New Hampshire Home Care Staffing Shortage: What Families Can Do

The Scale of the Problem

New Hampshire has one of the fastest-aging populations in the country, and its home care workforce has not kept pace. The state's Choices for Independence (CFI) Medicaid waiver authorizes home care hours for thousands of residents who meet nursing facility level of care — but authorization and delivery are two different things. Families routinely find that their parent's approved care plan sits partially or entirely unfilled because agencies cannot recruit enough direct support workers to cover their caseloads.

The federal class-action lawsuit Fitzmorris v. Weaver, filed against the state, directly addresses this failure. The core allegation is that New Hampshire's Medicaid reimbursement rates are too low to attract and retain home care workers, which means the state is authorizing services on paper while structurally preventing their delivery. For families, the legal proceedings offer long-term hope but no immediate solution — the case is ongoing, and even a favorable ruling would take time to translate into more workers at the bedside.

Why the Shortage Is Worse in Home Care

The staffing crisis affects nursing homes and assisted living facilities too, but home care is hit hardest because of structural disadvantages in how the work is organized:

Pay disparity. Private-duty home care agencies in New Hampshire charge families $35 to $50 per hour, but the worker typically receives $15 to $20 per hour after the agency takes its margin. Medicaid-funded home care pays agencies even less, which compresses worker wages further. A certified nursing assistant can earn more working a facility shift with guaranteed hours, benefits, and proximity to coworkers than driving between rural home care clients.

Transportation burden. New Hampshire is geographically spread out, with long drives between clients in rural counties like Coos, Grafton, and Carroll. Agencies struggle to staff shifts in areas where a worker might drive 30 minutes each way for a two-hour visit — the economics simply don't work at current reimbursement rates.

Isolation. Home care is solitary work. Workers in facilities have colleagues, supervision, and social interaction. Home care workers are alone in a client's house, often managing complex care needs without backup. This makes the work less attractive to a workforce that already has other options.

What Families Can Do Right Now

If your parent has approved CFI waiver hours that agencies cannot fill, you are not stuck waiting. Several practical strategies can close the gap.

Use the Self-Directed Care Option

The CFI waiver supports a self-directed care model where the recipient (or their authorized representative) hires, trains, and manages their own caregiver — including a family member, friend, or neighbor. The caregiver is paid through a fiscal management agency at competitive rates funded by NH Medicaid.

This option sidesteps the agency staffing problem entirely. Instead of waiting for an agency to assign a worker, you recruit someone your parent already knows and trusts. The caregiver must be at least 18 years old and pass a criminal background check. Spouses can serve as caregivers, but this requires written confirmation from DHHS Division of Long-Term Supports and Services (DLTSS) — your care coordinator can initiate that request.

Stack Multiple Service Sources

The CFI waiver is not the only source of home support. Families often leave other programs untapped:

• National Family Caregiver Support Program (NFCSP): Administered through local Area Agencies on Aging, this program provides respite grants, caregiver training, and supplemental services with no income test. Contact your local ServiceLink office to apply.
• Title XX Social Services Block Grant (SSBG): Funds home care and adult day services for adults with income below $1,645/month. This program operates independently of Medicaid.
• Meals on Wheels and senior transportation: These services reduce the total burden on paid caregivers by covering nutrition and medical transportation needs through the Older Americans Act network.

Negotiate with Multiple Agencies

Don't accept a single agency's waitlist as the final answer. CFI waiver participants have the legal right to choose their Case Management Agency (CMA) and home care providers. If your current agency cannot staff your parent's authorized hours, ask your care coordinator about transferring to a different provider. Some agencies have stronger recruitment pipelines in specific regions of the state.

Raise the Issue with Your Care Coordinator

Document every instance of unfilled authorized hours — dates, times, which shifts went uncovered, and the impact on your parent's safety. This documentation serves two purposes: it supports any formal complaint to DHHS about inadequate service delivery, and it strengthens the record if your family needs to appeal a care plan reduction or pursue additional services through the administrative hearing process.

The Longer View

The staffing crisis is structural, not cyclical. It will not resolve on its own without significant changes to reimbursement rates, worker training pipelines, and the economics of rural service delivery. Families who rely on a single agency or a single funding stream are the most vulnerable to gaps.

The Aging in Place in New Hampshire guide covers the self-directed care setup process step by step — from requesting the fiscal management agency to drafting a caregiver agreement — along with the non-Medicaid safety net programs that can supplement your parent's approved care hours while the broader system catches up.

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