I once cared for a client in his home who seemingly had a complete plan of care: medications, meals, housekeeping, safety checks. Every visit was documented. Every task was finished. He was also one of the loneliest people I have ever known, but nothing in his chart would have shown that.
Loneliness in home care is usually treated as a clinical problem or a social one, but it is also a design problem. Nobody in this field set out to build a service that delivers everything except company. Home care has become good at measuring what it can count. Tasks completed, minutes worked, notes filed, incidents avoided. Those measures exist for good reasons. They protect clients, satisfy payers, and allow agencies to operate at scale. Organizations naturally produce what they measure. Nothing in those measures tells us whether anyone actually felt less alone.
The clearest example is electronic visit verification. Under the 21st Century Cures Act, states must use EVV for Medicaid personal care and home health services delivered in the home. It is now the most complete record the field has of what happens during a visit. It captures the service performed, the client, the caregiver, the date, the location, and the time the visit begins and ends. Six things. None of them is whether the visit reached anyone.
That is not a flaw in EVV. It was built to confirm that visits occurred, and it does that well. But it has become the field’s default picture of home care, and there is no place in the picture for the part of the visit that mattered most to someone like my client.
The Decisions That Add Up
Consider the operating decisions one at a time.
Visit length is set by authorization and by margin. When a visit is scheduled to the minute required for the tasks, the 10 minutes that might have become a conversation are not cut deliberately. They were never allocated.
A client who meets a different caregiver every week starts over every week, and so does the caregiver.
Caregiver continuity is treated as a scheduling variable. Filling the shift counts. Filling it with the same person does not. Yet continuity is what makes a relationship possible. A client who meets a different caregiver every week starts over every week, and so does the caregiver.
Training follows the same pattern. Curricula are built around transfers, infection control, body mechanics, and documentation because those are the areas where regulators and liability live. Communication, when it appears, is usually a module about reporting to a supervisor. Very little teaches caregivers how to build trust with the person in the chair.
Quality measurement and reimbursement close the loop. Agencies are paid for units of service and evaluated on outcomes that connection does not appear in. What is not paid for is not scheduled. What is not reported rarely exists to the people making the next round of decisions.
None of this is negligence. It is the accumulated result of choices that each made sense on their own.
Yet, intent matters less than outcomes. The Centers for Disease Control and Prevention has linked loneliness and social isolation to depression, declining physical health, dementia, and earlier death. The National Academies reached similar conclusions in its 2020 report on social isolation and loneliness in older adults. For many home care clients, the caregiver is the most consistent person they will see all week. Sometimes the only one. That places a meaningful amount of health-related contact in the hands of a workforce whose job description rarely acknowledges it.
I am not proposing a new program. The field does not need a loneliness initiative layered on top of a system that already squeezes out conversation. Conversation and continuity are assets home care already has. They are unrecognized, unmeasured, and unfunded, but they already exist. The work is to protect and support them rather than invent something new.
For workforce training, it means teaching conversation as a professional skill alongside technical competencies and telling caregivers plainly that talking with a client is part of the work, not a break from it.
Agency leaders will read this and think about margin, and they are right to. Home care runs thin, and none of this works if it means unpaid time. But the changes that matter most are not additive. Scheduling the same caregiver with the same client does not cost more than scheduling a different one. Naming a relational goal in the plan of care does not lengthen the visit. Teaching conversation as a skill can replace training hours rather than adding them. The expensive version is a new service line. The affordable version is deciding that what caregivers already do counts.
Where the Work Starts
For agencies, that means treating continuity as a quality decision rather than a scheduling convenience and making relationships part of the plan of care. For workforce training, it means teaching conversation as a professional skill alongside technical competencies and telling caregivers plainly that talking with a client is part of the work, not a break from it. For payment and quality policy, it means asking whether current measures capture any of this and building measures that do.
My client did not need another program. He needed someone to pull up a chair. That opportunity already existed. Everyone in his life who could have done it was busy completing the things we had decided to count. We did not mean to design conversation out of home care, but we can decide to design it back in.
Dustin Prestridge spent two decades leading large operational teams before becoming a caregiver following his diagnosis with early-onset Parkinson’s disease. He is a psychology student at Seattle Central College and a research assistant in Dr. Patrick Raue’s CREATIV Lab at the University of Washington, where his work focuses on caregiver interaction and loneliness among older adults receiving home care.
Photo credit: Shutterstock/NewAfrica
