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Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist


Home health agencies (HHAs) developed strategies to respond to challenges during the COVID-19 pandemic, including providing new incentives to maintain staff and seeking alternative sources of personal protective equipment. HHAs have also benefited from support from the Centers for Medicare & Medicaid Services (CMS), such as regulatory flexibilities and expanded telehealth allowances, but staffing challenges persist. In light of the expanded use of telehealth, more information is needed to determine its future use across different home health services.


The COVID-19 pandemic required HHAs to adapt their care to respond to COVID-19's infectious nature, as well as other circumstances from the pandemic. HHAs play an important role in caring for Medicare beneficiaries: in 2020, the first year of the COVID-19 pandemic, HHAs cared for over 3 million beneficiaries. CMS requires HHAs to prepare for and respond to emergencies and, during those emergencies, CMS can offer regulatory flexibilities and supports (which we refer to collectively as regulatory flexibilities) for various requirements. This report provides insights into HHAs' experiences that will help stakeholders continue managing the response to COVID-19 and prepare for future emergencies.


We surveyed a nationally representative sample of 400 HHAs, 396 of which participated in Medicare, in fall 2021 to ask about their experiences early in the pandemic and at the time we administered the survey. We projected our results to the 72 percent of Medicare-participating HHAs represented by our sample. In addition, we interviewed 12 HHAs about notable challenges, strategies, or other experiences they identified in their surveys. We also interviewed staff at CMS about its support of—and perspectives on—HHAs' provision of care during the pandemic.


Like all health care providers, HHAs have experienced multiple challenges to providing care during the COVID-19 pandemic. HHAs have continued to experience longstanding staffing challenges as well as new ones resulting from the pandemic, such as maintaining staffing despite quarantine and isolation protocols. These staffing challenges persist for many HHAs despite efforts to address them. In addition, HHAs faced numerous and widespread infection control challenges, including accessing personal protective equipment (PPE) to limit exposure and spread, but these have mostly eased since early in the pandemic.

HHAs' own strategies to respond to the pandemic included offering paid leave to retain staff and finding PPE from nontraditional sources. HHAs have also benefited from government support—including regulatory flexibilities instituted in response to the declaration of a public health emergency—and this support has mitigated some staffing challenges. For example, by the Federal government's allowing new types of providers to certify and order home health services and complete certain patient assessments, HHAs could more efficiently provide care. Telehealth flexibilities under the public health emergency have also helped HHAs provide care while reducing COVID-19 exposure and dealing with staffing shortages. However, HHAs' challenges with telehealth raise questions about its future role in home health care, and—because of limited reporting requirements—CMS has limited insight into HHAs' telehealth use. Finally, the emergency preparedness plans required by CMS guided HHAs' responses to the pandemic but fell short of fully addressing a global emergency such as COVID-19.


CMS has an opportunity to assess how to best help HHAs prepare for and respond to future emergencies, as well as to evaluate how changes to the home health landscape can better serve patients. To that end, we recommend that CMS evaluate how HHAs are using telehealth-specifically, the types of services provided via telehealth and the characteristics of patients who benefit from these services. We also recommend that CMS-to inform decision-making-evaluate how the regulatory flexibilities it has offered in response to the COVID-19 public health emergency affect the quality of home health care. Finally, we recommend that CMS-in collaboration with the Administration for Strategic Preparedness and Response's (ASPR's) Technical Resources, Assistance Center, and Information Exchange (TRACIE)-apply lessons learned from the COVID-19 pandemic to update and/or develop emergency preparedness trainings and materials for HHAs on responding to infectious disease outbreaks. CMS concurred with all three recommendations.