Home care is broken

I spent the last couple of years building a startup in home care. We started with documentation, then ran into staffing shortages and closed medical record systems.

Almost 90% of adults 50 to 80 want to stay in their homes as long as possible. In 2025, around 11k Americans turned 65 every day, the most on record. The industry meant to support them splits into three sectors: personal care, home health, and hospice. Each has its own staffing problems, and all three depend on medical record software.

Personal care

Personal care workers help seniors bathe, dress, prepare meals, and stay socially connected.

A caregiver makes about $35k a year, roughly $17 an hour. At the agencies I worked with, caregivers drove between clients on their own time, so the effective rate was even lower. The work is physically hard and emotionally draining, with few opportunities for promotion.

Caregiver turnover across the industry is nearly 80%, up more than 12 points in two years. At that rate an agency with 100 caregivers hires and trains roughly 80 replacements a year. For the senior, that means repeatedly meeting a new caregiver and explaining their preferences again.

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 can't build a stable workforce at $17 an hour minus unpaid drive time. Agencies can't pay more, because Medicaid sets the reimbursement rate for a large share of these hours. I don't have margin figures. The owners described margins as thin, and none believed they could raise wages without a rate increase.

Home health

Home health provides clinical care at home. Nurses, physical therapists, and occupational therapists visit patients after surgery, during recovery, or to manage chronic conditions.

Every visit requires documentation. The largest assessment is OASIS, a standardized document of more than 40 pages that CMS requires for reimbursement. Missing or incorrect fields can cause payment and compliance problems.

Clinicians get paid only for time with patients, so they document at night after the last visit. Several told me they were still writing OASIS assessments near midnight.

We built Northlight to reduce that documentation work.

Hospice

Hospice is end-of-life care. Clinicians and volunteers manage pain and support families.

Federal regulation requires hospices to staff volunteers for at least 5% of total patient care hours. The coordinators I spoke to called recruiting and keeping volunteers their hardest staffing problem. I don't have turnover numbers for them.

The staff I spoke to who had left hospice described spending their days caring for dying patients and their evenings on regulatory paperwork.

The fax problem

Agencies get patients through referrals, and the referrals come by fax. When hospitals discharge patients who need home health or hospice, they fax clinical histories, medication lists, and physician orders to agencies.

Agency staff read each fax by hand, decide whether they can accept the patient, and respond. The intake teams I worked with couldn't get through a day's referrals in a day. By the time someone reviewed one, another agency had taken the patient.

A 2019 rule requires hospitals to plan patient discharges, give patients their post-acute options, and support "seamless exchange of patient information between health care settings." Seven years on, it hasn't changed how referrals arrive.

Closed medical record systems

Every software team I watched try to sell into this market, including my own, struggled to get access to the existing medical record systems.

A handful of vendors dominate home care electronic medical records, or EMRs. WellSky is the largest. Their systems date to the early 2000s and handle scheduling, documentation, billing, and compliance.

The systems we worked with had no public APIs or webhooks. Customers were afraid to switch because migration could disrupt operations and create compliance gaps for months. The vendors we approached priced each integration as a custom project.

Every vendor wanted a revenue share for an integration partnership. We didn't sign one. Afterwards, agency staff told us their vendor had called tools like ours a security risk, and our conversations with those agencies stopped. I can't prove cause, but that was the sequence.

Scheduling tools and care quality analytics need to read EMR data. Automated documentation needs to write it. We needed the vendor's cooperation to do either.

Meaningful Use regulations and billions in federal incentives pushed hospitals to adopt electronic health records. Post-acute care did not receive the same incentives, and its EMR vendors built closed systems.

Tools still need EMR access

Software can extract fields from faxed referrals and compare them with agency capacity. Agents can draft OASIS assessments from visits. Voice AI can handle scheduling calls and shift check-ins.

Each tool needs to write its output into the EMR. Without that access, agency staff still have to enter the information themselves.

Of the teams I've watched get integration access, all did so through a revenue share or acquisition.

Regulation could require interoperability. Browser agents could use the existing interfaces. Agencies could also demand integration access from their vendors together.

Growing demand

The number of Americans 65 and older is on track to nearly double to 95 million by 2060. Agencies already struggle to retain caregivers at $17 an hour.

A startup has little control over Medicaid rates or caregiver pay. I'd focus on getting new tools to work with the existing EMRs.