affecting older people and long-term care
services. Each canton has its own government and set of rules
for each sector of the health care system. However, cantons may
coordinate their actions at the regional or national level.
Swiss government policy has favored home care, over care in
nursing homes, for several years. The government is working
to ensure that individuals who require nursing home care can
stay in their own homes or apartments until the end of life and
will not be required to move to a special care unit. There are two
reasons why home care is preferred:

Delivering care services within the older person’s social
environment allows relatives, friends and neighbors to
continue providing informal care.
 Home care reduces the pressure on nursing home beds and
leads to a more rational and economical use of those beds.
When nursing home beds are not available, older people
who cannot remain at home often are sent to the hospital,
even though they do not have a medical need to be there.
Insurance providers, not the government, pay almost all the
expenses associated with physician-approved, home-based
medical care. Care recipients pay a small percentage (10%) of
these expenses out of their own pockets. Reimbursement rates
for home-based medical care are consistent and do not fluctuate.
However, the tendency for insurance providers to reduce their
fees each year has resulted in lower prices for consumers, but
lower reimbursements for organizations that provide services to
those consumers.
Swiss providers considering an expansion into medical home
health care services must obtain a license after demonstrating
that they meet criteria established by the canton. License
holders must have the professional staff necessary to deliver
medical care. If a provider meets this requirement, it will be
approved, receive a license, and be free to open a home health
care agency. The government continues to monitor the agency
to ensure that it provides quality services.
Each canton has one government-sponsored home health care
agency. The government-sponsored home health care provider
in Bern is strong and has been operating for many years.
Private providers, including Alterszentrum Viktoria home
health care, compete with the government agency. This makes
it challenging, from a business point of view, to enter the home
health care market and obtain new clients.
Sodexo • IAHSA • LeadingAge | 13
ALTERSZENTRUM VIKTORIA
Process for Launching the Program
When the Alterszentrum Viktoria board of directors approved
home and community-based services as a new service line,
it was making a strategic decision to grow the organization.
The government approved Alterszentrum Viktoria’s request to
provide home health care and provided the documentation that
the organization needed to deliver these services.
Alterszentrum Viktoria decided to focus primarily on offering
medical home care due to the great need—and high demand—
for these services in the community. State-mandated insurance
covers medical care services if a physician prescribes them.
Competition in the Marketplace
Alterszentrum Viktoria provides limited non-medical home
care and, at this time, is not interested in expanding its nonmedical care. Providing non-medical home care is much more
challenging than providing medical home care because statemandated insurance does not cover non-medical services and
providers do not need a license to enter the market.
Several factors increase competition among providers of nonmedical care services:
On the regulatory side, however, the Canton of Bern has
few regulations for the home health care service sector. It is
relatively easy for providers to enter the market once they have
hired professional staff. If an agency has a license and maintains
standards of quality, it faces few problems from the canton. An
agency that wishes to provide non-medical care is not required
to obtain a license or to meet any government requirements.
This regulatory environment made it fairly easy for
Alterszentrum Viktoria to diversify its services.
Expansion into Home and CommunityBased Services
Alterszentrum Viktoria was established in 1995 as a nursing
home. The organization began offering primarily medical
and limited non-medical care to external clients in 2011.
Alterszentrum Viktoria’s diversification into home care was
driven primarily by government policies that provide stronger
support to home care services than to nursing home services.
Alterszentrum Viktoria’s management and board of directors
made the decision to provide services to the general public so
the organization could diversify its services and reach a larger
percentage of the older population. Management and board
were also seeking an opportunity to market the organization’s
other services to home care clients who might require higher
levels of care and services over time.
It is not uncommon for nursing home providers in
Switzerland to launch external home care services. Most (90%)
Swiss adults who require assistance live in their own homes.
Only a small percentage of these adults reside in nursing
homes. In this market environment, the survival of nursing
homes depends on their ability to offer services to external
clients. However, competition for these external clients is fierce.
14 | Residential Provider Expansion into Home and Community-Based Services

Many agencies offer non-medical care services.
Consumers must pay for non-medical services out of their
own pockets.
 Clients often do not want to pay for the assistance they
receive.

Intense market competition also characterizes the medical
home health care market. Specifically:

Home health care providers face competition from many
private and government-owned agencies. As a result,
growing a client base is a slow process for most providers.
 The market is open to any provider that obtains a license.
There are no mandated restrictions on the number of home
health care agencies that can deliver services in a specific
geographic area.
Description of the Program
Partnerships
Alterszentrum Viktoria provides its home health care
services in-house and does not partner with outside agencies,
although it does belong to an association representing notfor-profit providers. The organization considered establishing
a partnership to lower its investment in software and staff
education. However, stiff competition made it difficult to
collaborate with outside agencies. In addition, partnerships
with outside entities are not common in Switzerland. Most
organizations believe that they can “do it better” on their own.
Having an in-house agency allows Alterszentrum Viktoria
to deliver home health care services to individuals in the
community and to bring these services to independent residents
who live on its campus. Alterszentrum Viktoria’s board of
directors is considering the possibility of converting the nursing
Timeline
1868
ALTERSZENTRUM VIKTORIA
Guesthouse
called Viktoria
built.
1870
Viktoria is a sanatorium.
1897
Expansion of
Viktoria sanatorium
into Viktoria hospital.
1991–95
Viktoria Hospital converted
to a nursing home.
2008
Opening of day center.
2011
Founding of home
health care agency.
Sodexo • IAHSA • LeadingAge | 15
home portion of its campus to independent apartments.
The organization would then bring at-home services to the
apartments. This option could help the organization reach more
clients and strengthen its home health care service agency.
Admission Criteria
Before an individual can receive medical home health care, a
physician must determine that he or she meets the criteria for
this care. Non-medical care does not require a doctor’s approval
and individuals do not have to meet eligibility requirements
before they can receive these services.
Services
Alterszentrum Viktoria offers a range of medical care services
to support older adults so they can stay in their own homes
for as long as possible. As a supplement to medical care, the
organization’s staff also provides limited non-medical services,
including meals, cleaning, transportation and shopping.
Alterszentrum Viktoria clients who require extensive nonmedical services must receive those services from a different
provider. The organization maintains a list of providers
in Bern that can deliver this type of care. Staff will make
recommendations to clients who need more services than
Alterszentrum Viktoria can provide.
Alterszentrum Viktoria staff members provide home health
care services for a minimum of 15 minutes. The organization
offers services from 7 a.m. to 11 p.m., on weekdays and
weekends. The agency does not provide overnight care, mostly
because it is too small to offer this type of coverage.
Clients
Alterszentrum Viktoria has been providing home and
community-based services for the past four years. It has been
difficult to expand the program’s client base due to competition
from other providers. As a result, the organization currently
serves only 23 individuals. Most clients (95%) receive medical
care. On average, Viktoria adds five to eight new clients each year.
Alterszentrum Viktoria was not able to provide demographic
information about its home health care clients. While the
organization collects data about residents living on its campus,
it does not currently gather information about clients living in
the community. The organization estimates that only about half
of its clients live alone and do not have family caregivers.
Quality Assurance
The Canton of Bern monitors the quality of Alterszentrum
Viktoria’s home health care services. Bern, like other cantons,
strictly supervises home health care providers and specifies
guidelines for provider quality and staff professionalism. At a
minimum, the canton conducts an annual, unannounced site
visit to assess the agency. During this annual assessment, the
home health care provider uses special instruments to measure
the quality of its services. Alterszentrum Viktoria does not track
quality measures outside of the government oversight process.
The government uses its funds as leverage when providers do
not fulfill regulatory requirements. If an agency does not meet
16 | Residential Provider Expansion into Home and Community-Based Services
ALTERSZENTRUM VIKTORIA
the canton’s standards, the canton will discontinue payment for
services and close down the provider.
When a client has a complaint about a home health care
agency, its staff or services, the complaint is first addressed
by the organization. If the organization is not successful in
resolving the issue, the complaint is then forwarded to a canton
office that is charged with handling complaints about home
health care services.
Since non-medical care services are private pay, the cantons
do not conduct oversight to ensure the quality of those services.
Instead, the private market controls quality and outcomes. It is
assumed that clients will select a different provider if an agency
does not meet a client’s quality standards.
Alterszentrum Viktoria’s home health care staff consists only
of nurses. There are no aides on staff. After the government
issues a license, it supervises home health care nurses in the
same way that it supervises nursing home nurses.
Workforce
Alterszentrum Viktoria’s home health care agency has two codirectors and nine full-time nurses. The organization’s clientbase is not large enough to warrant additional staff. Home
health care nurses care for the same clients each week, when
possible, and work in the home environment, either on-campus
or off-campus. The home health care staff receives the same
benefits as residential care staff.
Alterszentrum Viktoria’s nursing home and home health
care agency have the same director and structure. However, the
residential and non-residential settings do not share nurses. All
home health care staff members are new hires. The organization
does not redeploy staff from elsewhere in the organization to
work in the home health care agency.
Other staff in the home health care agency, including human
resources, marketing, billing and information technology
(IT) staff, are shared with Alterszentrum Viktoria’s corporate
offices. This sharing has created challenges for the billing
staff, which needed additional training about the specialized
billing practices associated with home health care services.
The deployment of a new billing software for home health care
services will require additional support from the IT department.
All nurses at Alterszentrum Viktoria receive in-service
training and attend workshops directed by the head of the
nursing department. Nurses from residential care and home
health care are cross-trained. It can be taxing to bring these
two staff groups together for training due to the nurses’
attitudes toward the sector in which they do not work and
are not likely to work. Alterszentrum Viktoria is aware of the
differences between these two staff groups, and addresses those
differences during training workshop discussions.
Organizational Culture
The nursing home and home health care agency at Alterszentrum
Viktoria are not separate entities and the organizational culture
for home health care and residential care staff is the same, since
the newer home health care agency adopted Alterszentrum
Viktoria’s culture when the agency was created.
Workers from residential care and non-residential care have
opportunities to interact with each other and exchange ideas.
This can occur during formal meetings and the training/
workshops mentioned above. In addition, home health care and
nursing home staff members can meet and engage with each
other in a shared dining room.
This sharing of organizational culture is not typical in
Switzerland. In most organizations, home health care agencies
are separate from their parent organizations and have vastly
different cultures. These culture differences are due, in part,
to the political debate over home health care that is currently
taking place in Switzerland as the government increases its
support for home health care services while decreasing its
support for nursing home care. The debate extends to the
relative merits of the different models of care.
Alterszentrum Viktoria did not face any pushback from its
staff when it expanded its services. Many nursing homes in
Switzerland diversify into different service models, and home
health care is a common service model. Staff members had no
trouble accepting the expansion.
Financial Implications
Alterszentrum Viktoria’s home health care agency is based
on the organization’s campus, but it has its own building. The
diversification of the organization’s services involved an initial
investment in office space, equipment and staff.
The home health care agency has not yet broken even and
may find it difficult to generate adequate revenues until the
agency can expand its small client pool. This will be a challenge,
given the competition for home health care clients. For the time
being, other Alterszentrum Viktoria service lines can make up
for the losses incurred by the home health care business line.
Alterszentrum Viktoria’s management and board of directors
have considered discontinuing the home health care agency
because of slow growth and competition. However, they decided
to continue the agency’s operation because of its potential to
bring future customers to the organization’s residential care
services. For this reason, the continuation of home health care is
believed to be an advantage for the organization.
Perceived Challenges
Alterszentrum Viktoria’s home health care agency faces a
variety of perceived challenges:

Market competition with other providers makes it difficult
to grow and expand the home health care service business.
 Competition from the official government-sponsored home
health care service provider is fierce. Private providers
must prove to clients that they are better, faster and have
higher quality than the government-sponsored home
health care agency.
 A Swiss nursing shortage makes it difficult to find and hire
qualified personnel to provide medical care to people in
their homes. Non-professional staff members, including
aides, are easier to recruit and hire.
Sodexo • IAHSA • LeadingAge | 17
ALTERSZENTRUM VIKTORIA
A Swiss nursing shortage makes it difficult to find and hire qualified
personnel to provide medical care to people in their homes.

Alterszentrum Viktoria has found it difficult to make
a profit from its home health care business. The
organization’s management is unsure how long it will take
for this business to break even, if ever.
 Lack of growth is the greatest barrier to the sustainability
of Alterszentrum Viktoria’s home health care program.
The organization has addressed this challenge by adopting
a comprehensive strategy to market its entire organization,
not just its home health care services. Alterszentrum
Viktoria advertises its other services—including concerts,
a day care center and a campus restaurant—in hopes that
these opportunities will help the organization connect
with prospective clients and create public awareness of its
home health care operation.
Perceived Benefits
Alterszentrum Viktoria executives believe that the benefits of
providing home health care services outweigh the challenges
associated with the expansion. Those benefits include the
following:

The ultimate benefit associated with home health care
services is the opportunities they create for Alterszentrum
Viktoria to gain future customers.
 Alterszentrum Viktoria can now offer services along the
entire continuum of aging services, including independent
living, home health care, and special nursing services for
people with dementia.
 Alterszentrum Viktoria has positioned home health care
as one of many points of entry into the organization and
a link to its nursing home. As the home health care staff
builds relationships with the public, the individuals they
encounter become potential customers who may eventually
move to the Alterszentrum Viktoria campus, either as
independent, assisted living or nursing home residents.
The ultimate benefit associated
with home health care services
is the opportunities they create
for Alterszentrum Viktoria to gain
future customers.
18 | Residential Provider Expansion into Home and Community-Based Services
Outcomes
Alterszentrum Viktoria has not evaluated the impact of its
home health care service program. The board of directors is
discussing plans to conduct such an evaluation at a future date.
Lessons Learned
Providers considering diversifying their services face risks,
but the benefits can be substantial. Offering a variety of
services, and knowing the external environment, can help
an organization determine which services will lead to greater
success.
Alterszentrum Viktoria learned the hard way just how
important it is to understand the market before launching a
new business line. Viktoria did not research the market and just
“jumped into” the home health care business without knowing
its competitors. That experience convinced Alterszentrum
Viktoria that organizations should consider pre-development
market research before launching a new home health care
program. Such research would help an organization gain a
better understanding of its market and the expertise needed for
each new business line.
Case Study
FEROS CARE
COOLANGATTA, QUEENSLAND, AUSTRALIA | March 2015
Introduction
Feros Care is a not-for-profit, non-sectarian, standalone
organization based in Coolangatta, Queensland, in the
Commonwealth of Australia. The organization provides a wide
range of aging-related services to older adults along Australia’s
eastern coast.
Feros Care provides services through three types of
programs:

Two low-care nursing homes6
 One high-care nursing home7
 Home and community-based service lines
The organization’s home and community-based service
lines include:








Nursing services
Personal care
Home care
Social care
Wellness services
An extensive range of telehealth services
Overnight and weekend respite care
Allied health care featuring community-based chronic
disease management and other services subsidized by
Australia’s Medicare program.
Policy Context
Australia is currently implementing a major reform of its aged
care systems. There are currently five major government-funded
home care programs. Feros Care has worked closely with all
of these programs to expand its home and community-based
service programs.
The Commonwealth Home Support Program (CHSP)
provides entry-level care for older adults who need governmentfunded support to remain at home. These services operate on
a wellness model and may include a range of low-intensity
services like domestic assistance, personal and social care,
transportation and meals. CHSP is the largest governmentfunded program in Australia.
The Home Care Packages Program serves individuals with
complex chronic conditions who are eligible for residential aged
care8 but are striving to age in the community. The program
allocates home health and community aged care “packages”
to older adults based on their level of need, as assessed by the
government’s Aged Care Assessment Team. Eligible older adults
receive one of four packages, which range from a relatively modest
level of support (Level 1) to a very high level of support (Level 4).
The packages cover a combination of clinical, personal and social
care that may include nursing care, personal care, allied health,
and domestic and social services. All levels of support include
an option for dementia care. Feros Care currently receives the
majority of its funding from the Home Care Packages Program.
The Veterans’ Community Nursing Program aids
individuals who have served in the armed forces. These
beneficiaries receive home health care, including nursing and
personal care. The program also covers the cost of care for
veterans’ spouses, widows and widowers.
The Veterans’ Home Care Program serves veterans, their
spouses, widows or widowers. Beneficiaries receive non-medical
home supportive care that is similar to the services provided
through CHSP.
The Allied Health Services Program provides a range of
health services in hospitals, community health centers, homes,
rehabilitation units and the community. Australia’s Medicare
and private reimbursement fund the program. Services include:
Sodexo • IAHSA • LeadingAge | 19
FEROS CARE
Physiotherapy
Podiatry
Dentistry
Audiology

Occupational therapy
 Social, mobility, pain management, fall-prevention and
disease management programs designed to support
healthy aging
Organizations like Feros Care face two primary complications
as they provide services and supports to older Australians:
consumer-directed care and government regulation.
Consumer-directed care: Australia began promoting
consumer-directed care in 2012 as part of its Living Longer
Living Better aged care reform legislation. Consumerdirected care allows clients to choose their preferred
provider, thus giving older Australians more control over
their care and who provides it. The consumer-directed care
policy places additional administrative and cost burdens on
providers of aged care. For example, Feros Care and other
providers sometimes must enter into new partnerships with
local providers in order to honor clients’ choices.
 Government regulation: Organizations providing
government-funded services are highly regulated and
must comply with strict funding agreements, guidelines,
external audits and external complaint mechanisms. In
contrast, there are almost no regulations governing the
provision of private-pay services. Most of the care that
Feros Care provides is at least partly government-funded.

Expansion into Home and CommunityBased Services
Feros Care was established in 1990 as a small, low-care nursing
home in Byron Shire, New South Wales. The organization has
followed a steady path of expansion since then, as the following
timeline illustrates.
1997: Feros Care added a high-care nursing home.
1999: Feros Care won funding to establish a small homecare service providing 25 older adults in Bryon Shire with
community aged care packages. Providers of these packages
receive a certain amount of funding per day to provide a range
of services that support an older adult aging at home. Such
packages might include the following services:
 One nurse visit per week for chronic disease management
 Weekly shopping services
 Transportation to therapy appointments three times each
week
 Assistance with cooking and light housework for two
hours a day
20 | Residential Provider Expansion into Home and Community-Based Services
2002-2003: The organization developed a plan to expand its
home and community-based services and began carrying out
the plan. Although the expansion proceeded slowly for the first
two years, the organization has grown by more than 20% per
year since 2005.
2005: The organization began offering home health care and
home care in the private-pay market.
2012: Feros Care purchased another community-owned
company operating a large nursing home.
2015: Feros Care currently provides a range of home and
community-based services through various government
programs and for private-paying clients. These services are
available in a 3,000-kilometer area along Australia’s East
Coast. The service area spans four states: New South Wales,
Queensland, Tasmania and Victoria.
Reasons for Expansion and Growth
Feros Care’s decision to expand its home and community-based
services was primarily market-driven. Although Feros Care was
operating at a surplus in the early 2000s, its leaders knew that
the organization would be vulnerable to competition due to its
small size and the fact that the Byron Shire area did not have a
large aging population.
Feros Care realized it would soon struggle to compete for
funding against providers in neighboring areas that had larger
populations and greater proportions of older adults. The
organization decided to expand its services and geographical
reach for the following reasons:

Expanding Feros Care’s home and communitybased services seemed less risky than expanding the
organization’s assisted living and nursing home operations.
Home and community-based services held two advantages
in comparison with residential care: a lack of adverse media
coverage and a much-reduced set of regulations.
 An expansion into home and community-based services
would not be as capital-intensive as an expansion of
residential care. Feros Care would not need to build new
buildings or invest in new infrastructure.
 The expansion would provide Feros Care with a much
larger potential market. Most (80%) of older adults in
Australia were receiving government-funded support
services in 2003, and the vast majority of those older adults
were still living in their homes.
Feros Care’s senior managers and board of directors made
the decision to expand into home and community-based
services as part of the organization’s strategic planning
deliberations. The expansion received little-to-no resistance
from staff members, who expressed excitement about Feros
Care’s vision for the future.
Timeline
FEROS CARE
1990
Began as low-care
nursing home in
Byron Shire, New
South Wales.
1997
Added high-care nursing home.
1999
Received government funding
to provide home care to 25
older adults.
2002
Began competing for home care and
home health care government funding
on wider scale.
2005
Began offering privatepay home care and
home health care.
2015
Provides a range of government-funded
and privately paid home health, home care
and other HCBS to older adults along the
3,000-km eastern coast of Australia.
2012
Purchased a company operating
a large nursing home.
Sodexo • IAHSA • LeadingAge | 21
FEROS CARE
Dependence on Government Programs
Initially, Feros Care provided only government-subsidized
home care. The availability of government packages has greatly
influenced organizational discussions regarding possible
expansion into the private-pay home care market.
In 2005, for example, the organization performed a market
analysis to gauge opportunities within the private-pay market.
At the time, long waiting lists for government-funded aged care
threatened to curtail the organization’s growth potential. Feros
Care viewed a private-pay expansion as a way to grow outside
its current market and region, and to become more competitive
with larger home care providers.
The organization began offering a few private-pay services in
2005. However, an extensive expansion into private-pay services
was put on hold when the government increased its funding for
aged care that same year. Essentially, the government’s decision
to increase its funding of aged care allowed Feros Care to grow
by winning more government packages.
Feros Care is once again considering an expansion of its
private-pay services. This latest discussion stems from a
government move in July 2014 to develop more stringent means
testing for the receipt of home care packages. The new rules
could make it cost-efficient for some consumers to purchase
Feros Care’s private services. As a result, the organization
expects the private-pay home care business to grow over the
next several years.
Ironically, the few private services Feros Care began offering
in 2005 allowed the organization to compete more effectively
for government packages. As Feros Care began offering services
in other regions, it learned that those services were often
superior to services offered by other providers. Feros Care’s
responsiveness, flexibility, staff values and philosophy of care
helped it build a strong reputation in these regions. As a result,
the organization became even more successful at acquiring
government contracts. This success spurred a positive feedback
cycle that helped Feros Care further improve and expand its
services, succeed during subsequent funding rounds, and then
improve and expand its services even more.
Description of the Program
Services Provided
Most of the home and community-based services that Feros
Care provides are delivered to older adults who receive
assistance through the Home Care Packages Program. To a
lesser extent, the organization provides services to older adults
covered by the Veterans’ Community Nursing, Veterans’ Home
Care, Commonwealth Home Support, and Allied Health
Services programs.
Feros Care provides non-medical and medical services through
these government programs and for its private-paying clients.
Non-medical services include:
 Light housework
Cooking
 Lawn care
 Pet care
 Assistive and smart technologies
 Moving services
Table 1. Services Provided by Feros Care
DOMESTIC CARE
PERSONAL CARE & NURSING
WELLNESS AND LIFESTYLE
Cleaning & Light Housework
Personal Self Care (showering,
Companionship & Social Support
Personal Laundry
dressing, grooming, toileting)
Accompanied Community Outings
Unaccompanied Shopping
Continence Management
Counseling & Chaplaincy Services
Errands & Bill Paying
Clinical Care
Maintaining Independence Program
Accompanied Transport
Palliative Care
Mobility Exercise Programs (Strong
Home-Cooked Meals
Dietary Planning & Education
Foundations & Forever Young)
Home Maintenance
Mobility Assistance & Equipment
Respite (in-home, day, residential)
Lawn Mowing & Gardening
Communication Aides
Day Trips & Social Groups
Pantry/Cupboard & Spring Cleaning
Accompanied Medical Appointments
Volunteer Activities
Moving Services
Foot Care & Nail Care
Falls Prevention & Re-ablement
Pet Care
Life Link Personal Alarms
Reminiscence, Hobbies, Crafts
Internet Training & Support (banking,
Lifelink Smart Home Monitoring (auto
Telehealth Vital Signs Monitoring
shopping)
night lighting, bed/chair/door sensors,
Internet training & Support (virtual
Technology (Robo-vac cleaners)
environmental alerts)
visiting & social connections)
Hairdressing: Visiting Services
Beautician: Visiting Services
22 | Residential Provider Expansion into Home and Community-Based Services
FEROS CARE

Internet training and support
Personal care
Companionship
 Accompaniment to appointments
 Counseling and chaplaincy services
 Exercise programs
 Respite care
 Efforts to help older adults
participate in community outings
and wellness programs

organizations that work under contract to provide frontline staff
to its service lines. These agreements clearly spell out specific
service delivery expectations and requirements. Feros Care
also closely monitors client feedback and reported incidents
associated with contract providers. The organization does
not hesitate to discontinue partnerships due to differences in
corporate philosophies or inadequate care provision.
Medical home care services include, but
are not limited to:
 Continence management
 Palliative care
 Nutritional planning and education
 Mobility assistance and home
retrofitting
 Foot and nail care
 Medical monitoring services offered
through telehealth programs
Feros Care provides around-the-clock
care when needed, and its Contact and
Referral Center is staffed at all hours.
While the organization does not offer
live-in staff placements, it does provide
nighttime and weekend care when clients
are discharged from the hospital and for
other needs. Feros Care regularly provides some services, such
as personal care and help with medications, to clients during
evening hours and on weekends.
See Table 1 for more details about Feros Care’s home health,
home care and community services.
Partnerships
Feros Care delivers services using a combination of its own
staff and service partners from the surrounding community.
When Feros Care expands into new regions, the organization
strategically engages service partners in those areas to deliver
direct care until it has a sufficient number of clients and
services. At that point, Feros Care begins recruiting its own
direct-care staff while maintaining its relationships with
local service partners. Feros Care calls on those partners for
assistance during times of high care volume.
In contrast, Feros Care does not contract for any care
coordination or case management services. Because care
coordinators play a major role in monitoring direct-care
provision and upholding its quality, Feros Care always fills
these positions with its own staff members. This is one way that
the organization works to ensure that its client assessment and
care planning activities meet the highest standards, and that its
service philosophy and the quality of its care are maintained.
Feros Care employs other strategies to ensure that it
maintains high standards of care. For example, Feros
Care signs formal service/brokerage agreements with all
Feros Care has 245 service partners across all of its service
lines. The organization selects partners based on a number of
factors, including reputation, price, capabilities and flexibility.
Feros Care contracts with several franchisees associated with
larger home care organizations like Just Better Care and Home
Instead. The executives of these franchises tend to be smallbusiness owners who care deeply about maintaining good
relationships with other providers. These business owners help
Feros Care maintain its reliability, which is a source of pride for
the organization.
Australia’s implementation of consumer-directed care adds
to the complexity of contracting for services. Empowered to
choose the provider they want, consumers can select a local
cleaner to do their housework instead of the service provider
with which Feros Care has an agreement. In cases like this,
the consumer-directed care program requires that Feros
Care perform the necessary inquiries and develop a service
partnership with the provider preferred by the client.
Sources of Reimbursement
Feros Care receives Commonwealth reimbursement from the
Department of Social Services and the Department of Veterans
Affairs for the services it provides through the Home Care
Packages, Veterans’ Community Nursing, and Veterans’ Home
Care programs. Medicare, private insurance,9 and privatepay clients pay for services provided under the Allied Health
Services program.
Sodexo • IAHSA • LeadingAge | 23
FEROS CARE
Feros Care also receives some state funding for post-acute
care that is managed by state health departments. These
programs include Transitional Care; ComPacks, which
provides immediate access to short-term community services;
and programs for sub-acute care. State funding is generally for
short-term interventions designed to reduce the likelihood of
readmission.
Consumer Eligibility
In order to be eligible for government-funded programs,
Australians are required to participate in an independent
assessment, conducted either by telephone or in-person, or
both. Independent assessors include the Aged Care Assessment
Team for home care packages and the new Regional Assessment
Service Team for the Commonwealth Home Support Program.10
The approvals process for each major government program is
as follows:
Home Care Packages Program: Traditionally, a local Aged
Care Assessment Team determined an individual’s eligibility
for a home care package after conducting an in-person
assessment. This system changed on July 1, 2015. Now, clients
access the Aged Care Assessment Team through Australia’s
new My Aged Care Gateway, which makes an initial phone
assessment and then refers eligible individuals to the Aged Care
Assessment Team.
Commonwealth Home Support Program: Beginning July
1, 2015, the client calls the Commonwealth’s My Aged Care
Gateway for an initial phone assessment. Eligible individuals
are then referred to the Regional Assessment Service for an inhome, face-to-face assessment. The assessors complete a goaloriented support plan and make the necessary service referrals
to the client’s preferred home support service providers.
Veterans’ Community Nursing Program: Clients must
receive a referral for an approved service from a doctor or
nurse. The amount of funding is based on the individual’s level
of need.
Veterans’ Home Care Program: A regional Veterans Home
Care Assessment Team determines the individual’s needs and
the level of support they may receive.
Allied Health Services Program: A doctor must approve
the client’s participation in this Medicare-funded system for
chronic disease management and other allied health services.
Private health providers have predetermined eligibility criteria.
Clients must access approved providers, including Feros Care.
Individuals can access all of these services regardless of their
financial means. However, retirees who are not receiving a full
pension may be required to make substantial co-payments.
There are no requirements for receipt of privately paid services,
other than ability to pay.
Provider Eligibility
Providers must apply for the right to provide services through
government-funded programs. There are no upper limits on the
number of clients a provider organization may accept through
the Commonwealth’s veterans’ programs.
24 | Residential Provider Expansion into Home and Community-Based Services
In contrast, providers participating in the Home Care
Packages Program are awarded a license for a certain number
of packages. For example, they may be allocated packages for 50
clients at a given time.
Providers in the Commonwealth Home Support Program are
given a certain amount of money to provide a given number of
services. For example, providers may be allocated $100,000 in a
given year to provide 1,000 medical transport trips.
Feros Care Clientele
Feros Care provided this snapshot of its home and communitybased services clients:







The average age of clients is 82 years, and 59% are at least 80
years old.
Two-thirds of clients are female.
Most clients have at least one chronic condition.
One-quarter of clients are nursing home certifiable but are
living at home with assistance.
Three-quarters of clients are receiving lower level care to
help them maintain their independence.
Most clients have financial needs, and 85% are full
pensioners.
Less than half (44%) of clients live alone without a full-time
family caregiver.
Quality Assurance
Feros Care is committed to ensuring that it maintains high
quality standards, through its own efforts and the efforts of its
service partners. Quality is assured through four strategies.
1. The Commonwealth’s Aged Care Quality Agency regularly
conducts on-site audits of government-funded community
care programs, and compares providers’ quality assurance
systems against a set of common standards.
2. Feros Care contracts with a standards-compliance
company called SAI Global for comprehensive quality
management of all its programs. Feros Care and SAI Global
track many measures, including the following:








Daily incident and hazard reporting
Systems of improvement
Workflow management
Customer feedback programs
Internal audit programs
Business excellence parameters
Response times
Adherence to policies and procedures
3. Feros Care employs a chief resolution officer who oversees
the resolution of all complaints to the organization’s
Customer Feedback Program.
4. Feros Care uses its care coordinators to oversee the work
performed by direct-care aides and to ensure that high
quality is maintained. Care coordinators integrate the
feedback they receive from clients with data collected
Feros Care provided this snapshot of its home
and community-based services clients:
Feros Care
Clientele
A snapshot of Feros
Care’s home and
community-based
services clients
82
Average
age of clients
59
% at least 80 years old
2/3
1
1/4
are female clients
number of chronic conditions
for most clients (at least)
clients who are nursing
home certifiable, but live at
home with assistance
75
85
% of clients receiving
lower level care to help
maintain indepencence
% of clients who are
full pensioners (most have
financial needs)
44
% of clients who
live alone without a full-time
family caregiver
Sodexo • IAHSA • LeadingAge | 25
FEROS CARE
through tracking of quality indicators. The coordinators
discuss issues with aides as they arise, and pass information
to supervisors. This information is included in daily
communication updates on services and clients, monthly
staff meetings, and performance reviews.
Marketing
Feros Care uses many venues to spread the word about its home
and community-based services. The organization employs a
comprehensive branding and marketing strategy that includes
Feros Care magazine, newspaper advertisements, local media
coverage, social media outreach, and participation in such
community events as expos, festivals and public celebrations.
The organization also employs a comprehensive strategy to
engage referral sources. These strategies include scheduled visits
with referring agencies; participation in networking events,
speaking engagements, celebrations and other events; and
maintenance of an extensive customer relations database.
Figure 1. Feros Care: Annual Growth
Since Expanding to Home and
Community-Based Services
2002-03
2003-04
2004-05
2005-06
2006-07
2007-08
2008-09
2009-10
2010-11
2011-12
2012-13
2013-14
2014-15
0%
5% 10% 15% 20% 25% 30% 35%
26 | Residential Provider Expansion into Home and Community-Based Services
Feros Care uses its care
coordinators to oversee the work
performed by direct-care aides
and to ensure that high quality
is maintained. Care coordinators
integrate the feedback they
receive from clients with data
collected through tracking of
quality indicators.
Financial Implications
In 2005, Feros Care served 50 clients per year. In 2014, the
organization served approximately 4,000 clients, and it expects
to serve at least 6,000 clients in 2015, due to the advent of new
government-funded transportation and allied health services.
Client numbers could expand even further to 30,000 clients per
year due to the organization’s recent approval to operate the
Regional Assessment Service for the Commonwealth Home
Support Program (CHSP). However, services to some CHSP
clients may be provided only on a short-term basis.
Figure 1 presents Feros Care’s annual growth, beginning
in 2002-2003 when the organization began its expansion
into home and community-based services. Feros Care has
experienced double-digit growth during most years since home
and community-based services became its largest service line.
The first two years of Feros Care’s expansion into home and
community-based services (2003-2005) proved difficult, as the
organization struggled to find its niche in a field crowded with
many competitors. However, Feros Care’s growth has exceeded
20% per year for almost every year from 2006 until the present.
In 2003, the organization funded its community care services
with only $250,000. In contrast, current funding levels for
community care is $35 million. The new Regional Assessment
Service is likely to bring this growth level to $45 million in
2016.
The initial growth period did not require a large expansion
of the Feros Care staff. Prior to 2005, Feros Care hired a
part-time marketing assistant and a part-time writer who
was responsible for submitting applications for government
packages. The organization’s chief executive officer also spent
considerable time on marketing and budgeting efforts. Once
the organization began to obtain a significant number of
government contracts, however, these positions began paying
for themselves. The organization’s home and community-based
service program broke even in 2007.
FEROS CARE
The bulk of Feros Care’s current revenues stem from the
services it provides to a quarter of its clients. That’s because
Feros Care receives most of its funding from the Home Care
Packages Program, despite the fact that the Commonwealth
Home Support Program (CHSP) is larger and serves more
of Australia’s older adults. Generally, the monetary value of
individual home care packages is much greater than the value of
packages provided through CHSP. For example, a typical CHSP
client might only be approved to receive $2,000 per year in
services, whereas typical home care packages range from $7,500
to $45,000 per year.
Workforce
Feros Care employed approximately 350 people in 2014. More
than 280 of these employees were care aides, and a majority
of these care aides worked in the organization’s home care
division.
Nurses comprised just over 5% of Feros Care staff in 2014
when Feros Care also used staff members to develop staff rosters
(6%) and coordinate services (8%). Allied health professionals,
who work in a Feros Care service line that is growing rapidly,
are expected to comprise 5% of the organization’s employees by
the end of 2015.
Feros Care expects its workforce profile to change over
the next year, although home care workers will continue to
comprise the majority of its staff. The organization expects to
see staff growth in three areas:
Allied health: The allied health line will soon be expanding
due to the increased use of specialists like physiotherapists
and occupational therapists in Feros Care’s restorative care
programs. These specialists operate a range of mobility,
strengthening, fall-prevention and wellness programs
designed to increase the independence of clients.
 Telehealth: The number of telehealth nurses performing
chronic disease management is expected to increase
as Feros Care’s telehealth services continue their rapid
growth.
 Information technology (IT): Feros Care will also be
expanding its IT staff to meet the growing needs for health
technology in clients’ homes.

Staff Benefits
Because Feros Care is a not-for-profit provider, its employees
can receive some of their income tax free. Feros Care also offers
employees:






Wellness programs11
Free gym memberships
In-house leadership programs
External education
An employee assistance program
Discounted mobile technologies
Feros Care employees do not receive health insurance
through their jobs because Australia has a public insurance
program.
Staff Recruitment and Training
Working in home care differs greatly from working in
a residential setting for aides at Feros Care and other
organizations.
Home care aides work alone primarily and perform a greater
variety of tasks for clients than aides in residential settings.
Home care aides have more responsibility to make accurate
and timely observations and to prudently make care decisions
on their own. They also have to be more flexible and versatile
than residential employees, since they are called on to provide
cleaning, cooking, social care and, in some cases, therapy
support in addition to traditional care tasks.
For these reasons, Feros Care generally does not redeploy
residential aides to home care unless those aides are very open
to working on their own and undertaking all the activities
required to support clients. Residential care aides may never
have performed activities like cooking and cleaning as part of
their prior professional responsibilities.
In addition to taking direct job inquiries, Feros Care partners
with jobs networks and registered training organizations to
identify the most qualified candidates. Once potential hires
have been identified, Feros Care conducts structured interviews
and tests applicants’ skills in such areas as technology and
observation, before making hiring decisions. Feros Care
has found that it is important to hire staff members who are
independent, are known to the organization, have experience,
and understand the expectations of the job.
Independence: Feros Care looks for staff members who are
self-starters and are comfortable working alone most of the
time. These staff members also need to be comfortable using
technology to stay connected with the organization and with
clients.
Known quantities: Feros Care places great importance on
hiring aides it knows and trusts. That’s why the organization
reduces its reliance on contracted services after it has settled
in a new region. And that is why Feros Care grooms its best
home care staff for management and supervisory positions,
rather than hiring staff from outside the organization or from
its residential services division. Feros Care also shares executive
and billing staff across its home and residential care divisions,
rather than hiring additional staff from outside the organization.
Feros Care places great importance
on hiring aides it knows and trusts.
That’s why the organization reduces
its reliance on contracted services
after it has settled in a new region.
Sodexo • IAHSA • LeadingAge | 27
FEROS CARE
The hiring process for care coordinators is an exception to
this practice. When expanding into new geographical areas,
Feros Care hires local residents to serve as care coordinators
because these individuals are familiar with local communitybased services. Feros Care carries out an extensive training
program for these new hires so they will be well versed in the
organization’s philosophy and procedures and well prepared to
uphold the quality and reputation of the Feros Care brand.
Experience: Feros Care works hard to recruit aides and other
personnel who are already experienced at providing care in the
community. Applicants’ values, service philosophy and love
of working with older adults play a large role in the selection
process. In its search for employees with these soft skills,
the organization may hire workers with less-than-developed
clinical and care skills, and then provide mentors and training
to help these staff members develop any missing skills.
Clear expectations: Detailed position statements ensure
that job candidates understand Feros Care’s expectations
for them. Feros Care has mechanisms in place to ensure that
staff members understand unwritten ground rules and the
organization’s underlying philosophy. In addition, a staff
competency registry contains information about mandatory
and additional qualifications for each major role. Feros
Care takes steps to ensure that new staff members know
how management views their performance. It also provides
opportunities for staff members to give feedback during regular
performance reviews.
Staff Training and Orientation
Feros Care uses various training processes to maintain the
competence of new hires and existing staff. Training begins at
the time of hiring and continues throughout employees’ tenure
with the organization. New hires undergo a staged orientation
program that reviews the organization’s comprehensive staff
handbook and the mandatory competencies for their positions.
New staff members are on probation during the first six
months of their employment and receive a number of supports
to ensure their success:

Feros Care pairs new staff with a current staff member in a
similar role.
 New staff members are closely monitored and supported
through the organization’s Staff Candidate Care Program.
 To foster tight coordination, Feros Care provides
smartphones to all new direct care staff, case managers,
nurses and allied health professionals.
Beyond required training, Feros Care employees have
numerous opportunities to develop themselves professionally.
These opportunities include enrolling in certificate courses and
workshops, and participating in educational competitions.
Feros Care runs an ongoing education competition that
encourages employees to earn points on “Passport to Learning”
28 | Residential Provider Expansion into Home and Community-Based Services
Training begins at the time of hiring
and continues throughout employees’
tenure with the organization.
continuing education cards. Employees who complete various
learning and development activities receive awards like gift
cards and entry into drawings for substantial prizes.
Feros Care also provides access to internal and external
professional networking websites and gives employees
opportunities to develop their leadership abilities. The
organization offers the Seven Star Staff Development Program, a
three-year leadership course culminating in the attainment of a
nationally recognized management certificate.
Perceived Challenges
Feros Care has faced challenges throughout the organization’s
growth process, including challenges associated with meeting
the needs of clients around the clock, communicating with
remote staff, and navigating a highly competitive home care
market.
Meeting the Needs of Clients Around the Clock
Clients with substantial care needs experience a greater
level of risk living in the community than they would in a
residential setting. In order to provide care for these clients
around the clock, Feros Care staff members must learn about
additional services available in clients’ communities and the
capabilities and availability of family members and close
friends to ensure that clients’ needs are met when Feros Care
aides are not with them.
FEROS CARE
Feros Care has learned that it needs a substantial number
of part-time staff working flexible hours to meet clients’ needs
on a 24/7 basis. The growing use of telehealth technologies has
helped the organization monitor clients at all times. However,
training staff to use and maintain these technology solutions
has required substantial effort.
Communicating with Remote Staff
Communicating effectively with remote staff, ensuring that
they have adequate support, and helping them to feel valued,
has also been challenging. To accomplish these goals, aides and
care coordinators depend heavily on technology, including an
advanced videoconferencing infrastructure. In addition, the
organization provides regular opportunities for face-to-face
socializing through organization-sponsored and individual
celebrations. Feros Care’s many care-related awards have
presented opportunities for celebrating the organization’s
successes and fostering a sense of pride and teamwork.
Fierce Competition
The competition among Australian providers of home care
services is fierce and has required Feros Care to define its
niche sharply, rapidly and innovatively. As part of that effort,
the organization seeks to provide care in regions with a
demographic makeup that will support home care services.
Feros Care resolved to meet new care needs without opening
numerous new offices. Technology has helped the organization
maintain a central organizational structure while creating
virtual offices that rely on electronic records and other
technologies. This high-tech approach has allowed Feros Care to
move quickly as it launches high-quality community programs
in distant geographic areas. At the same time, Feros Care uses
remote-monitoring technology to provide care at all hours when
it is needed.
Feros Care’s technological expertise and its commitment to
preserving high-quality services have allowed the organization
to distinguish itself from competitors. The organization
advertises these differences to consumers and showcases them
in funding applications. Strengthening the organization’s virtual
infrastructure will help it offer even more telehealth services so
it can compete even more successfully in distant areas.
The advent of consumer-directed care in 2014 made it even
more important for Feros Care to raise its brand profile so
potential clients would choose its services rather than the
services of a local competitor.
The fierce competition for home care packages has presented
a more general challenge. Applicants to the Home Care
Packages Program are requesting many more packages than
are available. In 2014, for example, 1,821 home care companies
sought 108,281 packages, yet the Commonwealth allocated only
6,598 packages to only 137 of the applying companies. That year,
providers requested a total of $577 million worth of packages,
but the government allocated only $53 million.
The allocated packages have been distributed
disproportionately. The top-10 organizations applying for home
care packages received 30% of the total number of packages.
The top-20 applying organizations received 50% of the packages
allocated to the 137 successful companies. Given this intense
competition, Feros Care is continually exploring new strategies,
models and innovations.
Perceived Benefits
Feros Care’s executives and staff have found the provision of
home care to be extremely rewarding, despite the challenges
associated with that care provision. The organization’s
leaders report that they have greatly enjoyed the challenge
of leveraging a limited capital outlay to expand services and
supports to more older adults in the community. They have
also derived great satisfaction from pioneering new models
and growing their organization’s competencies in a market
that is growing, thriving and constantly evolving. These
leaders take enormous pride in their service lines’ growth and
their company’s reputation. They are relieved that expansion
into home and community-based services does not require
the physical or capital outlays associated with expanding
residential aged care.
Outcomes
Feros Care has not conducted any formal evaluations of its
programs, beyond analyzing income growth, geographic
expansion and the organization’s profile within the industry.
Home and community-based services have grown into the
organization’s largest and most successful business line. These
new services have greatly augmented the organization’s profile
and its leadership within the industry. As a result, Feros Care
has won national and international awards and its leaders are
asked to speak at national and international conferences.
The success of this business line has allowed Feros Care to
help many more older adults and their family/support networks.
It has also provided the organization with a healthy cash flow
that, in turn, has benefited all its service lines.
Home and community-based services have grown into the organization’s
largest and most successful business line. These new services have greatly
augmented the organization’s profile and its leadership within the industry.
Sodexo • IAHSA • LeadingAge | 29
FEROS CARE
Lessons Learned
Feros Care offers the following suggestions for residential
service providers that are considering or already expanding
into home and community-based services:








Start with relatively few services and clients and gradually
build up your capabilities.
Identify organizations that already provide the services
you want to offer. Visit those organizations to learn about
their successes and challenges.
Invest in hiring staff members who have experience
providing care in the community.
Invest in technology, like telehealth, to enhance service
provision.
Engage in a continual process of staff and systems
development. Recruit potential hires well, offer them
good initial training, and continually train them
throughout their tenure with the organization. Provide
frequent feedback and review. Document the models that
work for you.
Involve members of a care recipient’s family/support
network in the care planning process. Treat these
individuals as partners.
Listen carefully to clients and members of their family/
support networks to ensure that you understand their
priorities. Don’t impose your expectations. Learn what
consumers value most and be sure to provide it.
Make sure that informal caregivers are adequately
supported.
30 | Residential Provider Expansion into Home and Community-Based Services

Know the communities in which clients live. Link clients to
additional services as needed.
 Employ a comprehensive strategy to promote your services.
Market your brand extensively, and engage referral sources
by meetings with referring agencies, attending networking
events, accepting speaking engagements, and sponsoring
celebrations and other organizational events. Use these
events to promote your brand.
 Demonstrate success and quality in related fields—like
mental health, care for people with disabilities, postacute care, and private home care—when competing for
government funding for home and community-based
services.
Engage in a continual process of
staff and systems development.
Recruit potential hires well, offer
them good initial training, and
continually train them throughout
their tenure with the organization.
Case Study
ISABELLA GERIATRIC
CENTER
NEW YORK, NEW YORK | May 2015
Introduction
Isabella Geriatric Center is a not-for-profit, non-sectarian
organization in New York City that has pioneered the care
of older adults since 1875. Isabella grew from a traditional
nursing home into a leading health care organization that
provides a continuum of services on its own campus, in
the Washington Heights and Inwood neighborhoods of
Manhattan, and throughout New York City’s five boroughs
and surrounding suburbs.
In addition to a 705-resident nursing home, Isabella offers
moderately priced senior housing, adult day health services,
child day care, certified home health care, licensed home
care services, short and long-term rehabilitation, a service
program for Naturally Occurring Retirement Communities
(NORC),12 community-based care coordination, and other
community programs designed to help older adults remain
healthy and independent at home.
This case study of Isabella’s expansion into home
and community-based services was conducted through
interviews with executives at Isabella Geriatric Center and a
two-day site visit at Isabella Geriatric Center.
Sodexo • IAHSA • LeadingAge | 31
ISABELLA GERIATRIC CENTER
Policy Context
Isabella began offering home care after New York State
instituted the Nursing Home without Walls (Lombardi)
program in 1977 to help Medicaid-eligible older adults with
chronic illnesses and disabilities remain in the community. The
program offered eligible Medicaid beneficiaries an alternative
to institutionalization by providing medical, nursing and
rehabilitative care at home. Lombardi participants also had
access to home health care aides, social day services, homedelivered meals and transportation to and from medical
appointments. Isabella supplemented the program’s Medicaid
reimbursement with grant funding.
New York Governor Andrew Cuomo recently disbanded
the Lombardi program and began implementing an array of
cost-cutting initiatives for Medicaid beneficiaries, including a
requirement that all New York Medicaid recipients enroll in a
managed care plan. This new mandate has made it necessary
for Isabella to alter its approach to recruiting and billing clients.
Prior to the managed care mandate, Isabella recruited adult
day health services clients from the community. Now, Isabella’s
adult day health program depends on care settings like doctors’
offices to refer clients to the program.
New York State has joined the Delivery System Reform
Incentive Payment Program (DSRIP) to further reduce
Medicaid costs. Nine states, including New York, have adopted
DSRIP to date.
DSRIP fundamentally restructures the way care for Medicaid
recipients and the uninsured is delivered and billed. Hospitals,
physician practices and other health care providers work
together through the program to meet specific measures that
are designed to reduce costs while improving or maintaining
health outcomes. One of DSRIP’s major goals is to reduce
hospital admissions and readmissions by 25% in five years.
New York State providers that succeed in meeting DSRIP
measures will receive a portion of $6.4 billion in shared savings
from the federal government’s Medicaid reform initiatives.
Successful providers may also draw on over $1 billion in federal
savings for capital outlays that will make care more efficient.
Hospitals participating in the DSRIP program determine which
DSRIP measure they will address, and how they will distribute
savings, if any, to participating partners.
Isabella’s partnerships with four DSRIP participants could
bring the organization a share of newly available funds that
will reward teams meeting specific program objectives. The
program is nascent and rapidly evolving, and Isabella does not
yet know how beneficial its participation will be.
Expansion into Home and CommunityBased Services
History of the Expansion
Isabella established its nursing home in 1875, and began
offering senior housing at Isabella House in 1964. Both of these
residential options are delivered in two buildings: a 17-story
building and a 13-story building in the Washington Heights
neighborhood on Manhattan’s Upper West Side.
32 | Residential Provider Expansion into Home and Community-Based Services
Providing services to the greater community was a natural
move for Isabella because it is well established and well known
in New York. The organization began offering home-based
services in 1989, seeking Lombardi program funds to care for
community-dwelling Medicaid clients who were seriously ill or
had disabilities. In 1991, Isabella began providing child day care
onsite at its nursing facility. In 2000, Isabella added adult day
health services to the community-based service lines it provided
from its Washington Heights campus.
More recently, Isabella began providing a diverse array of
community-based health, wellness and care management
services for older adults. Those services, described fully in the
next section of this case study, include a supportive service
program for NORC residents; service-specific case management
services provided by a consortium of eight community services
providers; an information and referral clearinghouse for older
adults and their caregivers; education, counseling, and wellness
programs provided by Isabella’s Institute for Older Adults;
certified home health care; and licensed home care services.
Reasons for Expansion and Growth
Isabella’s expansion into home and community-based services,
while facilitated by the availability of Lombardi program funds,
was mission-driven.
Isabella realized that few members of its community were
likely to move to the organization’s nursing home or senior
housing property. Given its long-standing ties to families in
northern Manhattan, Isabella wanted to serve that community
in other ways by developing a continuum of services that would
support older New Yorkers who wanted to remain in their homes.
The expansion into home and community-based services also
supported Isabella’s longstanding mission to provide services
and supports to poor, underserved, and non-English-speaking
older adults. Isabella executives believe that an enduring
commitment to the community distinguishes not-for-profit
providers from their for-profit counterparts. Not-for-profit
providers, they believe, are less inclined than for-profit
providers to abandon that commitment for financial reasons.
Description of the Program
Services Provided
Adult Day Health Care: Since 2000, the Isabella Adult Day
Health Care Program has provided health care to approximately
40 older adults per day. The program operates Monday
through Saturday from 9 a.m., to 3 p.m., at nearly a full daily
census. It provides participating adults with health care, social
activities, recreation and meals. A substantial portion of clients
has serious psychological or neurological issues, including
depression and intellectual disabilities.
The program staff includes social workers, two registered
nurses (RN), certified nursing assistants (CNA), a recreation
therapist and bus monitors. Members of the program staff work
with each client to develop a care plan that outlines goals in
such areas as nutrition, exercise and medication adherence. The
plans’ goals are reviewed and updated every six months.
Timeline
1875
ISABELLA GERIATRIC CENTER
Opens as a
nursing home.
1964
Opens Isabella House
providing senior housing.
1989
Begins providing home health
and home care through the
Lombardi Program.
1991
Begins offering child
day care onsite at its
nursing home.
2000
Begins offering adult day
health care onsite at its
nursing home.
2009
2014
Establishes Isabella Care
at Home, Inc., a certified
home health agency.
Establishes Isabella Visiting
Care, Inc., a licensed home
care agency.
Sodexo • IAHSA • LeadingAge | 33
ISABELLA GERIATRIC CENTER
Naturally Occurring Retirement Communities: Isabella
has been serving older adults in two Naturally Occurring
Retirement Communities since 2006.

The El Corazon Neighborhood Naturally Occurring
Retirement Community (NNORC) consists of 40
contiguous low-rise buildings within six square blocks.
 The Fort George VISTAS Naturally Occurring Retirement
Community (NORC) is located in three high-rise buildings
at the Mitchell-Lama Co-Op.
Each NORC houses approximately 400 residents, 275 of
whom make use of services that Isabella delivers in each
building. The design of both programs is based on a standard
model for NORC services developed by New York City’s
Department for the Aging. The programs’ core service areas
are social work assistance and case management, health care
assistance and health care coordination.
Staff members and community partners provide NORC
residents with comprehensive services that include the
following:

Social work services
Individualized health care assistance and management
provided by a nurse
 Health promotion and screenings
Education
Recreation
 Support groups
 Volunteer opportunities

The El Corazon NNORC, currently funded by the New
York State Office for the Aging and New York City Council
discretionary funding, provides additional services to New
York’s low-income immigrant communities. Full-time social
workers and part-time nurses provide these services five days
a week on site at the NNORC, at a centralized storefront,
and during home visits. In addition, staff offers a menu of
preventive care and health-related activities. NNORC provides
these much-needed additional services without the help of a
distinct housing partner.
Isabella Visiting Care, Inc.: Launched six years ago, Isabella
Visiting Care Inc., (IVCI) is a licensed home care services
agency currently providing more than one million hours of
home care services each year to more than 500 New Yorkers
over the age of 18. Services are available in Manhattan, the
Bronx, Brooklyn, Queens and Westchester County.
IVCI offers paraprofessional and escort services, with
oversight by a registered nurse, that include:
Cooking
Cleaning

Personal care
 Medication reminders
34 | Residential Provider Expansion into Home and Community-Based Services
Companionship

Care management for individual with complex
chronic conditions
Agency services are delivered by hourly and live-in home
health aides. A nurse is on-call at all times. IVCI hires its own
home health aides and trains them, in its own program, to
meet New York State certification requirements. The agency
uses Home Health Aide Exchange to match home health aides
with clients based on availability, proximity, relationships,
and preferred language. Language is an important placement
criterion since half of Isabella’s clients are Hispanic and a
growing number are Chinese or Russian.
IVCI currently employs 650 home health aides, most of whom
live in and feel a connection with the community. Many aides
work with one or just a few clients each week. This helps aides
feel “like family.” Clients may invite aides to birthday and other
parties, or refuse to receive medical treatment unless their home
health aide is present.
Isabella Care at Home, Inc.: Launched one year ago, Isabella
Care at Home, Inc., is a certified home health agency providing
post-acute, part-time or intermittent skilled health care and
support services to individuals over the age of 18 who reside in
Manhattan, Bronx, Brooklyn, Queens and lower Westchester
and whose needs may be relatively short-term. Services are
provided directly or through contracts with other providers.
They include:
ISABELLA GERIATRIC CENTER







Management of transitions between a hospital or nursing
facility and home
Comprehensive health assessment
Skilled nursing
Physical, occupational and speech therapy
Social work services
Nutrition counseling
Supplemental assistance with home care and personal care
Ninety-one clients had been admitted to the program as of
the first quarter of 2015. Clients typically stay in the program
for four to six weeks.
Home Health Program: Isabella’s health home program
provides care management services to over 130 Medicaid
beneficiaries with complex chronic conditions who are enrolled
in two New York State Department of Health-designated Lead
Health Home Programs. The program is designed to manage
clients’ health conditions and prevent hospital admissions and
the overuse of Emergency Room (ER) services.
The home health program began in 2012 as a Medicaidfunded operation. Today, five care coordinators serve 132
clients. In addition to providing care coordination services,
the home health program links clients to doctors and other
providers in the community. The care coordinators develop,
review and update a care plan for each client every six months.
Care Management Services: Isabella’s Care Management
Services program provides services to more than 650 members
of managed long-term care programs. The following care
management services are provided by a team of health care
professionals led by an RN or social worker, as appropriate:

Pre-enrollment assessments
Coordination of services
 Authorizations for changes/additions to care
 Communication with physicians, medical professionals
and family members, as needed
 Assurance of continuity of care throughout the health care
system.

Upper Manhattan Partnership for Senior Independence:
Isabella is a founder and leading partner of the Upper
Manhattan Partnership for Senior Independence (UMPSI), a
consortium of eight community service providers in Northern
Manhattan. Social workers in the UMPSI Program provide
free, service-specific case management to older adults living
in Washington Heights, Inwood and Central or West Harlem.
UMPSI connects older adults with meal, transportation, social
work, wellness, benefits enrollment, and other services.
Isabella Senior Resource Center: Founded in 2004, the Isabella
Senior Resource Center provides information about health care
services and insurance, and assistance with benefits enrollment,
to older adults and their caregivers.
The Institute for Older Adults: Established in conjunction with
the 1995 White House Conference on Aging,13 the Institute for
Older Adults provides free education, counseling, health, wellness
and exercise programs to approximately 4,000 New Yorkers over
the age of 50. The institute offers a 50+ Club and a Walking Works
Wonders program that provides free exercise classes to more than
500 community residents.
Partnerships
Isabella has a long history of working with community partners to
meet the needs of older adults. It is a member of the Washington
Heights and Inwood Council on Aging (WHICOA), a partnership
organization through which more than 40 community
organizations advocate and provide resources and services for
more than 28,000 older adults and their informal caregivers
each year. Isabella’s Senior Resource Center, UMPSI and case
management programs often refer clients to the services of other
WHICOA members.
Isabella has also become a generous benefactor to neighboring
not-for-profit organizations in Northern Manhattan. For example,
the organization offers not-for-profit organizations and local
public schools free use of its meeting space so they can carry out
education initiatives.
Overall, Isabella has an outstanding relationship with its
community. However, the recent expansion process has strained
some of those ties. For example, Isabella Adult Day Health Care
initially sought to recruit clients from local senior centers that
provide social activities and recreation but not health care.
Fearing that they would lose clients to Isabella’s new program,
the senior centers restricted the organization’s access to senior
center clients. As a result, Isabella initially had trouble building
its daily census for the adult day program. Despite early struggles,
the adult day health center has become an important and wellrespected program among Isabella’s WHICOA partners, which
include several senior centers.
Isabella has also recently partnered with other providers
through the DSRIP program. These partners include:

Mt. Sinai Health System
New York Presbyterian Health & Hospitals Corporation
 Advocacy Community Partners, a consortium of area
physicians

Isabella may consider forming additional partnerships as it
seeks to remain financially independent and to define and pursue
its community-oriented mission.
Marketing
Marketing efforts for most of Isabella’s service lines are centrally
coordinated. These efforts once were focused on recruiting older
adults from the community by:


Conducting direct mail campaigns
Talking with older adults at health fairs, senior centers,
doctor’s offices and clinics
Sodexo • IAHSA • LeadingAge | 35
ISABELLA GERIATRIC CENTER

Purchasing print and radio advertising in English and
Spanish
 Seeking media coverage from local televisions stations
The Spanish radio advertisements and direct mail campaigns
were particularly effective at engaging a local immigrant client
base.
Television and radio continue to be important vehicles for
Isabella’s marketing. However, most of the marketing team’s
efforts currently focus on social media and Isabella’s website.
The marketing team places ads on Facebook and Google+ and
maintains an active Twitter account. It also monitors these
outlets multiple times a day to ensure that they are enhancing
Isabella’s reputation.
The marketing team responds promptly and courteously
to any concerns posted on social media. The team also
demonstrates publicly that Isabella is investigating any
complaints. In cases where complaints are unfounded, the
team contacts the social media outlet where the complaint was
aired and urges that outlet to remove the inaccurate material.
The marketing team is still determining the best strategies for
harnessing the power of social media marketing.
Members of Isabella’s marketing staff have learned to make
use of the buzzwords that community members prefer to hear
during discussions of aged care services. For example, “mental
health” services tend to carry a stigma among Latino clients,
but these clients will use “wellness” services that incorporate
the same approaches. Over time, Isabella has developed a
language with which the community is very comfortable.
The re-emergence of managed care plans as dominant payers
for home and community-based services has necessitated
changes in Isabella’s marketing strategy. For example, the
management of Isabella’s adult day health program taps
into the managed care market by raising its profile with
physicians, eldercare attorneys, geriatric care managers and
other stakeholders who refer older adults to its services.
These strategies partially overlap with efforts to market the
organization’s residential services, which depend on the same
referral sources.
Members of Isabella’s marketing
staff make use of the buzzwords
that community members prefer
to hear during discussions of
aged care services.
In the process of developing the NORC programs, Isabella
surveyed building residents, conducted a community needs
assessment, and carried out grassroots marketing, such as
door-to-door advertising and blood pressure screenings.
Specifically, staff members used a number of strategies to
recruit participants:
36 | Residential Provider Expansion into Home and Community-Based Services

They placed flyers under residents’ doors in 40 apartment
buildings. The flyers advertised a day when eligible residents
could visit the Isabella Senior Resource Center, complete a
survey and receive a free Red Cross emergency kit.
 They developed a database, which is continually updated
and contains information about residents who want to take
part in NORC activities and services.
 They began sending residents a calendar of NORC
activities. This calendar has evolved into a monthly
newsletter.
The NORCs now provide residents with an expanded
array of services in core program areas. An initial key to
success was staff’s ability to attract prospective clients with
healthful and delicious ethnic food that appealed to residents
of the increasingly diverse Washington Heights and Inwood
neighborhoods. Program staff serves healthful lunches at
celebratory events, and snacks during all education and
recreation programming events.
The Institute for Older Adults distributes a quarterly
newsletter containing advice about healthy aging and
information about Isabella’s programs. Every two months, 4,000
members of the institute receive postcards with information
about upcoming educational seminars, wellness and exercise
programs and trips to local cultural sites.
Sources of Reimbursement
Each of Isabella’s major services accepts the following forms of
reimbursement.
Isabella Adult Day Health Care: Medicaid managed care
plans and private pay
 Isabella Visiting Care, Inc.: Private pay and most longterm care insurance plans
 Isabella Care at Home, Inc.: Medicaid, Medicare and most
insurance plans
 NORC Services: Funded by New York City and New York
State grants
 Isabella Home Health: Medicaid
Quality Assurance
Isabella’s adult day health care program measures quality
by regularly asking families to complete annual satisfaction
surveys and by tracking how several quality indicators are
associated with specific agency initiatives.
For example, the adult day health program monitors hospital
admissions, readmissions and ER use among specific client
groups, including clients who receive mental health care. The
organization discovered that its psychological services appear to
reduce preventable hospitalizations and ER visits.
Isabella completes and monitors all assessments required by
the Centers for Medicare & Medicaid Services (CMS)14 for its
home health and home care agencies. These measures, which
are incorporated into the Home Health Compare website,
include assessments of client pain, depressive symptoms, falls,
pressure ulcers and wound management. In addition, CMS
ISABELLA GERIATRIC CENTER
Table 1. Demographic Composition of Isabella’s
Community-Based Programs
ADULT DAY CARE HEALTH CARE PROGRAM
93.4%
Hispanic
6.6%
African American
EL CORAZON NEIGHBORHOOD NORC PROGRAM
90.8%
Hispanic
4.7%
Asian
3.5%
Caucasian
1%
African American
FORT GEORGE VISTAS NORC
38%
Hispanic
35%
Caucasian
23%
African American
4%
Asian
ISABELLA CARE AT HOME
40%
Hispanic
29%
Caucasian
22%
African American
2%
Asian
7%
Unknown
ISABELLA HEALTH HOME PROGRAM
72%
Hispanic
21%
African American
5%
Caucasian
2%
Asian
required OASIS reports track clients’ progress as they receive
care. Isabella also tracks the quality of its processes, including
the accuracy and timeliness of initial assessments. Data is
submitted to CMS on a quarterly basis.
Clients receive a statement of their rights at the outset of
care. Those rights include a requirement that Isabella will
thoroughly investigate any complaints. Home health clients
also have the option to call the U.S. Department of Health
and Human Services with their complaints. Home health
and personal care aides, if implicated, provide their version
of events to the Isabella administration before there is a final
adjudication. Isabella may reassign, discipline or terminate an
aide if it is found that poor performance led to the complaint.
Isabella follows up on all incidents and keeps clients’ physicians
informed of the investigation’s progress.
Financial Implications
Isabella has experienced a decline in fee-for-service Medicaid
reimbursements at the same time that it has gained revenue
from Medicaid Managed Care and Medicare. In 2013, the
organization generated just under $127 million in revenues,
and had a $2 million surplus after making all payouts. This
compares favorably to 2012, when the organization operated at
a deficit.
Because Isabella Care at Home, Inc. started in mid-2014,
it has not yet generated a revenue gain as the program is still
in a start-up phase. Isabella Visiting Care, Inc., has improved
its contribution to the bottom line each year and is partly
responsible for the organization’s favorable financial outcomes
in 2013.
Workforce
Isabella employs approximately 1,200 people, 900 of whom
are members of SEIU 1199, the health care workers’ union in
New York. Union membership includes a variety of direct-care
workers: aides, dieticians, cooks, housekeeping staff, social
workers, therapists and others.
Initially, Isabella contracted with 10-15 home care
agencies to provide its home health and home care services.
This arrangement made it difficult to ensure quality and
maintain communication with partner agencies. To address
these difficulties, Isabella soon began hiring non-unionized
employees to staff its home care agencies. As the number of
aides grew, the 1199 SEIU union became interested in Isabella.
The organization’s aides became unionized in 2011.
Isabella’s nursing home and community-based staffs are
largely separate as a result of their relatively small number of
interactions. CNAs seldom cross from residential to home care
settings, although they may perform private-duty work on
the side, if desired. However, Isabella’s use of a shared support
staff across nursing home and home care groups increases
cohesion between these two groups of workers. Additionally,
nearly all employees across Isabella’s service lines attend the
organization’s holiday parties, summer barbeques and other
staff events.
Sodexo • IAHSA • LeadingAge | 37
ISABELLA GERIATRIC CENTER
Staff Benefits
Pay rates are determined through negotiations with the union.
Table 2 shows the current hourly pay rate for home health aides
versus CNAs, not accounting for overtime or holiday pay.
Isabella Visiting Care licensed home care agency
 650 home health aides
 Administrative staff
 Supervisors and managers
Table 2. Hourly Pay Rates for Home Health
Aides and CNAs

HOME HEALTH AIDES CERTIFIED NURSING ASSISTANTS
$10.00/hr
$16.50/hr
$11.10/hr on weekends
N/A
Isabella Care at Home certified home health agency
5 supervisors
 1 physical therapist per visit
 1 occupational therapist per visit
 1 speech therapist per visit
 4 full-time field RNs
 4 RNs per visit
Isabella Care Management Program
3 supervisors
 3 support staff
 7 care coordinators
 4 RN Assessors

Most benefits provided to union members are determined
through negotiations with the union, paid by Isabella to
the union, and distributed to workers by the union. Isabella
compensates non-unionized workers with the same pay and
benefits as unionized workers. This helps to level the playing
field for workers of both groups. Table 3 presents the benefits
that Isabella’s home health aides currently receive.
Staff Roles and Numbers by Service Line
Isabella Adult Day Health Care
 2 nurses
 1 social worker
 2 CNAs
 1 manager
 1 program assistant
 3 bus monitors
 Psychiatric nursing or other student interns
NORC Services (Latino staff members from the local
community)
 1 director
 11 staff members
 60 volunteers
Isabella Health Home
1 manager
 4 care coordinators

UMPSI Program
1 manager/director
 3 supervisors
 14 case managers
 1 administrative/intake worker

Table 3. Current Benefits for Home Health Aides
PAID TIME OFF
1 hour for every 17 hours worked
HOLIDAY PAY
$15-$20/hour
TRANSPORTATION SUBSIDIES
None, unless accompanying a client to an appointment
HEALTH INSURANCE
Isabella pays into a union-managed fund
LIFE INSURANCE
Isabella pays into a union-managed fund
PENSION
$2.54/aide/hour, through the union
TUITION REIMBURSEMENT
$2/aide/hour, through the union
SUPPLIES
Uniforms and protective gear
38 | Residential Provider Expansion into Home and Community-Based Services
ISABELLA GERIATRIC CENTER
Staff Recruitment
The human resources (HR) department at Isabella’s nursing
home hires all nursing home staff and supervisory and
management team members. Isabella Visiting Care Inc., (IVCI)
hires home health aides separately. The HR department at
IVCI also hires home health aides to meet the organization’s
contractual obligations with its partners, including hospice
programs.
The IVCI HR staff members recruit home health workers
through a variety of means:
Job fairs: HR staff members participate heavily in job fairs
with community-based organizations, the New York State
Department of Labor and other training organizations
they respect.
 Newspaper ads: The HR department places advertisements
in newspapers as needed.
 Training programs: Some aides are recruited after they
attend Isabella training programs. The HR department
selects the students who excel in the program and exhibit
an ability to work independently and responsibly.
 Word of mouth: The largest percentage of aides is
recruited through word-of-mouth recommendations
stemming from Isabella’s strong reputation in the
community. Even though Isabella does not pay
substantially more than similar employers in its area,
the organization does provide competitive pay and
comprehensive health benefits. It also supports employees
by writing letters of reference for apartments and
providing educational, personal development and other
opportunities for advancement.

IVCI recruiters prefer to hire home health aides who have
prior experience. They seek aides who feel a calling to the work,
will perform well in the home setting, can handle challenging
clients, and will maintain their professionalism in adverse
situations or perhaps even when wrongly accused. During job
interviews, recruiters ask experienced candidates to describe a
difficult situation they faced with a client, how they managed it,
and what they learned from the experience. Prospective aides
with no prior experience are presented with a difficult situation
and asked to role-play their response.
The nursing home’s HR department uses similar
interviewing techniques when recruiting candidates to
fill other home care staff positions at Isabella, including
paraprofessional coordinators. Recruiters do not require that
coordinators have prior experience in their role. Nonetheless,
recruiters have found that experience as a front-line staff
member in multiple settings often helps individuals perform
well in a coordinator role.
Required Qualifications for Aides
Nursing home-based CNAs and home health aides must meet
different requirements in order to qualify for employment
at Isabella. In addition to meeting training and certification
requirements, nursing home aides must be able to read, write
and speak English fluently, and to have a high school diploma
or a GED certificate. In contrast, home health aides are not
required to be fluent in English or to have a high school diploma
or equivalent.
Training for aides
New home health aides must attend a one-day orientation that
educates them about Isabella’s mission, history and general
operating procedures. In order to continue working at the
agency, aides are also required by New York State to undergo
12 hours of in-service training each year and to score at least
75% on annual competency exams and skills assessments
administered by Isabella Visiting Care, Inc.
Isabella offers free in-house training programs for home
health aides and CNAs. Home health aides receive 90 hours of
instruction during these training programs. This represents
15 hours more than the New York State requirement. Isabella
has come to rely on the training programs as a vehicle for
recruiting aides.
Retention of Aides
The annual turnover rate for Isabella’s CNAs is 10%. The
turnover rate for home health aides is only slightly higher,
approximately 12% per year. These rates tend to fluctuate with
economic cycles and industry trends.
Staff Satisfaction
Overall, Isabella’s home health aides find their jobs rewarding
and enjoy the independence that comes with their positions.
This satisfaction might be linked to several factors:

Isabella’s paraprofessional coordinators match home health
aides and clients based on personal traits and geographical
location, and frequently match aides to one or two clients to
whom they provide care all week every week. This practice
fosters the development of close relationships between
home health aides and their clients. It also ensures the
client’s conformity with the care plan.
 Home health aides can choose whether to continue
working with clients with whom they have been matched.
 Aides seldom lack work. Due to demand for Isabella’s
services, the paraprofessional coordinators quickly match
aides to new clients when former clients no longer need
their services.
Home health aides acknowledge several challenges associated
with their work. These include:

Developing new relationships: When working with a new
client, aides must strive to establish a unique bond with the
client that will lead to a close relationship. Aides expressed
a desire for courses that would teach them how to nurture
trusting relationships with clients.
Sodexo • IAHSA • LeadingAge | 39
ISABELLA GERIATRIC CENTER
When working with a
new client, aides must
strive to establish a
unique bond with the
client that will lead to a
close relationship.
Resistance to the care plan: Some clients may demonstrate
their resistance to following the care plan in a variety of
ways, such as not taking their medication as prescribed.
While aides are held responsible for the client’s welfare,
they lack the authority to administer medications or
provide skilled care.
 Trust issues: Clients sometimes have trust issues with
aides, falsely accusing them of actions such as stealing.
Aides must learn not to take such incidents personally.
 Family relations: Home health aides sometimes find it
challenging to interact with clients’ families, as many
families insist that Isabella aides provide care for them as
well as the client. As a result, some aides prefer to work
with clients who live alone.
in accordance with those plans. As part of their oversight
role, nurses are required to call clients every one to two
months and to make an in-home visit every six months.
Nurses are also required to make an in-person visit when
aides report that clients are not following their care plans.
 Safety concerns: Supervisors cited safety as a major issue
in their community. To ensure the safety of employees
working in violent neighborhoods, supervisors send aides
out in pairs and provide each aide with a telephone. They
also track aides’ locations using web-based software.
All care delivered by the home health aides is supervised by a
nurse. These supervisors acknowledged several challenges.


Turnover: The home care industry generally undergoes
considerable churn. Staff members jump from agency to
agency as they seek job placements that best fit their needs.
This creates considerable stress for supervisors.
 Staff assignments: Isabella does not reimburse home
health aides for their travel expenses or travel time. As a
result, aides do not want to work outside the community in
which they live. This can make it difficult to provide care
for clients living outside the Washington Heights-Inwood
neighborhoods. It also interferes with efforts to expand
services to new geographic locations.
 Live-in requests: Supervisors find it difficult to meet the
requests of some clients for live-in aides. Home health
aides are not paid for time they spend sleeping in clients’
homes, and these aides often do not want to be away from
home overnight.
 Difficulty supervising a large workforce: Nurses supervise
many aides, and sometimes they do not take the time to
determine that the clients’ needs are being met and that
difficult clients are accepting their care plans and behaving

40 | Residential Provider Expansion into Home and Community-Based Services
Perceived Challenges
Executives and managers at Isabella highlighted three major
challenges that they have faced during the expansion process.
Effective communication: Staff members have worked
hard to maintain effective communication throughout
the organization. With over 1,200 employees in a variety
of service lines, it has sometimes been difficult to make
sure that front-line workers are adequately supervised and
supported, that nurses have followed up with clients as
needed, and that clients are being served in a manner true
to Isabella’s mission. A related challenge has been ensuring
that all staff members are adequately educated about
pertinent special topics like best practices for communitybased mental health care. Isabella has addressed this
challenge with in-service training sessions presented by
instructors who are deeply immersed in the topic area.
 Managed care: Participating in managed care plans has
complicated the task of providing the best care possible
for clients. Every six months, for example, nursing and
social workers in Isabella’s adult day health care program
must administer an evaluation that takes a minimum of
45 minutes per enrollee to complete. Moreover, a client
experiencing a new issue triggers the requirement to
complete another 45-minute, issue-specific questionnaire
to determine whether a doctor or nurse should reevaluate
the client. It can be time-consuming and challenging
ISABELLA GERIATRIC CENTER
to complete all forms that are required so that clients
with multiple health problems can be evaluated by the
appropriate clinicians.
 Staying true to mission while adapting to changes
in the health care landscape: Isabella’s mission calls
the organization to provide members of the greater
community with the services and supports they need to
age as they wish. This usually entails remaining healthy at
home for as long as possible. In cases where skilled nursing
care is required, Isabella remains committed to providing
the highest quality of care within its nursing home setting.
The organization will be challenged as it strives to meet
the needs of the community while navigating a changing
operational landscape characterized by new funding
sources, technological advancements and increased
consumer expectations.



Perceived Benefits
Isabella staff members derive satisfaction from helping the
community’s older adults age as they wish while, at the same
time, overcoming issues that they say make their work difficult.
For example, home health aides report that they derive the
greatest satisfaction from developing close ties with their clients
and helping them feel better physically and mentally. Yet, they
also report that many clients are non-compliant with their care
plans and difficult in other ways.
Similarly, adult day health program employees said
they enjoy helping clients improve their health and seeing
corresponding declines in measures such as ER use and
hospital admissions.
Managers of the NORC and case management programs
derived great satisfaction from learning about and working
with community partners to help the older adults they serve,
and making use of policy levers available to advance their
causes.
Isabella executives cited the pleasure they take in weathering
the rapidly changing health care landscape, and being able to
continue to fulfill the organization’s mission.




Lessons Learned
Isabella executives and managers offered the following
suggestions for residential organizations that are currently
expanding or considering expanding their home and
community-based services:
Home health aides report that they
derive the greatest satisfaction from
developing close ties with their
clients and helping them feel better
physically and mentally.

Hire your own aides. To facilitate effective communication
across your organization, consider hiring your own home
health aides to provide this care, and consider offering
training to ensure you have an ample supply of home health
aides you trust. When Isabella evaluated the quality of care
it was providing while contracting out services through
more than 15 home health agencies, the organization
concluded that it could provide better care with in-house
staff. This has been confirmed in subsequent evaluations.
Care for your home health aides. Provide aides with
needed services, such as promptly written letters
of recommendation if they request them. This will
help you engender loyalty among current aides and
recruit additional aides through word-of-mouth
recommendations.
Strive to attract and hire home health aides with prior
experience. Community-dwelling older adults are older,
sicker and frailer than ever before. You and your clients will
want to have dependable home health aides on staff.
Conduct practical job interviews. Present real-life
scenarios and monitor how prospective home health aides
respond. Pay attention to who “gets it” and who does not
during training sessions and orientations. Trust your
instincts in selecting the most qualified aides.
Consider creating new career paths for your workers.
Lack of growth opportunities can result in higher
turnover. Isabella created positions for a Senior CNA and a
Rehabilitation Coordinator in its nursing home. CNAs and
other aides aspire to fill these positions.
Don’t become complacent, even if your programs are
running well. The health care landscape will continue
evolving and communication breakdowns will occur. One
executive recommended that every staff member walk onto
the job each day “as if it is your first day there.” In a related
point, supervisors and executives urged their counterparts
at other organizations to “stay hands-on and involved.”
Recognize the power of food. Provide tasty food at
community events for prospective clients. They will
appreciate the extra effort you made and they will return
for future events.
Monitor social media. Social media outlets are great
marketing tools but they must be continually monitored for
complaints and negative posts. If someone posts something
negative on your site, determine whether there is any basis
for the negativity. If there is, follow it up aggressively with
an investigation and proper resolution. If there is no basis
for the comment, ask the site to clear the comment.
Additionally, home health aides at Isabella recommended
the following:
Reimburse home health aides for transportation to and
from clients’ homes. This practice will encourage aides
to accept distant assignments and to begin serving new
locations.
Sodexo • IAHSA • LeadingAge | 41
Case Study
TABITHA HEALTH CARE
LINCOLN, NEBRASKA | March 2015
Introduction
Tabitha Health Care is a not-for-profit, Lutheran organization
that delivers a comprehensive line of services to older adults
living in Southeast Nebraska. Headquartered in Lincoln,
Tabitha offers rehabilitation services, long-term care, assisted
living, affordable senior housing, and a variety of homeand community-based services. Its three nursing homes
offer palliative care, memory care, Green House living and
outpatient therapy services. Its home and community-based
services include:

Home health care, including palliative care
Non-medical home care
 Meals on Wheels
 Adult day services
 EngAGE Program, a full-service health care coordination
program

Established as an orphanage in 1886, Tabitha evolved into
a nursing home in 1890, and has since expanded to provide
older Nebraskans with a continuum of long-term services and
supports.
This study of Tabitha’s expansion into home and communitybased services was conducted through interviews with
executives at the organization.
Policy Context
Nebraska has a multitude of very specific, sometimes
conflicting and often outdated regulations governing the
delivery of long-term services and supports. These regulations
are generally written with the view that various care sectors
within the field of long-term services and supports represent
42 | Residential Provider Expansion into Home and Community-Based Services
separate industries that require their own regulations. These
regulations do not adequately address the rapidly evolving field
of long-term services and supports, or the need of providers in
that field to offer services that span the continuum of care.
The state’s complex regulatory framework has complicated
Tabitha’s efforts to provide seamless care to older Nebraskans.
Nevertheless, Tabitha has worked hard to transcend these
limitations so it can provide a full range of innovative services.
The organization has been assisted by the advocacy efforts of
LeadingAge Nebraska, a state association of not-for-profit aging
service providers.
Expansion into Home and CommunityBased Services
In 1966, Tabitha began offering home health care in the Lincoln
metropolitan area. Tabitha expanded its home health services
to other Nebraska counties in 1974, and now serves 28 counties.
The organization began offering non-medical home care in 1982
and hospice care later in the 1980s.
Tabitha’s expansion into home and community-based services
was primarily mission-driven. The organization wanted to
provide a continuum of compassionately delivered care to
more older adults, and realized that it could reach only a small
percentage of prospective clients through its residential services.
The advent of Medicare in the mid-1960s helped to advance
Tabitha’s mission by allowing the organization to reach a much
greater number of older adults living in their homes. Tabitha
launched its home health agency in 1966 to take advantage of
new Medicare reimbursements. Those reimbursements, in turn,
allowed Tabitha to meet the needs of a much larger clientele. The
organization moved into home care delivery when it saw that
many clients needed services that Medicare did not reimburse.
TABITHA HEALTH CARE
Many private-pay clients currently
make use of both services.
Despite its early reliance on
Medicare reimbursements, Tabitha
also has a long history of providing
unreimbursed, mission-based care.
This tradition continues today
through a variety of service lines,
including home and communitybased services. When Tabitha needs
money to launch new projects or
expand existing projects, it seeks help
from its own foundation, other local
foundations and private donors.
Tabitha’s expansion into home
and community-based services has
not been entirely smooth, due to
market competition, the challenges
of rural service delivery, and lack of
cooperation from other care sectors.
The organization has responded to
these circumstances by reorganizing
its service delivery scheme to make it more efficient.
For example, Tabitha initially provided home and
community-based services in northern Kansas, but pulled out
of the state once local providers began offering similar services.
Similarly, Tabitha cut back on service delivery in northern
Nebraska when Medicaid reimbursements became insufficient
to support those services.
Hospitals have also played a role in restricting Tabitha’s
expansion. For example, physicians did not strongly support
the use of hospice and home health care in David City, a city
of 3,000 residents in eastern Nebraska. Tabatha’s client base
in David City became too small to justify maintaining an
office there. Tabitha continues to provide services in the area,
however.
Tabitha originally maintained three regional offices in
Nebraska, but has cut back to two regional offices in recent
years. Five satellite offices have helped the organization serve
a large geographic area more efficiently. These satellite offices
do not have full-time staff but serve as “drop sites” where the
organization’s registered nurses (RN), therapists, certified
nursing assistants (CNA) and personal care aides (PCA) can
download client data to their laptops, pick up or return supplies,
and attend regional meetings and training sessions.
Description of the Program
Tabitha provides regulated medical home health care through
an agency called Tabitha Home Care, which was expanded in
2009 when Tabitha acquired another home health agency. The
organization delivers non-medical home care through a licensed
agency called Home Care Specialties of Tabitha.
Partnerships
Members of the Tabitha staff deliver most of the organization’s
home and community-based services. However, the
organization has formed partnerships with other agencies to
fill geographic gaps in its service delivery. For example, Tabitha
contracts out some therapy services in the northern part of the
state, and in areas that are distant from Lincoln. In addition,
the organization partners with other agencies, as needed, to fill
service delivery needs of particular clients.
Tabitha’s strongest partnership is with Bryan Health, which
operates a network of hospitals in the Lincoln metropolitan
area. Tabitha first partnered with Bryan in 1987 to provide
skilled home health care to heart transplant patients through a
program called Tabitha Bryan Special Care.
Tabitha continued to support Bryan Health after that
organization established its own home health agency and
merged with a county hospital. When Bryan Health decided to
close its home health agency in 2009, Bryan and Tabitha merged
their home health care businesses, further expanding Tabitha
Home Health. Most recently, Tabitha partnered with the Bryan
Heart Institute to ensure that patients with congestive heart
failure can safely transition from hospital to home. The goal of
the partnership is to reduce preventable rehospitalizations.
Sources of Reimbursement
Approximately half of Tabitha’s reimbursements for skilled
nursing, assisted living, and home and community-based
services come from Medicaid. The other half comes from
Medicare, the U.S. Department of Veterans Affairs (VA),
commercial insurance, private pay and charity care.
Private insurance and Medicare are the most significant
payers for home health care. Tabitha has seen large increases
in the number of clients using commercial insurance and
in the number of reimbursements it receives from Medicare
Advantage plans.
Sodexo • IAHSA • LeadingAge | 43
Timeline
1886
1890
TABITHA HEALTH CARE
Expanded to
provide shelter
to the indigent
elderly.
Founded as
an orphanage.
1909
Expanded to provide nursing
care and tuberculosis
hospital services.
1960
Role as orphanage ends.
1966
Expanded to provide certified
home health care.
1974
Expanded to provide home care.
1979
1982
Beginning of Tabitha Hospice.
Hospice becomes
Medicare-certified.
1990
Hospice expands to
neighboring counties.
1997
Tabitha home care services
expand geographically.
2001
Intergenerational service,
providing child care, begins.
44 | Residential Provider Expansion into Home and Community-Based Services
TABITHA HEALTH CARE
Approximate reimbursement figures for Tabitha’s various
agencies in 2014 include the following:
Non-medical home and personal care: Medicaid (25%)
and private pay (75%)
 Home health care: Medicare traditional or HMO plans
(81%); Medicaid traditional or HMO plans (10%), and VA,
commercial insurance or private pay (9%)
 Hospice: Medicare (88%), Medicaid (2%), commercial
insurance (7%), and VA, private pay and other sources (less
than 3%)
 Adult day services: Private pay (62%), Medicaid (13%) and
other payer sources (less than 25%)


Nutrition and lifestyle counseling
Disease management education
 Hands-on personal care, companionship and supervision

Tabitha also offers non-medical home care, including
personal care, housekeeping, errands and companionship. The
organization is currently licensed to deliver adult day services
for up to 36 individuals per day. Tabitha hopes to expand that
number to 46 clients. Currently, about 20 older adults use the
organization’s adult day services on a given day.
Tabitha offers the following services under its private-pay
model:
Admission Criteria
Tabitha’s medical models of home health care follow Medicare
admission guidelines. Before a client can receive services, a
physician must certify that the client is “homebound,” meaning
that the client finds it taxing to leave home.
The requirements for non-medical home care depend on the
payer source. Medicare does not pay for non-medical care and
private-pay clients must meet very few requirements.
Tabitha executives note that a growing number of individuals
are purchasing long-term care insurance packages. These
policyholders, who represent approximately 15% of Tabitha’s
non-medical home care clientele, face few restrictions in
accessing home care, although their plans often require them
to pay a substantial portion of care costs. Long-term care
insurance frequently covers only 10%-15% of the costs of nonmedical home care services.
Medicaid and VA clients are subject to the greatest number
of restrictions as they try to access non-medical home care
services. For example:


Services
Each year, Tabitha provides more than 1 million service hours
to clients. Its home health offerings include the following
services:







Skilled visiting nurses
Physical therapy
Occupational therapy
Speech therapy
Social work/case management, not including behavioral
health
Home health aide services
Nutrition counseling
Licensed practical nurse (LPN) visits to check blood
pressure, set up medication boxes, etc.
 Registered nurse (RN) visits
 Certified home health aide visits
 Personal care attendant visits
Figure 1. Payer Sources for Home Health Care
Medicaid Waiver clients living in Lancaster County must
be certified as needing nursing home services. This means
they must have difficulties performing more than three
activities of daily living (ADL) or have substantial cognitive
impairment. Difficulty performing instrumental activities
Figure 2. Payer Sources for Home Care
81%
Medicare
Medicare
Medicaid
Other
75%
Other
9%
20
25%
Medicaid
10%
0
0%
40
60
80
100
0
20
40
60
80
100
Sodexo • IAHSA • LeadingAge | 45
TABITHA HEALTH CARE
Figure 3. Payer Sources for Hospice
Figure 4. Payer Sources for Adult Day
Medicare/
Other
88%
Medicare
Medicaid
Medicaid
2%
13%
Other
20
62%
Private Pay
10%
0
25%
40
60
80
100
of daily living (IADL) can be cited as a contributing factor
to the need for a nursing home level of care.
 VA clients must meet the same requirements that apply
to Medicaid Waiver clients. In addition, these clients are
eligible to receive non-medical services if they require
home care while receiving hospice services, or if they have
two ADL dependencies along with more than two other
conditions, such as more than three IADL impairments,
clinical depression, or a solitary living arrangement.
Service Hours
Tabitha clients living in the Lincoln metropolitan area pay
a minimum charge for one hour of private-duty care. The
minimum charge for private-duty care is two hours elsewhere
in the state.
Intense competition for highly qualified staff in the
Lincoln area has made it challenging for Tabitha to provide
around-the-clock services when clients need them. The city’s
unemployment rate is currently only 2.4%, and competition
for workers affects all industries. Maintaining sufficient staff,
especially as the baby boomers age, will continue to be a
challenge.
Approximately 60%-70% of Tabitha’s home health and
home care clients have family caregivers, but these caregivers
are usually unable to stay with the care recipient around the
clock. Many caregivers are adult children who live out of town.
Tabitha offers respite care as a service through its private-duty,
hospice and adult day services programs. Tabitha executives
believe that respite services are underutilized due to cultural
reasons: Nebraska’s citizens believe they are “tough” and “can
take care of themselves.”
Client Demographics
Tabitha provided the following demographic descriptions of the
older adults using its varied service lines during 2014.
46 | Residential Provider Expansion into Home and Community-Based Services
0
10
20
30
40
50
60
70
80
Home health care: About 85% of home health care clients
were age 65 years or older, and more than 60% of clients were
age 75 years or older.
Hospice: Approximately 85% of hospice clients were age
65 years or older, and nearly 60% were age 75 years or older.
Just over 55% of hospice clients were female. About 97% of
hospice clients were non-white Hispanic while 3% were African
American and white Hispanic.
Home care: Tabitha was unsure about the demographic
makeup of its home care client populations.
Adult day health care: As of March 2015, 75% of adult day
clients were age 70 years or older, and 33% were age 80 years
or older. Almost half (48%) of adult day clients were female.
Almost all (99%) were white, with African Americans making
up only 1% of the client population. Almost three-quarters
(70%) had mild, moderate or severe dementia. In addition:





39% paid for services privately.
11% paid privately or with long-term care insurance.
29% were covered by the VA.
14% were covered by a Medicaid waiver program.
7% were covered by a Medicaid block grant program.
Non-medical home care clients: Tabitha did not have readily
available descriptive statistics for its non-medical home care
client population.
Financial Implications
Tabitha Home Health Care serves a 28-county area and
averages 10 referrals per day or about 300 referrals per month.
Tabitha’s Continuum Navigation division receives referrals and
incorporates them into the organization’s service lines.
The average daily census for home health is 254 clients.
Maintaining that client level requires approximately 280
referrals per month.
TABITHA HEALTH CARE
Finding the right mix of clients, payers and services is a
challenging endeavor for Tabitha. For example, a veteran
might be referred to Tabitha for occupational therapy, which is
reimbursed at $90 a visit. However, the time it takes to acquire
the referral might cost $400. Tabitha must consider these
factors when calculating potential revenue.
Revenues from Tabitha’s hospice services are lower than
hospice-related revenues that providers in other regions of the
country report. Tabitha executives attribute lower revenues to a
lack of comfort with hospice among Nebraska physicians. As a
result, Tabitha’s average hospice stay is a very short 14-21 days.
Tabitha executives believe that the quality of care at the end of
life could be improved if Nebraska doctors would initiate endof-life conversations with their dying patients earlier in their
illness.
Quality Oversight
There are two layers of quality assurance at Tabitha.
External: Tabitha engages in federally required quality
assurance programs that are managed by the Centers
for Medicare & Medicaid Services14 (CMS). Internal
quality boards evaluate the CMS-mandated data to track
the organization’s accountability and progress toward
achieving goals.
 Internal: For the last three years, Tabitha’s corporate office
has evaluated quality across all of the organization’s service
lines to provide a broad view of how Tabitha is performing
and how it might improve. An internal Continuum Quality
Group meets quarterly to determine how the organization’s
different service lines impact its overall quality and to
identify advantages and disadvantages of different services
for clients receiving different levels of care. The group also
evaluates the results of analyses and surveys conducted
by outside firms. For example, SHP Consulting conducts
data analytics and benchmarking for the hospice and
home health care service lines. My InnerView conducts
satisfaction surveys with adult day health clients. Tabitha
evaluates its own private-duty home care service line.

An internal Continuum Quality
Group meets quarterly to
determine how the organization’s
different service lines impact its
overall quality and to identify
advantages and disadvantages
of different services for clients
receiving different levels of care.
Workforce
Nurses and therapists provide many of Tabitha’s home health
services. In addition, Tabitha staffs its home health and home
care agencies with CNAs and PCAs. A strong CNA pool of
60-70 full-time aides and approximately 100 part-time aides
delivers private-duty care. The organization tries to hire home
care aides from the communities they will be serving.
Frontline staff members delivering Tabitha’s home and
community-based services provide clients with private-duty
care and extended-hour care ranging from one to 24 hours.
Figure 5 shows Tabitha’s 2014 full-time and part-time staffing
levels by role. All full-time CNAs, PCAs, therapists and nurses
receive full benefits, including paid time off, health insurance,
life insurance (if desired) and dental and vision benefits (if
desired).
Tabitha has found that aides, therapists and nurses prefer
working in either a residential setting or in clients’ homes, but
not usually both. For this reason, the organization maintains
separate direct-care workforces for its nursing home and
assisted living settings, and its home and community-based
services. In contrast, these business lines share corporate,
marketing, information technology and case management staff.
Certification and Training
Home health aides currently undergo the standard Medicare
certification process, which includes a 75-hour course plus 12
additional hours of training. PCAs receive initial competency
training provided by the corporate office. Staff members also
receive ongoing, in-service training. In 2014, Tabitha began
the practice of sending two PCAs to clients’ homes. The buddy
system is designed to familiarize new aides with their clients,
ensure quality, and facilitate continuity of care in the event that
one aide is not available.
Organizational Culture
When Tabitha began offering home health care,
reimbursements for the new services were plentiful and the
nascent home and community-based services line was growing
quickly. The organization’s nursing home served long-stay
clients almost exclusively, and clients seldom transitioned from
the nursing home to home care.
These factors helped to create a disconnect between Tabitha’s
nursing home and home health care staff. Members of the home
care staff considered themselves to be “at the top of the heap”
and regarded the nursing home’s staff with some disdain.
Tabitha executives knew that these attitudes would make it
more difficult to create a seamless experience for clients across
the continuum, particularly as the nursing home began serving
more short-stay clients. Nurses and aides from the different
settings would need to work together to coordinate care
transitions as clients moved from short-stay nursing to their
homes with the support of Tabitha’s home health care services.
The service lines still have a tendency to compete with one
another. For instance, members of home health care staff may
Sodexo • IAHSA • LeadingAge | 47
TABITHA HEALTH CARE
Figure 5. Full-Time and Part-Time Staffing by Role
57%
CNA
61%
3%
PCA
Clinical
Manager
11%
14%
0%
12%
10%
Therapist
46%
RN
24%
LPN
Therapy
Aides
3%
7%
3%
0%
want to keep a client in need of hospice care on their roster and
continue trying to meet the client’s needs at home. Tabitha’s
management works to mitigate employees’ competitive urges by
continually reinforcing the principle that clients’ needs come
first. This effort has helped Tabitha’s management and staff work
together more effectively.
Although the frontline staff in Tabitha’s different service lines
remains largely separate, the organization asks some nurses and
aides to be available to provide 24/7 emergency services when
other staff members are not available. This request, which most
often affects skilled nurses who are needed for home health
care, is not easy for staff members who prefer to work in their
own settings.
Tabitha executives acknowledge that these coverage issues
could be resolved if the organization maintained a float pool
of staff that could serve in any capacity. However, creating
this pool would require different hiring procedures, different
management styles and a more unified organizational culture.
Perceived Challenges
Tabitha has faced several major challenges, in addition to the
workforce challenges described above. These challenges include:

Rural service delivery: Nebraska’s rural nature has forced
Tabitha to rethink some of its expansion plans for areas
that are distant from Lincoln. The organization still finds
it challenging to maintain good financial returns on rural
care when its staff must spend hours driving long distances
to serve clients. In addition, many rural clients want to
48 | Residential Provider Expansion into Home and Community-Based Services
Full-time





Part-time
receive care from local, familiar home health and home
care aides who they might see in church and at the grocery
store. Tabitha has made an effort to hire local home care
staff so its services remain competitive.
Market competition for clients: While providing services
in Kansas, Tabitha was crowded out of the market by a new
group of local providers.
Market competition for staff: The proliferation of
providers has made it challenging for Tabitha to fill
top staff positions across the organization. If this trend
continues, outstanding staff members will be spread thinly
across many organizations and there may eventually be no
excellent providers in the market.
Regulatory challenges: Tabitha has been affected by the
multitude of seemingly unnecessary state regulations that
have proliferated over the past two years. For instance,
while building a new hospice center located only 900 feet
from its already-certified and licensed skilled nursing
home, Tabitha was required by a newly changed state
statute to obtain separate certification and licensing.
Fluctuating client base and revenues: Maintaining the
right case mix with a constantly fluctuating client base
has been challenging for Tabitha. Fluctuating revenue
levels have also challenged the organization as it works
with different payers and experiences unpredictable
reimbursement delays.
Required documentation: A physician is required to
authorize all home health services. This requirement
TABITHA HEALTH CARE
creates so much paperwork that Tabitha employs a fulltime assistant to ensure that the organization has the
documentation it needs to receive payment for physicianordered services. Tabitha also conducts regular educational
sessions with physicians to ensure that every referral to
home health care is accompanied by the signed document.
Perceived Benefits
Tabitha executives report that home and community-based
services have enhanced the organization’s ability to fulfill
its mission by providing high quality care across clients’
continuum of needs.
Executives say they feel extremely gratified to have developed
a loyal client base that turns to Tabitha for all its care needs.
An adult child might seek progressively higher levels of care
for a parent and then turn to Tabitha decades later to care for
a spouse. Providing home and community-based services has
been especially satisfying because it allows Tabitha to develop
relationships with clients earlier in the aging process.
Tabitha pioneered the use of case managers, now called
Continuum Navigators, in its region in the 1990s. These
employees quickly became central to the organization’s mission
to provide care across service lines and throughout the aging
process. Families appreciate knowing they can turn to the same
organization, and the same continuum navigators, over a span
of years. Over time, this appreciation has grown into a strong
trust in Tabitha and the services it provides.
Outcomes
Tabitha regularly evaluates its service lines and maintains
dashboards and scorecards that track key measures, such as
rehospitalizations. On average, Tabitha’s clients are discharged
home more frequently, and rehospitalized less often, than their
peers at the city, county or state levels.
Lessons Learned
Throughout its expansion into home and community-based
services, Tabitha has learned several lessons, including the
following:
Put the client first. Think of each client initially as a “blank
page” whose needs and wishes you will identify and then
meet. Do not make assumptions at the outset about what
would be best for a given client.
 Maintain a diverse menu of services. Design these services
to fill the variety of care needs that emerge from early in the
aging process to the end of life. Partner with organizations
that can fill specific gaps in your services.
 Pick partners who align with your business and
philosophy. Make sure your partners provide the services
you need and that your “business chemistry” is compatible.
 Operate above margin. Make sure that at least one of your
service lines is operating well above its margin. This will
allow you to rebalance your other services, as needed, in
the face of continually changing services, regulations and
reimbursements. 
Home and communitybased services
have enhanced the
organization’s ability
to fulfill its mission by
providing high quality
care across clients’
continuum of needs.
Sodexo • IAHSA • LeadingAge | 49
CONTINUING
CARE RETIREMENT
COMMUNITIES
50 | Residential Provider Expansion into Home and Community-Based Services
Case Study
BALLYCARA VILLAGE
OF FRIENDS
SCARBOROUGH, QUEENSLAND | March 2015
Introduction
BallyCara Village of Friends (BallyCara) is a not-for-profit
provider of aged care located on the eastern coast of Australia,
about 44 kilometers from Brisbane. The organization is owned
and operated by the Queensland Hibernian Friendly Society, a
“public benevolent institution that serves the community and
disadvantaged people.”
Since 1983, BallyCara has been providing independent living,
assisted living and nursing home care to older adults living
on its Scarborough campus. Older adults living in their own
homes could not access BallyCara’s services until 2011, when
the organization’s senior management team decided to enhance
its mission by providing services to consumers living in the
community.
This case study describes BallyCara’s expansion into home
and community-based services through one private-pay and
two government-subsidized service programs. The study was
conducted through interviews with staff from the BallyCara
Village of Friends.
Policy Context
Australia is currently reforming its aged care systems in an
effort to create a better and more sustainable system and to
provide older adults with more choice and better access to
services. More than half of Australians who receive aged care
services receive that support at home.15
As part of its reform effort, the government created the Home
and Community Care (HACC) program, which is designed
for older people who are able to live on their own, and do not
require higher levels of care at home. Another government
initiative called the Home Care Packages Program, serves
individuals with complex chronic conditions who are eligible
for residential aged care but want to age in the community.
Home Care Packages
In 2013, the Australian government replaced three separate
programs that previously provided government-funded
aged care services with the Home Care Packages Program.
The new program offers coordinated packages of services
that are tailored to meet the specific needs of individuals.
The government allocates home health and community
aged care packages to older adults based on their level of
need, as determined through assessments conducted by the
government’s Aged Care Assessment Team.
The government funds the Home Care Packages Program and
approves the providers who will deliver packaged services. The
program has required a hefty investment of government funds: $1.2
billion (AUD) in 2013-2014 and $1.3 billion (AUD) in 2014-2015.
Aged care organizations are approved to provide services
through the Home Care Packages Program and they must
participate in an annual bidding process called the Aged Care
Allocation Rounds. The bidding process enables prospective and
existing approved providers of aged care to apply for Australian
Government funded age home care packages, and/or financial
assistance in the form of a capital grant. The program is
designed to control the supply of packages by allocating a fixed
number of packages to various regions throughout the country.
The Home Care Package bidding process is extremely
competitive. There is no guarantee that an approved
Sodexo • IAHSA • LeadingAge | 51
BALLYCARA VILLAGE OF FRIENDS
organization will actually receive an allocation of packaged
services that it can provide directly to consumers. If an
approved provider does not receive an allocation, it can only
deliver packaged services in partnership with an approved
provider that received a package allocation.
The Home Care Packages Program will change significantly
in July 2015 when all packages must be delivered in accordance
with a Consumer Directed Care (CDC) framework. The
Australian Government is making this change because it
believes that consumer-directed care represents a more
sustainable and affordable model.
The CDC framework is designed to empower consumers by
allowing them to decide what types of care and services they
will access, and how, when and by whom those services will
be delivered. In addition, the CDC model gives consumers a
personalized budget containing information about available
funding and how the money is being spent. Providers can help
consumers develop their care plans and individualized budgets.
All Home Care Package providers will have to convert
existing packages to the new CDC framework by July 2015,
if their services are not already consumer-directed. This will
involve changing long-standing delivery systems and staffing
patterns.
BallyCara will have less trouble than most providers in
adapting to the new requirements because the organization
designed its service model for the Home Care Packages
Program knowing that the CDC framework for service delivery
would be required.
Reimbursement Rates
Government reimbursement rates for home care are fairly
consistent. However, the number of Home Care Package
allocations can fluctuate. Until now, providers that have
longstanding relationships with government agencies have had
the advantage when the packages are allocated. It remains to be
seen how pending legislative changes to the aged care system
will impact this arrangement.
Expansion to Home and CommunityBased Services
In 2011, BallyCara’s senior management team began exploring
the possibility of enhancing the organization’s mission by
providing services to consumers living in the community.
Community care services became part of BallyCara’s strategic
plan after the organization’s management team spent several
years discussing possible service models.
BallyCara’s expansion into home and community-based
services was spurred, in part, by the government’s new
emphasis on home care, and its willingness to fund that care
through new and expanded programs, including governmentsubsidized Home Care Packages. BallyCara’s leaders felt that
the organization could leverage increased government support
to fulfill its mission to reach more clients in the community
and become a “one-stop shop” for consumers.
52 | Residential Provider Expansion into Home and Community-Based Services
The BallyCara management team had little hesitation about
diversifying the organization’s service lines, given the potential
benefits they anticipated. However, some BallyCara board
members expressed concern about how the community-based
service line would impact the organization’s residential options.
These board members worried that older adults would not use
BallyCara’s residential care options if they could access services
and supports while staying in their own homes. Board members
had several other questions about the proposed community
services program:

How would BallyCara implement the expansion program?
What level of investment would be required to build the
service line’s infrastructure and workforce?
 How would the new program impact BallyCara’s existing
residential services business model?
 How would the new service line affect BallyCara’s brand
identity?

The decision to diversify BallyCara’s service line was made
jointly by the board of directors and management, with the
ultimate decision coming from the board of directors.
The management team—including the chief executive officer,
director of aged care, and quality manager—focused on integrating
BallyCara’s new home care model with the organization’s other
services so an expansion into home and community-based services
would not compromise existing services. This integration process
involved the development of new operating systems and new
staffing models for the at-home programs.
BallyCara launched its home and community-based services
program, called BallyCara Community Care, in October 2013.
The rollout had several steps:

During the first phase of the expansion, BallyCara
Community Care offered social and personal care services
to on-campus residents, but not to individuals living in
the external community. All the on-campus services were
private-pay.
 Next, the program offered short-term housing and support
to disadvantaged people living in the external community.
These services were provided through outside funding or
other charitable organizations.
 BallyCara then applied for and received permission from
the Australian government’s Department of Social Services
to launch the Home and Community Care (HACC)
program. HACC provides at-home services to older people
who are able to live on their own, and do not require higher
levels of care at home. BallyCara launched HACC in 2014.
 BallyCara received approval to participate in the Home
Care Packages Program, which serves individuals with
complex chronic conditions who are eligible for residential
aged care but want to age in the community. The
organization is now waiting to receive allocations from the
government so it can begin directly delivering Home Care
Packages to older adults living in its community without
working with a partner provider.
Timeline
BALLYCARA VILLAGE OF FRIENDS
1983
Began as a
retirement
community in
Queensland,
Australia.
2011
Decision by management
team to provide services
in the community.
2013
Added home care:
Social and personal
care services to clients
residing on the campus.
2014
Received government
approval for
the Home and
Community Care
program, but still
awaits allocation
from the government
to administer
the program
independently.
Sodexo • IAHSA • LeadingAge | 53
BALLYCARA VILLAGE OF FRIENDS
BallyCara Community Care faced some initial challenges as
it rolled out its community services program. Key challenges
were associated with the need to:



Invest in the community services program before the
program generated revenues
 Hire qualified staff members who had experience in the
home environment and understood the relationship
between the residential and home care models
 Brand the organization as both a community care provider
and a residential care provider
Description of the Program
The BallyCara board of directors approved a strategic plan that
included the development of three community care services for
BallyCara:

A private-pay Personal Services program
The Home and Community Care (HACC) program
 The Home Care Packages Program

Services are generally provided Monday through Friday.
BallyCara offers limited evening and weekend services. The
organization provides around-the-clock coverage to residents on its
campus through an emergency call system. On-site staff members
respond to the calls and provide medical attention as required.
Personal Services
BallyCara’s fee-for-service Personal Services Program is
customized to the individual consumer and offers more
control, choice and flexibility than government-subsidized
programs. BallyCara offers a range of home and communitybased services through this program:
54 | Residential Provider Expansion into Home and Community-Based Services





Personal care, including assistance with showering,
dressing and medication monitoring
Domestic assistance, including house cleaning and laundry
assistance
Home maintenance, including minor general repair and
care of the house or yard
Home modifications like alarms, ramps and support rails
Transportation to attend appointments, shop and engage in
social activities
Center-based adult day programs offering social activities
in a community setting
Social support, such as offering companionship or taking
people shopping or to appointments
Home and Community Care (HACC)
Providers in the government-subsidized HACC program
assess consumers to ensure they are eligible for the program’s
specific set of approved services. The non-clinical (non-medical)
services offered through HACC include:

Domestic assistance, including help with routine household
tasks like gardening or maintenance
 Social supports, including transportation to social activities
and shopping, which help older people maintain their
independence, health and well-being
 Center-based adult day programs, including small group
activities that take place either every day or several times a
week
BallyCara may be able to provide additional services to
HACC clients, as needed. Those services would be paid for with
HACC funds for a short period of time or through the privatepay Personal Services program.
BALLYCARA VILLAGE OF FRIENDS
Home Care Packages
The government-subsidized Home Care Packages Program
offers support services and case management services to
support a full range of care needs, from basic to high-level.
The coordinated package of services includes:

Personal care, including help with showering or bathing,
dressing and mobility
 Support services, such as washing and ironing; house
cleaning, gardening, basic home maintenance, home
modifications related to the care needs; and transportation
for shopping, medical appointments and social activities
 Allied health supports, including physiotherapy,
occupational therapy, physical therapy, services of a
dietitian, and hearing and vision services
Four levels of Home Care Packages meet different ranges
of care needs:

Level 1: Basic care needs
Level 2: Low-level care needs
 Level 3: Intermediate care needs
 Level 4: High-level care needs

Older adults receiving care under a Home Care Package sign
a Home Care Agreement with their home care provider. The
agreement identifies the care and services the consumer will
receive. The government makes payments directly to the home
care provider. The provider spends these funds on the service
package described in the Home Care Agreement.
Funding Challenges: BallyCara had an opportunity to obtain
funding for the Home Care Packages Program in 2013 when
the Australian government opened up the bidding process
in an effort to expand the availability of home care services
throughout the country. In prior years, it was difficult for new
providers to enter the program.
The Australian government’s Department of Social Services
has recognized BallyCara as an approved provider of Home
Care Packages since 2014. However, BallyCara cannot deliver
Home Care Package services directly to older consumers
because it has been unsuccessful in obtaining Home Care
Package allocations during the annual Aged Care Allocation
Rounds. The organization plans to apply for an allocation
during the next bidding round. In the meantime, BallyCara
Community Care provides home care and case management
services through formal agreements with other approved Home
Care Package providers that have received the government
allocations in its region.
BallyCara may have a new opportunity to deliver Home Care
Package services in 2017 if the government approves a legislative
proposal allowing approved providers to deliver Home Care
Package services without the need for an allocation. There is no
certainty that the provision will be approved. If it is, it could
open new opportunities for BallyCara.
Clinical Care
BallyCara focuses exclusively on providing non-clinical care
in the community. If BallyCara receives an allocation of
Home Care Packages, it may begin providing the clinical care
component of the Home Care Packages Program. The move
into home health care would bring with it more government
oversight of service provision and staff training, and would
require BallyCara to extend its service hours to include evenings
and weekends. These requirements would add to the cost of
providing clinical care services.
Partnerships
The Personal Services and HACC programs are operated
as service lines under the umbrella of BallyCara’s parent
organization and use in-house staff. BallyCara also works as a
subcontractor for a local Home Care Package provider that has
received a government allocation.
BallyCara also has an arrangement with a community
organization that serves homeless older adults. BallyCara
helps the organization’s clients transition to different levels
of housing, depending on their needs. For example, the
organization might help some clients move to a nursing home
or receive palliative care.
In addition to these “formal agreements” with external
agencies, BallyCara has less formal arrangements with referral
groups and health networks. These collaborations create
important connections that will eventually give BallyCara the
opportunity to deliver services in different regions, to serve clients
of other residential care providers, and to identify educators who
can train BallyCara staff to provide direct care to clients.
Sodexo • IAHSA • LeadingAge | 55
BALLYCARA VILLAGE OF FRIENDS
Sources of Reimbursement
BallyCara’s Personal Services program is entirely private pay.
The organization receives federal reimbursements from the
Department of Social Services (Aged Care) for services delivered
through the HACC and Home Care Packages Program.
Even though the Australian government subsidizes the
HACC and Home Care Packages Program, these programs still
require that care recipients pay something for the services they
receive. Most clients in the HACC program pay a small fee for
each service they receive. The fee amount, agreed upon by the
individual and the service provider, depends on the individual’s
income and the type and number of services requested. This fee
helps cover staffing and equipment costs.
Recipients of Home Care Package services also pay a basic fee.
The fee might be calculated as a percentage (17.5%) of the basic
Age Pension for an individual. Low-income clients may pay an
income-tested care fee featuring annual and lifetime caps. Once
consumers reach this cap, they cannot be asked to pay any more
income-tested care fees.
Eligibility
Personal Services: The Personal Services program does not
have any eligibility requirements.
HAAC: The HACC program requires an assessment by the
service provider. In addition, eligible consumers must:






Be age 65 or older (50 years and over for Aboriginals and
Torres Strait Islanders)
Live in the community
Have difficulty performing activities of daily living
(showering, house cleaning, meal preparation, shopping,
etc.) due to functional limitation
Demonstrate that their capacity to live independently in the
community is at risk
Not have access to a Home Care Package
Not live permanently in a residential care setting
Home Care Packages: Access to the Home Care Packages
Program requires an assessment by a member of the Aged
Care Assessment Team to determine if the individual is eligible
to receive government-subsidized aged care services. The
assessment for an approved individual will identify the types
of services the individual can receive. The assessment also will
determine which level of package the individual will receive.
Clientele
BallyCara Community Care serves approximately 200 clients
across all service lines and averages 428 service hours each
month. The number of clients has increased significantly over
the past year, mostly because of BallyCara’s participation in the
HACC program.
BallyCara added 100 clients in 2014 and expects similar gains
over the next 12 months. Half (55%) to three-quarters (70%) of
BallyCara Community Care clients come through the HACC
program while only about 10% of clients come through the Home
56 | Residential Provider Expansion into Home and Community-Based Services
Care Packages Program. The remainder of BallyCara’s clients
(20%) receives services through the Personal Services program.
Client demographics are varied. The average age of all clients
receiving some type of home and community-based services is
83. Seventy percent of these clients are women.
Clients in the Personal Services program have the financial
capacity to pay for services. In contrast, HACC clients represent
a lower socio-economic group and have greater demographic
diversity.
BallyCara staff members were not sure what percentage of
clients has access to family caregivers. The majority of clients
either does not have a caregiver or has a family member
accessing services on behalf of the individual.
Quality Assurance
BallyCara Community Care has a robust quality assurance
system to ensure that its community services programs meet the
highest standards. As BallyCara expands into other regions, the
organization will need to enhance its systems to ensure quality
in the wider geographical area.
The organization’s quality improvement initiatives drive
continuous improvements of its programs. Those initiatives
include the following:

The organization’s technology infrastructure allows staff
members to obtain and update information about clients.
This improves communication about the individual among
staff members.
 A committee of the organization’s leaders reviews data
from client and family feedback surveys and manages the
process for acting on the findings.
 Support advisors coordinate and assist aides who work in
clients’ homes. These advisors also interact with clients to
ensure they are satisfied with their services.
 Management supervisors, who oversee the support
advisors, seek feedback from clients to ensure their
satisfaction with services and staff performance.
Advertising/Promoting Services in the Community
BallyCara has stepped up the promotion of its services in the
past year. The organization works with private health networks
to gain referrals and to drive collaboration and innovation that
will improve health and wellness outcomes in the community.
BallyCara faces ongoing challenges as it tries to engage with
and educate consumers. For example, educating consumers about
the Consumer Directed Care (CDC) framework is critical to
enhancing consumer understanding of the Home Care Packages
Program. The Australian Government has relied on its website
to communicate with consumers about CDC. However, many
consumers still do not understand the new framework. BallyCara
holds information sessions for consumers and has initiated oneon-one discussions to educate consumers about this new feature
of the Home Care Packages Program. The organization’s goal is
to inform consumers about the services available to them and
help consumers gain access to those services.
BALLYCARA VILLAGE OF FRIENDS
BallyCara relies primarily on its own staff and rarely uses
contract staff. Contract staff, when needed, are hired on a shortterm basis to fill a staff shortage related to an aide’s absence or
an unexpected growth in the number of clients. Aides receive
personal and professional development opportunities as their
primary benefit.
The supervisory team includes a full-time manager and two
part-time support advisors. The organization is in the process
of establishing a supervisory role for advisors. The advisors may
provide onsite monitoring of aides twice a year while introducing
mechanisms for clients to contact the support advisor and
manager with questions or concerns.
The team is exploring the pros and cons of placing an advisor
in a client’s home for the sole purpose of monitoring the aide and
assuring quality staff performance. Team members are looking at
ways to support quality through other avenues, such as training
sessions and regular team meetings.
BallyCara Community Care
strives to provide a single point
of contact for clients as a way to
establish trusting relationships
between aides and clients and
allow aides to understand the
needs and preferences of clients.
Financial Implications
Initially, BallyCara did not receive government funding for
services it provided and was required to make an investment
of about $200,000 (AUD) in its community care service
line. Government funding offset a similar investment by the
organization in the second year of the program.
During the last few years, BallyCara’s investment has
increased to $400,000 (AUD). Funding from the Australian
Government offset those costs.
BallyCara’s community care services were operating at a
surplus within a year after their launch. The organization’s
leaders are satisfied with how the programs are tracking in
terms of revenue generation. They anticipate the private-pay
Personal Services Program will continue to grow.
Workforce
BallyCara Community Care employs eight permanent,
part-time aides and three supervisors. Some employees are
unionized, but the majority are non-union workers. The unions
have little impact on the organization.
Staffing Across Service Lines
Aides and supervisors serve both on-campus residents and
off-campus clients who require at-home services. BallyCara
Community Care strives to provide a single point of contact
for clients as a way to establish trusting relationships between
aides and clients and allow aides to understand the needs and
preferences of clients.
Aides work either in the residential setting or the home care
setting and do not move across settings. Most of the community
services staff have been new hires and were not redeployed from
BallyCara’s residential setting. However, two staff members who
were hired from the residential care setting have been reliable and
strong performers.
BallyCara’s community services and residential care business
lines each have their own management teams, but share corporate
staff, including staff working in quality management, financial
management, billing, human resources, and information
technology.
Staff Training
BallyCara seeks to maintain the competence of staff through
in-house trainings. The organization holds regular meetings
with senior staff and regular training for aides. New legislative
requirements to incorporate a Consumer-Directed Care (CDC)
framework into the Home Care Packages Program will require
intense training so staff members can conform to the CDC
requirements, manage client agreements and understand how to
deliver consumer-directed care.
BallyCara’s residential staff and home care staff have numerous
opportunities to interact and engage with each other. Interviewees
report that interactions between managers of both business lines
are more effective than interactions among direct-care staff.
Managers from both service lines connect with one another during
senior staff and organization-wide meetings. Aides from home
care and residential care interact during an initial orientation
session, mandatory annual training sessions, and all-staff meetings.
BallyCara continues to develop opportunities for staff members to
engage and share information.
Sodexo • IAHSA • LeadingAge | 57
BALLYCARA VILLAGE OF FRIENDS
Workforce Challenges
BallyCara Community Care’s key workforce challenge has
been recruiting the “right” people and providing enough work
hours to attract and retain new staff. Home care aides must
be comfortable working independently in a person’s home
and with less supervision. Similarly, supervisors must be able
to trust aides who work most of their hours without direct
oversight. Other workforce challenges include the following:
Need for a variety of skills: The work of aides is primarily
domestic in nature. BallyCara is able to find prospective
workers who have the qualifications for this domestic work.
However, as BallyCara Community Care begins delivering
higher levels of care to people in the community, it will
need staff members who can provide clinical and personal
care, perform domestic household chores and provide
clients with social interaction.
 Offering challenging work: Most aides would prefer to
carry out work tasks that are more challenging than the
domestic work they currently perform. These staff members
would like to perform clinical care. However, this is not
currently allowed.
 Scheduling: It is important to provide staff with enough
hours to entice them to remain with the organization. This
can be challenging in the home care environment, where
schedules are often unpredictable. For example, BallyCara
Community Care may need to reduce an aide’s work hours
when a client no longer requires services or is hospitalized.

BallyCara invests significant time in the screening and
interviewing process it uses to recruit and select aides and
ensure they are a good fit for their role. The Human Resources
officer conducts the initial screening for prospective employees.
The Director of Community Services and the Community
Service Manager then conduct in-person interviews and
reference checks. Once an aide is hired, BallyCara provides
supervision and a support network for the new recruits.
Organizational Culture
Even though BallyCara’s community services program initially
blended with the parent corporation’s organizational culture,
the management team still struggled to ensure that the home
care workforce was engaged with the rest of the organization.
Team members recognized that the community care workforce
needed its own identity. The nature of home care work, which
involves less teamwork and less supervision, was different than
the nature of work for BallyCara’s residential care staff.
BallyCara decided to provide the community services team
with its own building adjacent to the main site. Home care aides
also have their own uniforms and receive recognition for their
accomplishments from BallyCara. However, BallyCara still works
to engage the home care team in the larger organization. The
differences between the home care environment and residential
care environment will continue to be a challenge as BallyCara
expands its community services program to other regions.
58 | Residential Provider Expansion into Home and Community-Based Services
For many years, BallyCara’s mission statement was based
on residential care policies and language. The BallyCara
management team rewrote the mission statement when the
organization began delivering at-home services. The new
statement references home care, and reflects the organization’s
growing range of services.
The home care management team communicates with staff
across service lines and updates them about the organization’s
work in the community and its range of services. BallyCara
uses its website and other communication tools to keep
employees informed of each service line’s activities. The
website also provides a forum where staff members can
exchange information.
Perceived Challenges
Market competition, for both private-pay and governmentfunded services, is the greatest challenge facing BallyCara as it
tries to operate and sustain its community services program.
This competition affects BallyCara on several levels:
Diversification is common: It is not uncommon for
Australian residential service providers—both not-forprofit and for-profit—to diversify their service lines by
expanding into community care services. This competition
makes it difficult to grow the BallyCara client base.
 Expansion in other geographic areas: Competition
will also be a factor if BallyCara rolls out its community
services in other regions. In order to accomplish this goal,
the organization’s executives will have to enhance internal
structures and communication platforms and identify gaps.
It will also have to find ways to establish a brand identity in
a larger geographic area.
 Allocation of Home Packages: Even though it is an
approved provider in the Home Care Packages Program,
BallyCara has not been able to obtain any of the Home
Care Packages allocated by the government. As a result, it
can only participate in the program through partnerships
with other providers.
 Balancing reimbursements: BallyCara strives to balance
its privately funded services with its government-funded
services. The organization is considering whether it
should focus on expanding its private-pay Personal
Services program. The Australian Government controls
the supply of providers in its subsidized programs and
is slow to approve eligibility for its shrinking service
packages. This suggests that consumers will need to
pay out-of-pocket for a growing number of services. In
addition, clients may receive certain types of at-home
services more conveniently from the private market than
through the government assessment and approval process.
BallyCara wants to be positioned to take advantage of
private-market opportunities that will supplement its
government-funded services.

BALLYCARA VILLAGE OF FRIENDS
By providing a range of services, BallyCara is a “one-stop shop” for
consumers seeking to meet aging-related needs.
Perceived Benefits
Despite the challenges described above, BallyCara executives
have found it beneficial and rewarding to provide community
services. These services help the organization support
more older adults and form relationships with more clients
throughout the continuum of care.
By providing a range of services, BallyCara is a “one-stop
shop” for consumers seeking to meet aging-related needs. Staff
members are familiar with the individual’s values and service
preferences. This enables BallyCara to tailor its services to the
needs of the individual.
Outcomes
BallyCara has not conducted any formal evaluations of its
programs. Its community care programs continue to grow.
These services lines allow the organization to help many more
older adults and their loved ones. As BallyCara expands into
the private market with its community services program, it has
the potential to earn revenues to support the program.
BallyCara is looking to design a system to evaluate its
community services program. The organization plans to
involve different community groups, such as families of
prospective clients and stakeholders, in this process.
Lessons Learned
BallyCara executives offer the following suggestions for
residential service providers that are considering expanding
into home and community-based services, or are beginning the
expansion process:

Establish a network. Before you put any services in place,
establish referral and partnership networks that will help
you develop and implement your plans. Networks and
referral channels are essential to building a client base.
In Australia, home care providers collaborate more than
residential providers do. Residential providers are reluctant
to work together and exchange information.
Maintain your brand identity. BallyCara executives
spent considerable time thinking about how the
organization’s dual role as a community care and
residential care provider should be presented to
consumers. They decided to reinforce the parent
corporation’s brand by clearly identifying the different
service lines that now come under the organization’s
umbrella. The management team continues to review
this strategy, particularly as the organization expands
the geographic reach of the community care program.
 Keep staff informed. Educate and communicate with
staff early in the expansion process. Staff members
should be informed about what home care is and how an
expansion into home and community-based services will
benefit the organization, its workforce and community.
 Educate consumers. Host well-run informational
sessions for consumers and back up oral presentations
with written materials. Web-based advertising is less
useful with older adults.

BallyCara executives spent
considerable time thinking about
how the organization’s dual role as
a community care and residential
care provider should be presented to
consumers. They decided to reinforce
the parent corporation’s brand by
clearly identifying the different
service lines that now come under
the organization’s umbrella.
Sodexo • IAHSA • LeadingAge | 59
Case Study
FIRST CHOICE
Virginia Mennonite Retirement Community
Bridgewater Retirement Community
Sunnyside Retirement Communities
HARRISONBURG, VIRGINIA | April 2015
Introduction
Three independently operated aging services organizations in
central Virginia have expanded their home and communitybased services by jointly purchasing an existing home health
and home care agency called First Choice.
The not-for-profit, faith-based partners include:
Virginia Mennonite Retirement Community (VMRC) is
a continuing care retirement community (CCRC) offering
independent living, assisted living, memory support
and dementia care, and a “complete living care” option
that delivers long-term care services in a “home-style
community-within-the-community.” Established in 1954, the
Harrisonburg-based VMRC also provides health services,
including a wellness center, community health center,
outpatient therapy and transitional rehabilitation care.
 Bridgewater Retirement Community (Bridgewater)
is affiliated with the Church of the Brethren and offers
independent living, assisted living, memory care and
skilled nursing care to adults 55 and older. The CCRC,
based in Bridgewater, was founded in 1965.
 Sunnyside Communities (Sunnyside) owns and operates
not-for-profit CCRCs in Harrisonburg, Martinsville
and Summit Square. Founded in 1912, the organization
offers independent living, assisted living, memory care,
health care and therapy services. It is affiliated with the
Presbyterian Church.

60 | Residential Provider Expansion into Home and Community-Based Services
VMRC and Bridgewater purchased First Choice in 2007.
Sunnyside joined the partnership in 2015.
Senior Options, a limited liability corporation associated with
Westminster-Canterbury on Chesapeake Bay in Virginia Beach,
provides technical assistance and consulting services to First
Choice. Westminster-Canterbury also operates its own home
health and hospice service in Hampton Roads, VA.
This case study describes the home and community-based
services program operated through the VMRC-BridgewaterSunnyside partnership. This study was conducted through
interviews with executives at the three CCRCs, Senior Options
and First Choice.
Policy Context
The Commonwealth of Virginia administers a certificate of
need program designed to regulate the number of beds in
hospitals and nursing homes and create a balance between the
level of need in a region and the number of providers who are
allowed to enter the market.
Home health care in Virginia is not regulated by the
commonwealth’s certificate of need program. This lack of limits
on the number of home health providers might be expected to
facilitate the process that home health providers must follow to
enter the market. However, the licensing system still experiences
delays, making it difficult for an organization to launch a home
health or home care business.
Timeline
1912
FIRST CHOICE
Sunnyside Communities
begins operations.
1954
Virginia Mennonite Retirement
Community is established.
1965
Bridgewater Retirement
Community is founded.
1977
First Choice home care and home
health agency begins operations.
Mid-2000s
2007
VMRC and Bridgewater jointly decide
to expand into home and communitybased services and work with Senior
Options to assess the best approach
to entering the market.
VMRC and Bridgewater jointly
purchase First Choice.
2015
Sunnyside joins the VMRCBridgewater joint venture.
Sodexo • IAHSA • LeadingAge | 61
FIRST CHOICE
Expansion into Home and CommunityBased Services
About a decade ago, Bridgewater and VMRC were each
considering options that would allow their organizations to
expand service delivery beyond their campuses. Even though
they were competitors, the presidents of both organizations
decided to work together to diversify their business lines. They
reasoned that a joint venture made sense for the organizations,
which had similar missions and cultures, as well as a shared
desire to provide a continuum of services and supports to oncampus and off-campus residents through one entity.
Bridgewater and VMRC engaged Senior Options, a
third-party consulting firm, to assess the feasibility of each
organization establishing its own home health agency. The
assessment identified several barriers to such an endeavor,
including:


Potential financial losses
Fierce competition in a crowded market
As an alternative, VMRC and Bridgewater decided to
purchase an existing agency that already had a market share
and a reputation for delivering home health care. When the
First Choice home health agency came up for sale in 2007,
Bridgewater and VMRC formed a joint venture and purchased
the agency.
The Harrisonburg-based First Choice, established in
1977, was a Medicare certified agency16 that provided skilled
home health care to a large private-pay clientele. Purchasing
the agency meant that VMRC and Bridgewater could start
providing services immediately. Sunnyside joined the joint
venture in 2015.
Reasons for Expansion and Growth
VMRC and Bridgewater had similar reasons for wanting
to expand into home health and home care services. Both
organizations wanted to:
62 | Residential Provider Expansion into Home and Community-Based Services

Extend their reach to individuals who would never move to
their campuses but needed support to age in the place they
called home
 Provide services, as part of a continuum of care, both oncampus and off-campus
 Diversify their business models and create additional
revenue streams
 Establish relationships with community-dwelling
consumers who might consider moving to the retirement
communities when they required higher levels of care
Sunnyside’s leadership also wanted to take advantage of
the market demand for at-home services to add to its revenue
streams. The organization initially weighed three options:
establishing its own agency, buying an existing agency, or
affiliating with an organization that was already operating an
agency. The Sunnyside leadership team decided that partnering
with VMRC and Bridgewater was its best option for two
reasons:

Sunnyside expected that the process to start its own
certified home health agency would be expensive and could
take up to a year.
 Sunnyside’s leadership wasn’t sure there were enough
potential clients in the external community to justify an
investment in its own agency.
Description of the Program
Services Provided
Today, First Choice is a for-profit limited liability corporation
with its own offices. It offers a broad range of in-home services
that are paid for by Medicare,17 commercial insurance and
individual consumers. The agency is Medicare-certified to serve
individuals in four counties in central Virginia. It provides:

Skilled home health care covered primarily by Medicare
and some commercial insurance
 Non-clinical home care that is exclusively private pay
FIRST CHOICE
Non-medical services include:
 Bathing and dressing assistance
 Walking and exercise activities
 Eating assistance
 Meal preparation
 Medication reminders
 Transportation for errands, medical appointments
and social outings
 Respite care
 House cleaning
Laundry
 Linen service
 Dry cleaning drop-off and pickup
 Grocery shopping
 Assistance with entertainment
Consumers who do not require hands-on personal care can
also receive services that provide companionship and assistance
with chores, in addition to the non-medical services listed
above.
Medical home care services include, but are not limited to:
 Skilled nursing
 Physical therapy
 Occupational therapy
 Speech therapy
 Medical social work
 Home health aide
First Choice provides around-the-clock home care and home
health care services. Home health care clients are not required
to receive a minimum number of service hours per visit.
However, consumers using home care services must receive at
least two hours of services per visit. The agency provides 24hour coverage in shifts.
Partnerships
The VMRC-Bridgewater-Sunnyside collaboration represents the
primary partnership associated with First Choice.
First Choice was licensed to provide Medicare-certified home
health when it was purchased by VMRC and Bridgewater.
However, the agency provided little skilled care because it did
not want to compete with local hospitals that were providing
these services. The First Choice purchase offered VMRC,
Bridgewater and Sunnyside the opportunity to offer home
The residential and community-based
service lines in each organization
must meet the same expectations for
quality and follow the same approach
to providing consumer-centered care.
skilled care with a business partner that had experience
providing the service and had the required license.
The partnership faced initial challenges associated with the
effectiveness of First Choice’s leadership and operations. To
address these issues, the partners engaged Senior Options to
provide technical assistance to the agency. Since 2014, Senior
Options has offered billing, clinical, financial, marketing,
regulatory and operational support to help strengthen First
Choice and make it successful.
VMRC, Bridgewater and Sunnyside work well together,
primarily because their cultures are so well aligned. First Choice
has become embedded into the culture of its three partners.
Leaders of all three organizations report that their expansion
into home health did not require any changes to their corporate
cultures. The residential and community-based service lines in
each organization must meet the same expectations for quality
and follow the same approach to providing consumer-centered
care. The only difference is that each organization’s care
philosophy has been extended to consumers in the community
and is no longer limited to on-campus residents.
Consumer Eligibility
Consumers can receive Medicare home health care from First
Choice if that care meets these eligibility guidelines:

A physician must order care.
The individual must be homebound, which means he or she
leaves the home infrequently and with great effort.
 Care is provided on an intermittent basis.
 A skilled health care professional, such as a nurse or
therapist, provides care.

There are no eligibility requirements for home care, apart
from the ability to pay for the services. First Choice conducts
an in-home assessment to determine the individual’s need for
specific home care services and to customize the care plan.
First Choice Clientele
First Choice provides home health and home care services to
clients on CCRC campuses and to clients living in the external
community. A majority of community-based clients has a
family caregiver, although that person may not be the best
provider of care. Less than 15% of community-based clients live
alone and do not have a family member or friend who acts as a
caregiver.
Home care clients: First Choice provides approximately
4,000 hours of home care service each month. This number
has dropped recently due to client deaths or moves to nursing
homes. The majority of private-care clients live on the CCRC
campuses.
First Choice accepts one or two new clients per month,
although that number varies. The agency serves a broad range
of short-term and long-term clients. Many clients have received
home care services for many years. Most clients can afford to
pay for services.
Sodexo • IAHSA • LeadingAge | 63
FIRST CHOICE
Home health care clients: First Choice’s average daily census
includes 65 to 70 home health care clients. The agency averages
375 new home health care clients each year. Two-thirds of home
health care clients reside in the external community and onethird live on a CCRC campus. The number of on-campus clients
may change with the addition of Sunnyside to the partnership.
Most home health care clients are white and reside in a rural
area. More than a third (35%-40%) are middle income or above.
Quality Assurance
First Choice is committed to ensuring that it maintains high
quality standards and reliable services. The agency uses the
following strategies to ensure quality.

Patient satisfaction surveys: A third-party organization
conducts satisfaction surveys when home health care
clients are discharged from the program. First Choice
started conducting patient satisfaction surveys for home
care clients in March 2015. The surveys are reviewed on
a monthly basis. The agency plans to conduct follow-up
phone calls with clients to identify issues that should be
addressed.
 Key indicators: The First Choice administrator and her
team have developed key indicators to measure quality
in home care. Indicators include missed visits, late visits,
hours that the agency cannot provide home care, and
complaints. The administrator reviews the data and
develops plans to address any issues.
 Data tracking: The Centers for Medicare & Medicaid
Services14 requires Medicare-certified home health agencies
to collect and transmit data for all adult patients whose
care is reimbursed by Medicare or Medicaid. The data
include two types of measures that are used to guide
quality and performance-improvement measures. Processof-care measures assess how often First Choice provides
the recommended care and the rate at which the agency
uses specific evidence-based processes of care. Outcomesof-care measures assess how well the home health agency
helps clients regain or maintain their ability to function.
First Choice tracks these measures on a monthly basis as
part of its overall quality-improvement process. When
numbers are unfavorable in specific areas, the leadership
team develops an action plan to improve the score.
Typically, this is achieved through staff training. The
agency also uses outcomes data in its marketing campaigns.
 Supervision of aides: Supervisors speak with clients and
their family members about the care they receive from
staff. Complaints about home care go to the agency’s
scheduling coordinator and, if not resolved, are sent to the
administrator for assessment and resolution. Complaints
about home health care go directly to the administrator.
 Record review of client’s charts: Nurses and therapists at
First Choice conduct a quarterly review of the client charts
maintained by other staff members. If nurses and therapists
have trouble finding documentation, the leadership team
develops an action plan to improve quality.
Marketing
First Choice employs many strategies to spread the word about its
home health and home care services. The agency has an outreach
coordinator who works to establish relationships with community
members and promote First Choice services. The outreach
coordinator uses the following avenues to promote the agency:

Meeting with on-campus residents during weekly
transition meetings at each CCRC
 Attending community events like health fairs and visiting
nursing homes to raise awareness of the program
 Networking to gain referrals from hospitals, doctor’s
offices, assisted living communities and other organizations
not affiliated with the CCRCs
 Maintaining an up-to-date website and using social media
to disseminate information about the program and gain
referrals
VMRC, Bridgewater and Sunnyside have integrated home
health care services into their marketing efforts and discharge
processes. When a client is discharged from one of the CCRC’s
nursing homes and requires home health care, the organizations
are able to connect them to First Choice. The CCRCs also
provide residents with a list of other agencies in the area, but
promote the fact that they own First Choice.
Financial Implications
The initial investment to purchase First Choice was $500,000.
Workforce
First Choice employs approximately 50 staff members, most
of whom are part-time. The agency contracts with its CCRC
partners when it needs the services of a therapist.
First Choice staff members include:
Administrator






Scheduling coordinator
40 home health and home care aides
Health information coordinator
Outreach coordinator
Approximately five registered nurses (RN)
Office manager
First Choice consistently assigns two to three aides to care for each client.
This ensures that the client will become comfortable working with several
caregivers, rather than relying on only one aide.
64 | Residential Provider Expansion into Home and Community-Based Services
FIRST CHOICE
First Choice consistently assigns two to three aides to
care for each client. This ensures that the client will become
comfortable working with several caregivers, rather than
relying on only one aide. This arrangement helps prevent client
anxiety when an aide is unable to provide care.
RNs supervise the home care aides by accompanying them
on visits to clients’ homes and observing the delivery of care.
The aides are supervised in this way at least every 60 days.
RNs or therapists supervise the home health aides. Medicare
requires that aides be supervised every 14 days or less.
Staff Benefits
All full-time aides receive health, dental and vision insurance
coverage and retirement benefits.
Staff Recruitment and Training
Aides who work in home care have a vastly different experience
than aides working in residential settings. An aide who prefers
working independently will be attracted to the home care setting,
while an aide who prefers working with others will be drawn to
residential care. For this reason, First Choice home health aides
work separately from the aides who work in residential settings at
the CCRCs. Movement across settings is rare.
Home health aides must be certified nurse aides and are
required to participate in 12 hours of in-service training per
year. Aides who provide skilled care receive more training than
aides who provide home care services.
Home care aides can be certified nursing assistants (CNA),
but it is not a requirement. Ideally, the candidate will have
prior home care experience. The agency will provide training
for home care aides who do not have experience in the home
setting.
Home health aides and home care aides receive monthly inservice trainings that are scheduled during work hours. Annual
training on some topics is required. First Choice used to train
certified and non-certified home health aides together. Now,
the agency conducts separate training for home health and
home care aides.
While the home health workforce is stable, the home care
workforce has a high turnover rate. Home care aides lack the
commitment of home health aides, possibly because home
health aides tend to fill full-time positions and receive higher
pay. The turnover rate among home care aides could make it
difficult for First Choice to meet the demand for home care
services. Offering benefits to full-time aides has helped raise
their commitment level. These aides now feel part of the team.
Perceived Challenges
Market competition has been the greatest challenge facing First
Choice. Prior to the partnership with the CCRC communities,
a local hospital’s home health and hospice program competed
with First Choice and made it difficult for First Choice to grow
its client base. The hospital’s restructuring created a market
The nurses and administrator provide
the training and hold the aides
accountable for the assistance they
provide in a person’s home.
opportunity for the agency. First Choice hired the hospital
agency’s nurses and executive director. These staff members
had many years’ experience in home care and their names were
recognized in the community. These factors helped strengthen
First Choice, particularly on the home health side.
The First Choice partners report that the home care side of
the business is more challenging to manage than the home
health care side because the home care staff is more transient
than the home health care staff. In addition, problems on the
home care side of the business can impact the home health
business.
First Choice has addressed these challenges by holding
in-service training sessions for home care aides. The nurses
and administrator provide the training and hold the aides
accountable for the assistance they provide in a person’s home.
First Choice managers are also making an effort to help the
aides feel part of the organization. Offering benefits to full-time
home care aides was a major component of that effort.
Perceived Benefits
The executives of VMRC, Bridgewater and Sunnyside report
that the provision of home health care and home care has been
beneficial for each organization.
VMRC appreciates the fact that the joint venture has allowed
it to offer assistance to individuals who want to stay in their
own homes.
Bridgewater’s leadership believes the partnership has helped it
“close the loop” on the continuum of care by offering additional
services to on-campus residents and consumers living in
the community. The organization’s diversification has raised
Bridgewater’s community profile and offered it the opportunity
to market its residential services to clients who are now
receiving care in their homes.
Sunnyside, which has only been part of the joint venture for
a few months, already has seen positive financial returns from
First Choice. Sunnyside residents, particularly those who had
been interested in receiving home care services, welcomed the
expansion.
Outcomes
First Choice has not conducted any formal evaluations of its
programs, beyond analyzing client satisfaction surveys and
outcomes data for its home health care services. The agency
receives positive feedback from clients, especially residents at
CCRCs who appreciate receiving home care services.
Sodexo • IAHSA • LeadingAge | 65
FIRST CHOICE
Lessons Learned
First Choice and executives from its CCRC partners offer the
following suggestions for residential service providers that
are considering expanding into home and community-based
services or have already begun the expansion process:
Be patient. Expanding into home and community-based
services can be a slow process. The timeline will depend on
whether a provider starts its own agency or purchases an
existing agency.
 Be prepared to put time and energy into the new service
line. Although VMRC, Bridgewater and Sunnyside
purchased an existing agency, it took a great deal of
work to integrate that agency into their businesses. The
consulting services and expertise provided by Senior
Options have been beneficial. It would have been difficult
for any of the partners to support a home health care
business on its own.
 Advocate and educate. It’s important to ensure that staff
members accept your new community-based business
line. Advocate for home health with your staff and educate
those employees about the benefits of your diversified
service line. Make sure aides have a good understanding
of home care. It is not always “glamorous” to work in
someone else’s home and can be disappointing. Before
hiring a new home care aide, First Choice conducts a “ride
along” to help the person get a better sense of home care.
 Protect your reputation. It’s important to understand
that the reputation of your home health and/or home
care agency will affect the reputation of your entire
organization.

66 | Residential Provider Expansion into Home and Community-Based Services
Case Study
SHEPHERD’S CARE AT HOME
EDMONTON, ALBERTA, CANADA | June 2015
Introduction
Shepherd’s Care Foundation (foundation) was established in 1970
and provides a campus-based continuum of care that includes
independent living, supportive living,18 and nursing home care. The
foundation is a not-for-profit organization that has five locations
in Edmonton and Barrhead, and manages a number of additional
care sites. It serves more than 1,600 older adults who have low or
moderate incomes. The organization’s vision is to provide “agingin-place services with excellence.” Service options include:

Home care
Supportive living, which blends a homelike environment
with 24-hour nursing care
 Supportive living with dementia
 Long-term care services provided by a registered nurse
(RN) around the clock

The design of the foundation’s service program is based on
its person-centered care philosophy, which emphasizes an
individual’s autonomy, choice and flexibility. Staff members are
viewed as “flexible solutions masters” who listen to residents
and find creative ways to meet their requests.
In 2008, Shepherd’s Care Foundation became the first
organization in Canada to receive accreditation as an aging
services network through CARF International, an independent,
not-for-profit accreditor of health and human services in several
service areas, including aging services. The organization was
reaccredited in 2011.
Shepherd’s Care Foundation established Shepherd’s Care at
Home (agency), its home care agency, in 2014.
This study was conducted through interviews with staff at
Shepherd’s Care Foundation and Shepherd’s Care at Home and
a site visit at Shepherd’s Care at Home.
Policy Context
Provincial governments are primarily responsible for senior
care in Canada. Each province has different rules and
regulations for long-term services and supports. The Province
of Alberta, where Shepherd’s Care Foundation is located, has
strict regulations for publicly funded home care and home
health care. Alberta Health Services (AHS), Canada’s first
province-wide, fully integrated health system, has proprietary
control over the delivery of services for most providers. AHS
uses funding and regulations to influence how providers deliver
services within the province. AHS also restricts the number
of publicly funded agencies providing services. There are no
comparable restrictions for the private agencies.
Alberta’s political leadership changed significantly in
May 2015 when voters ended the 44-year dominance of
the Progressive Conservative Party and brought the New
Democratic Party into leadership. How these political changes
will affect the provision of health care, particularly home health
care, is uncertain.
Most (90%) long-term services and supports delivered
in Alberta, including home care, are publicly funded. The
government does not require care recipients to undergo asset
testing in order to qualify for services. On the contrary, most
Albertans expect the government to cover the majority of their
costs for long-term services and supports. Consumers do not
expect to pay for services out of their own pockets.
The increasingly complex care needs of older Albertans
could challenge the sustainability of the government-funded
system of long-term services and supports. The fact that home
care costs are rising faster than the savings these services bring
to the health care system is putting political pressure on the
government to balance the budget. In an emerging trend, many
consumers in Alberta will receive a mix of publicly funded and
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SHEPHERD’S CARE AT HOME
private-pay home care services because publicly funded health
care will not meet all consumer wants or needs.
AHS recently introduced a new government-funded service
called “Added Care.” Administered through the government’s
Supportive Living program, “Added Care” provides extra
hours of supportive care to individuals who are on the waitlist
for higher levels of residential care. The initiative is part of
Alberta’s new strategy to offer older adults and adults with
disabilities greater choice and the ability to remain in their own
homes and communities.
Through the AHS Coordinated Access process, consumers
in need of services are assessed to determine which program
and level of care would meet their needs most effectively. These
consumers receive information about the range of available
services and options—including the availability of affordable
accommodations—to meet their assessed needs.
Expansion into Home and CommunityBased Services
Shepherd’s Care Foundation began offering home and
community-based services in October 2014. The decision
to expand the organization’s service lines was driven by the
foundation’s need to diversify its portfolio and increase the
percentage of the revenues it receives from private-pay clients.
Sixty percent of the foundation’s revenue came from the
government in 2012. The foundation’s leadership team does
not believe that dependence on government funding is a
sustainable model, given the growing challenges associated
with the government’s policy to provide free health care to
all citizens. The agency’s leadership team is also aware of the
growing tendency for not-for-profit providers in the United
States to expand their operations to include home health and
home care programs.
Shepherd’s Care Foundation initially conducted limited
market research to determine service needs on its campus and
in the external community. Findings from focus groups showed
a gap in the availability of companionship and transportation
services. The focus groups did not gather information about
consumers’ willingness to pay for these services, despite the
fact that consumer hesitation to pay for services could limit a
home care agency’s growth potential.
After reviewing the market research and perceived trends in
Alberta, the foundation’s leadership team decided to establish
a home care agency called Shepherd’s Care at Home. The new
agency would be a for-profit entity that would be independent
and separate from Shepherd’s Care Foundation. Board
members felt that establishing a separate corporate entity made
sense for the following reasons:

Concerns about unions: Shepherd’s Care Foundation
has collective labor agreements with the largest union in
Alberta. Because the annual compensation rates included
in the agreements increase at twice the rate of inflation,
the cost of providing services exceeds the government
reimbursement rate for those services. Foundation leaders
68 | Residential Provider Expansion into Home and Community-Based Services
reasoned that establishing the home care agency as a separate
entity would keep the union from applying the foundation’s
collective agreement to the new home care agency.
 Unique identity: Foundation leaders also wanted the new
home care agency to have its own identity as a service
provider. For this reason, it decided that the new agency
would have its own management team and board of directors.
 A different type of business: The board recognized that
the business models for home care and residential care were
so different that these business lines should be housed in
separate organizations and not merged into one organization.
Shepherd’s Care Foundation has been challenged by the fact
that it launched Shepherd’s Care at Home at a time of political
upheaval in Alberta. That upheaval could bring about policy
changes that might impact the new home care agency. On the
other hand, Shepherd’s Care at Home also has an opportunity
to provide and supplement government-funded home care at
a time when consumers are looking for more services than the
government can provide.
Description of the Program
Services Provided
Shepherd’s Care at Home only provides non-medical care or
home care. The agency delivers most of its services (80%) to the
foundation’s on-campus residents, while a smaller portion of its
services (20%) are used by external clients living in their own
homes in the community or on other residential care campuses.
This distribution of clients is a direct result of the agency’s
two-pronged strategy to build its client base on the foundation’s
campus first and then expand service delivery to the wider
community. This strategy allowed Shepherd’s Care at Home
to begin delivering services in October 2014, before a legal
structure for the new agency was in place.
Many foundation residents receive services through
the government’s “Added Care” program, which provides
additional supports to help older adults remain at home.
20%
80%
On-campus residents
External clients
Timeline
SHEPHERD’S CARE AT HOME
1970
Established
Shepherd’s Care
Foundation.
2008 + 2011
Shepherd’s Care
Foundation awarded CARF
Accreditation as an Aging
Services Network.
2014
Launched Shepherd’s
Care at Home in
Edmonton, Alberta.
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SHEPHERD’S CARE AT HOME
“Added Care” could potentially offer Shepherd’s Care at
Home a solid client base. However, because “Added Care”
services are based on client needs, the amount of service hours
delivered through the program can fluctuate on a monthly
and annual basis.
Shepherd’s Care at Home’s participation in the “Added Care”
program allows the foundation to provide additional services
to its residents without putting added pressure on its own staff.
Residents receive regular care from their permanent foundation
aide and “Added Care” services from the Shepherd’s Care at
Home aide.
The agency’s campus-based business model has encountered
some challenges due to the fact that many foundation residents
cannot afford to pay privately for services. These challenges
underscore the need for the agency to build a private-pay client
base in the external community. Eventually, the Shepherd’s Care
at Home executive director hopes to reverse the agency’s client
mix so most clients come from the external community. These
external clients may be better equipped to pay for services.
Shepherd’s Care at Home provides person-centered care
and recognizes each client is different and unique. It strives to
meet the wishes of the individual and promote his or her choice
and independence. Aides also take time to know clients and
immediately respond to their requests. The agency’s philosophy
of care is based on three Cs:19
Compassion:
Staff members provide honest, respectful
and compassionate care.
 Communication: The agency team listens to the needs
of the client and presents the best options for care. Team
members ensure that the consumer and family know what
is happening each step of the way.
70 | Residential Provider Expansion into Home and Community-Based Services
Consistency: The
team provides consistent and reliable
services to each client. Each team member is matched
carefully with a client. Care and services remain consistent.
Shepherd’s Care at Home primarily provides transportation
and companionship services. The agency plans to grow these
two programs before branching out to other service areas.
Shepherd’s Care at Home plans to add personal care to its
service options in the future. AHS’s limits on coverage for
skilled home health services are increasing the need for privatepay services. Shepherd’s Care at Home believes it may have a
role to play in supplementing publicly funded skilled services
with private-pay services. The agency is in the process of hiring
a licensed practical nurse (LPN) as clinical director to oversee
the development of its personal care services.
Following is a list of Shepherd’s Care at Home’s current and
future services:
Transportation services currently include door-to-door
transportation for:
Appointments
 Personal errands
 Shopping trips
Assistance and companionship services currently include, but
are not limited to:
 Accompaniment on a walk
 Accompaniment to medical appointments
 Assistance with grocery shopping
 Light housekeeping and laundry service
 Meal preparation
 Medication reminders
SHEPHERD’S CARE AT HOME









Mental stimulation
Overnight services
Pet care
Playing cards and games
Reading a book or watching a movie
Respite care
Safety monitoring
Social visiting
Sharing a hobby
Personal care services will include, but will not be limited to:
 Assistance with dressing or putting on shoes
 Assistance with feeding
 Assistance with bathing and personal cleanliness,
including dental hygiene and shaving
 Incontinence care and toileting
 Managing care for people with Alzheimer’s disease
and other dementias, including managing behaviors,
encouraging engagement, and assisting with activities of
daily living
 Medication management
 Mobility assistance, including helping individuals get in
and out of the bed
Shepherd’s Care at Home learned from market research that
its competitors are charging between $27 and $35 per hour
for a minimum of three to four hours of service. Based on this
information, the agency decided to charge an hourly rate of $30
for its services and to require a minimum of two service hours
per visit. So far, most prospective clients seem willing to pay
these fees.
Partnerships
Shepherd’s Care Foundation and Shepherd’s Care at Home
operate as separate businesses. Shepherd’s Care at Home will
have its own board of directors and management team when it
becomes “official and legal” later this year.
Consumer Eligibility
Consumers do not need to meet any eligibility requirements,
other than ability to pay, in order to receive private-pay services
from Shepherd’s Care at Home. The agency’s executive director
conducts an assessment to determine each client’s service
needs, and works with family members to develop a care plan.
Clients receiving publicly funded home care services on the
campus are assessed by a team at Shepherd’s Care Foundation
to determine their eligibility for services.
Shepherd’s Care at Home Clientele
Shepherd’s Care at Home was providing an average of 263
hours of service per month after its “soft” launch in October
2014. The agency has increased those hours significantly. Since
February 2015, the number of non-skilled service hours has
held steady at 1,500 per month for approximately 35 to 40
clients.
The agency’s clients differ in their service needs and the
amount of services they receive each week. Some clients require
an hour or two of weekly services while others need 20 hours of
service delivery during the same time period. Given the range
of clients’ need for service hours, Shepherd’s Care at Home
feels that the number of service hours it provides each month
is a better indicator of its service volume than the number of
individuals served.
The agency anticipates that service hours will increase
exponentially over the next few months once its ownership
framework is established and it can market its services more
actively. The executive director would like service hours to
grow to 2,000 hours per month over the next few months.
One strategy for accomplishing this goal involves targeting
the agency’s marketing efforts to older adults living on other
residential campuses.
Shepherd’s Care at Home does not have demographic data
about its clients. Approximately 70% of clients do not have
family or friend caregivers. Most clients have a low to modest
income.
Quality Assurance
Shepherd’s Care Foundation has received accreditation
from CARF International over the last three years. CARF
International’s standards, which are designed to “promote
quality, value and optimal outcomes of services,” have guided
the development of the Shepherd’s Care at Home agency.
Shepherd’s Care at Home does not have a formal quality
assurance process. While Shepherd’s Care Foundation has a
quality committee, agency staff members have not been part of
that committee. It is not clear whether Shepherd’s Care at Home
will establish its own quality care committee or be integrated
into the foundation’s quality committee.
Most of the agency’s quality assurance efforts currently take
place through communication with aides, clients and family
members. The agency does not conduct client satisfaction
surveys, but is considering implementing a survey process to
track satisfaction with companion, transportation and personal
care services. The agency also may administer staff satisfaction
surveys.
Shepherd’s Care at Home aides who provide “Added Care”
services to foundation residents follow an informal quality
assurance system, but it is a “work in progress.” The manager
of the foundation’s Supportive Living unit, where “Added
Care” services are delivered, works with the agency’s executive
director to resolve any quality-related problems.
When a client complains about services, the executive
director of Shepherd’s Care at Home will talk with the client
and the aide to understand their different perspectives. The
executive director will also assure family members that the
situation will be addressed. As Shepherd’s Care at Home
becomes more established, the agency may implement a more
formal system to assess and address clients’ complaints. Agency
aides working in the foundation’s Supportive Living unit
follow the foundation’s procedures for documenting clients’
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SHEPHERD’S CARE AT HOME
complaints and concerns. During this process, the unit’s
manager:
build relationships with consumers and providers in various
sectors, including:


Provides the client with a timeline for addressing the
concern
 Gathers information to understand the perspectives of
clients and aides
 Meets with the executive director of Shepherd’s Care at
Home to develop solutions to the problem
Marketing
The Shepherd’s Care Foundation and Shepherd’s Care at Home
market their programs separately. Marketing for residential
care takes place primarily through fundraising efforts. With
a two-year waiting list, the foundation does not have to
actively promote its services. On the other hand, Shepherd’s
Care at Home needs to create awareness of its program and
distinguish its services from the competition. The agency
believes that its person-centered approach to care and its policy
regarding service hour minimums puts it at an advantage when
marketing its companionship and transportation services. The
agency anticipates that its marketing strategy will change when
it begins offering personal care services.
The agency believes that its personcentered approach to care and
its policy regarding service hour
minimums puts it at an advantage
when marketing its companionship
and transportation services.
Despite their separate marketing efforts, the foundation
and the agency do work together to market their services.
For example, the foundation refers clients to the agency when
those clients are on the waiting list to receive campus-based
accommodations.
Shepherd’s Care at Home has “softly” promoted its services
for several months. The agency will formalize its promotional
efforts after it becomes a distinct legal entity. In the meantime,
the agency has connected with most of its clients through
referrals from the foundation. Because the foundation serves a
low- to modest-income population with limited resources and
ability to pay for services, growth of the agency’s home care
business has been limited. Shepherd’s Care at Home will soon
need to expand its clientele to include older adults who are
willing and able to pay for the services.
In a few months, Shepherd’s Care at Home plans to launch
an active marketing campaign that will create community
awareness about the program, brand the agency’s services and
72 | Residential Provider Expansion into Home and Community-Based Services
Independent senior living communities where managers
tend to be more open to private-pay home care services
Churches
 Senior centers, where agency staff can distribute flyers
and make presentations to older adults and recreation
coordinators
 Community events that attract older adults
 Grocery stores where agency staff can distribute flyers
Shepherd’s Care at Home has already held informational
seminars to help community members navigate Edmonton’s
system of long-term services and supports. These seminars
have been well attended and have yielded positive feedback
from families and individuals. As a result, more relatives of
foundation residents are requesting companionship services
for family members with Alzheimer’s disease and other forms
of dementia. Families recognize that agency services can help
these older adults stay in their current residence rather than
relocating to a more secure unit on the foundation’s campus.
The agency’s marketing team has experienced challenges as it
attempts to build relationships with providers and inform them
about its services. These challenges include:
Difficulty marketing to hospitals: Hospital staff members
often do not think about home care services as an option
for their patients and may not be willing to learn about
these services. In addition, there is often not one hospital
staff member who serves as a contact person for agencies
like Shepherd’s Care at Home. The agency could address
this challenge by trying to build a rapport with the hospital
staff when residential clients are hospitalized.
 Resistance from consumers: Consumers do not always
believe they need the services that Shepherd’s Care at Home
provides. To address this challenge, staff members often
market the agency’s services indirectly. For example, staff
members may offer to help a client by providing informal
help with a few tasks. The appreciative client may then
request formal services from the agency.
 Providers’ lack of receptiveness to agency services: Some
providers of aging services may already have established
relationships with other home care agencies and may not be
interested in making Shepherd’s Care at Home their provider
of choice. The agency could overcome this challenge by
targeting its marketing efforts to consumers who live in their
own homes and not on a campus. These consumers could
purchase a small number of services at first and continue to
use the agency as their service needs increase.

Shepherd’s Care at Home also is considering targeting its
marketing efforts to family members, in addition to older adults.
The agency’s outreach coordinator could educate family members
who are responsible for making decisions about whether a relative
needs services and what services are most appropriate.
SHEPHERD’S CARE AT HOME
As the official launch of Shepherd’s Care at Home
approaches, the agency has an opportunity to review its
business model, client projections and operational strategies
and then identify two or three tangible strategies for carving
out the agency’s market niche. Strategy development would be
enhanced by market research that assesses:

The potential size of the service market
How Shepherd’s Care at Home compares with its
competitors
 Emerging trends in the field of aging services
 New opportunities to fill service gaps and convince clients
to pay for services
 The agency’s pricing structure

Financial Implications
Shepherd’s Care Foundation made an initial investment of
approximately $250,000 (CAD) when it expanded into home
and community-based services. The investment covered the
following costs:





Purchase of a van
Salary and wages, which represented most of the costs
Marketing and advertising
Office space rental
A consultant to develop a business plan
Shepherd’s Care at Home is not generating a profit at this
time, but anticipates doing so within a year after the program
officially opens later this year.
When the agency does begin generating profits, its
revenues will be used to supplement the government-funded
reimbursements that the foundation now receives. The
foundation’s reimbursement rates are lower than the cost of
care. To date, the foundation has reduced its expenditures in
areas that don’t impact resident care. Profits from Shepherd’s
Care at Home will help strengthen the foundation’s bottom line
and ensure that it can continue serving older adults who cannot
afford to pay the full cost of care.
The foundation’s board of directors will be watching
carefully to see if Shepherd’s Care at Home can expand its
client base beyond foundation residents. Some believe that if
agency financials do not improve substantially over the next
year, members of the board of directors may question whether
it makes sense to continue the agency’s operations.
Workforce
Shepherd’s Care at Home employs 45 workers, including:

Executive director
Outreach coordinator
 Approximately 40 to 45 home health aides
 Four drivers
 An office assistant

The agency employs certified home
health aides or aides who are working
toward their certification. These aides
are well positioned to provide more
clinical care when the agency begins
offering personal care services.
The agency’s home care aides are all casual workers and do
not receive benefits. This arrangement gives Shepherd’s Care
at Home the flexibility it needs to accommodate the changing
needs of its clientele. As the client base grows, the agency will
be able to increase the hours that current staff members work
rather than hiring additional staff.
Executive Director: Shepherd’s Care at Home plans to
involve its executive director in all aspects of its work and
give her many hats to wear. The executive director currently
supervises all of the agency’s aides and goes on visits to
clients’ homes to monitor quality. In addition, the executive
director is responsible for hiring and training staff and shares
responsibility for overseeing the agency’s billing system.
The executive director accompanies aides on their first visit
to the client’s home and updates the aide about the client. The
executive director occasionally visits the clients and stays in
touch with the family members to make sure they are satisfied
with their services and don’t have any concerns. Aides reported
that the executive director is very responsive when they are
seeking advice about a particular situation.
Aides: Although Shepherd’s Care at Home provides primarily
non-medical care, the agency employs certified home health
aides or aides who are working toward their certification. These
aides are well positioned to provide more clinical care when
the agency begins offering personal care services. Some current
aides have worked in both residential and home care while
others only have experience in the home care setting. All aides
were new hires. No aides were redeployed from the Shepherd’s
Care Foundation’s residential setting.
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SHEPHERD’S CARE AT HOME
Aides account for their time by using a timesheet that is
signed by the client. When an assigned aide is unavailable, the
executive director appoints another aide to provide a client’s care
temporarily. When no substitutes are available, the executive
director covers a shift.
Approximately 40 Shepherd’s Care at Home aides care for 45
clients. Many of the aides are assigned to one client. The agency
practices consistent assignment, which allows aides to build
relationships with their clients and become familiar with their
wants and needs. Clients who require 16 or more hours of care
each day have three or four aides assigned to them. The executive
director takes personalities into account when matching clients
and aides.
Supervision: Shepherd’s Care at Home plans to hire an LPN
and an RN consultant to oversee the personal care side of the
agency. The LPN will conduct orientation for aides and introduce
them to their new clients. He or she also will supervise the aides
during visits to the home and make reports about the quality
of those visits to the agency’s executive director. The LPN will
also communicate with family members, conduct training and
education, and hire new staff. The agency will determine the
frequency of supervision for aides.
Aides interact with the supervisor and the agency’s executive
director primarily through text messages and emails. They rarely
see or interact with their supervisor. When aides provide care to
residents of Shepherd’s Care Foundation, the LPNs on the unit are
available to answer any questions. The aides also submit a written
report documenting any personal care services they provide to
clients. No report is required for companion services.
Some workforce challenges include:
Unreliable schedules for aides: Since aides typically work
with only one client, an aide may not have work when the
client no longer requires services. A high number of referrals
makes it possible for the agency’s executive director to
reassign aides to new clients in a timely manner.
 Aggressive or combative clients: An aggressive or combative
client can cause injury to an aide. The aides at Shepherd’s
Care at Home have developed strategies to address these
behaviors. After getting to know their clients, aides can
devise innovative strategies for calming clients who become
combative. If these strategies are unsuccessful, the aide
will notify the LPN at the foundation or call the agency’s
executive director for advice on how to handle the situation.
 Caring for clients with dementia: Aides appreciate the
opportunity to form relationships with clients and to feel that
they are making a difference. Clients often view their aides
as family and friends. However, it can be difficult for aides to
form relationships with individuals with dementia. Clients
with dementia may not remember the aide from one visit to
the next. Aides must reestablish their connection with the
client at each visit.
 Dealing with clients who resist care: Some clients refuse an
aide’s assistance with tasks that are outlined in the care plan.
Aides must create a balance between respecting the wishes

74 | Residential Provider Expansion into Home and Community-Based Services
of clients and providing services necessary to maintain the
individual’s health and quality of life.
 On-the-job training: Shepherd’s Care at Home doesn’t
hold orientation sessions for new aides and those aides
do not shadow experienced aides. Aides who are new to
the field could benefit from a buddy system that helps
them understand the home environment, observe how an
experienced aide interacts with clients, and review care
basics.
 Consistent assignment: Shepherd’s Care at Home strives
to ensure that each client has an aide who can continue to
provide higher levels of care when they are needed.
Staff Benefits
All aides at Shepherd’s Care at Home are casual workers who
are not entitled to benefits. The aides are reimbursed for travel
expenses when they escort a client to an appointment. However,
aides are not reimbursed for mileage when they visit clients. In
addition, aides receive a four-percent premium when they work
holidays. Aides on the day shift are paid the same hourly wage
as aides who work the evening shift.
Staff Recruitment and Training
Shepherd’s Care at Home has no difficulty recruiting staff.
The agency receives resumes from prospective employees
on a regular basis. The recruitment process emphasizes the
importance of hiring the right people and ensuring the agency
and its culture represent a good fit for the individual. If the
executive director does not believe this to be the case, she will
suggest other employment options for the individual.
Shepherd’s Care at Home uses a thorough process to hire the
right staff members. The executive director conducts a national
criminal background check on all aides. In addition, she
interviews potential aides to assess:

General experience caring for older adults and younger
adults with disabilities in any setting
 Personality and attitude, including the ability to work on
a team, serve customers, respect others, deliver personcentered care, maintain a positive attitude, solve problems
and be dependable
 How the individual interacts with others and addresses
issues
Shepherd’s Care at Home currently has a low turnover rate.
Only one staff person has left the agency since October 2014.
This is consistent with, and could be related to, the low turnover
rate at Shepherd’s Care Foundation, which is known for having
a positive work environment and supportive management.
Agency staff members have around-the-clock access to the
executive director. The new LPN is expected to contribute to the
positive work environment because she will have the time and
clinical expertise to support aides.
The agency plans to provide quarterly trainings once the
LPN is hired. These trainings will focus on specific diseases
SHEPHERD’S CARE AT HOME
and other issues that affect the agency’s clientele. The LPN will
select the training topics with input from aides. The aides from
Shepherd’s Care at Home and Shepherd’s Care Foundation will
have separate trainings.
Shepherd’s Care at Home and Shepherd’s Care Foundation
have similar organizational cultures. Because Shepherd’s Care
at Home is relatively new, there have been limited opportunities
for interaction between agency and foundation staff. It can be
challenging to create an environment where the aides who work
independently and do not report daily to the agency can engage
with one another, share information and develop relationships.
The only time aides see each other is when there is a hand-off in
a client’s home.
The executive director hosted a holiday party for staff and
plans to host other special events throughout the year. Aides
may also have opportunities to meet during the quarterly
trainings and staff meetings.
Perceived Challenges
Shepherd’s Care at Home faces significant competition from
other home care service providers. As the government scales
back on the type and number of services it will cover, more
private home care agencies are being launched. The agency also
encounters competition from larger private home care agencies.
On-campus residents are not required to use Shepherd’s
Care at Home as their home care service provider. As a result,
residents are not always aware of the agency’s transportation
and companionship services. A more robust marketing effort
could encourage residents to consider Shepherd’s Care at Home
when they require assistance.
Other challenges include:
 Launch delays: Shepherd’s Care at Home was delayed in
launching its program while it created a separate legal
entity, developed a business plan and put a business
structure into place. This process required more time and
effort than anticipated.
 Increases in client base: Keeping up with a significant
increase in the number of home care clients has been
challenging for Shepherd’s Care at Home. When the
number of clients nearly doubled from 800 to 1,500 in
February 2015, the agency had some difficulty hiring and
training staff to meet the demand.
 Cost of labor: Unions have a powerful voice and control
the supply of labor in the home care sector. If Shepherd’s
Care at Home makes a collective agreement with the
unions that is similar to the union’s collective agreement
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with Shepherd’s Care Foundation, the costs of care could
increase by 30%. If these costs are passed on to clients, the
agency’s hourly rates will be significantly higher.
Logistics: Providing transportation services across a large
region presents logistical challenges.
Changing consumer mindsets: Alberta Health Services
covers the fees for most long-term services and supports.
As a result, older Albertans don’t expect to privately pay
for their care. This mindset has affected the transportation
services that Shepherd’s Care at Home provides. This
service hasn’t done as well as expected and is operating at
a loss. An informal survey found that 80% of foundation
residents use family and friends for transportation, which
can place a burden on families who may be juggling family
and work issues. For this reason, Shepherd’s Care at Home
plans to target its private-pay transportation services to
family members.
Low demand: The economic circumstances of many
foundation residents suggest that they are not an ideal
audience for private-pay services.
Competitors with volume and pricing advantage:
Agencies competing with Shepherd’s Care at Home can
offer lower prices because they have a larger client base.
False sense of optimism: Shepherd’s Care Foundation
assumed that private-pay home care services would
be an “easy sell” for consumers seeking to supplement
government-funded services. This has not been the case.
Administrative practices: The business model for home
care is different than the business model for residential
care. It’s important to understand that residential care
administrative practices are not effective for home care
agencies.
Communication rift: The leadership teams from
Shepherd’s Care Foundation and Shepherd’s Care at Home
have not collaborated enough as they strive to understand
the market and establish a niche for their services.
Funding: Agencies that provide publicly funded services
lack a profit margin. While reimbursement rates are
currently stable, the government keeps changing the
services that it will cover. As long as Shepherd’s Care
at Home provides private-pay services exclusively,
this dynamic will not impact its operations. However,
fluctuating coverage could become an issue once the agency
moves more into the publicly funded market.
Providing in-home services helps to improve quality of life for Shepherd’s
Care at Home clients. These services can enhance an older person’s health
and ability to function.
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SHEPHERD’S CARE AT HOME
Perceived Benefits
Despite the challenges outlined above, the leadership teams
at Shepherd’s Care Foundation and Shepherd’s Care at Home
identified numerous benefits associated with providing home
care services, including:
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Aging in place: Consumers who receive services from
Shepherd’s Care at Home can stay at home longer.
Financial rewards: The agency may be able to earn greater
revenues by providing private-pay services than it can by
providing publicly supported services. Those revenues can
help subsidize shrinking government reimbursement for care.
Rural outreach: Shepherd’s Care at Home currently serves
an urban population, but a large percentage of Albertans
lives in rural areas. The agency’s leadership team would
like to provide home care services to individuals residing
in rural areas in the next five to 10 years.
Support for foundation aides: Aides from Shepherd’s
Care at Home are helping to support foundation residents
through the government-funded “Added Care” program.
Asking the agency to provide this care has helped the
foundation meet the needs of its residents while easing the
pressure on its permanent aides.
Improving quality of life: Providing in-home services
helps to improve quality of life for Shepherd’s Care at Home
clients. These services can enhance an older person’s health
and ability to function. For this reason, agency staff members
believe they are making a difference in people’s lives.
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Outcomes
Given the novelty of Shepherd’s Care at Home, the agency has
not conducted any formal evaluations of its services. Shepherd’s
Care at Home plans to conduct client and referral source
surveys to determine whether and how it has assisted clients
and helped community organizations.
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Lessons Learned
Shepherd’s Care at Home and Shepherd’s Care Foundation
offer the following suggestions for residential service providers
that are considering or already expanding into home and
community-based services:
Build relationships. Developing good relationships
with community organizations, providers, clients and
family members can help an agency create awareness
about its program and develop strong referral sources.
When building relationships with consumers and family
members, be sure to create a personal connection with the
individual. Follow-up with clients when they return from
the hospital to determine their preferences and needs.
 Test the business idea before launching the program.
Make sure you have a solid business plan and a vision for
how to operationalize your program. Identify, through
market research, where the business can grow and
understand the competition. It is essential to know what
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76 | Residential Provider Expansion into Home and Community-Based Services
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is occurring in the market, whether there is a need for
services, and whether consumers are willing to pay for
those services. Wait to hire new staff until consumer needs
justify a workforce expansion.
Understand how for-profit and not-for-profit business
models differ. This understanding is important in
situations where the residential care provider is a not-forprofit organization and the home care agency is a forprofit organization. Growing a for-profit entity requires a
distinctive mindset and business plan.
Establish a brand identity. A home care agency may not
have the same bond with off-campus consumers as it does
with the on-campus residents. The agency must establish
itself within the external community and can’t rely on the
residential care provider’s brand identity.
Identify shared goals. This is important if the home care
agency is affiliated with, but independent from, a larger
organization. Leadership teams from both groups must
have the same goals for the home care agency.
Conduct extensive market research to understand
the target group. This research should identify service
needs and gaps as well as consumer willingness to pay for
services. While market research conducted by Shepherd’s
Care at Home demonstrated a need for transportation, the
study did not take into account whether people would be
willing to pay for these services. Consumer unwillingness
to pay for services has made it difficult to grow the agency’s
transportation component. One possible alternative might
involve expanding the target market for transportation
services to include other populations like younger people
with disabilities.
Recruit the right executive director. The executive director
must understand how to provide both private-pay and
government-subsidized services.
Understand the pros and cons of offering personal care
services. Personal care services entail higher administrative
costs due to the policies and practices required to obtain a
license and provide licensed services.
Get comfortable with growing pains. Growing pains
are always associated with a new service line that forces
an organization to step outside its core business. The
management team must learn from this experience and put
processes in place to improve the system.
Conduct staff meetings. These meetings allow staff
members to develop relationships with and learn from
each other. They also provide a good opportunity for staff
members to discuss their clients and share information that
will help them address potential issues.
Develop a strategy. Ask the leadership team to develop
a strategy for the home care program. Seek different
perspectives and get input from all team members. Measure
progress against a formal business plan at regular intervals
so you can make quick changes to the plan, add new
resources as needed, and adjust forecasts for future results.
Share what you learn with the board and other stakeholders.
Case Study
WELL-SPRING RETIREMENT
COMMUNITY
GREENSBORO, NORTH CAROLINA | January 2015
Introduction
Well-Spring Retirement Community (Well-Spring) is a not-forprofit continuing care retirement community (CCRC) located
in Greensboro, NC. Well-Spring was established in 1993 by a
coalition of nine local churches.
Well-Spring provides accommodations at every level of care,
including independent living, assisted living, and skilled care.
The organization received the North Care New Organizational
Vision Award, which is a special licensure designation for
nursing homes, adult care homes and home care agencies that
voluntarily meet higher standards for workplace culture.
To accommodate its expansion into home and communitybased services, Well-Spring created an umbrella organization
called Well-Spring Services, Inc. This parent organization
includes four distinct service lines:

Well-Spring Retirement Community
Well-Spring Home Care, which provides non-medical
home care services
 The Adult Center for Enrichment (ACE), a provider of
adult day care, caregiver education and respite day services
 Two Programs of All-Inclusive Care for the Elderly20
(PACE): PACE of the Triad in Greensboro and PACE of the
Southern Piedmont in Charlotte, NC
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This study was conducted during interviews with staff
from Well-Spring Services, Inc., and the Adult Center for
Enrichment.
Policy Context
The North Carolina Department of Health and Human Services
requires that organizations obtain a certificate of need and
a license before they can provide medical services through
a certified home health agency. Many state governments in
the United States use certificate of need laws to regulate the
number of beds in hospitals and nursing homes and to create a
balance between the level of need in a region and the number of
providers who are allowed to enter the market.
Providing non-medical care through a home care agency does
not require a certificate of need in North Carolina. However,
applicants must:

Acquire a license to operate a home care agency
 Meet specific standards regarding administration, staff
competencies, supervision of patient care, and records
 Have written policies and procedures that comply with
rules established by the North Carolina Department of
Health and Human Services
 Run criminal background checks on all employees
Agencies may be denied a license if they do not understand or
comply with all requirements.
For many years, North Carolina issued a specified number
of licenses for home care agencies. But in 2009, the North
Carolina Department of Health and Human Services instituted
a brief moratorium on its practice of restricting the number of
home care licenses it would issue. The state soon reinstated the
practice of limiting new home care licenses, making it difficult
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WELL-SPRING RETIREMENT COMMUNITY
for an organization to enter the market unless it partners with
or purchases a license from an existing provider.
Barriers to the development of adult day programs focus on
reimbursement rather than regulation. Only about half the
counties in North Carolina have adult day centers due to adult
day’s numerous funding sources. It can be time-consuming and
complicated to navigate these multiple funding layers.
Expansion to Home and CommunityBased Services
Process for Launching Program
Well-Spring launched its home and community-based services
program between 2009 and 2012. The decision to diversify
services, as described in Well-Spring’s 2008 strategic plan,
reflected the organization’s desire to expand its services. Oncampus residents requiring home care services were using
outside entities and Well-Spring watched potential revenue
going to other providers. The organization believed that it could
provide quality home care services to on-campus residents and
compete for external clients when its brand awareness grew.
The following staff members were involved in the
development of the home care program:

Chief executive officer/president
Chief financial officer
Controller
 Human resources director
 Health care administrator
 Marketing staff
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The CCRC’s management and members of the board of
directors had ongoing discussions before agreeing to the
expansion of service lines. They continue to discuss the value
of expanding into home and community-based services. While
board members agreed to the diversification, they actively track
the venture’s profit margins, quality measures and service volume.
The decision to add new service lines was driven by the need to:
Create a continuum of care for CCRC residents and
external clients: Well-Spring wanted to be a “one-stop
shop” that would allow consumers to access and obtain a
variety of needed services from one agency.
 Bring continuity to a fragmented market: The aging
services market did not include a not-for-profit home care
agency dedicated to providing quality services. This gap
represented an opportunity for Well-Spring.
 Serve the underserved: Well-Spring’s strategic discussions
took place during the 2008 economic downturn, when
the Well-Spring Retirement Community was attracting
only a fraction of local older adults over the age of 75.
Well-Spring’s management and leadership teams believed
that home and community-based services offered the
organization an opportunity to reach more members of
this age group, especially those who were not interested in
moving to a CCRC.
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78 | Residential Provider Expansion into Home and Community-Based Services
Fulfill Well-Spring’s not-for-profit mission: Well-Spring
strives to serve all older adults, not just a small percentage
of the older population. The organization’s board of
directors felt an obligation to do more than provide CCRCbased services.
 Support individuals in their own home: Well-Spring’s
decision was rooted in the desire of older adults to remain
in their own homes, and the interest of government
programs to support aging in place. Organization leaders
knew from experience that government resources were
insufficient to meet the growing need for long-term services
and supports. They viewed home and community-based
services as an affordable way for older people to fulfill their
preference to remain at home.
 Build an awareness of long-term services and supports:
That awareness might spur community-dwelling older
adults to seek on-campus services, and possibly move to
Well-Spring’s CCRC, in the future.
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Well-Spring provides non-medical home care to residents of
its retirement community and to clients who live in the external
community. The organization decided not to provide home
health care because of government restrictions that make it
difficult to enter the market. When Well-Spring was considering
its expansion into home and community-based services, North
Carolina was not issuing certificates of need for home health care.
When Well-Spring clients require home health care services,
the organization refers them to Advanced Home Care, a
preferred home health provider and a partner in Well-Spring’s
PACE programs.
The regulatory environment actually enabled Well-Spring to
establish a non-medical home care agency. In 2009, when the
Department of Health and Human Services instituted a brief
moratorium on its practice of restricting the number of home
care licenses, Well-Spring took advantage of the opportunity to
establish a home care agency.
Well-Spring experienced some initial challenges while
implementing its home and community-based services
program. Key challenges include the following:
Understanding the funding sources for adult day: While
CCRCs provide private-pay services, adult day services rely
on multiple funding sources. Well-Spring staff members
ventured into new territory as they learned to work with a
variety of adult day funders.
 Finding staff for home and community-based programs:
Well-Spring found it difficult to recruit, screen and train
qualified staff when its home care program was growing at
a fast rate.
 Securing office space: Initially, Well-Spring Home Care
and the Adult Center for Enrichment (ACE) were located
in separate off-campus locations, and home care staff used
unoccupied residential space on the CCRC campus until a
new resident moved into the space. Well-Spring has since
leased space close to the CCRC for the ACE leadership, the
home care team and staff of Well-Spring Services, Inc.
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Timeline
WELL-SPRING RETIREMENT COMMUNITY
1993
Began as a continuing care
retirement community.
2008
2011 + 2012
Started home care program.
Acquired Adult Center for
Enrichment (ACE), an adult
day program, and integrated
into Well-Spring Services
parent corporation.
2016
Home care will move under ACE’s
legal structure and ACE will be
the hub for HCBS division.
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Description of the Program
Well-Spring Home Care delivers 90% of its services to residents
living on the Well-Spring CCRC campus and less than 10% to
external clients. The organization is in the process of growing
the external component of the home care program with the
goal of achieving an equal percentage of on-campus and
external clients.
The adult day program is the largest segment of the
organization’s community-based services. Well-Spring’s
management viewed adult day as a prime opportunity to
participate in health care reform initiatives and the work of
Accountable Care Organizations (ACO).21 The organization
believes that adult day programs can be important ACO
partners because they can help ACOs reduce or prevent hospital
readmissions and ease transitions from hospital to home.
Partnerships
Each of Well-Spring’s home and community-based service
lines is a subsidiary of Well-Spring Services, Inc. Well-Spring
decided to structure the organization in this way for three key
reasons:
Economies of scale: All corporate functions—including
human resources, finance, and technology—are carried
out through the umbrella organization.
 Limited liability: With an umbrella organization in place,
the liabilities of the home and community-based services
would not affect Well-Spring’s CCRC and vice-versa.
 Existing contracts: Having an umbrella organization
allowed the Well-Spring CCRC to maintain its existing
vendor contracts.
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Well-Spring works with ACE to provide adult day center
programs, caregiver education and respite day services. The two
organizations reviewed their cultures, core values, and visions,
and consulted with attorneys, before ACE was incorporated
into the Well-Spring Services organization. The partnership
benefitted both organizations.
80 | Residential Provider Expansion into Home and Community-Based Services
10%
90%
On-campus residents
External clients
Well-Spring recognized that ACE had expertise and a
successful track record in adult day services. ACE had contracts
and relationships with funders and interested donors. It
also employed organizational leaders who could add “bench
strength” to the overall Well-Spring management team. A
partnership with ACE would allow Well-Spring to move ahead
quickly in the adult day services sector.
The partnership also provided ACE with the opportunity
to move forward and expand. The ACE leadership viewed a
partnership with another organization as a critical step in
ensuring its own ability to navigate North Carolina’s regulatory
environment and federal health care laws. In addition, ACE
was growing at a fast pace and research suggested that the pace
of growth would continue for several years. The center did not
have the capacity to meet anticipated demand.
Well-Spring Home Care will move under ACE’s legal
corporate structure on January 1, 2016. The new structure will
help Well-Spring manage risk and will allow ACE to serve as the
hub for the home and community-based services division. The
home care program will continue to be branded as Well-Spring
WELL-SPRING RETIREMENT COMMUNITY
Home Care. ACE will operate the adult day center program,
caregiver education, respite day services and home care.
Admission Criteria
Each program under the Well-Spring Services umbrella has
different eligibility requirements.
Well-Spring Home Care clients must meet these eligibility
requirements:

Be at least 62 years of age
Receive an assessment that includes an appraisal of needs
and an in-home inspection to ensure a safe and adequate
physical environment for care
 Live in the geographical area that Well-Spring serves
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Clients of the Well-Spring Adult Day Center must meet these
basic eligibility requirements:

Be at least 18 years of age
Be comfortable in a group environment
 Receive an individualized assessment to ensure their needs
can be safely met at the adult day center
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Eligibility requirements for the adult day center can change,
depending on the rules and regulations of the funding source.
PACE clients must meet these eligibility requirements:

Be at least 55 years of age
 Meet requirements for a nursing home level of care, as
determined by the North Carolina Division of Medical
Assistance
 Have the ability to live safely in the community at the time
of enrollment
Sources of Reimbursement
Adult day service has diverse funding streams, including:
 Private pay, which accounts for 25% of funding
 Medicaid Community Alternatives Program (CAP) for
Disabled Adults
 Department of Veterans Affairs
 Home and Community Care Block Grant
 State adult day care funds
 Long-term care insurance
The Well-Spring Home Care program is exclusively private
pay. Well-Spring chose not to seek Medicaid funds for its home
care services because of the low reimbursement rates ($13 per
hour) in North Carolina.
Adult Day Services
ACE provides adult day services, group respite programs and
caregiver education. The adult day program operates Monday
through Friday from 7:30 a.m. to 5:30 p.m.
The adult day program served more than 200 clients in 2014
and offered respite services to more than 200 caregivers. The
program is certified to serve 108 individuals each day and
averages about 90 people per day. The program is looking to
expand so it can serve more people.
Adult day services include:
 Breakfast, lunch and afternoon snacks
 Exercise programs and recreational activities
 Bathing and ancillary services, such as podiatry
 On-site nursing services, such as medication
administration, provide by a Registered Nurse (RN) or a
Licensed Practical Nurse (LPN)
 Access to computers
 Speech, occupational and physical therapy provided by
contractors
 Transportation to and from the adult day center
 Educational and cultural programs
 Instruction and assistance with personal and health care
needs
Group respite allows individuals who are caring for family
members to have a break from caregiving responsibilities. The
individual requiring care can participate in activities, exercise,
music, lunch and interaction with peers in a safe and secure
setting and with close supervision.
Education programs offer short-term and ongoing
opportunities for caregivers to receive the information they
need to support themselves and help their loved ones. These
opportunities include educational sessions, caregiver support
groups and annual caregiver retreats. In addition, ACE offers
caregiver educational programs to local congregations and
organizations.
Well-Spring Home Care Services
Well-Spring Home Care offers non-medical services that
include:
 Assistance with activities of daily living, such as bathing,
dressing and grooming
 Laundry and light housekeeping
 Respite care
 Transportation to and from appointments and meetings
 Weekly medication monitoring and reminders by an RN
 Meal preparation and feeding
 Toileting and incontinence care
 Transferring in and out of chair
 Assistance getting in and out of bed
 Activities to stimulate mental awareness
 Hobbies and games
 Outings and trips
 Assistance with correspondence
 Help with reading
 Companionship and conversation
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WELL-SPRING RETIREMENT COMMUNITY
Well-Spring Home Care requires a minimum of one hour of
service for external clients, but prefers four hours. The agency
will provide less than one hour of services to residents of the
Well-Spring CCRC as long as the shorter visit is compatible with
the agency’s schedule. It also provides services on weekends and
offers around-the-clock coverage.
Well-Spring Home Care provides 10,000 billed service hours
per month, primarily to clients on the CCRC campus. The
agency plans to increase the average number of billed hours it
provides to external clients each month from approximately
1,000 to 8,000 hours. It anticipates reaching that goal in two
to three years, assuming it does not acquire other home care
agencies in the area.
Well-Spring initially depended on a network of existing
partners, including the Area Agency on Aging, Department of
Social Services and other social service organizations, to refer
external clients to its home care services. Well-Spring Home
Care has since implemented a formal referral process. There is
significant competition in the market. Well-Spring Home Care
remains focused on providing the highest quality of service, not
the cheapest services.
Demographics
Home care: The majority of home care clients are women who
are 55 years old or older, white, and have an annual income over
$65,000. Transportation and housekeeping are the most popular
services. CCRC residents tend to have more extensive needs for
home care services than external clients. Less than one percent
of the home care clients do not have a family caregiver.
Adult day program: The majority of the adult day center
clients are women over the age of 60 who belong to a minority
group and have Alzheimer’s disease or a related dementia (See
Figure 1). A very small percentage of adult day clients (3%) do
not have a family caregiver.
Quality Oversight
Well-Spring Home Care clients use a formal system to report
their complaints about services. Clients also have access to
managers who will address any conflicts that arise.
Figure 1. Demographics of Adult Day
Center Clients
80%
60+
Female
Minority
Alzheimer’s disease or
related dementia
50%
53%
66%
82 | Residential Provider Expansion into Home and Community-Based Services
The adult day program conducts feedback surveys and uses
the results to improve its services. In addition, the program has
a Clients Rights Committee that handles unresolved complaints.
Future Services
Well-Spring’s management has considered offering a continuing
care at home (CCaH) program, which provides a full package
of CCRC services to older people living in their own homes.
However, the organization is not sure its local market could
support a traditional CCaH program at this time.
Well-Spring Home Care does plan to offer home modification
services and home-delivered meals within the next two
years. The organization intends to collaborate with outside
organizations to deliver these services, either through a joint
venture or by incorporating an appropriate agency into the
Well-Spring Services organization.
Workforce
Well-Spring’s adult day program and home care agency have
separate workforces. The adult day program currently employs
40 people and the home care agency has a staff of 100 people.
The vice president of home and community-based services
oversees staff members in both programs. The workforce is
expected to grow as the home care side expands its client base.
Well-Spring Home Care
Well-Spring initially hired several CCRC employees, including
one employee who became the home care manager. However,
the majority of new hires have come from outside the
organization. Well-Spring did not have the capacity to staff the
home care agency using CCRC employees.
The director of clinical services is responsible for the daily
operations of the home care agency. Her leadership team
includes RN supervisors, a department coordinator, and office
associates that oversee, train and supervise aides.
The home care agency’s staff includes a manager and 92 home
care aides, of which 36 are full-time employees. The aides serve
on-campus clients and off-campus clients. Well-Spring Home
Care does not currently have any contract staff.
Most of the home care agency’s new hires had prior
experience in home care and did not require specific training
about the home care environment. Staff members from both
Well-Spring’s residential setting and home care agency receive
orientation together. The orientation sessions for the home
care staff introduce new hires to the organization and provide
information about working in the home care environment.
Staff also can take in-service education that is tailored to their
department.
Staff at the home care agency receive transportation subsidies
and are offered health insurance. Unlike staff in the residential
setting and the ACE staff, home care staff does not receive paid
time off.
Adult Day Program
ACE used existing employees to staff the adult day program
because the organization existed before its partnership with
Well-Spring. Staff positions for the adult day program include:
WELL-SPRING RETIREMENT COMMUNITY












Executive director
Assistant executive director
Activities director
Family support specialist
Assistant program director
Director of caregiver education
Respite directors
Financial/administrative assistant
Program director
Assistant program director
Health coordinator
Director of business and development
The adult day center’s program director, assistant program
director, RNs and other leadership staff provide ongoing support
and direction to the frontline staff. The program director is
responsible for the daily operations of the adult day center.
ACE contracts with some ancillary service providers for
therapy and podiatry services.
Well-Spring used a transition committee and sub-committee
to help staff understand the adult day model and to address
issues that surfaced while ACE was being integrated into the
Well-Spring Services organization. For example:

Well-Spring integrated ACE’s billing staff into its corporate
office. The ACE billing staff was familiar with the billing
operations for adult day services and helped educate WellSpring’s chief financial officer and controller about these
operations, including the program’s many payer sources.
 The human resources staff had to become familiar with
the regulations for adult day programs and how those
regulations differed from skilled nursing regulations. They
received help in this regard from the ACE administrative
staff. This sharing of information was one benefit of
collaborating with an existing provider of adult day
services.
 Well-Spring and ACE held social gatherings and
joint trainings of the administrative teams at both
organizations. This helped to create camaraderie between
the two groups.
Shared Functions
The Well-Spring subsidiaries share back-end office functions
such as payroll, human resources, accounting, compliance and
training. Members of Well-Spring’s corporate staff, particularly
human resources and billing staff, were challenged by their
expanding responsibility to serve the organization’s CCRC,
adult day program and home care agency.
Well-Spring outsources the billing for its PACE program due
to the complexity of the payment model. However, as the PACE
census increases, the organization is exploring the possibility of
handling PACE billing internally.
Organizational Culture
Well-Spring’s adult day program, home care agency and CCRC
are all subsidiaries of the Well-Spring Services corporate
Well-Spring strives to recruit, train
and retain the best staff possible
across its entire family of services
so that all services can provide
quality care.
organization. The CCRC and home care agency currently share
organizational cultures, mainly because they operate on the
same campus. The organization’s leaders believe that the home
care agency will develop its own culture when it moves from the
CCRC campus.
There are basic differences between the organizational
cultures of the residential business model and the home
care agency, due to the fact that home care staff work far
more autonomously than residential care staff. Despite these
differences, Well-Spring strives to recruit, train and retain the
best staff possible across its entire family of services so that all
services can provide quality care. The organization also makes
an effort to create a shared culture of excellence with new
employees across the organization through joint orientations,
shared training and employee events.
Residential and home care staff members interact well
together. Some conflicts exist between these groups because
CCRC aides receive paid time off, while home care aides do not.
Financial Implications
Well-Spring’s investment in home care was minimum and
consisted primarily of staff labor costs and an initial investment
of less than $15,000 in computers and the licensing process.
Well-Spring has recouped this investment. Home care is a
lucrative service line for the corporation and has provided net
margins every year since 2009.
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WELL-SPRING RETIREMENT COMMUNITY
Well-Spring’s investment in ACE was more substantial. The
organization spent $1.8 million to renovate the ACE building,
and incurred additional expenses while consolidating and
integrating the two agencies.
Given the debt service on the adult day program, Well-Spring
anticipates breaking even over the next two to three years. Since
joining Well-Spring two years ago, ACE has increased its net
assets by 150%, due, in large part, to a major capital campaign
that allowed the organization to purchase and renovate its
newest adult day center.
Well-Spring board members have been satisfied with the
financial performance of the PACE program and the home care
agency. Board members also are satisfied with ACE’s new building
and with its efforts to obtain contributions for the project.
Board members would like to see ACE improve its financial
performance by attracting more private-pay adult day clients.
Perceived Challenges
Market competition, particularly in the external community,
is the greatest challenge facing the Well-Spring Home Care
program. Well-Spring Home Care is the top provider of home
care on the CCRC campus and is now trying to expand its reach
off-campus.
Greensboro has many home care providers and potential
clients have several options when they need care. The
organization’s leaders believe that quality services and
continuous improvement will help distinguish Well-Spring
Home Care from the competition. The agency conducts
strategic marketing in the community to ensure its continued
growth and to garner a greater percentage of external clients.
Other challenges for the home care program include the
following:
Maintaining adequate staff: It can be challenging to
recruit and retain enough qualified aides to meet the needs
of a growing client base. Well-Spring Home Care leads the
way with competitive pay rates for its staff.
 Regulations: Burdensome regulations can create barriers
to growth. Well-Spring works with LeadingAge and
other associations to educate policymakers about home
care services. Sharing resources and staff talents with
other strong, not-for-profit organizations has helped the
organization address regulatory challenges.
 Reliance on philanthropy: Well-Spring relies on capital
campaigns to support its CCRC, but the organization’s
home and community-based services rely on philanthropy
for support. Each year, Well-Spring holds fund-raising
events and applies for foundation grants to fund its adult
day program.
 Many reimbursements: The adult day program is
challenged by its reliance on an increasingly complex
mix of private-pay and publicly funded reimbursements.
The program must follow rules and regulations for each
funding source. Program leaders see the need to educate
consumers and policymakers about the importance of adult

84 | Residential Provider Expansion into Home and Community-Based Services
day in the continuum of care. They would like to see adult
day eventually become a covered Medicaid benefit, if and
when the Medicaid program is reformed.
Perceived Benefits
Well-Spring Services, Inc., has benefitted tremendously from
efforts to promote its brand as a regional provider of aging
services. The organization offers a variety of services to a broad
spectrum of aging adults. Several clients who received care at
home transferred to the CCRC campus when their care needs
changed and they required higher levels of care. Well-Spring
has enjoyed several other benefits including the following:
Strengthened governing boards: Well-Spring has three
boards that represent the CCRC and home care; PACE; and
adult day services. Each board includes talented individuals
with expertise in their fields. Cross-pollinating the talent
in all of Well-Spring boards has benefitted the entire
organization. However, it can be challenging to keep all board
members informed of the organization’s varied activities.
 Expanded opportunities for staff: Well-Spring has
strengthened the quality of its management team through
the addition of individuals with expertise in the field of
home and community-based services. By offering a diverse
collection of services, Well-Spring has created additional
job opportunities and career ladders for all staff and given
managers the opportunity to expand their career horizons.
 Mission achievements: Well-Spring’s mission is to provide
a continuum of services for older adults and improve their
lives. New service lines have allowed the organization to
serve older adults with a range of incomes and care needs.
Consumers can receive a variety of services, and help
navigating the care system, from one organization.

New service lines have allowed the
organization to serve older adults with
a range of incomes and care needs.
Financial sustainability: The Well-Spring management
and board of directors did not anticipate that the
organization would earn high net margins from its home
and community-based services. However, Well-Spring has
the advantage of offering an array of services to a larger
number of older adults, while receiving reimbursement
from multiple payers.
 A larger market: Well-Spring initially served only the
small portion of older adults who wanted to live on a CCRC
campus. Now, the organization can serve many more older
adults with a variety of services. The home care model has
given the organization a revenue stream and an expanding
client base at a time when consumers are less interested in
moving to a CCRC. Consumers who want to live in their
own homes now have more care options.

WELL-SPRING RETIREMENT COMMUNITY

New partnerships: Providing home and communitybased services has improved Well-Spring’s standing in the
community and expanded the number of organizations,
including accountable care organizations, that now think
of Well-Spring as a potential partner. In addition, adult day
services could become a strong PACE partner if changing
regulations introduce more flexibility into the PACE model.
Lessons Learned
Throughout its expansion process, Well-Spring has learned
several lessons it would like to share with other providers who
are considering expanding, including the following:

Outcomes
Well-Spring Home Care has not yet conducted a formal survey
to evaluate its program. The program plans to administer client
and employee satisfaction surveys in the next year or two.
The adult day center conducts surveys of caregivers and
participants. Key survey findings indicate that the program
has improved the quality of life and health for caregivers and
participants. In 2013-2014 majorities of caregivers reported:






Reduced stress
Increased knowledge of community services
Ability to continue working, if needed
Improved job performance, if working
The perception that the service prevented a relative’s move
to a long-term care setting
The conviction that the value of service was worth the cost
Caregivers reported that family members participating in the
adult day program:
 Maintained or improved their chronic disease condition
and felt better
 Maintained or improved sleep patterns (19% improved)
 Maintained or expanded conversation or communication
(25% improved)
 Maintained or improved mobility and flexibility (34%
improved).
 Maintained or increased personal hygiene (25% improved)
 Maintained or improved medical condition (25%
improved)
 Decreased emergency care episodes
Survey participants noted their appreciation for the
friendships formed and the feeling of self-importance that
clients experience at the adult day center.
During interviews conducted in 2013-2014, a majority of
adult day participants (88% or higher) reported:
 Feeling better coming to the program
 Experiencing less pain (if they normally have pain)
 Enjoying activities
 Receiving help as needed
 Being treated with dignity and respect
 The perception that coming to the program makes their
life better
 Satisfaction with coming to the program
 Helping to lead activities







Educate board members. Management should constantly
and consistently explain the reasons why the organization
should diversify its services and begin offering home and
community-based services. The education process should
continue even after the decision is made.
Develop a mix of in-house and partnership programs.
When collaborating with outside organizations, consider
the organizational culture of the agency and make sure the
organizations are compatible.
Educate staff. Make sure staff members are familiar with
home care trends and understand why it is beneficial for
the organization to expand into the home care market.
Resources that explore the future of aging services are often
helpful in educating staff.
Be patient. It takes time to understand and implement a
new model of care.
Build your referral network. Develop relationships with
other organizations that can become referral sources for
your services.
Partner with competitors. It’s important to weigh whether
you want to be a competitor or partner with other providers
in your community. There are times when the partnership
route brings the best return.
Market community-based services differently. Marketing
home and community-based services is different than
marketing CCRC services. CCRC marketing tends to be
based on word-of-mouth and resident satisfaction. Home
care marketing is referral-based. In addition, prospective
residents take their time when deciding to move to a
CCRC. Home care clients make their decision quickly,
often when they have an urgent need for services. Being
available when the consumer needs help is critical. WellSpring makes itself available by building relationships with
hospitals through the discharge process.
Ask a partner to help you expand. Regulations governing
home and community-based services are becoming more
complex, whether they apply to care delivery, accounting or
human resources. Partner with an established organization
that has experience with the service you want to establish.
That partner can help you understand how to operate
within the regulatory environment.
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CONTINUING
CARE AT HOME
PROGRAMS
86 | Residential Provider Expansion into Home and Community-Based Services
Case Study
CADBURY SENIOR LIFESTYLES
CHERRY HILL, NEW JERSEY | LEWES, DELAWARE | December 2014
Introduction
Cadbury Senior Lifestyles operates two traditional, campusbased continuing care retirement communities (CCRC):
Cadbury at Cherry Hill in New Jersey and Cadbury at Lewes in
Delaware. Each of Cadbury’s CCRCs also offers the Cadbury
at Home program, which brings traditional CCRC services
into the private homes of program members. Cadbury was one
of the first pioneers to offer this hybrid CCRC model, which
has become known in the United States as Continuing Care at
Home (CCaH).
A CCaH member pays an entrance fee and a monthly fee
in return for a comprehensive package of services that are
provided for the remainder of the member’s life, unless the
individual opts to cancel his or her membership. The service
package typically includes access to a variety of home and
community-based services, including home health care,
home care, delivered meals, adult day programs, home-based
technologies, home inspections and transportation. CCaH
packages also provide access to assisted living and nursing care
if and when that care is needed.
Some CCaH membership plans offer an all-inclusive service
package for no additional cost, over and above member’s
entrance and monthly fees. Other plans require co-payments
by the individual or through the individual’s long-term care
insurance policy.
A CCaH program strives to design and deliver a package
of home and community-based services that will help CCaH
members postpone or prevent the need for assisted living or
nursing home care.
Unlike traditional CCRCs, CCaH programs do not require
their members to take up residence on a CCRC campus.
As such, programs appeal to older consumers who are not
interested in leaving their homes and who would probably never
move to a CCRC campus.
This study of Cadbury at Home was conducted during
interviews with staff from the Cadbury Continuing Care at
Home program and Cadbury Senior Lifestyles.
Policy Context
The majority of states in the United States have some type of
regulation governing CCRCs. However, state CCRC regulations
vary widely and can range from strict rules requiring fullfledged licensing or significant regulatory oversight, to
moderate rules requiring minimal financial controls and
consumer disclosures, or certificate of need oversight. Several
states have minimal or no regulatory oversight of CCRCs.
States regulators also take differing approaches to defining
the type of CCRC services that can be delivered through an
off-campus CCaH program. Some states take the view that
CCRC existing regulations already cover the CCaH concept
and do not need to be expanded to address this new model. In
other states, however, the statutory or regulatory definition of
a CCRC, or other regulations, have barred the development of
CCaH programs by restricting CCRCs and CCRC contracts to
the campus setting. In states that do not regulate CCRCs, there
has been no need to consider any regulatory action regarding
CCaH programs.
Cadbury Senior Lifestyles operates the Cadbury at Home
program in New Jersey and Delaware. The Department of
Community Affairs (DCA) strictly regulates CCRCs in New
Jersey. After Cadbury Senior Lifestyles educated DCA about
CCaH programs, the department determined that the state’s
existing CCRC regulations applied to these at-home programs
and that the new model would not require a separate set of
regulations.
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CADBURY SENIOR LIFESTYLES
The Department of State regulates CCRCs in Delaware,
which has fewer CCRC regulations than New Jersey. Cadbury
was able to use the same disclosure statement it filed in New
Jersey to open and run its CCaH program in Delaware.
Expansion to Continuing Care at Home
Cadbury Senior Lifestyles (formerly Cadbury Senior Services)
has been a service provider since 1977, when it opened its first
CCRC—Cadbury at Cherry Hill—to provide independent
living, assisted living and nursing home care on one New
Jersey campus. The organization also operates Cadbury at
Lewes, a CCRC in Delaware; the Cadbury at Home CCaH
program; Cadbury Consulting, a professional consulting firm;
and Cadbury Foundation, the fundraising entity for Cadbury
Senior Services and all its affiliates and services.
In the mid-1990s, Cadbury Senior Services decided to
expand the number of older adults it could serve. However,
expansion through the CCRC model was not possible due to
lack of land on which to build a bricks-and-mortar CCRC. The
Cadbury at Home program was incorporated in 1998 as a way
to reach and provide services to older adults who wanted to stay
in their own homes and live independently.
In 1995, Cadbury received a three-year grant from the Robert
Wood Johnson Foundation to conduct a market study that
would help it understand community needs and determine
local interest in a CCaH program. Cadbury also used grant
funds to educate the New Jersey Department of Community
Affairs about the CCaH concept and work with the department
to establish a regulatory structure for the new model.
Cadbury’s research yielded the following findings:

There was a market for a CCaH program, given the high
percentage of older adults who wanted to stay in their own
homes.
 Other existing programs targeted older adults living in
their own homes. However, these programs were not tied
to a CCRC.
 Many of the other at-home programs were not owned by
a single organization. Rather, they operated as networks
of providers from whom consumers could purchase
individual services.
With these findings in hand, the management and board of
Cadbury Senior Services implemented a comprehensive process
to determine whether to expand the organization’s services into
the external community. The CCaH concept was new at the
time and there were no other providers offering the program
in New Jersey. Launching the program would be risky for
Cadbury Senior Services and there were no guarantees that it
would succeed.
It took several years of board meetings and discussions to
reach an agreement to expand Cadbury’s services beyond the
CCRC campus. The board chair had initial concerns about
diversifying the organization’s services and preferred, instead,
to continue building on the organization’s existing services
88 | Residential Provider Expansion into Home and Community-Based Services
and strengths. The board chair stood aside from the decision
because he saw that the remaining board members wanted to
move forward.
Members of Cadbury’s marketing staff also raised concerns
about establishing a CCaH program. They feared that Cadbury’s
campus-based CCRCs would be competing with the CCaH
program for the same type of customer. These fears proved to
be unfounded. Cadbury’s experience has shown that CCRC
and CCaH programs do not compete with each other. Different
types of consumers are interested in each program. The two
programs continue to work closely together.
Process for Launching the Cadbury at Home Program
Cadbury created a separate corporate entity for what would
eventually become known as “Cadbury at Home.” This allowed
the organization to reduce any risks that the program might
pose for the corporate organization. The CCaH concept was
relatively new at the time and management did not want
any financial losses associated with the Cadbury at Home
program to impact its established CCRC. Creating a separate
CCaH entity made it easier to launch Cadbury at Home as an
additional program under the CCRC’s existing license and
certification.
Program staff at Cadbury at Home worked with actuaries to
price the CCaH program appropriately for individual members.
This was a challenging task because a similar model did not
exist. The Cadbury at Home program continues working with
actuaries to assess and study its membership fees.
Cadbury at Home also needed to balance the need for
steady membership growth with the need to select the right
participants for the program. Applicants are accepted into
the Cadbury at Home based on their financial and medical
eligibility. The medical underwriting process is more stringent
for individuals seeking to join the program than for individuals
seeking to qualify for the CCRC.
Description of Cadbury at Home
Cadbury at Home combines several long-term services and
supports—including home care, assisted living, nursing home and
the financial protection of long-term care insurance—into one
comprehensive program. Individuals pay a membership fee and
a monthly maintenance fee. In return, they receive appropriate
long-term services and supports as their health changes.
Individuals are interested in the Cadbury at Home program
for a variety of reasons, including the difficulties associated with
activating a long-term care insurance policy. For example, many
long-term care policies cannot be activated until a person needs
assistance with at least two activities of daily living (ADL). In
addition, many policies have an “elimination period,” which can
range from 30 to 180 days. The elimination period represents
the time it takes for the long-term care insurance policy to
be activated once a person demonstrates a need for a service.
During this period, policyholders must pay all care expenses
out of pocket. The Cadbury at Home program is working with
actuaries to blend program membership with long-term care
Timeline
CADBURY SENIOR LIFESTYLES
1977
Began as a
continuing care
retirement
community in
Cherry Hill, NJ.
1995–1998
1998
Conducted market research
study to determine interest
for the “at home” program,
funded by the Robert Wood
Johnson Foundation.
Incorporated Cadbury at Home
program in Cherry Hill, NJ.
2007
Opened continuing care
retirement community in
Lewes, DE.
2015
Began operating Cadbury
at Home program in
Lewes, DE.
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CADBURY SENIOR LIFESTYLES
insurance to reduce gaps in coverage. The blended coverage
abolishes the elimination period and pays for services not
covered by long-term care insurance.
The Cadbury at Home program has advantages over longterm care insurance for the following reasons:

It is easier for Cadbury at Home members to activate
services. Members can receive services after they
demonstrate the need for assistance with only one ADL.
 The Cadbury at Home program provides lifetime coverage
and is much more comprehensive and personalized than
many long-term care insurance policies. For example, the
program’s personal care coordinators work with members
and their family members to make sure members receive
the assistance they need.
Admission Criteria
Individuals must be at least 60 years old to qualify for Cadbury
at Home. The program also considers the financial situation
and medical needs of the person seeking membership.
Applicants are required to submit five years of medical notes
from their physicians and other health care providers.
Persons with managed chronic conditions may meet the
criteria for membership. However, persons with an existing
diagnosis of neurological issues or any type of dementia will
not be considered. The program’s personal care coordinator
administers a Mini-Mental State Examination and other tests
to determine an applicant’s cognitive health.
A Review and Admissions Committee works with the
program’s medical director to determine whether an applicant
qualifies for Cadbury at Home. The committee consists of the
program’s executive director, care coordinator and members
of the sales and marketing team. Each person on the review
committee interacts with the prospective member to determine
whether the applicant is appropriate for the program.
The care coordinator conducts an extensive assessment of
the prospective member and develops a relationship with the
individual and his or her family. Assessments and screenings
include the following:

Cognitive tests
 Functional assessments
 Geriatric screenings
 A home screening
The home screening is designed to make sure the prospective
member’s home is appropriate for aging in place. If the home
has a staircase, for example, the care coordinator might inquire
about the family/individual’s willingness to install a stair glide.
The care coordinator might also determine whether the family/
individual is willing and able to place a hospital bed or another
type of bed on the home’s first floor if the prospective member’s
bedroom is located on an upper floor.
Marketing and sales representatives inform and educate
potential members about the program. This interaction
provides an opportunity for staff to gauge whether the
prospective member is appropriate for the program. The sales
team is trained to recognize circumstances or situations that
would make a prospective member ineligible. Based on their
interaction with the prospective member, team members offer
their input to the Review and Admissions Committee.
Couples applying to the Cadbury at Home program could
find that one spouse is eligible for the program while the other
does not meet the program’s criteria. The person who does not
qualify can participate in a Consultative Care Program, which
features a fee-for-service contract with no up-front or ongoing
monthly service fees. Another program, called the Consultative
Care PLUS program, requires an upfront payment of $7,000 and
a $350 monthly fee covering 12 hours of services and two hours
of care coordination per month. Participants pay for additional
services on a fee-for-service basis.
Services
The following services are offered to Cadbury at Home
members:









Home care companion/homemaker
Home health care provided by a home health aide
A live-in companion, when needed
Delivered meals, if their need is due to a medically
necessary or temporary situation, and if they are provided
by a home health aide
Adult day services
Access to an emergency response system
Transportation for medically necessary outpatient surgery,
short procedures or planned hospitalizations, as long as
they are recommended by a physician
A safety and functional inspection of the home, conducted
by a licensed occupational therapist during the first year of
membership and thereafter, as needed
Access to assisted living and nursing care, when needed
In addition, the Cadbury at Home program provides a
number of other services that do not involve direct care delivery.
These services include:
Marketing and sales representatives inform and educate potential members
about the program. This interaction provides an opportunity for staff to
gauge whether the prospective member is appropriate for the program.
90 | Residential Provider Expansion into Home and Community-Based Services
CADBURY SENIOR LIFESTYLES
Table 1. Membership Options
PAYMENT PLANS
Type of Service
Platinum*
Gold
GoldPlus**
Silver
Bronze
HEALTH SUPPORT SERVICES
Home health aide
100%
100%
100%
85%
100%
Companion/homemaker
100%
100%
100%
85%
100%
Live-in companion
100%
100%
100%
85%
65%
Delivered meals
100%
100%
100%
85%
100%
Adult day program
100%
100%
100%
85%
100%
Emergency response
100%
100%
100%
100%
100%
Home inspection
100%
100%
100%
100%
100%
Transportation
100%
100%
100%
10%
100%
100%
100%
100%
70%
0%
100%
100%
100%
70%
0%
ASSISTED LIVING CARE
NURSING HOME CARE
*Cadbury at Home will refund 90% of the membership fee to a Platinum member’s estate.
** A GoldPlus member must maintain a long-term care insurance policy that meets Cadbury at Home’s criteria.
Social and member events: The program hosts three or
four luncheons per year and monthly gatherings where
members can get acquainted and create a network. It also
sponsors book clubs, day excursion trips, exercise classes,
arts and craft classes, wellness seminars, speakers and other
events. These events are offered for free or a nominal fee.
 Service referrals: The program offers referrals for various
types of home-related services, including handyman services,
housekeeping, medical equipment, bathroom conversion,
lawn service and transportation. Members are responsible
for covering the cost of these services. Some providers offer a
10% discount to Cadbury at Home members.

Some Cadbury at Home service providers also deliver services
to residents on the CCRC campus. This arrangement is based
on the quality of the providers’ services, not on any prearranged
agreement between the program and the service providers.
Cadbury at Home members can move to the CCRC’s campus
if they require greater assistance or simply prefer campus living.
The cost for assisted living or nursing home care for Cadbury at
Home members can be significantly reduced, depending on the
membership plan. For example, when members transition from
their homes to a Cadbury nursing home, they will continue
paying the Cadbury at Home monthly fee for their plan type,
rather than the $12,000/month nursing home rate. In a case
where a Cadbury at Home member and a CCRC campus
resident are vying for the same spot in the nursing home, the
campus resident has priority.
Sources of Reimbursement
Cadbury at Home is a private-pay program. Some services, such
as at-home care after a hospitalization, are eligible for Medicare
coverage. The CCaH team encourages members to maintain
their Medicare and supplemental insurance. Members sign an
addendum to the membership contract stating that Cadbury is
not responsible for any co-payments or medical expenses.
Membership Plans and Fee Structure
Cadbury at Home offers five different lifetime membership
options:
Platinum
Gold
Gold Plus
Silver
Bronze
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CADBURY SENIOR LIFESTYLES
Table 2. Average Fee Structure
PLAN
INITIAL FEE
MONTHLY FEE
Gold
$58,000
$466/month
Silver
$49,601
$455/month
Bronze
$26,534
$368/month
Services available to members do not vary by plan. However,
membership costs and possible co-payments do differ by plan.
The Gold and Platinum membership plans offer 100%
coverage for services and carry a stable monthly fee. The other
plans require some type of co-pay for services. Members who
choose the all-inclusive Gold Plan receive all services without
paying any additional fees. This is the most expensive plan
available to members.
The majority (63%) of Cadbury at Home members have Gold,
Platinum or GoldPlus memberships. GoldPlus integrates an
individual’s existing long-term care insurance coverage into the
plan.
Individuals have various reasons for choosing a specific plan,
including their financial situation and their level of comfort
with taking risks. Individuals who choose Gold or Platinum
plans tend to be risk-averse and anticipate needing services in
the future.
Cadbury at Home fees depend on the age of the applicant and
the type of membership plan he or she chooses. Each member
pays an initial membership fee and a monthly fee. Table 2
provides an example of the average fees associated with each
plan for a 75-year old member.
Membership
As of 2014, the Cadbury at Home program had over 200
members. The number of new members continues to grow.
Typically, the program enrolls 30 new members each year. Four
hundred members have joined the program since it began. The
flexible CCaH model does not limit the number of people who
can enroll in the program. Each care coordinator is responsible
for approximately 75 members. When membership expands,
additional care coordinators are added as needed.
Program demographics indicate that Cadbury at Home
members have these characteristics:

Overall, members are “healthy and active,” although their
health problems have increased over the years.
 Members’ average age has consistently been 76.6 years
throughout the history of the program. Prospects in the
organization’s Delaware program are younger than New
Jersey prospects. Many new members in Delaware are in
their early or mid-60s.
 More than half (53%) of the members are couples. Among
92 | Residential Provider Expansion into Home and Community-Based Services

single members, there is a 2:1 ratio of women to men.
Almost half of members who joined the program in the
past three years have long-term care insurance.
While Cadbury at Home participants can cancel their
membership at any time, only two members have left the
program during the past few years. In general, members who
leave the program lose 2% of their entrance fee for each month
they belong to the program.
Cadbury at Home has revised its membership guidelines to
allow members to move from one location to another as long as
the program receives sufficient notice and is able to contract for
services in the person’s new locale. If costs at the new location
are higher than the previously quoted rate, the member pays the
difference. In the past, Cadbury at Home membership was not
portable. Members who moved were dropped from the program.
Partnerships
Cadbury at Home contracts with partner agencies that provide
the program’s at-home services. The CCaH team follows
a comprehensive process when selecting partner agencies.
The team:

Meets with key staff at the prospective partner agency
Interviews agency staff members about the agency’s history,
services provided, organizational challenges and staffing
issues
 Requires each agency to complete an application requesting
information about licensing, insurance certifications, and
other business-related documentation

The Cadbury at Home team uses a consensus process to
decide whether to accept a service provider agency as a partner.
The team will stop using the services of a contracted agency if
that agency does not meet the program’s standards of care.
Workforce
The Cadbury at Home program has a small, but strong
workforce that is separate from the Cadbury CCRC staff.
Cadbury made this decision because it wanted clearly defined,
separate teams to focus on the needs of each program. The
CCRC and CCaH programs do share human resources and
finance staff with the parent organization.
Key positions within the Cadbury at Home program include:






Care coordinators
Office manager
Program director
Executive director
Director of marketing
Retirement counselor
Program demographics indicate that
Cadbury at Home members have
these characteristics:
The Cadbury at Home team recommends the following
staffing positions for a new program:
Program Director
Sales representative
 One care coordinator for every 60-70 members
 Part-time administrative assistant


The Cadbury at Home program team has faced few, if any,
challenges in the area of workforce. The CCaH model posed the
most challenges for the sales team, which had to learn how to
build relationships with prospective members, identify medical
conditions that would prohibit people from enrolling in the
program, and help members function independently in their
own home.
Program Director
The Cadbury at Home team recommends that the program
director have a social work or marketing background, as well as
experience with long-term services and supports.
Care Coordinator
The care coordinator, who typically is a licensed Master of
Social Work, is the backbone of the Cadbury at Home program
and sets the program apart from other long-term care options.
The care coordinator is proactive and works as an extension
of the member’s family to keep the member independent,
healthy and living at home. The care coordinator carries out the
following roles:

Links members with needed resources
Connects by telephone with members at least once every
three months
 Conducts in-person visits once each year, at a minimum, to
assess the individual and his or her needs.
 Visits members who are in the hospital
 Assists members and helps them understand how to use
their Medicare and long-term care insurance benefits

The average care coordinator carries a caseload of
approximately 75 members. This caseload is manageable
because most Cadbury at Home members are healthy and
independent. Only a few members require services or use the
care coordinator extensively.
The number of service coordinators employed by a CCaH
program will depend on the size of the program. The New Jersey
Cadbury at Home program employs three care coordinators.
In Delaware, the program director also serves as the care
coordinator due to the program’s small size.
Overall, members are “healthy and active,”
although their health problems have
increased over the years.
76.6
Average age throughout history of the
program. Delaware is the exception, with
many new members in their mid-60s.
53 2:1
% members who
are couples.
ratio of single
women to men
50
% of members who joined the program in the past
three years who have long-term care insurance.
Sodexo • IAHSA • LeadingAge | 93
CADBURY SENIOR LIFESTYLES
The care coordinator is the backbone
of the Cadbury at Home program
and sets the program apart from
other long-term care options.
The care coordinator is proactive
and works as an extension of
the member’s family to keep the
member independent, healthy and
living at home.
Organizational Culture
The organizational culture of the Cadbury at Home program
is similar to Cadbury’s CCRC and parent organization. The
CCRC and CCaH programs do not compete with each other
because they cater to different types of individuals.
The Cadbury at Home program is mission driven. It was
established as a way for Cadbury to provide another option
for individuals to access needed long-term services and
supports. The Cadbury at Home program and Cadbury’s
CCRCs work together to support individuals in their decisionmaking process. For example, during the initial assessment of
prospective members, a staff person may determine that the
CCRC is a better option than the CCaH program or vice-versa.
Older adults from a variety of cultures take advantage of
the Cadbury at Home program rather than moving to one of
Cadbury’s CCRC campuses. For example:

Members of the Lesbian, Gay, Bisexual and Transgender
population in Delaware prefer to stay in their own homes
and not move to a CCRC campus. This group has been a
key audience for the Cadbury at Home program.
 The Cadbury at Home program is making headway with
the Indian community because adult children, who would
have cared for their parents in the past, are not always
available to provide services and supports to relatives.
Despite its appeal to a variety of populations, the Cadbury
at Home program has not faced significant challenges
related to cultural diversity. The program works with outside
organizations to train and educate its staff in this area.
Financial Implications
Cadbury at Home’s initial start-up expense was approximately
$500,000. A CCRC board member provided a line of credit to
launch the program and was repaid within three years. It is
estimated that the start-up costs for implementing a similar
program today would be higher, probably in the area of
94 | Residential Provider Expansion into Home and Community-Based Services
$800,000 to $1,000,000.
CCaH programs do not require the development of bricksand-mortar buildings and can continue to serve an increasing
number of older adults. On average, a provider can expect losses
for four or five years, followed by positive cash returns. The
program generally requires 125 to 150 members to break even.
The Cadbury at Home program broke even around Year 3.
A similar program will likely have a slower growth rate today
than the growth rate Cadbury experienced in the late 1990s
because prospective members have less disposable income due
to the recession. The economic climate was the primary reason
the Cadbury at Home program was established as a separate
entity from Cadbury’s CCRC. Because the CCaH model was
new, Cadbury did not want to put the CCRC at risk if the new
program ran into trouble. One disadvantage of this approach is
that CCaH revenues must also be kept separate and cannot be
used to support the CCRC.
Perceived Challenges
A CCRC considering implementing a CCaH program may face
some operating barriers and challenges. The Cadbury at Home
program’s greatest challenges are:
The economy: The economy can impact the financial
strength of a CCaH program. Since the Cadbury at Home
program relies on disposable income, interest in the
program declines when the economy is down.
 Consumer needs: Understanding the needs of people who
sign up for a CCaH program can be challenging. Program
developers need to balance several goals, including keeping
the program affordable, aligning it with long-term care
insurance products, and ensuring that program fees are
actuarially sound.
 Managing utilization of program services: A CCaH
program will experience losses if the utilization of services
is too high. Program flexibility has allowed the Cadbury at
Home program to enjoy a growing membership. But early
members have aged over the program’s 15-year history
and now have greater health care needs. Care coordinators
help keep service utilization in balance by using services
creatively and anticipating and addressing health-related
issues early before they become expensive health crises.

The Cadbury at Home program is
mission driven. It was established
as a way for Cadbury to provide
another option for individuals to
access needed long-term services
and supports.
CADBURY SENIOR LIFESTYLES

Marketing the program: Educating older consumers so
they understand the CCaH concept is one of the greatest
challenges in marketing the Cadbury at Home program.
Many consumers do not understand that they will continue
to live in their own home and that bundled services are
brought to them. Education is a very important strategy to
distinguish the program from the traditional CCRC.
Perceived Benefits
A CCaH program can provide several benefits for the
organization and the consumer:





Adapts to the needs and desires of the consumers:
Cadbury at Home fulfills a consumer’s desire to receive
services at home. More people, especially members of the
next generation of older adults, want to age in their own
homes. Fewer people want to move onto a CCRC campus.
Protects the assets of the consumers: The cost of long-term
care insurance is “astronomical” and continues to grow,
according to Cadbury at Home staff. Many consumers are
unaware of the gaps and costs associated with long-term
care insurance.
Creates consumer awareness of CCRC options: This
awareness will be important when the individual or family
member requires assisted living or nursing home care or
decides to move to a campus setting.
Expands the organization’s reach: CCRCs with CCaH
programs can serve more older adults.
Creates a sense of community: The Cadbury At Home
program offers older adults living outside the CCRC campus
an opportunity to connect with their peers in the community
and use services and amenities on the CCRC campus.
The Cadbury at Home program is considering the
development of a CCaH program for low-income individuals.
According to current plans, the program would be governmentsubsidized and would follow the basic format of the current
Cadbury at Home program. The current political climate makes
it difficult to seek the investment required to carry out this plan.
However, the Cadbury at Home team believes the program
could save federal and state government funds by reducing
hospitalizations and use of nursing homes among older adults.
Outcomes
The Cadbury at Home team has conducted evaluations of the
program through member satisfaction surveys. The survey
results show that current members feel they are:
The Cadbury at Home team also believes that its bundled
services have helped members stay at home. Since its inception,
the program has not had more than two people require nursing
home care at any one time. Only one of the program’s 200
members was receiving services and supports in a long-term care
setting at the time of this study.
Lessons Learned
Cadbury at Home was one of the first programs to provide
bundled at-home services to residents in the community. Several
CCRCs have modeled their program after Cadbury’s model and
worked with Cadbury’s consulting firm to research, develop
and implement the program. Cadbury provides training for
organizations and programs seeking to implement a similar
program. Cadbury Consulting trains organizations in four areas:

Admission process
Role of the care coordinator
 Role of the sales and marketing teams
 Effective strategies for operating the program

The Cadbury at Home program has learned many lessons that
can assist other CCRCs considering a CCaH program.





Recruit and enroll the right members. Complete a prudent
evaluation to ensure that prospects qualify, both medically
and financially.
Find the right staff. Staff members should have the right
personality and background to launch and operate a CCaH
program. Successful staff members will be entrepreneurs at heart.
Offer different payment options. A CCaH program
will capture more people who want to age in place than
a “traditional” CCRC can. The financial opportunity is
great because the program is not limited to high-income
individuals. Offering different payment options makes
program membership feasible for more individuals.
Do not create a separate entity for the CCaH program.
Making the program part of the overall organization will
allow it and the CCRC to benefit from each other.
Do not market the CCaH program in the same way you
market the CCRC. Primarily, the Cadbury at Home program
uses direct mail with testimonials. The team also relies on
referrals and informational sessions with financial experts
and elder care attorneys. Large seminars are conducted
throughout the year and are successful. However, the Cadbury
at Home team has learned that smaller group seminars of six
to 10 people can also be very effective.
Satisfied

Meeting their desire to stay at home to receive services
Protecting their assets and not burdening their families
 Content they have a plan in place to allow them to age in
their own home

Sodexo • IAHSA • LeadingAge | 95
CONCLUSION
Eight nursing homes, continuing care retirement communities
(CCRC) or CCRC-like entities in the United States, Australia,
Canada and Switzerland expanded their business lines to include
the delivery of home and community-based services (HCBS). In
addition, one CCRC in the United States created an innovative
way to deliver a comprehensive package of CCRC services to older
adults living in their own homes.
The organizations participating in this study differed in a
number of ways, including:






Design of the current HCBS line
Number of years since the initial expansion
Size of the workforce
Number of clients served
Primary payer sources
Regulatory challenges encountered while operationalizing
the program
Despite these differences, organizations shared many of the same
aspirations, faced common challenges, enjoyed similar benefits,
and learned a variety of lessons during the expansion process.
Organizations diversified their service lines for a combination of
reasons. All wanted to fulfill their organization’s mission and reach
a greater percentage of the vulnerable, older adult population.
HCBS programs allowed providers to offer a continuum of
care, including care in the home, through one organization.
Additionally, home and community-based services were viewed as
a feeder program for an organization’s retirement community and
a source of additional revenue for the organization.
The home environment and the residential setting attract
different types of workers. Home care workers tend to desire more
independence and handle a multitude of tasks in their daily work.
While most organizations used separate groups of aides in their
residential and home-based settings, both service lines typically
shared support functions like billing and human resources.
Providers faced several challenges while establishing and
operating their HCBS programs. Among the greatest challenges
96 | Residential Provider Expansion into Home and Community-Based Services
were market competition and the ability to distinguish a program
from the competition. HCBS programs often operated at a loss
for the first year, before breaking even. Regulatory limitations
or moratoriums on new providers presented barriers for some
organizations seeking to provide specific home and communitybased services, such as home health care. Some providers faced
difficulties finding qualified staff and ensuring that new hires
represented a “good fit” for the home setting.
Despite these challenges, providers identified several benefits
associated with an expansion into home and community-based
services. For example, the expansion process helped organizations
fulfill their mission and provide services to a greater number of older
adults, including individuals who want to age in their own homes.
Several HCBS programs generated profits that helped support the
larger organization. Finally, the provision of home and communitybased services helped providers develop relationships with people in
the community and secure referrals to on-campus services.
The organizations learned many lessons through the
expansion process. Most providers emphasized the importance
of conducting market research to understand the competition,
identify business models that are thriving in the local market,
ascertain gaps in local services, and create a niche for the
organization’s services. The providers learned that referral-based
marketing strategies work better for home and community-based
services and differ from the word-of-mouth marketing strategies
that work best for residential services. This lesson underscored
the importance of establishing a network and relationships with
potential referral sources in the community.
Organizations looking to expand into home and communitybased services have a number of options as they operationalize
their plans. These organizations can start a new program, make
selective acquisitions of existing programs, or develop strategic
partnerships that can share the risks and responsibilities associated
with expansion. Organizations should take adequate time during
the planning process to determine which option is best for them.
Footnotes
1
One agency: Interview with the one supervisor
for all staff.
2
NORC staff members provide residents with
social work, nursing, health education and
benefits enrollment.
3
A CCRC is a retirement community that offers
several levels of health care on one campus: 1)
Independent Living for residents who do not
need assistance; 2) Assisted or Supportive Living
for those who require little supportive help with
activities of daily living; and 3) Skilled nursing
or rehabilitation care (short-term and long-term
care).
4 Program of All-Inclusive Care for the Elderly or
PACE is a program that coordinates the care for
each person enrolled in the program based on
their needs through comprehensive services and
supports.
5 One aging service provider offered a different
model of the home and community-based
services. This program is not included in the
overview of the providers.
6 Formerly known in Australia as “hostel care,”
low-care nursing homes allow people to live in
independent units while providing all meals and
assisting clients with chores and some activities
of daily living and instrumental activities of daily
living. This service seems to be similar to the
assisted living concept in the United States and
Canada.
7 High-care settings provide care that resembles
nursing home care in the United States.
8 According to the Australian Institute of Health
and Welfare, permanent residential aged care
is offered to people who can no longer be
supported living in the community. A residential
aged care facility assesses the care needs of
residents requiring permanent care. Depending
on a person’s assessed needs, permanent care
is currently offered at two levels: low care and
high care. Permanent residents receiving low
care require accommodation and personal care.
Residents receiving high care require 24-hour
nursing care in addition to their low-care needs.
9 Private insurance does not fund most home-based
care.
10 Feros Care was recently chosen as one of 13
organizations in Australia to operate a Regional
Assessment Service.
12 A naturally occurring retirement community is
a community that was not originally designed
for seniors, but that has a large proportion of
residents who are older adults (at least 60 years
old). These communities are not created to meet
the needs of seniors living independently in
their homes, but rather evolve naturally, as adult
residents age in place.
13 The White House Conference on Aging is a oncea-decade conference sponsored by the Executive
Office of the President of the United States which
makes policy recommendations to the president
and Congress regarding the aged.
14 The Centers for Medicare & Medicaid Services
(CMS) is a U.S. federal agency that administers
Medicare (federal health insurance for older
adults), Medicaid (federal health insurance for
low-income individuals), and the State Children’s
Health Insurance Program (federal health
insurance for low-income children).
15 Australian Government: Department of Social
Services website
16 A Medicare certified home health agency is
approved by Medicare and meets certain health
and safety requirements.
17 Medicare is the federal health insurance program
for persons 65 and older, certain younger people
with disabilities, and people with End-Stage Renal
Disease (permanent kidney failure requiring
dialysis or a transplant, sometimes called ESRD).
18 Older adults live in a home-like setting where
they can remain as independent as possible while
accessing accommodations and services that
meet their changing needs.
19 Shepherd’s Care at Home website: http://
shepherdscareathome.com/
20 PACE is a home and community-based services
program that provides comprehensive and
coordinated services and supports to older adults
based on their individual needs. The program is
designed to help individuals with a nursing home
level of need to continue living in the community,
rather than moving to a nursing home or other
care setting.
21 Accountable care organizations are groups
of doctors, hospitals, and other health care
providers who come together voluntarily to
deliver coordinated high quality care to their
Medicare patients.
11 These programs include FerosFitnesForever,
which offers nutritional, exercise and stressreduction counseling and other activities.
Sodexo • IAHSA • LeadingAge | 97
98 | Residential Provider Expansion into Home and Community-Based Services