Ten conversations into my goal of having 100 interviews with senior care providers, I want to start sharing what I'm hearing. The care agency owners, administrators, and operators I've spoken with so far are spread across Texas, Florida, Ohio, California and Arizona. This letter is for you. The busy owners and operators who graciously took time to talk with me. I learned that you all run different kinds of businesses: private-pay home care, some majority Medicaid waiver agencies, some home health, some a mix of home care with residential care facilities too. Your markets are different. Your payer mixes are different. Your challenges are not identical.
HOWEVER, several patterns and themes are showing up everywhere when I ask you: "How is your experience staffing shifts?" Or "How do you find qualified clients?" That's what this issue is about—the common themes and patterns. I hope it may be interesting to you to see my most updated synthesis of learnings. Maybe there is something new you can take away. It's the least I can do, try and share something valuable, for you taking time to teach me so much. Let's get started.
Five Patterns I'm Hearing Consistently
With only 10 interviews, I want to be careful about calling these definitive findings. But I'd be doing these conversations a disservice if I didn't note how consistently certain themes came up. Every single person I've spoken with has touched on each of the following:
- The "balance" problem. Keeping caregiver supply and client demand in proportion at the same time. Too many clients relative to staff risks service failures. Too much staff relative to clients risks losing caregivers who need hours. Every operator described some version of this ongoing calibration.
- The caregiver "bench." Maintaining a pool of trained, background-checked, per-diem caregivers who aren't currently assigned to cases but can be called on quickly. Building this "bench" and keeping it warm is a consistent priority I've heard from you all.
- Pre-hire attrition. Candidates who don't show up to interviews, or disappear between hire and first shift. Or worse—"no call, no show." One agency owner estimated that roughly 7 in 10 applicants don't show to an interview. The pipeline problem is apparent.
- Paid lead platform frustrations. Non-exclusive leads, upfront costs before conversion, and referrals that don't fit the agency's actual capabilities. Several operators described these platforms as expensive and unreliable, but a "necessary evil" for client acquisition.
- Reimbursement and margin pressure. Medicaid and waiver reimbursement rates that make it hard to pay caregivers competitively. Medicare Advantage rules that have narrowed what qualifies for coverage. Cost of living and inflation causing private pay rates to be unaffordable for many. The squeeze on margins is limiting what agencies can invest in their workforce, operations, marketing, and growth.
What Operators Are Actually Doing Right Now
These aren't recommendations from me. They're practices that operators described during our conversations when I asked how they manage the staffing, client, and "balance" challenges. Some of these are familiar. Some surprised me. I'm sharing them as field intelligence. Hopefully you find something thought provoking and applicable to your operations.
On building and holding a caregiver "bench":
- Start every new hire PRN with short shifts first. One operator puts all new caregivers on per-diem (PRN) status starting with four-hour shifts before increasing their case load. Reliability problems surface before they cause a real gap in care.
- Keep interviewing even when you're fully staffed. Multiple operators described recruiting as a continuous function, not something that gets turned on when a gap appears. The bench needs to be replenished constantly.
- Accept that caregivers work for multiple agencies and compete on being easy to work with. Several operators said they have stopped trying for exclusivity. Instead, many focus on being the agency that calls first, communicates well, and treats caregivers fairly so you are the preferred agency when caregivers' availability opens.
- Reallocate bench staff during slow periods rather than watching them drift away. At least two operators described moving underutilized caregivers temporarily into administrative or residential care roles to preserve the relationship when client census dips. "If you don't put them to work, you lose them."
On finding caregivers beyond job boards:
- Health fairs as a dual-purpose recruiting and branding channel. One operator partners with their local Workforce Commission to attend health fairs. Candidates from those events tend to have genuine interest, not just a reflexive response to a posting.
- A dedicated full-time recruiter as a structural investment. More than one operator credited hiring a full-time recruiter with improving her pipeline quality. She described the results as significant. Most smaller agencies haven't made this hire.
- Employee referrals as the highest-quality pipeline source. Multiple operators described referrals from existing caregivers as producing the most reliable hires. Designing a simple referral incentive structure is worth considering if you don't have one. People do like to work with their friends.
One calendar note that surprised me:
- Plan for tax refund season bench attrition. A franchise operator mentioned that February–April reliably thins her bench as caregiver schedules shift when IRS refund money arrives. She now front-loads recruiting in January. A small adjustment with a real operational payoff.
The Balance Problem: What It Actually Feels Like to Manage
I want to spend a little more time on this "balance" concept, as it was a pattern that came up most frequently and I think it's worth understanding beyond a bullet point.
The balance "tension" isn't just about having enough staff. It's about two variables that move independently and affect each other in real time. Client census goes up; you need more caregivers. A caregiver quits; you may need to pause client intake. A marketing push works too well and you're suddenly understaffed. A slow month leaves your bench idle and they find other work.
One operator who has been in home care for over a decade described it this way: the constant tension between building a caregiver roster and bringing on clients without overextending the team or ending up with cases you can't staff. What stayed with me was the word "tension." Not a problem. A tension. Something you manage, not something you solve.
A newer agency owner described a recent week in which there were missed approximately 30 hours of potential care due to a staffing gap. It was described as a week where the balance math just didn't work out.
The Benchmark: The Caregiver-to-Active-Client Ratio
Multiple operators cited a target ratio of 1.5 to 2 caregivers per active client as a marker of stability. Below that range, a few back-to-back call-outs can cascade into missed care. Above it, you have room to absorb normal disruption. If you don't know your current ratio, this week is a good time to calculate it.
How Operators Are Finding Clients
Most of this issue has focused on the staffing side of the equation, but the balance tension runs in both directions. Client acquisition came up in every conversation, and a few things stood out.
Paid lead platforms like A Place for Mom are widely used and widely criticized. The frustrations are specific: leads get sent to multiple agencies at once, creating "call fatigue" for families who immediately receive several simultaneous calls after submitting one inquiry. Agencies pay before they know if the lead will convert. And the leads are often not matched to an agency's actual service area or capabilities.
The operators with the most stable client pipelines tend to be less dependent on any single paid platform. What's working: hospital and assisted living discharge relationships, Medicaid waiver case manager referrals, VA Aid and Attendance referrals, word-of-mouth from satisfied families, and community presence built through things like dementia education sessions, community events, and local recognition. Google Ads were mentioned by more than one operator as converting better than Facebook ads for direct inquiries.
Multiple operators flagged the Medicare GUIDE program: a newer CMS initiative covering dementia care coordination as an emerging payer and referral pathway worth tracking. I expect this to come up in future interviews and will dig into it more in the next issue.
Three Lines That Stayed With Me
"The constant tension between building a caregiver roster and bringing on new clients without overextending the team, or ending up with clients you cannot staff."
— Home care operator · 10+ years in the industry
"As gas goes up, staffing goes down."
— Home care franchise operator
"Any society should be judged by the way they care for those with the least."
— Home care operator · 15+ years in the industry
Topics I Expect to Cover in Coming Issues
These are themes that have come up often enough in the first 10 interviews that I'm confident they'll get their own treatment.
- Caregiver no-call/no-shows: what's driving them and what's actually reducing them
- Building referral pipelines that don't depend on paid lead platforms
- Medicaid waiver participation: the trade-offs operators are actually making
- VA Aid and Attendance: how to get started and what the experience looks like
- Caregiver screening and interview processes that operators say are working
- How AI-driven search is changing the way families find care and what that means for operators
If There's Something You Want Me to Ask
If there's a topic you'd like me to bring into future interviews—something you're wrestling with yourself, or something you'd genuinely like to know how other operators across the country are handling—please just reply and let me know. I'll work it in.
And if you know someone in home care, home health, or senior living who would be open to a conversation with our team, or who might find this newsletter useful, I'd be grateful for the introduction. Thank you for your service to your community. Take care.
— Dr. Logan DuBose, MD, MBA
Co-Founder, Olera, Inc. · NIA SBIR Interview Series Project · logan@olera.care
As part of our ongoing NIA-funded Small Business Innovation Research (SBIR) grant, Olera, Inc. is conducting 100 in-depth interviews with owners, operators, and administrators across the long-term care industry. This work is funded through a Small Business Innovation Research (SBIR) grant from the National Institute on Aging. Our grant award supports research and development of innovations in community-based long-term care. Findings from this interview series will directly shape Olera's current research and development agenda and NIH reporting.
Notes from the Field goes out as new interviews are completed, roughly monthly. All operators are anonymized by region and agency type. Nothing in this newsletter is sponsored or affiliated with any vendor.
Co-Founder & COO