First, let me describe the clientele for those who aren't familiar.  Generally speaking they are people with disabilities under the age of 60 with income anywhere from poverty level to upper-middle-class.  All have long-term disabilities, many of which are permanent.

Many home care agencies struggle to make money providing to Medicaid waiver.  For many it's simply a breakeven endeavor used to provide hours to caregivers.  Other organizations have been successful at making profits using Medicaid waiver, and here are six strategies that have helped.

Client/caregiver matching -- Being a profitable provider to Medicaid waiver means that you run a high-volume, high efficiency operation.  Getting the right client with the right caregiver takes extra time, and schedulers often fall back to the "any warm body" strategy.  I've seen this more frequently with demanding and/or impolite clients.  (Believe it or not, people in wheelchairs can be jerks too.)  Taking extra time to find a caregiver who can get along with a particular client will often reap benefits.  A client who has failed to retain caregivers this year will be very happy to find one who is a perfect personality match.  When that good match is found, the calls to the scheduler and the money you spend on this particular client will decrease.

Recruit dependable caregivers -- Years ago we conducted a detailed client satisfaction survey and found that the most important aspect of a caregiver is dependability.  I know from personal experience that a caregiver with excellent clinical skills and a sparkling personality is only valuable to me if he/she will be at my home at 6:30 a.m. on time every day.  Identifying dependable caregivers early can save you lots of money in the long run.  Dependability is one of the six characteristics that can be assessed in pre-employment testing and interviewing.

Improve continuity -- Several times agencies have tried to convince me that having multiple levels of caregivers provides more stability and security.  One agency even provided a total of 12 different individuals during a single two week pay period.  They weren't my agency for long.  For most clients two caregivers is the optimum.  Only use more than two if the client has more than 40 hours weekly.  I realize this presents a scheduling challenge, but in the long run it will save you money.

Reduce travel time -- If you serve a large geographic area, try to get highly organized to reduce travel time.  Shorter commutes create happier caregivers, happier clients and a happier bottom line.  One New York City agency who serves many Medicaid waiver customers who live in public housing has been successful in recruiting caregivers from the same building.

Upsell -- In today's market consumer preference is highly regarded.  Nowhere is this truer than Medicaid waiver, where empowering recipients is a mark of success.  Talk with your happy clients, and ask how you could make them happier by providing more care.  Then help them get in touch with their case managers and help them to become better self advocates.  I'm not suggesting that you get every client to simply ask for more hours, but identify areas of a client's life that would be improved with additional care.

Lobby -- Running an efficient operation is terrific, but ultimately, the fastest way to improving profits is to increase rates paid to Medicaid waiver providers.  In many states, individual agencies don't get a choice about the rates they are paid.  Get organized and lobby legislators and program directors for increased rates.  Connect with other Medicaid waiver providers, and without violating antitrust, share data that will bolster your case.  A true lobbyist isn't a beggar or whiner.  A true lobbyist shows data that supports their cause.  Show how increasing funding to the Medicaid waiver program will save money in other areas, promote the economy, provide to the underprivileged, or reduce bureaucracy.

The six techniques not only work for Medicaid waiver, but for other governmental programs as well.  Apply them to other state or county funded agencies or even philanthropic community groups.