My agency is also paid per episode for CHHA cases, in other words, bundling.
We have suffered major layoffs of clerical staff (which basically means more work for us nurses in the end) and have over the past few years not filled many nursing positions when nurses left due to retirement or for other jobs.
But, this is mostly due to the fact that I work for a government agency in the public health dept (which umbrellas the CHHA, LTHHCP and PCA programs as well as the mandated maternal/child health programs), and our county supervisors have over the past few years basically bankrupted our county, so the layoffs have not exactly been a result of our home care agency efficiency, but rather "across the board" layoffs in every department of the county (except for DMV and the snowplow drivers, but that's a whole 'nother story!)
The introduction of electronic charting has caused our visit times to be longer, and so we are seeing more patients, it's taking us more time to see those patients, and our reimbursement rates are less.
However, there are so very many changes happening in health care, I'm another one who is of the mindset that home care is eventually going to be playing a much bigger role in the overall industry, as it's clearly been proven that home care after hospital discharges reduces rehospitalization rates.
I think it's going to be a very bumpy ride and many smaller home care agencies and even governmental home care agencies may go under or be sold to private entities (two surrounding counties where I live have been sold to private agencies).
With good leadership and extreme proactiveness in adapting to changes and having fleets of home care nurses that are extremely educated and proficient in OASIS documentation (required by Medicare) will make or break an agency in the immediate future.
But the longer term future of home care is, again in my opinion, going to burst with need of nurses and programs.