To see why the home health field is growing, consider the case of Agnes Dutill, 55, who is visually impaired and has mild memory loss. The self-described street musician, who has sung for tips in Suburban Station, said she would be in a nursing home if it weren't for caregiver LaSandra Brown.

Each day, Brown goes to Dutill's home in West Philadelphia to help her wash, dress, and take her medications, as well as cook, clean, and do laundry. The two women and Dutill's guide dog, Rosa, often take walks or go shopping, marking the highlight of Dutill's day.

The assistance is critical because "I can live in my home," Dutill said. Her caregivers "even gave me a handbook in Braille. The other agencies didn't."

Brown works for My Independence at Home, a personal-care agency based near City Avenue. It recently was named Minority-Owned Small Business of the Year by the Small Business Administration of Eastern Pennsylvania, and is one of four home-care agencies named to the Philadelphia 100 list of fastest-growing companies.

The sector's showing is not surprising. As more baby boomers become seniors, home health has boomed as well, growing about 10 percent a year nationally, said Vicki Hoak, executive director of the Pennsylvania Homecare Association. The growth is fueled by the aging population and the government's desire to encourage the disabled and the elderly to stay at home rather than entering a nursing home, where the costs are much greater.

The need is especially prevalent in Pennsylvania, which has one of the oldest populations of any state. As of 2016, there were 629 home-care agencies in the five counties of Southeastern Pennsylvania. Among the largest are Bayada, Holy Redeemer, Penn Home Care, Mercy Home Health, and MARSCare.

Competition for workers is stiff, Hoak said. Medicaid, for low-income Americans and the disabled, reimburses an agency $19.52 an hour per patient, while Medicare, which covers only skilled care such as nursing or physical therapy, reimburses for a 60-day period, with the national average being $3,037, Hoak said.

Agencies will often turn to private-pay clients to help cover their budget. "It's a tough business," Hoak said.

My Independence was started in 2013 by Lisa Robinson, an Army veteran with a master's degree in organizational communication, who experienced home-care firsthand. She had a stroke at 33 and spent two months in rehab. "I credited my coming out of my stroke to the care I received. I decided to start my own agency."

She and business partner Rhonda Winfield started working out of a church. The agency now has 120 employees and more than 75 clients. It offers nonskilled home-care services to the elderly and adults with physical and intellectual developmental disabilities. Its revenues have risen by 47 percent over the last three years, going from $1.7 million to $2.5 million.

As health costs keep rising, experts are asking, "How can we spend our dollars smarter — keep patients out of the hospital? Patients want to remain at home, get service at home," said Nick Seabrook, managing principal of BlackTree Healthcare Consulting. The national firm based in Conshohocken is another agency on the list of  the region's 100 fastest-growing companies.

Seabrook, who has a degree in accounting from Villanova University, is a co-founder of BlackTree, which offers consulting and management services to home-health and hospice-care firms and nursing facilities. Its revenues have jumped from $7 million to $11.7 million over the last three years, a 67 percent surge.

Two other firms — Patient Care Coordination and Open Systems Healthcare, both based in Philadelphia — also made the list.

Patient Care Coordination offers services in care management for individual clients, said Paul S. Rimar, executive director. The firm monitors the care an agency provides a Medicaid recipient and insures there has been proper use of services. Rimar has a master's degree in social work from Temple University and worked widely in health before starting the firm four years ago.

Open Systems offers in-home care to 1,550 Medicaid and private-pay consumers in Pennsylvania as well as clients in Delaware, Florida, and Missouri. It's the largest of the four home-health firms on the list, more than doubling its revenue from $27.7 million in 2015 to $58.4 million in 2017.

Charles "Chip" Hill, COO and president of Open Systems, said consumers should know that Medicare Advantage —  a privately run Medicare alternative that limits members to a smaller network of providers — will begin in 2019 to offer a supplemental benefit providing for nonskilled personal care at home. "It's a great service for themselves or a loved one," he said.

One big problem for agencies is finding and retaining caregivers. "Talent acquisition is certainly a challenge in our industry, especially with so many competing in the Philadelphia area … for the same workforce," Hill said.

In Pennsylvania, the application process for Home and Community Based Services is changing for those on Medicaid. Gov. Wolf's administration, which launched Community HealthChoices in southwestern Pennsylvania on Jan. 1, will roll out the same program here next January.

Rimar said that Medicaid recipients here who need a waiver for in-home care must sign up with one of three managed-care organizations, Keystone First, PA Health and Wellness, or UPMC to be eligible beginning Jan. 1. If they don't choose by Dec. 21, the state will pick a managed-care plan for them.

The state expects about 128,000 individuals to sign up in the southeast. Once enrolled, they can still change their mind about which plan they want in the future, said Heather Hallman, a special adviser to the secretary of human services.

With many baby boomers entering retirement, Rimar said, the need for in-home care services "is definitely growing. So many individuals require supports." The firm's revenues have gone from $519,000 to $3,200,000 million in three years. Now the new Medicaid benefits will make it easier for the disabled and those in hospice care to remain at home.

Technology to assist with the billing, coding, and record-keeping for in-home services also is changing. Robinson said that her firm recently purchased software to allow My Independence employees to use a phone app, allowing "electronic visit verification," which Pennsylvania wants to implement by summer 2019.  "It's easier for aides to clock in and out," she said.

Seabrook agreed that with changing governmental requirements, it's "more of a heavy lift" for agencies in how they handle each individual client's case while meeting HIPAA requirements for patient privacy.  "Each payer is unique," he said. "There's definitely concern."

For Rimar, the firm he established to help promote in-home care is more than a business. "It's my calling," he said. "I have to give back."