Better Jobs Better Care: Retaining Long-Term Care Workers

Long-TermCare Reform HCBS and Olmstead

Better Jobs Better Care: Retaining Long-Term Care Workers

Good direct-care workers - nursing assistants, home health aides and personal care attendants - are essential to high-quality, long-term care for seniors and the disabled because they provide the bulk of hands-on, paid care for these populations. Unfortunately, there is a severe shortage of these workers, and it will likely worsen as the baby boomers age. The Bureau of Labor Statistics estimates that personal and home care assistance will be the fourth-fastest growing occupation by 2006, with a dramatic 84.7 percent growth rate. But if the need for workers will soar, the supply will not. The number of people who need long-term care is expected to increase much faster than the supply of people between ages 20 and 64, who make up most of the direct care workforce.

Currently, direct care work is physically and emotionally demanding, and working conditions are often unfavorable. Workers leave the field because of low wages, lack of benefits, limited opportunities for advancement, lack of appropriate training, poor public image, lack of respect and exclusion from patient-care planning. "Annual turnover rates are 70 percent," said Debra Lipson, deputy director for the demonstration project Better Jobs Better Care, citing a study by the American Health Care Association. "In other words," she said, "two out of three direct-care workers leave their jobs in the course of a year."

The median hourly wage for direct-care workers in 2002 was $8.70, according to the U.S. Bureau of Labor, but there is great discrepancy between wages for workers in institutions and those who work in personal homes. "In a hospital, an aide gets about $18,000 [a year]. In a nursing home, they may get $15,000 and, in a residential care home, it's like $12,000, which has got to change," stated Lipson. A March 2004 study from the Paraprofessional Healthcare Institute and the North Carolina Department of Health and Human Services found that 35 states (out of the 44 responding states) considered current worker vacancies a serious issue.

A BETTER WAY

To reduce high vacancy and turnover rates among direct-care staff in all long-term care settings and, in the end, improve the quality of care, The Robert Wood Johnson Foundation and The Atlantic Philanthropies have funded a 4-year $15.5 million research and demonstration program called Better Jobs Better Care.

The Institute for the Future of Aging Services at the American Association of Homes and Services for the Aging is the program office for Better Jobs Better Care, providing technical assistance to the grantees in partnership with the Paraprofessional Healthcare Institute, a non-profit health-care employment development and advocacy organization.

The organization is using two types of grants - for demonstration programs and research and evaluation projects - to identify which interventions appear to be most effective in recruitment and retention of direct-care workers, said Lipson. In July 2003, the project awarded up to $1.4 million to each of five grantees in Iowa, North Carolina, Pennsylvania, Oregon and Vermont.

Over the next three and a half years, the demonstration projects will test innovative strategies to improve the recruitment and retention of direct-care workers. These strategies include training for direct-care workers and their supervisors and organizational cultural change for direct-care workers to be much more involved in patient care. "The aides spend the majority of their time with long-term care clients, but oftentimes their input is ignored," said Lipson.

In addition, the project awarded up to $500,000 to each of eight universities and centers in September 2003 for two years to conduct research and evaluations on workplace and public policy interventions. The demonstration grantees in the five states will then have a year to disseminate their findings.

Here is how the project is testing new approaches in three states: Iowa, North Carolina and Vermont.

IOWA

The average aide turnover in nursing homes in Iowa is estimated at 80 percent and is reported to be as high as 200 percent in some facilities. To chip away at these percentages, the Iowa CareGivers Association - one of the country's first independent statewide professional associations for direct-care workers in long-term care - along with a coalition of providers, state agencies and consumer organizations, received a Better Jobs Better Care grant. The funding will allow the coalition to expand and enhance the state registry of nursing assistants, study health insurance coverage and develop peer mentor training programs.

As required by federal law, Iowa's Department of Inspection and Appeals maintains a registry of certified nursing aides (CNAs) who work in nursing homes. However, the database currently does not include direct-care workers in other settings. The coalition is using its grant to include in the registry health-care aides, rehabilitation aides, medicine aides, personal care attendants and other personnel who work under the direction of a nurse.

The registry is designed to detect and monitor abuse. "But we're hoping that it will be a means to have a profile of these workers to determine the supply of workers and how many use it as a stepping stone to a career and how many leave after three months," said Di Findley, executive director of the Iowa CareGivers Association.

The grant also will allow the association to update a 2001 wage and benefits survey. "What we learned [in 2001] is that 70 percent of those surveyed said their employer offered health insurance, but 43 percent said they could not afford it," said Findley. "With this grant, we will repeat the survey and add more questions to find out how many are without coverage."

The association then will study the feasibility of offering health insurance to its members. "Some say that it would be cost-prohibitive for our association to provide health insurance to these workers because they are high risk," Findley said. For example, the workers often have to lift their clients, which puts them at high risk of injury and increases the cost of premiums.

Another grant initiative is to develop peer mentor training for direct-care workers. The association has recruited 11 nursing homes and 4 home-care providers to participate in an orientation program in April 2004. The mentor training was first piloted in nursing homes in 1998, and now with the grant funds, it is being modified for home settings.

CNAs in nursing homes are required by federal law to have 75 hours of training. This peer mentor training program would be an additional two days beyond the federal requirement. This program will "launch workplace culture changes to give clients more control and empower workers within the organization," said Findley.

While the grant dollars are crucial, the majority of the association's funding is from state and federal dollars. Legislators have been "very responsive to recruitment and retention and [have] appropriated dollars to our organization," she said. "They understand the importance of these issues because of the high numbers of older people."

Change is slow to occur, Findley acknowledged. But she pointed out that more than 80 providers requested applications and 40 returned them to participate in the Iowa Better Jobs Better Care program. "That tells us people are ready for change," she said.

NORTH CAROLINA

In the Tar Heel State in 2002, the turnover rates for direct-care workers in home-care agencies averaged 39 percent; in nursing homes, 95 percent; in adult-care homes, 115 percent, according to the state Department of Health and Human Services and the University of North Carolina, which analyzed data from the annual provider licensure renewal process.

The significant shortage of direct-care workers has motivated the department to join a broad coalition of providers, workers, advocacy organizations and other state agencies. The coalition is using its Better Jobs Better Care grant to develop a voluntary, special licensing designation for home care companies, adult care homes and nursing facilities that have excelled in recruiting and retaining workers.

The coalition is hoping that facilities that obtain the special licensure will eventually be rewarded with increased Medicaid reimbursement, said Susan Harmuth, project director. But in the meantime, at the very least, the new licensure could "serve as a marketing tool for providers," she added.

During the first year of the grant, the coalition plans to create four major domains - balanced and safe workload, supportive workplaces, opportunities for advancement, and training - for the special licensure. During the second year, the state quality review organization will work with other state regulatory agencies to determine which providers meet the criteria. After a pilot period, the project is expected to go statewide by the end of the grant in December 2006, said Harmuth. Coalition members "will be able to compare turnover data from those providers who received the special designation with the state average," she said.

The state applied for the grant "to build off of some of the other projects in the state," said Harmuth. For example, the state is developing two new job categories for direct-care workers: medicine aide and geriatric nurse aide. Also, the state's "Win a Step Up" program provides financial and other incentives for workers who complete additional training and commit to staying with their current employer.

"The big thing is that we came together early with all of the stakeholders, and we're all looking at ways to address the shortage," said Harmuth. With the help of an outside facilitator, we are reaching consensus and moving forward, she concluded.

Vermont

Like the coalitions in Iowa and North Carolina, the Community of Vermont Elders (COVE) - a consumer advocacy organization devoted to improving the lives of seniors - and about two dozen other organizations in Vermont had been working collaboratively for years to improve the direct-care workforce. A study commissioned by the Vermont Department of Aging and Disabilities found that the turnover rates range from 35 to 60 percent in nursing homes and home health agencies and are up to 400 percent in residential care homes.

The project is using its Better Jobs Better Care grant to expand quality criteria for nursing homes to include workforce measures, increase reimbursement for workers in residential care facilities and adult-day programs, develop licensure for personal care attendants and initiate a certificate of proficiency program for direct-care workers to receive specialized training.

The Vermont Department of Aging and Disabilities has a $125,000 fund to reward nursing homes that achieve success in four areas of quality, said Tim Palmer, COVE's executive director. Through the Better Jobs Better Care grant, the state will now "add a fifth criterion that will gauge recruitment and retention of direct-care workers," he said. Out of a total of 44 nursing homes in the state, up to five nursing homes will receive $25,000 in 2005 based on how well they meet the five criteria.

COVE also has been working to increase reimbursement especially for residential care facilities and adult-day programs. COVE members have been testifying before various legislative committees that these workers should be paid more on par with workers in other long-term care settings. Vermont is one of the few states that has a budget surplus, and last year, the state increased funding for residential and adult day care by $100,000, Palmer said.

This year, the budget has not yet been approved, but the House Appropriations Committee has approved another increase for both types of providers. "There is a willingness on the part of the legislature to invest in those aspects of the long-term care continuum that support older Vermonters to stay at home," commented Palmer.

Personal care attendants in Vermont are not licensed by the state right now, so the coalition also is developing a consistent definition of the training and skills that a personal care attendant should have, said Palmer.

Finally, the project is creating a certificate of proficiency program through which direct-care workers in fields such as mental health, dementia and Alzheimer's, hospice, palliative care, and/or rehabilitation can receive specialized training and then be compensated at a higher level. COVE will begin issuing the certificates in early 2005, but members hope that a statewide entity will eventually take over. That way, the certificates "can be generally available and acknowledged in the industry across the state," Palmer said.

Referring to the state's small size and the large number of grant initiatives, Palmer said he thinks Vermont was chosen for the grant because "what appears to be a small investment goes far here."

Lipson summed it up: "This field has been so neglected and so ignored for so long. Even in the midst of [most states] cutting back, we hope this project will make a better case for investing in this workforce."

For more information on Better Jobs Better Care, go to http://www.bjbc.org/.

This story appeared in the April 19th issue of State Health Notes, Vol 25, #418 (PDF version). Please visit the website at www.ncsl.org/shn.