Home Care Is Broken
I spent the last couple of years building a startup in home care. I went in thinking the problem was documentation. Documentation turned out to be the part I could see from outside.
In a 2022 University of Michigan poll, 88% of adults ages 50 to 80 said it was important to remain in their homes as long as possible (62% very important, 26% somewhat). In 2025, an average of 11,400 Americans turned 65 every day, 4.18 million over the year, the highest on record. The infrastructure meant to support them covers three sectors: personal care, home health, and hospice. Each has its own labor problem, and all three run on the same software.
Personal Care: The Caregiver Crisis
Personal care is the most basic tier. Caregivers help seniors with daily activities: bathing, dressing, meal prep, companionship. These are the people who show up at someone's home every day to make sure they are safe and fed.
The Bureau of Labor Statistics puts 2024 median pay for home health and personal care aides at $34,900 a year, $16.78 an hour. At the agencies I worked with, caregivers drove between clients on their own time, so the effective rate was lower than the BLS figure. The job is physically demanding, emotionally draining, and offers almost no career progression.
The Activated Insights 2024 Benchmarking Report puts industry-wide home care turnover at 79.2%, up more than 12 points over two years. At that rate an agency with 100 caregivers hires and trains roughly 79 replacements a year. For the senior on the receiving end, that is a rotating cast of strangers coming into their home, each one learning their preferences from scratch. Continuity of care, the thing that makes home care work at all, is close to impossible to maintain.
In the offices I sat in, administrative staff spent more of the week on recruiting and onboarding than on anything to do with care quality. You cannot build a stable workforce at $16.78 an hour minus unpaid drive time. Medicaid sets the reimbursement rate for a large share of these hours, so agencies cannot pay more by charging more. I do not have margin figures for the agencies I worked with; the owners described their margins as thin and none of them believed they could raise wages without a rate increase.
Home Health: Drowning in Paperwork
Home health is a step up in clinical complexity. Skilled nurses, physical therapists, and occupational therapists visit patients at home after surgery, during recovery, or for chronic condition management. The work does not end when they leave the patient's home.
Every home health visit generates documentation. The largest single piece is the OASIS assessment, a 40+ page standardized document CMS requires for reimbursement. Miss a field and you do not get paid. Fill one out wrong and you get compliance problems or audit flags.
Clinicians drive from home to home all day and are paid only for the time spent with patients. The clinicians at the agencies we worked with did their documentation at night, after the last visit. Several told me they were still writing OASIS assessments and SOAP notes near midnight.
I wrote about this in my post on browser agents for EMR automation. The documentation burden is what led us to build Northlight in the first place. The longer I spent in the industry, the more documentation looked like a symptom of something that runs through all three sectors.
Hospice: The Work Nobody Talks About
Hospice is end-of-life care. Hospice clinicians and volunteers sit with people who are dying. They manage pain, provide comfort, and support families through the worst moments of their lives.
Hospice carries the same documentation burden as home health, layered on top of that work. Volunteers are part of the staffing model by regulation: 42 CFR 418.78 requires a hospice to use volunteers for administrative or direct patient care in an amount equal to at least 5% of the total patient care hours of all paid employees and contract staff. The hospice coordinators I spoke to described recruiting and keeping those volunteers as their hardest staffing problem. I do not have turnover or burnout figures for hospice volunteers.
The staff who left, in the conversations I had, described the same combination: a day spent helping someone die with dignity, then regulatory paperwork in the evening.
The Fax Problem
Agencies get patients through referrals, and the referrals come by fax. When a patient is discharged from a hospital and needs home health or hospice, the hospital faxes over pages of clinical history, medication lists, and physician orders.
In 2026, agency staff still read each fax by hand, decide whether they can accept the patient, and respond. The intake teams I worked with could not get through the day's referrals in the day, because there were not enough people to triage them. By the time someone reviewed a referral, another agency had accepted it or the patient had been placed elsewhere.
CMS has rules pointing the other way. The Discharge Planning final rule, published September 30, 2019, requires hospitals to run an effective discharge planning process and give patients information about their post-acute provider choices, and CMS wrote that it "complements efforts around interoperability that focus on the seamless exchange of patient information between health care settings." Seven years on, it has not changed how referrals arrive.
The Technology Problem
For every software team I watched try to sell into this market, including my own, the legacy EMRs were the thing that stopped them. (The market figure everyone quotes is $130+ billion growing at double digits. I have not been able to trace it to a source I trust, so treat it as folklore.)
A handful of vendors dominate home care EMRs, WellSky the biggest. These systems were built in the early 2000s, designed for a pre-API world, and scheduling, documentation, billing, and compliance all run through them.
The systems I looked at had no public APIs, no webhooks, and no integration layer worth mentioning. The vendors have captive customers who are afraid to switch, because migration means months of disruption and possible compliance gaps. Since switching is expensive, opening up buys the vendor nothing. The vendors we approached had no documented API and treated any integration as a paid custom engineering project priced case by case.
Every vendor we approached wanted a revenue share as the price of an integration partnership. We did not sign one. After that, agency staff told us their EMR vendor had described outside tools like ours as a security risk and an unsupported integration, and our conversations with those agencies stopped. I cannot prove the vendor caused it, but that was the sequence.
A better scheduling tool needs data out of the EMR. Automated documentation has to write back into it. Care quality analytics need the records that live inside it. Every improvement has to pass through a vendor that does not want you there.
That is why home care technology is a decade behind hospital technology. Acute care went through its EHR transition, forced by Meaningful Use regulations and billions in federal incentives. Post-acute care was left out, and the vendors who filled the gap built closed systems.
Where Integration Fails
The AI for three specific tasks here already exists. OCR and document intelligence can parse a faxed referral into structured fields, triage it, and rank it against an agency's capacity. Background agents can listen to a clinician's visit, structure the conversation into clinical language, and fill out the OASIS assessment, which is the approach I described with browser agents. Voice AI can handle caregiver scheduling calls, shift check-ins, and training modules.
Each one has to land its output somewhere. The referral data goes into the scheduling module. The OASIS assessment populates a specific patient record. The caregiver check-in updates the care plan. All of those live in WellSky or whatever legacy system the agency runs, and that is the step where the product stops.
You can build a genuinely good AI product for home care and lose at the integration layer. Of the teams I have watched try, the ones that got in did it through a revenue share or by being acquired. I would not claim there is no third path, only that I have not seen one work.
Three things could shift that: regulation forcing interoperability the way Meaningful Use did for hospitals, startups routing around the EMRs with tools like browser agents, or agencies collectively demanding more from their vendors. The current arrangement holds only as long as agencies keep paying for software they cannot connect anything to.
Why This Matters Now
The number of Americans 65 and older is projected to nearly double, from 52 million in 2018 to 95 million by 2060. Turnover at 79.2% and median pay at $16.78 an hour describe a workforce that cannot be staffed at the wages currently on offer, and demand is rising against that.
Technology is one piece of this. Labor economics, Medicaid reimbursement rates, and a handful of EMR vendors set the boundaries. Of those, the closed EMRs are the constraint a startup can attack directly, and that is where I would spend the effort.