National Center for Health Workforce Analysis

Effects of the Workforce Investment Act of 1998 on Health Workforce Development in the States

November 2004

Submitted in completion of Cooperative Agreement # 4-U79-HP-00011-01 for the Bureau of Health Professions, Health Resources and Services Administration

FINAL REPORT

I. Table of Contents (for on-line viewing only) Printer-friendly report (Adobe/pdf)

II. Executive Summary

III. Why This Report?

IV. What Is WIA?
Origins and Goals
Structure
State and local Workforce Investment Boards (WIBs)
Services at the local level
Services at the state level
Funding Streams
National and state funding allotments
Allocation of funding streams within states
Accountability Measures
Implementation

V. The Health Workforce and WIA
Health Workforce Development Planning
State program highlights: CA, FL, GA, ME, MS, OH, OR,
TX, VT, WA, WV, WI
Programs to Promote Health Care Careers
State program highlights: GA, MS, NJ, OH, PA, SC, TX, WA, WI 41
Health Career Ladder Advancement
State program highlights: CA, FL, GA, MA, TX, WA
Building Health Workforce Educational Capacity
State program highlights: AZ, CO, GA, OR, TX, WA, WI
Health Workforce Retention
State program highlights: CA, MI, TX, WI
Direct Support for Health Careers Education and Training
State program highlights: CA, CO, DE, GA, MS, ND, PA,
SC, TX, VA, WA, WI
One-Stop Center Referrals for Health Workforce Jobs
and Education

VI. WIA Reauthorization

VII. Discussion

VII. Literature Cited

Susan M. Skillman, Joshua Sadow-Hasenberg, L. Gary Hart (Center for Health Workforce Studies, University of Washington) and Tim Henderson (National Conference of State Legislatures)

Address: Center for Health Workforce Studies, 4311 11th Avenue NE, Suite 210, University of Washington, Seattle, Washington 98105 (Phone: (206) 543-3557, FAX: (206) 616-4768, http://www.fammed.washington.edu/chws/)

Acknowledgments: Thanks to the many representatives of state and local workforce investment boards who took the time to respond to our questions. We are also indebted to Alice Porter for her editorial guidance, and Martha Reeves for word processing leadership.

II. Executive Summary

Introduction

The Workforce Investment Act of 1998 (WIA) replaced the Federal Job Training Partnership Act, with the goals of increasing the employment, retention, and earnings of participants in Department of Labor (DOL) employment and training programs, largely by increasing the occupational skills of participants. WIA was designed to streamline services, empower individual participants, provide state and local flexibility, and promote increased accountability in jobs programs.

WIA mandates that states and local areas carry out workforce planning in partnership with business, elected officials, labor, and other key stakeholders through Workforce Investment Boards (WIBs). Every state must be subdivided into workforce development areas, and direct services to clients are delivered through "One-Stop" centers in each of these areas. WIA provides job search assistance, assessment, and training for eligible individuals under three main funding streams: Adult, Dislocated Worker, and Youth. It promotes a "work first" mission for clients, and intensive training resources are provided only if clients do not become employed using other, short-term interventions.

When WIA was implemented beginning in 1999, shortages were emerging among many health workforce professions, and even greater shortages were being projected for the next several decades. DOL named health care as a high-growth industry, containing 10 of the 20 fastest-growing occupations from 2002 through 2012. But most of the health sector jobs that are in high demand require associate- or baccalaureate-level education or other specialized training. Many familiar with the needs of the health care sector wondered how, under these circumstances, WIA resources could relieve its workforce shortages.

This report describes how WIA resources have been used by state and local workforce investment boards to develop the health care workforce. We contacted state and local workforce boards to identify health workforce development activities supported with WIA resources through the DOL. This study also describes characteristics of WIA that can be used to support health workforce development.

Key Findings

As a result of the health workforce sector's high-demand status and states' relative flexibility in implementing WIA, a broad range of WIA-supported health workforce programs were implemented across the country. Health workforce development programs tend to fall into seven general categories: health workforce development planning, programs to promote health care careers, career ladder advancement, educational capacity building, workforce retention, direct training support to individuals, and referral of eligible individuals to health workforce jobs through One-Stop centers.

Health workforce planning: The structure of WIA and its financing features have facilitated assessment and planning efforts for many of the states and their local areas. About 15 percent of WIA funds may be reserved for statewide activities, including planning. Planning functions identified in the report include support for state health personnel shortage committees and task forces, data gathering and dissemination, and the development of grant programs to support activities to reduce shortages. States highlighted in the report: CA, FL, GA, ME, MS, OH, OR, TX, VT, WA, WV, and WI.

Programs to promote health care careers: Providing appropriate and timely information about health care careers to individuals who may become interested in choosing health care employment is critical to developing and maintaining the health workforce and filling the gaps for many occupations. In addition, the health care workforce needs to attract underrepresented minorities to better serve the overall population and to provide all racial and ethnic groups with the economic benefits of employment in the health care sector. This report provides examples of state and local WIB projects to introduce students to health care jobs and of programs to promote health care careers to low-income adults and those seeking a second career. In several states, WIBs have helped to mount media campaigns to inform the general population of the value and rewards of health care careers.
States highlighted in the report: GA, MS, NJ, OH, PA, SC, TX, WA, and WI.

Health career ladder advancement: One strategy for increasing the supply of health care workers is to encourage workers in entry-level positions to gain the training for higher-level health care positions. This approach is efficient because people who have already chosen jobs within the health care field do not need to be oriented to the nature and value of the work. In addition, health care institutions with in-house career ladder advancement programs promote employee loyalty through greater job satisfaction and commitment to the employing organization. One of the most common career advancements that the career ladder programs facilitate and that is described in this report is from licensed practical nurse (LPN, or licensed vocational nurse, LVN, in some states) to registered nurse (RN). Providing training opportunities for certified nursing assistants (CNAs) to become LPNs is another common type of career ladder advancement.
States highlighted in the report: CA, FL, GA, MA, TX and WA.

Building health workforce educational capacity: Qualified applicants to nursing schools are being turned away at institutions across the country, even as the Nation is experiencing an estimated shortage of nearly 140,000 RNs. Similarly, the educational capacity for other health workforce occupations does not produce enough health care workers to meet current demand. To get clients into training for the high-demand health care fields, WIBs explored such innovative approaches as loan repayment programs for faculty training, distance learning programs, provision of site coordinators to expand clinical training capacity, and pooling of WIA tuition resources to provide additional college course sections.
States highlighted in the report: AZ, CO, GA, OR, TX, WA, WI.

Health workforce retention: Many health care jobs are physically and emotionally demanding, which can lead to employee "burnout." Competition among employers for limited numbers of workers also contributes to high turnover. Retaining workers in the health care industry can be challenging, but recruiting and training new employees is a particularly expensive consequence if retention fails. While various strategies are considered effective for employee retention, WIA resources are best suited to retention programs that enhance opportunities for continuing education, certification, training, and career advancement. Providing mentors and preceptors to help employees get through professional hurdles also increases job satisfaction and retention.
States highlighted in the report: CA, MI, TX, and WI.

Direct support for health careers education and training: States also use WIA resources to route individuals directly into health care education and training programs. Some have used WIA funds for health profession-specific tuition. Others have used this resource to develop "Health Careers centers" or to set up training programs to prepare groups of clients for entry-level health care jobs. WIA also supports customized training for employers who are committed to hiring people who complete WIA-supported instruction.
States highlighted in the report: CA, CO, DE, GA, MS, ND, PA, SC, TX, VA, WA, and WI.

One-Stop center referrals for health workforce jobs and education: The linkages of clients to jobs through One-Stop centers are important to health workforce development, but the extent of their application is not easily quantified because WIA performance measures do not document the industry sector in which employment occurs. Because of the large number of health care jobs available compared with other industries, we can nonetheless be certain that One-Stop centers across the Nation have linked many individual job-seeking clients with health care jobs.

WIA's reauthorization by Congress was scheduled for 2003, but because of debate over changes in the program, a continuing resolution has extended the Act since that time. Reauthorization issues being debated are combining the funding streams to provide states with greater spending flexibility, changing WIB membership requirements and functions of local WIBs, tying WIA closer to delivery of Temporary Aid for Needy Families (TANF) services, easing access to training services, and reducing the number and alter the types of performance measures.

Discussion

WIA resources are used across the United States to build the health care workforce, especially for occupations with training requirements of two years or fewer. Use of WIA resources for data collection and planning supports a health workforce planning infrastructure that serves an even larger spectrum of the health workforce. But it is difficult to say how much WIA itself, and not the economic environment, has contributed to the significant emphasis many states and local workforce planning groups have placed on health industry jobs since 1999. Many regions, and several states, have not used WIA resources for specific programs to connect clients with health care jobs; it would require additional study to understand why the health sector was not a priority in those areas.

WIA has been a catalyst for helping to alleviate health care workforce shortages with pooled resources — mobilizing additional resources from both public and private sources. The WIA mandate for business partnership helped provide new opportunities for involvement of the health care industry in workforce planning. It also increased awareness of the health care industry's high-demand, high-growth status. But the health care industry would likely have been represented at many WIA planning tables without its mandated involvement. The health workforce shortage "crisis" had already brought many in the industry together to seek solutions.

Reauthorization may affect how WIA relates to the health care industry. If clients can be routed quickly to training programs, and if new performance measures are designed to support WIBs that encourage clients to receive training, more WIBs may take on health workforce development activities. Health industry participation in state and local WIBs, whether encouraged by WIA requirements or by activism within the industry, will continue to promote awareness of the health care sector's needs.

While this report has documented the process of health care workforce development with WIA resources, little information is available on the outcomes of these WIA-funded programs. Research and evaluations are needed to identify which programs are successful in increasing the supply of needed health care workers and connecting them with stable jobs that provide living wages.

WIA is not the sole vehicle for meeting our health workforce needs. Nonetheless, it provides a multi-billion dollar infrastructure that can help the Nation's health care industry fill major gaps in many entry-level, allied health and nursing jobs. Health care business, educators, policy makers and workers benefit from understanding how WIA relates to their needs and how changes will affect them in the future.

III. Why This Report?

The Workforce Investment Act of 1998 (WIA) was one of several efforts at "devolution" of Federal programs to provide greater state control of Federal resources. It represented the first major job training reform in more than 15 years—replacing the Job Training Partnership Act (JTPA). The legislation's goal was to increase the employment, retention, and earnings of participants in Department of Labor (DOL) employment and training programs, largely by increasing the occupational skills of participants. Among the DOL's stated principles for WIA were streamlining services, empowering individual participants, providing state and local flexibility, and promoting increased accountability. WIA reauthorized the DOL's Adult Education and Literacy programs, amended the Wagner-Peyser Act (the Federal-state partnership for providing unemployment insurance), and provided for linkages to other Federal labor programs. States were to have fully transitioned to the new WIA program by July 2000.

As WIA was being implemented, health care employers were experiencing major shortages of registered nurses (RNs) and other health professionals in all types of health care settings, including hospitals, long-term care, and ambulatory care facilities. At the same time, jobs in manufacturing and technology—business sectors whose employees were most often recruited and trained through JTPA programs—were in decline. WIA mandates that states carry out workforce planning with the involvement of business, elected officials, labor, and other key stakeholders. Having high demand for employees, health sector businesses were frequently at the WIA table to encourage that resources be spent to expand their pool of potential employees.

Responding to persistent need, programs to reduce health workforce shortages have been growing in number and intensity across the states during the past decade. These programs have occurred through sponsorship of state and local governments and professional organizations such as state hospital associations and nursing associations. For many who had been working in health workforce education, planning, policy, and research, WIA represented a new player on the scene. Those not familiar with the DOL's programs — in particular, with WIA — had questions about the law, the department's goals, and how these resources would be used. Specific questions about WIA's impact on the health care workforce included whether health care would surface as a priority for WIA funding among all states, which types of health workforce development programs would be implemented, how many professions would be involved, and whether the program would generate health workforce development models for others to follow.

The purpose of this report is to describe the extent to which WIA resources have been used by state and local workforce investment boards to develop the health care workforce. It provides examples of specific local and statewide health workforce development programs from the first years after WIA implementation, and it describes key features of WIA that lend themselves to health workforce development. This report should interest states and local jurisdictions that want to develop similar programs, Federal agencies that want to know how this program is being implemented in the health sector, and health workforce policy makers seeking new programs and resources for health workforce development.

IV. What Is WIA?

Following is a general overview of the WIA: its origin and goals, structure, funding streams, accountability measures, and implementation status. Health care is only one of several industry sectors for which WIA links clients with jobs. WIA is a complex law, with many rules, formulas, and exceptions. Basic knowledge of the law and how it has been implemented is necessary to understand how the health care industry can be served by WIA, as well as barriers to using WIA resources for health workforce development.

Origins and Goals

The aim of WIA was to overhaul and consolidate the fragmented system of U.S. workforce development programs in place prior to 1998. WIA was designed to provide job search assistance, assessment, and training for eligible individuals under three main funding streams: 1) Adult, 2) Dislocated Worker, and 3) Youth. The WIA required that specific employment-related services be administered through a "one-stop system" whose clients are both potential employees and employers.

The new "Workforce Investment System" was designed with the principles of streamlining services, empowering individuals, providing universal access, increasing accountability, providing new roles for local workforce boards, encouraging state and local flexibility, and improving systems to support youth (U.S. Department of Labor, 2003c). WIA replaced the JTPA, which had been the main vehicle for DOL employment programs since 1982. WIA brought together 17 Federal programs previously operating autonomously out of four different agencies. A primary change that WIA made to the JTPA was to mandate state and local Workforce Investment Boards (WIBs) and their core membership and functions. WIA requires each state to support a state-level WIB and be divided into local workforce development areas, each served by a local WIB. These WIBs guide all employment programs, as prescribed by WIA, in their region.

Signed into law on August 7, 1998, the Workforce Investment Act of 1998 has five components:

• Title I — Workforce investment systems
• Title II — Adult education and literacy
• Title III — Workforce investment-related activities
• Title IV — Rehabilitation Act amendments of 1998
• Title V — General provisions

Title I contains most of the details of the new workforce investment system. It describes the roles and functions of its components, how funds are allocated, how accountability is measured, how the programs are evaluated, and what special programs and technical assistance will be provided under the Act. Title II and Title IV reauthorize the Adult Education and Literacy and the Rehabilitation Act programs. Title III authorizes and links other related programs to WIA programs. Title V requires DOL to award "incentive grants" to each state that exceeds the state-adjusted levels of performance for each of the three WIA programs: workforce investment, adult education, and vocational education (states must submit applications for these incentive grants).

Structure

While not as "devolved" as block grants, WIA gives states and local areas more control over workforce development programs than existed prior to 1998. The law includes both mandatory and voluntary elements, and states have the opportunity to grandfather some existing programs if they are consistent with WIA's goals. As a result, the WIA programs vary among the states, although there are some core elements that are common to all WIA programs.

State and Local Workforce Investment Boards (WIBs)

Planning and oversight of state and local WIA programs take place through WIBs; one at the state level and one at each of the local workforce development areas required under the law. The mandated membership of the WIBs is intended to increase the likelihood of serving the two main customers of the new Workforce Investment System: local businesses and individuals seeking employment. Business, labor, and community organizations must be represented on state and local WIBs (see Table 1). WIA allows for some grandfathering of existing workforce boards and committees to become WIBs.

Table 1
Required Members for State and Local Workforce Investment Boards (WIBs)

Source: U.S. Department of Labor, 2003b.

The law permits great diversity in the structure of a local WIB. While some WIBs are both policy makers and service deliverers, many local WIBs work in partnership with a state agency or non-profit organization that actually delivers services to job seekers and employers.

Services at the local level

Under WIA, states must assign all their area into local workforce development areas. While most states have many local workforce development areas (New York has 33, Michigan has 25, and California has 50), some have only one or very few (North Dakota and New Hampshire have one, and Alaska has two). Regardless of the number in the state, each workforce development area operates with some common features, as described below.

One-Stop delivery system: WIA mandates that local programs be delivered through a One-Stop delivery system within each workforce development area. While workforce development areas have flexibility in designing their One-Stop systems, the One-Stop centers must have a physical presence in the local area and must have specified contractual relations with the local WIB. One-Stop centers may be operated by postsecondary educational institutions, local employment service offices, community-based organizations, for-profit entities, or government agencies. The One-Stop centers are responsible for providing services for Dislocated Workers and Adult programs.

One-Stop centers operate under a "work first" mission. Eligible clients are to be connected with resources to help them obtain jobs or promotions to higher-paying positions as quickly as possible. On-the-job training receives priority, as does short-term programs for upgrading skills, adult education and literacy programs, and customized training for an employer who is committed to hiring people who complete the WIA-supported training program.

One-Stop centers use WIA resources to provide job seekers first with "core," then "intensive" services, and if the client's needs are not met, the resources can be used for "training" activities (see Figure 1). One-Stop centers have limited discretion to provide customized services to clients. WIA funds may be used to pay for tuition and books, as well as to support services such as child care and transportation. "Core activities" include determining WIA eligibility, job search and placement assistance, career counseling, assistance in establishing eligibility for welfare-to-work and financial aid, provision of information on filing unemployment insurance claims, and providing various employment statistics. One-Stop centers can use "intensive services" for unemployed job-seekers who are unable to obtain employment through core services and for employed persons unable to be self-sufficient in their current jobs and who need services to keep their jobs or obtain new ones. Intensive services can be provided directly by the One-Stop centers or can be contracted to other entities. These intensive services include more comprehensive skill and needs assessments, group and individual counseling, career planning, and case management. WIA intended "training" services to be used if clients were not adequately served through core and intensive services and if clients were determined, through "core" and "intensive" assessments, to need additional training. Training is to be provided through Individual Training Accounts (ITAs) and only for occupations with demonstrated demand. ITAs act as vouchers that can be used to obtain services from WIA-eligible training providers. The ITAs are intended to promote customer choice—allowing recipients to purchase the training services (within some program constraints) that best meet their needs. This approach is a departure from the pre-WIA system of delivering training services, where program participants were often routed into specific program-funded training programs.

Figure 1
Progression of WIA Client Services Delivered by One-Stop Centers [D]

Figure 1 description: The first level of WIA client services to be provided by One-Stop Centers are "core" services including activities such as determining eligibility; outreach, intake and orientation; assistance with job search and placement; initial skills assessments; career counseling; compiling employment statistics; providing information on filing unemployment insurance claims; and providing assistance with accessing Welfare-to-Work and financial aid. After providing core services, One-Stop Centers may progress to "intensive" services, which include comprehensive skills and training needs assessment; group and individual counseling; development of individual employment plan and career counseling; and case management. After core and intensive services are offered, the One-Stop Center may provide "training" services. Training includes services such as occupational skills training; on-the-job training; upgrading skills; adult education and literacy training; entrepreneurial training; and customized training for employers who have committed to hiring.

One-Stop centers administer more than WIA programs. As shown in Table 2, job seekers and industry can access other DOL programs at One-Stop centers, as well as programs administered by the Federal Department of Education, Department of Health and Human Services, and Department of Housing and Urban Development. States may route other services, such as Temporary Assistance for Needy Families Program (TANF), through the One-Stop system. TANF is the Federal block grant program that provides states with funding for providing welfare services, replacing the Aid to Families with Dependent Children program, through the Personal Responsibility and Work Opportunity Reconciliation Act (PRWORA) of 1996. In 2001, 28 states had formal agreements that linked TANF to their WIA One-Stop systems (U.S. General Accounting Office, 2002b).

Eligibility: WIA Youth programs target low-income youth between the ages of 14 and 21 who need basic literacy skills or otherwise need assistance to complete their education or to find a job. Adults can use core services with no eligibility requirements. Priority for intensive services under WIA Adult programs is given to persons receiving public assistance or determined to be "low-income." Dislocated worker programs serve unemployed individuals and displaced homemakers, but they exclude long-term unemployed. The programs include provisions to encourage assistance to economically disadvantaged adults (determined through Census income data for geographic areas). Young adults ages 18-24 can obtain WIA resources through the Adult WIA programs, and when they use those programs, they do not have to meet the regular adult income requirements.

All individuals are eligible for "core" services from One-Stop centers. Local WIBs determine income eligibility criteria for adults who make use of the "intensive" One-Stop center services. The WIA requires that priority for adult "training" services go to welfare recipients and other low-income individuals. If resources are not limited, the "intensive" and "training" services can be made available to other clients. Dislocated worker funds must be used exclusively for services for persons who have been laid off or who have been notified that they will be laid off.

Postsecondary educational institutions and apprenticeship programs meeting basic criteria are automatically eligible to be WIA training providers. Each state's governor sets criteria for determining the eligibility of other training providers. All providers must meet minimum levels of performance and have their eligibility renewed at regular intervals.

Local planning and oversight: Local WIBs plan and oversee the WIA programs for their workforce development areas, with local elected officials' involvement. Among the mandates for local WIBs are that they develop local plans (subject to approval by the governor), designate One-Stop center operators and eligible training providers, and negotiate performance measures, which WIA requires. Some local WIBs have established additional workforce subpanels (e.g., "WIBlets" in Illinois and Health Skills Panels in Washington) to take on specific local workforce planning tasks. While membership of local WIBs is mandated by WIA, these sub-WIB planning panels have more freedom in selecting members and can address more targeted goals by selecting members with backgrounds more suited to specific industry or skills-related planning tasks.

Services at the state level

State WIBs are responsible for statewide workforce investment activities. They must develop five-year plans for state WIA activities, subject to approval by the Secretary of Labor. They develop and/or advise the governor on systems for statewide workforce investment and employment statistics, and they assist the governor in monitoring the statewide system. Statewide efforts that can be carried out by the state WIB include disseminating lists of eligible training providers, conducting evaluations, providing incentive grants to local workforce development areas, providing technical assistance to local areas with poor performance records, and supporting One-Stop centers and management information systems. States may also use WIA funds for activities such as incumbent worker programs (to assist employed workers to gain skills required for higher paying jobs), special programs in high-poverty areas, capacity building, and research. Required and allowable statewide activities are listed in Table 3, below. WIA is structured to provide states with set-asides from each funding stream for statewide activities (see Funding streams, below). In general, states may use up to 15 percent of funds from each funding stream for statewide activities.

Source: U.S. Department of Labor, 2003c.

Funding Streams

The WIA designates three major funding streams: Youth, Adult, and Dislocated Worker funds. The three WIA programs, housed in the DOL Education and Training Administration (ETA), have provided from $3 billion to $4 billion in workforce development funds each year since 2000 (see Table 4).

Sources: U.S. Department of Labor, 2003a; U.S. General Accounting Office, 2002c.

National and state funding allotments: The Secretary of Labor withholds 20 percent of Dislocated Worker funds for national programs such as National Emergency grants, technical assistance, and demonstrations. State WIA allotments are calculated annually based on formulas defined in the Act. State formula variables include the annual average number of unemployed, the annual average number of excess unemployed, the annual average number of long-term unemployed, and the number of economically disadvantaged youth within the state. Because of the variability of these factors, and because of changes from year-to-year in the Federal WIA budget, state WIA resources vary by state, and they can change significantly from one year to the next, as shown in Figure 2.

Figure 2
Examples of State WIA Allocations (Combined Youth, Adult and Dislocated Worker Funds Program Years 2000-03) [D]


Data compiled from: Federal Register, 2003; U.S. Department of Labor, 2001a.

Allocation of funding streams within states: For the most part, WIA distributes funds within states by formulas detailed in the Act. There are various exceptions, such as minimum allocations for some small states and hold-harmless assurances that ensure, for some allocations, that states receive no less than they received in a specified prior year. The Youth and Adult streams require that 85 percent of funds be spent on local programs. The Dislocated Worker stream requires that 60 percent of funds be spent on local programs, while 25 percent is earmarked for emergency state use, e.g., for rapid response if large numbers of workers lose their jobs because of major industry changes. The remaining 15 percent of each of the three funding streams are for discretionary use by the states, allowing state WIBs to create statewide strategies for workforce development, invest more heavily in particular funding areas, or any of the other activities listed in Table 3 (with administration activities limited to no more than 5% of funding).

Accountability Measures

WIA mandates program performance measures and evaluation. Several descriptive evaluations of WIA implementation have been published or are underway (Barnow and King, 2003; D'Amico et al., 2001; U.S. Department of Labor, 2001b; U.S. General Accounting Office, 2003b). The results of DOL-funded evaluations have described the speed at which states have implemented WIA, different structural approaches, effects of different political environments, implementation problems, and other comparative features, but there has been little description of the business sectors for which WIA has provided employees. This omission is not surprising, as the mandated WIA performance measures look only at numbers of persons employed (or, for youth, completing education programs), earnings, and satisfaction (see Table 5). The Act includes financial incentives for high performance on these measures and financial sanctions for poor performance (although these sanctions have not been implemented—see next section). WIA outlines a parallel incentive process for setting local performance levels between state and local WIBs. The DOL published results based on WIA performance measures in June 2003 (U.S. Department of Labor 2003c).

Sources: U.S. Department of Labor, 2000; U.S. General Accounting Office, 2003c.
* Of those who did not have a job when they registered for WIA, the percentage of adults who got a job by the end of the first quarter after exit. This measure excludes participants who are employed at the time of registration.
** Of those who had a job in the first quarter after exit, the percentage of adults who have a job in the third quarter after exit.
*** Of those who had a job in the first quarter after exit, the postprogram earning increases as compared with pre-program earnings.
**** Of those who received WIA training services, the percentage who were employed in the first quarter after exit and received a credential by the end of the third quarter after exit.

Implementation

Some state and local WIBs have used the implementation of WIA as an opportunity to substantially restructure their workforce development networks, while others have limited their changes to those mandated and have only cautiously exercised the options for new directions allowable under WIA (O'Shea and King, 2001). In a related way, the extent to which workforce development activities are led by the state WIB versus local WIBs also varies by state. At one end of the spectrum is Utah, which has only one WIB, and most workforce development activities are orchestrated through the State Department of Workforce Services. Florida and Texas also have strong state roles, backed by state legislation, but they still have active local WIBs. Others such as Maryland, Michigan, Missouri, and Oregon have very strong local WIBs with wide discretion in policy formulation and decision making (Barnow and King, 2003).

WIA performance measures have generated considerable discussion and controversy. The measures differ from those required under JTPA, and some participants complained that the new measures were quite onerous. While community colleges are major training providers for WIA programs, many perceived performance measurement as an unfunded mandate and limited their participation—slowing WIA implementation in some states (Dervarics, 2001; Shaw and Rab 2003). States' compliance with performance measurement was hampered because the WIA specifications were not released until the first year of implementation was underway. These problems were described by the General Accounting Office (GAO) in 2002 (U.S. General Accounting Office, 2002a) along with problems such as a lack of comparable data across states, sentiment that the measures lacked methods to factor-in local economic conditions, and a lack of measures to assess the performance of the One-Stop system as a whole (U.S. General Accounting Office, 2002a). Some states and local regions may have adopted a "creaming" approach to program enrollment: targeting individuals for enrollment who were more likely to score favorably on performance measures (Barnow and King, 2003; U.S. General Accounting Office 2003a). As a result of these controversies, states performing well on the performance measures have remained eligible for WIA performance incentive grants, but the DOL postponed financial sanctions for not meeting minimum performance. Much discussion has addressed ways to improve WIA performance measures, and as a result, the Bush Administration and the House and Senate have included modifications in their WIA reauthorization proposals (see WIA Reauthorization section).

Other important implementation factors have been the level of WIA's contribution to the overall pool of workforce funding for a state, as well as limits to the amount of resources an individual client can receive. WIA funding makes up variable amounts of states' total workforce development streams: other Federal, state, and local funds combine with WIA to create the total resource pool. WIA's contribution can be a very small portion, as in Texas where WIA makes up only 16 percent of the state's Workforce Commission's budget and in Utah, where WIA provides only three percent of Utah's Department of Workforce Development budget. The fact that state workforce development is supported, and complicated, by multiple funding sources drove WIA's emphasis on One-Stop centers and attempts to merge some funding streams. Some states have succeeded more than others on creating relatively seamless systems that help connect clients to resources, patching together resources for which the client is eligible from the various Federal and state workforce programs. Success has been related to the strength of state leadership to support seamless programs, being able to manage the variability of funding among employment programs, and applying creativity to overcome the barriers of program compartmentalization (examples include meeting the individual administrative requirements of programs such as TANF, Employment Security, and Food Stamp Employment and Training — all programs that are important employment resources) (Barnow and King, 2003). For industries such as health care, in which many jobs require college education at two-year, four-year, or higher levels, WIA resources alone usually cannot carry a client through to attainment of a higher paying job.

WIA is described and implementation is detailed in the reports listed in Table 6, as well as in the references cited in this report.

V. The Health Workforce and WIA

WIA was designed to give states and sub-state regions considerable latitude to build systems of workforce development that meet the needs of local business while giving job seekers choice among job and training opportunities. The Federally imposed structure includes many mandatory elements that give the workforce programs some common features and constraints, but it also encourages flexibility in some aspects of the program so that states and local areas can respond to workforce needs and development resources in their areas. As a result, there has been great variability in the extent and types of WIA-supported workforce development activities across the United States since the Act was implemented.

States' political and economic environments, how they had previously managed their JTPA programs, and their level of business involvement in workforce planning have all been significant factors in how fast and in what form WIA was implemented. In general, business involvement in WIA has not been as great as hoped, but business has more often been active at the planning table when specific industries' workforces were targeted for development (Barnow and King, 2003; D'Amico et al., 2001; National Governors' Association, 2002). Industry-specific, or "sectoral" strategies have strengthened relationships between the One-Stop centers and the business community as they work together to solve specific industry problems (John J. Heldrich Center for Workforce Development, 2002). In the late 1990s and early 2000s, the health care sector has faced shortages of many different professionals, and these have brought that industry's representatives to many WIA planning tables across the Nation. The Nationwide shortage of RNs, the largest single profession in the health workforce, was the impetus for many health sector leaders to get involved in statewide and local workforce forums. In many state and local health workforce development programs, the health sector business partnerships filled the gaps where Federal resources were limited or could not be used.

The health care sector includes many types of facilities, some of which are for-profit businesses and others, not-for-profit community services. These facilities include hospitals, medical clinics, long-term care facilities, dentists' offices, laboratories, pharmacies, and public health agencies. Health care facilities employ a large array of occupations, requiring various training routes. Medical care is generally provided in hospitals and medical clinics that employ some professions that require long training paths—e.g., physicians, physician assistants, and advanced registered nurse practitioners (ARNPs)—as well as staff who can be trained on-the-job or in short training courses, such as certified nursing assistants and pharmacy technicians. In-between are many medical professionals who can be trained in two through four years, including RNs, radiographer/radiology technologists, and medical/clinical laboratory technologists. In long-term care facilities, RNs, licensed practical nurses (LPNs, also called licensed vocational nurses or LVNs in some states), and certified nursing assistants (CNAs) make up the majority of employees. Their training ranges from on-the-job (CNAs), to specialized training programs and associate degree programs (LPNs and RNs), to baccalaureate degree programs and higher (RNs and ARNPs).

Most oral health care services are delivered by dentists, dental hygienists, and dental assistants in private dental offices. Dentist training is at the graduate (post-bachelor's) level. Initial training for dental hygienists is at the associate degree or bachelor's degree level, while most dental assistants are trained on-the-job. Public health services rely heavily on RNs to carry out their functions, but among clinically trained professionals, the field also uses physicians, dentists, dental hygienists, and LPNs. Most health care disciplines rely on the services of pharmacists (now trained through post-graduate programs), laboratory personnel (several training routes), and many administrative professions.

Because of its "work first" emphasis, WIA has been blamed for reducing the flow of workforce training funding to community colleges, in contrast to the JTPA era (Shaw and Rab, 2003). WIA performance measures favor interventions that rapidly route clients to jobs rather than to more time-consuming training and education. But few of the health sector jobs that are in high demand can be obtained without associate or baccalaureate level education or other specialized training. This was less the case for the high-demand jobs in the manufacturing and high technology sectors during the JTPA era. Manufacturing and high tech sectors were in decline in many states at the time WIA was implemented, and they were losing their high-demand status. Many local and state WIBs and One Stop centers recognized that health care was gaining prominence as a high-demand industry and that, in spite of WIA's work first ethic, they needed to find ways to route clients into the specialized training required for health care jobs. WIA has many requirements, but the law provides considerable flexibility for program implementation. Many states and local WIBs saw health sector jobs going unfilled and side-stepped the work-first policy by finding ways to use WIA resources (often combined with other public and private job training resources) for needed training, very often in two-year and even four-year and higher education programs.

Worker retention was also recognized as a problem in the health care sector, especially for entry-level jobs. In this area, WIA's work-first emphasis was well suited to the industry. Incumbent worker training programs, which move entry level workers up a health care career ladder, have been developed in many states. These programs identify individuals who have already chosen a job in health care and provide skill-enhancement and training to advance their health careers.

As a result of the health workforce sector's high-demand status and states' relative flexibility in implementing WIA, a broad range of WIA-supported health workforce programs were implemented across the country. Health workforce development programs tend to fall into seven general categories: health workforce development planning, programs to promote health care careers, career ladder advancement, educational capacity building, workforce retention, direct training support to individuals, and referral of eligible individuals to health workforce jobs through One-Stop centers.

Table 7 summarizes, to the extent we were able to ascertain, the types of health workforce development activities developed by state and local WIBs since WIA started to be implemented. This wide range of programs is further described in subsequent sections of this report. Because it is possible for local WIBs to operate somewhat autonomously, a complete census of WIB workforce development programs would require contacting all the state and local WIBs across the United States—work that requires more resources than this project had available. From Fall 2002 through the end of 2003 we conducted internet searches for health workforce development activities by WIBs in all states and U.S.-associated jurisdictions. During that time we also made phone and e-mail contact with most state WIB offices and obtained further contact information and details on any health sector workforce development efforts in that state. Many states verified that, at the time of our contact, they were unaware of any specific health workforce development activities using WIA funding. It is significant to note that the states vary considerably regarding their use of WIA resources for health care workforce development.

The specific health professions that states have used WIA funds to develop are summarized in Table 8. Table 9 provides a summary of the level of education that these state programs use in their health workforce training efforts.

S=Funded with WIA resources at the state level
L=Funded with WIA resources at the local workforce development area level
*This list shows this project's findings as of February 2003. It does not represent the results of a full inventory of WIB-sponsored activities, but it does include all activities the project was able to identify from at least one contact with each U.S. state and associated jurisdiction.

*This list shows this project's findings as of February 2003. It does not represent the results of a full inventory of WIB-sponsored activities, but it does include all activities the project was able to identify from at least one contact with each U.S. state and associated jurisdiction.

*This list shows this project's findings as of February 2003. It does not represent the results of a full inventory of WIB-sponsored activities, but it does include all activities the project was able to identify from at least one contact with each U.S. state and associated jurisdiction.

Heath Workforce Development Planning
WIA was implemented beginning in 1999, when shortages were emerging among many health workforce professions and even greater shortages were being projected for the next several decades. Significant shortages of RNs, the dominant health workforce profession (there were nearly 2.7 million RNs in the United States in 2000), have been documented in nearly all states and projected to increase over the next 20 years (Buerhaus et al., 2000; National Center for Health Workforce Analysis, 2002). Licensed pharmacists have also been in short supply across the Nation and greater shortages are projected (Department of Health and Human Services, 2000). An additional 1.2 million nursing aides, home health aides, and other related entry-level positions were projected to be needed between 2000 and 2010 (University at Albany Center for Health Workforce Studies, 2003).

DOL names health care as a high growth industry, including 10 of the 20 fastest-growing occupations from 2002 through 2012. The agency cited expected growth of 59 percent for medical assistants, 49 percent for physician assistants, 48 percent for home health aides, and 47 percent each for medical records and health information technicians. According to the DOL, the health care industry is predicted to add 3.5 million jobs between 2002 and 2012 (U.S. Bureau of Labor Statistics, n.d.).

The call for skilled workers in health care caught the attention of many key policy makers throughout the country, including legislators, health care industry leaders, health professionals, educators, and workforce program administrators. Many states have formed health personnel shortage commissions and task forces to assess the situations and to recommend responses (Tim Henderson, National Conference of State Legislatures, personal communication; University at Albany Center for Health Workforce Studies, 2002). The structure of WIA and its financing features have facilitated these assessment and planning efforts for many of the states and their local areas. About 15 percent of the Adult, Youth, and Dislocated Worker WIA funds are reserved for statewide activities, including planning, and may be used for a wide variety of activities provided that not more than a third (5%) is spent on administration. "Statewide" funds are allocated at the state level, but the funds can be distributed by a state to individual areas for technical assistance, incentive grants for coordination and performance of programs, incumbent worker programs, capacity building, research, and other assistance to local areas. The 15 percent reserve from the three programs (Adult, Youth and Dislocated Worker) may be merged by states to increase services for any one of the program groups (U.S. Department of Labor, 1998).

Many states have used WIA funds (planning funds from the 15% statewide discretionary allocation) to support either all or part (combined with other Federal funds, legislative allocations, or as part of public-private partnerships) of their health workforce shortage task forces and commission work. Often, coordination among local WIBs is facilitated by state-level WIA resources. Many states consider timely information on which to base workforce planning to be a priority, and WIA resources have helped many states collect and analyze needed health care workforce data to achieve this timeliness. These funds have also been used to alleviate health workforce shortage problems identified by the state-level planning entity, for example, in grant programs to encourage local workforce development areas to implement nursing workforce development programs.

Following are examples of health workforce development planning activities, supported all or in part by WIA resources, from 11 states.

Program Highlight California
Nurse Workforce Initiative
Goal: To recruit, train, and retain licensed nurses in California.
Approach and status: In January 2002, the California Governor announced a $60 million, three-year program to recruit, train, and retain licensed nurses. Successful applicants received funding for nurse workforce training, retention initiatives, career ladder development, easing of licensing requirements, and a media campaign (see sections below for descriptions of many of these individual grant programs). As of summer 2003, WIA funding had been issued to 23 successful regional applicant institutions.
Funding sources: WIA state discretionary funds
Contact: California State Workforce Investment Board
(916) 324-3425

Program Highlight Florida
Nurses Now
Goal: To increase nurse training opportunities, identify innovative training delivery systems, and replicate innovative training experiences.
Approach and status: Nurses Now, a program managed by the Florida Agency for Workforce Innovation, uses WIA resources for a grant program to regional WIBs to address the need for RNs and LVNs. Grantee WIBs provide ITAs for WIA-eligible nurses statewide. The programs include an effort to recruit inactive, unlicensed nurses.
Funding sources: WIA discretionary funds, and ITAs
Contact: Workforce Florida, Inc.
(850) 921-1132
http://www.workforceflorida.com

Program Highlight Georgia
Georgia Health Workforce Policy Advisory Committee
Goal: To increase the number of qualified health professionals, improve the environment in which they work, and to build Georgia's capacity to effectively monitor the workforce and project future supply and demand.
Approach and status: The Georgia Health Workforce Policy Advisory Committee formed four subcommittees: data and forecasting; work environment and enhanced productivity; education, programming, and student financing; and recruitment and marketing. Among its accomplishments are developing analytic capacity to monitor the workforce and forecast future supply and demand, sponsoring a nursing faculty scholarship program, providing training grants to local WIBs through use of a WIA demonstration grant, and developing a career ladder "bridge" program for CNAs.
Funding sources: WIA demonstration grant ($784,000), WIA state discretionary funds, and support from many other public and private collaborators.
Contact: Georgia Department of Community Health
(404) 656-4507
Georgia Department of Labor
(404) 232-3907

Program Highlight Maine
Central Western Region WIB PACT
Goal: To develop the health care, information technology, and manufacturing workforce.
Approach and status: The Progressive Alliance for Careers and Training (PACT) is a 25-member board composed of business representatives, professional organizations, and One-Stop center managers that work to promote health care, information technology, and manufacturing jobs. The health workforce committee, which identified health career ladders and improving workplace culture as its main objectives, established a pre-qualification course leading to LPN licensing in three counties.
Funding sources: WIA discretionary funds.
Contact: Central/Western Maine Workforce Investment Board
(207) 753-9011
http://www.mainefocus.org

Program Highlight Mississippi
Mississippi Development Authority
Goal: To study the current health care workforce development and planning activities to increase health care workforce opportunities.
Approach and status: This program has collected and disseminated labor market information related to the current status of health care workforce supply and demand. Along with the Mississippi Legislature, Mississippi Council of Deans and Directors of Schools of Nursing, the Mississippi Nurses Association, and the Mississippi Organization of Nurse Executives, the Mississippi Development Authority supported research by the Mississippi Office of Nursing Workforce to identify barriers to nursing workforce development and to provide recommendations for strategies to overcome the identified barriers.
Funding sources: WIA state discretionary funds, through a contract from the Mississippi Development Authority to the Mississippi Office of Nursing
Contact: Mississippi Development Authority
(601) 368-3321
Mississippi Office of Nursing Workforce
http://www.monw.org

Program Highlight Ohio
State Health Care Workforce Advisory Board
Goal: To identify and address health workforce development needs.
Approach and status: The Ohio Legislature created the State Health Care Workforce Advisory Board in 2001 following a Healthcare Shortage Summit. The board is responsible for addressing statewide health care workforce shortages and includes four task forces: regulatory issues, issues for professional caregivers, nursing education and communication (including career ladders), and issues for direct caregivers (including credentialing for non-nursing health care workers).
Funding sources: Staff and administrative costs are funded by WIA discretionary funds
Contact: Ohio State Health Care Advisory Council
(614) 728-8104

Program Highlight Oregon
Oregon Workforce Investment Board
Goal: To research, identify, and analyze the most important factors in health care employment.
Approach and status: The Oregon WIB, in partnership with the Oregon Nursing Leadership Council, Oregon Department of Community Colleges, the Center for Nursing in Oregon, and Oregon Health Sciences University, formed a state steering committee to research factors in health care employment for 11 key occupations to create recommendations for a statewide strategic health workforce plan. The result is the report, Health Care Sector Employment Initiative: Taking "AIMM" at a Growing Crisis, available at http://www.workforce.state.or.us/owib/healthcare/index.htm.
Funding sources: WIA state discretionary funding
Contact: Oregon Workforce Investment Board
Health Care Initiative
(503) 329-7356

Program Highlight Texas
Achieving Performance Excellence (APEX) Grants
Goal: To provide training in health, education and information technology
Approach and status: This grant program provided funding to local WIBs for health, education and information technology workforce development.
Funding sources: WIA state discretionary funding
Contact: Texas Workforce Commission
(512) 463-2222

Program Highlight Texas
Health Services Steering Committee, Texas Gulf Coast Workforce Board
Goal: To address the need for nurses, pharmacy technicians, radiology technologists, and surgery technicians in the region, with initial emphasis on nursing.
Approach and status: The Health Services Steering Committee includes industry, community college, and university deans among its membership, and includes senior executives from area hospitals, health systems, and academic institutions. A steering committee oversees activities "to develop more collaborative relationships between business and education." The committee designated four areas of concern for which work groups were formed: marketing, education, workplace environment, and government relations. The government relations work group works with the state professional associations to support (without active lobbying) changes in laws that promote broad nursing education and employment. The committee has increased local nurse training capacity, increased local RN supply by training hospital employees to become nurses, and attracted and retained nurses by helping to improve the work environment.
Funding sources: WIA state discretionary funding
Contact: Gulf Coast Workforce Board
(713) 499-6651

Program Highlight Vermont
Vermont Healthcare Workforce Development Partnership
Goal: To increase the supply of health care workers in Vermont.
Approach and status: After the 12 regional WIBs in Vermont each developed strategic plans, most of which included focus groups in health care, they determined that many issues required statewide leadership. As a result, the Healthcare Workforce Development Partnership was formed. The Partnership has performed planning research, including nursing vacancy surveys, and it has compiled a statewide health care training chart showing the relevant organizations and type of health care training that exist in Vermont.
Funding sources: WIA state discretionary funding
Contact: Vermont Workforce Investment Board
(802) 828-4343

Program Highlight Washington
Pierce County Health Services Careers Council
Goal: To expand education and training for high-demand health care occupations and pursue other opportunities for alleviating the local shortage of health care personnel.
Approach and status: The Pierce County Workforce Development Council created the Pierce County Health Services Careers Council, made up of health employers, education, labor, and government participants. The council was one of the first health skills panels (now in place in all 12 workforce development areas) in Washington state. It formed five work teams: funding, career pathways/educational expansion needs, marketing, workforce research, and student retention and support. The council has strong industry involvement, and it has received many grants and implemented many health career-related programs since it began in 2001.
Funding sources: WIA discretionary funds, helping to support the coordination and administrative support for many other funding sources for council programs (e.g., Industries of the Future Skills Training grants, SKILLS-Securing Key Industry Leaders for Learning Skills, grants, state Board for Community and Technical Colleges High Demand grant, and direct cash and in-kind support from local industry partners).
Contact: Tacoma/Pierce County Workforce Development Council,
Health Skills Coordinator
(253) 404-3932

Program Highlight Washington
Washington Workforce Training and Education Coordinating Board
Goal: To identify health workforce development needs and priorities, and to provide resources for regional workforce development strategies
Approach and status: The board convened a Health Care Personnel Shortage Committee, followed by a Health Care Personnel Shortage Task Force, to identify statewide health workforce needs and priorities. It funded 12 Health Skills grants to support health workforce skills panels in each of the state's workforce development areas, contracted research on data needs for health workforce planning in the state, and contracted for a coordinating center to assist in the implementation of new Health Skills panels and communication among the 12 health workforce skills panels.
Funding sources: State WIA Discretionary
Contact: Washington Workforce Training and Education Coordinating Board
(360) 753-5653

Program Highlight West Virginia
West Virginia State Innovation Grant Program
Goal: To plan and coordinate local nursing workforce development.
Approach and status: The state WIB provided a state innovation grant to Region 1 in Beckley to hire a consultant and create a consortium of health care providers for nursing workforce planning. The consortium hired a coordinator for health workforce development activities in the region.
Funding sources: State WIA discretionary funds
Contact: Governor's Workforce Investment Board
Division of the West Virginia Development Office
(304) 558-7024

Program Highlight Wisconsin
Wisconsin Division of Workforce Development
Goal: To enhance health care workforce development and occupational English as a Second Language (ESL) training
Approach and Status: Wisconsin received a 2001 WIA Title V Performance Incentive Grant to enhance health care workforce development and occupational English as an ESL training. While the state secured the grant, it has passed management to the Wisconsin Association of Technical Colleges. Overall grant requirements mandate targeting of health careers, and some ESL/bilingual programs and grant applicants were required to be partners between WIBs and technical colleges. Grants have been awarded to regional applicants.
Funding sources: WIA Title V Performance Incentive Grant, with some supplemental funding from Perkins Vocational Education Program
Contact: Wisconsin Division of Workforce Development
(608) 266-9615

Program Highlight Wisconsin
Fox Valley WDB-Moraine Park and Fox Valley Technical Colleges
Goal: To support collaborative workforce development planning through a task force.
Approach and status: The Fox Valley workforce development board formed a health care shortage task force with the community colleges, the workforce development board, CEOs of local heath care industry, and representatives from the University of Wisconsin—Oshkosh. The board conducted a needs survey, with top priority for action given to creating a Paramedic Technician training program that was implemented using WIA incentive grant funds to pay the instructor's salary for one year. Next priority was given to a practical nursing program, with the first year targeting LPN training that also satisfied first-year requirements for an associate degree. Graduates can either enter the workforce or continue for an associate-level RN degree.
Funding sources: WIA incentive grant
Contact: Fox Valley Technical College
(920) 735-2488

Programs to Promote Health Care Careers

A critical factor in developing and maintaining the health workforce and filling the gaps for many occupations is providing appropriate and timely information about health care careers to individuals who may become interested in choosing health care employment. It is generally agreed that youth will be more likely to choose a health career early out of high school if they have early exposure to role models in the health professions and if their education includes strong math and science preparation. But it is not too late to target adults with health career marketing. RNs, for example, do not complete nursing school until an average of 10 to 15 years after high school. The average age of new RNs is 33 years for associate degree graduates and 28 years for baccalaureate graduates (Spratley et al., 2000). Many dislocated and incumbent workers may also be attracted to the relative stability and high earning potential of health care jobs.

In addition to simply filling gaps, the health care workforce needs to attract underrepresented minorities to better serve the overall population and to provide these groups with the economic benefits of employment in the health care sector. Healthy People 2010, the document that sets health goals for the United States, notes that

"…increasing the number of minority health professionals is viewed as a partial solution to improving access to care. Several studies have shown that underrepresented minority health profession graduates are more likely to enter primary care specialties and to voluntarily practice in or near designated primary care health workforce shortage areas."
Healthy People 2010 (http://www.health.gov/healthypeople/)

According to Grumbach and colleagues at the Center for California Health Workforce Studies (2002), "The under representation of minorities in the health professions is a public health crisis." Minority health professionals are more likely to practice in underserved, minority communities and serve disadvantaged patients, but African Americans, Latinos/Hispanics and American Indians/Alaska Natives are underrepresented in all health professions, as Table 10 shows.

Source: Grumbach et al., 2002.

Men are underrepresented in some health professions. Only 5.4 percent of RNs and 5.1 percent of LPNs in the country are male (National Center for Health Workforce Analysis, 2000; Spratley et al., 2000;). Nationally, less than 1 percent of dental hygienists, 13 percent of occupational therapists, 25 percent of radiologic technologists, and 26 percent of physical therapists are male (National Center for Health Workforce Analysis, 2000).

Across the country, RN shortages are projected to continue for the next couple of decades, with gaps measured in the hundreds of thousands of positions (National Center for Health Workforce Analysis, 2002). States report shortages of most all of the other predominantly female health professions, including CNAs—the backbone of the rapidly growing long-term care industry. The health care sector provides many career opportunities that are not being fully exploited by men and racial and ethnic minorities.

Many different strategies promote health careers, and WIA resources have been used toward this end by states and local workforce development areas. On the following pages, we offer examples from nine states.

Program Highlight Georgia
TEACH Academies
Goal: to introduce middle and high school students to health careers.
Approach and status: The Medical College of Georgia, through a grant from the Georgia Department of Labor, developed this program to train middle and high school teachers and counselors in health careers education and occupations. It established TEACH academies in six regions of the state.
Funding sources: WIA demonstration grant ($60,000 administered through the state WIB).
Contact: Georgia Department of Labor
(404) 232-3907

Program Highlight Georgia
Youth Health Care Awareness
Goal: To introduce young students to health care careers.
Approach and status: The Fulton county public schools, Fulton county government and the Fulton county WIB partnered on this program to increase the awareness of health care careers among the county's youth.
Funding sources: WIA demonstration grant ($56,652 administered through the state WIB); Fulton county general fund ($19,250); WIA formula grant ($82,500).
Contact: Georgia Department of Labor
(404) 232-3907

Program Highlight Mississippi
Mississippi Development Authority
Goal: To introduce low-income high school students to the health workforce, with encouragement to complete CNA training at a technical college.
Approach and status: This pilot study was designed to identify low-income high school students in the Meridien school district and introduce them to the hospital CNA and other nursing professions. Students are hired, receive training with a pre-nursing curriculum, and tour nursing workplaces. The program anticipates that after summer graduation, students will pursue a month of further training at a technical college. It provides financial incentives and high school credits, plus tutoring and life skills training.
Funding sources: WIA state discretionary funds, through a contract from the Mississippi Development Authority to the Mississippi Office of Nursing Workforce.
Contact: Mississippi Development Authority
(601) 368-3321

Program Highlight New Jersey
Mercer County, New Jersey WIB
Goal: To orient young adults and "second career-track" individuals to health care careers.
Approach and status: This work has been underway since 2001, when the Mercer County WIB created a health careers task force with workforce development professionals, health care employers, and community college representatives. One project produced brochures announcing the availability of health care professionals to give presentations on health careers to students.
Funding sources: WIA Youth funds, with business matching funds
Contact: Mercer County WIB
(609) 989-6827

Program Highlight Ohio
Ohio Health Care Workforce Advisory Board
Goal: To promote health care careers through a media campaign.
Approach and status: The campaign uses radio, television, a website, and print media to make the public more aware of the shortages of health care workers and to encourage people to consider health care careers.
Funding sources: WIA state discretionary funds and state general funds
Contact: Ohio State Health Care Advisory Council
(614) 728-8104

Program Highlight Pennsylvania
Lancaster County WIB
Goal: To market health care as a career, including to incumbent and dislocated workers.
Approach and status: The Lancaster County WIB and area hospitals and nursing homes collaborated on a media campaign in 2000 to produce television ads for health care careers that ran in a 10-county area. The WIB also arranged a hospital-based program called "Orientation to Health Careers" that provided incumbent and dislocated workers exposure to 30 health careers, provided career counseling, and tested participants on health career readiness (the TABE test of adult basic education).
Funding sources: Media campaign: WIA discretionary funds and sectoral grant, with matching funds from participating institutions
health careers orientation: State Adult WIA funds and TANF funds
Contact: Lancaster County WIB
(717) 735-0333

Program Highlight South Carolina
Critical Skills Gap Grants
Goal: To introduce youth to health care careers.
Approach and status: Multiple grants to local applicants:
Clarendon School District One: Introduces students (about 50 targeted) to various health care careers through the classroom, job shadowing, field trips, guest speakers, mentoring, work experience, career development, and employability skills. Students participating in the after-school program may also receive certifications in CPR, first aid, nursing assistant, and medical terminology.
Newberry School District: Trains high school juniors and seniors (about 20 targeted) interested in health care technician occupations by providing a technology-based training program that is modular in design and that allows for multiple group participation.
Lexington School District One: Establishes career paths for students (about 200 students ages 14 to 18) enrolled in information technology, computer programming, and health care. Participants may be eligible to receive nurse aid certification and articulated credit and/or dual credit options with local colleges and universities.
Communities in Schools: Introduces youth (about 70 targeted) to various health care and computer technology careers through classroom instruction, work experience, and vocational exploration activities. Program involves mentoring teams that include the student, adult family member, school staff, human service agency staff, and business partners.
South Carolina Hospital Association: Statewide program for career awareness and youth outreach, including dual college credit and mentoring.
Funding sources: WIA discretionary funds and state general funds
Contact: South Carolina Employment Security
(803) 737-3830

Program Highlight Texas
Gulf Coast Workforce Board
Middle School Student Awareness Project
Goal: To introduce middle school students to health care careers.
Approach and status: This interactive program reaches students and influential adults to introduce young people to health careers. Professionals, such as volunteer nurses, speak to students. The program includes before and after surveys to gauge awareness among middle school students.
Funding sources: WIA Youth and DOL Youth Opportunity funds
Contact: Gulf Coast Workforce Board
Health Services Steering Committee
(713) 499-6651

Program Highlight Texas
Gulf Coast Workforce Board
Summer Youth Activities
Goal: To introduce youth (ages 18 to 22) to health care careers.
Approach and status: This program provides summer internships for eligible youth at local health care businesses. Applicants can apply at a One-Stop center.
Funding sources: local WIB resources, with employer contributions
Contact: Gulf Coast Workforce Board
Health Services Steering Committee
(713) 499-6651

Program Highlight Washington
Health Careers Television Campaign
Goal: To promote health care careers.
Approach and status: This television campaign includes advertising of local training programs for health care workers.
Funding sources: four regional workforce investment boards, with overlapping television markets, and contributions from the local health care business sector
Contact: Pierce County Health Services Career Council
(253) 404-3932

Program Highlight Wisconsin
Western Wisconsin Workforce Development Board/Western Wisconsin Technical College
Goal: To increase the number of under-represented populations in the health care workforce.
Approach and status: This program supports career exploration and health care career workshops, including Division of Vocational Rehabilitation information workshops, coordination with the Ho-Chunk Nation, high school career days, and a regional career day.
Funding sources: WIA Performance Incentive Grant
Contact: Western Wisconsin Workforce Development Board
(608) 785-9211

Program Highlight Wisconsin
Fox Valley WDB/Moraine Park and
Fox Valley Technical Colleges
Goal: To market health careers.
Approach and status: Program supports health career exploration and career camps.
Funding sources: WIA Performance Incentive Grant
Contact: Fox Valley Workforce Development Board
(608)789-5610

Program Highlight Wisconsin
WOW Workforce Development Board/
Waukesha Technical College
Goal: To market health careers.
Approach and status: A Health Care Workforce Job Fair was held in March 2003.
Funding sources: WIA Performance Incentive Grant
Contact: Workforce Development Center of Waukesha, Ozaukee and Washington counties
(262) 691-5526

Health Career Ladder Advancement

One strategy to add to the supply of health care workers is to encourage workers in entry-level positions to gain the training for higher level health care positions. This approach is attractive for several reasons, including the efficiency of enlisting people who have already chosen jobs within the health care field and do not need to be oriented to the nature and value of the work. In addition, health care institutions such as hospitals can support in-house career ladder advancement programs that promote employee loyalty through greater job satisfaction and commitment to the employing organization. Employee retention is a major goal of employers because it saves resources that would otherwise be spent in employee recruitment and training, and low staff turnover rates usually contribute to more satisfactory workplace environments.

WIA is particularly applicable to career ladder programs because of the program's commitment of resources to incumbent (currently employed) workers who are earning low wages. The most common WIA-supported health care career ladder program moves employees through a series of nursing-related jobs, with CNA as the initial rung, moving up to LPN/LVN and to RN. Some ladder programs introduce individuals in entry-level and non-patient care positions to the nursing ladder, usually as CNAs.

Following are examples of WIA-supported career ladder programs from six states.

Program Highlight California
Central California Paradigm Program
Goal: To establish a career ladder to train 65 LVNs to become RNs.
Approach and status: In 2003, the Madera County WIB was awarded $700,000 from California's Nurse Workforce Initiative funding for an on-site career ladder. Six partner hospitals provided training for incumbent workers—LVNs as well as other hospital employees—to become RNs. Clinical rotations are carried out at Fresno City College. The funds pay for instructor salaries, a program coordinator at Fresno City College, and a case manager at the WIB. The program ends in 2005.
Funding sources: WIA state discretionary funds from the Nurse Workforce Initiative
Contact: Madera County Workforce Investment Board
(559) 662-4500

Program Highlight California
San Diego Nurse Workforce Initiative
Goal: To add 163 LVNs and RNs to the local workforce.
Approach and status: Employers screen and select incumbent workers for upgrade training, allow flexible scheduling for part time work for participants, and provide clinical instructors and classroom space. Depending on the participant's eligibility, the initiative through the local WIB may pay tuition and additional salary up to a capped level. The work began in 2001, and as of September 2003, 105 RNs, 19 LVNs, and 10 "re-entry" students enrolled in or completed the program, with 23 achieving licensure. The program is scheduled to continue through 2005.
Funding sources: WIA state discretionary funds, with private employer contributions for facilities, staff, and training
Contact: San Diego Worksource
(619) 238-1445

Program Highlight California
NCEN Nursing Workforce Initiative
Goal: To upgrade incumbent CNAs to LVNs, and LVNs to RNs.
Approach and status: Recruit and support incumbent workers and unemployed individuals to complete CNA, LVN, associate degree RN, and bachelor's degree RN training. Career ladder strategies are specific to each partner, including community colleges, county governments, and WIBs. Enrollments by Fall 2003 were 53 in associate degree RN training, 2 in bachelor's degree RN training, and 198 in LVN training.
Funding sources: WIA state discretionary funds ($2.1 million), with matching funds ($2.7 million) from in-kind contributions, primarily from community colleges and adult schools
Contact: Northern California Employment Network (NCEN)
(530) 872-9600

Program Highlight California
Ventura County Medical Career Ladder Initiative
Goal: To provide training to incumbent workers in the health care industry.
Approach and status: Programs include on-site training at Community Memorial Hospital for nurse technicians to become LVNs and opportunities for entry-level health care workers to become occupational therapists, pharmacy technicians, surgical technologists, and certified coders. Some programs also provide support services such as child care and transportation during training. The program, which began in 2001 and will expire in June 2004, expects to serve 90 participants.
Funding sources: $656,250 in WIA state discretionary funds for six established projects
Contact: Ventura Workforce Investment Board
(805) 652-7684
www.wib.ventura.org

Program Highlight California
Riverside County Economic Development Agency
Goal: To support multiple career ladder approaches.
Approach and status: Multiple programs:
NCLEX training for corpsmen: Assists military corpsmen leaving the service to become RNs. Corpsmen receive five days of intensive training to help them prepare for the National Council of State Boards of Nursing's NCLEX exam — required for nursing licensure.
Career development training for CNAs to become senior nurse assistants
Regional Training Collaborative: Riverside and San Bernardino counties collaborated on this program to provide on-the-job training for LVNs to become ADNs.
Funding sources: WIA discretionary funds through the Nurse Workforce Initiative
Contact: Riverside County Economic Development Agency
(760) 863-2525

Program Highlight Florida
Nurses Now
Goal: To increase training opportunities, identify innovative training delivery systems, and replicate innovative training experiences to increase the number of LPNs and RNs.
Approach and status: Managed by the Florida Agency for Workforce Innovation, this program is largely funded by a DOL-WIA demonstration grant to Florida's regional Workforce Development Boards to address the need for RNs and LPNs. Career ladder programs have been approved for education partners that streamline the advancement from CNA to patient care technician, from patient care technician to LPN, from LPN to paramedic, and from paramedic to RN. Earmarked grant funds give priority to activities that provide advanced education and to prepare RNs to become instructors. Applications for funding are required to include letters from local training entities that verify that the training slots would be available as identified in the proposed plan. Four regional grants were awarded to the successful regional WIB applicants.
Funding sources: WIA state discretionary funds and WIA demonstration grant
Contact: Workforce Florida, Inc.
(850) 921-1132
http://www.workforceflorida.org/

Program Highlight Georgia
CNA-LPN Bridge Scholarship
Goal: To provide career ladders for CNAs to become LPNs.
Approach and status: The Georgia Health Care Workforce Policy Advisory Committee, in partnership with the Metro Atlanta WIB and long-term care providers, established a bridge scholarship program with WIA funding. Two nursing homes, run by Ethica Healthcare, identified 20 CNAs for the bridge program. Ethica arranged for trainers to come to the nursing homes from technical institutions to assess candidates and prepare them for entry to an LPN training program. Ethica also provided tiered CNA job levels with corresponding title and pay increases to reflect the education achievements of participants. The Department of Technical and Adult Education developed curriculum that corresponded to the CNA job levels, as well as technical certificates of credit that would allow enrolled students to apply for HOPE grants for education expenses. The Georgia Board of Examiners of Licensed Practical Nurses made special arrangements for students graduating from this program.
Funding sources: WIA State discretionary funds, with partners including the Atlanta Regional commission/Atlanta Regional Workforce Board, the DeKalb Workforce Investment Board, Ethica Health Care, the Department of Technical and Adult Education, and the Georgia Department of Labor
Contact: Georgia Department of Labor
(404) 232-3907

Program Highlight Massachusetts
Extended Care Career Ladders Initiative
Goal: To promote career ladders for CNAs to become LPNs in the long-term care sector.
Approach and status: WIBs, in collaboration with community colleges, training providers, and community-based organizations, are using funds earmarked by the Massachusetts State Legislature for this career ladder program. The program implements career ladders for CNAs to become LPNs in more than 50 long-term care workplaces.
Funding sources: The Massachusetts Legislature earmarked $5 million in 2000 and $4.1 million in each of 2002 and 2003 for this program, which involves collaboration by regional WIBs.
Contact: Boston Workforce Development Coalition
(617) 522-6028
Boston Private Industry Council
(617) 423-3755

Program Highlight Texas
Gulf Coast Workforce Investment Board APEX Grant
Goal: To train incumbent workers to become RNs and other health care professionals.
Approach and status: Through two APEX grants from the Texas workforce Commission, this program identified entry level incumbent health care workers with interest in receiving training for career advancement. Most participants chose RN training, at both the associate degree and baccalaureate degree levels.
Funding sources: WIA discretionary funds (approximately $1.5 million)
Contact: Gulf Coast Workforce Board
(713) 499-6651

Program Highlight Washington
Pierce County Health Services Careers Council
Goal: To provide career development resources to incumbent health care workers.
Approach and status: Following Pierce County Health Services Careers Council recommendations, major health employers in Pierce County partnered with WorkSource to provide WorkSource Career specialists, co-located at local hospitals, with career development information for incumbent workers. Specialists recruit incumbent workers interested in career advancement, help them to identify career goals and aptitude, identify suitable training options, and screen the individuals' eligibility for WIA financial assistance. WIA funds may be used to pay for tuition and books, as well as support services such as child care and transportation. Partners have included Good Samaritan, Franciscan and Multicare health systems, and Madigan Army Medical Center.
Funding sources: WIA Adult, in-kind, and direct support from industry, and other training resources for which clients are eligible
Contact: Tacoma/Pierce County Workforce Development Council,
Health Skills Coordinator
(253) 404-3932

Program Highlight Washington
Seattle-King County Workforce Development Council
Goal: To increase capacity for training health care workers in high-demand occupations.
Approach and status: Sea-King WorkSource provides career specialists on-site at area hospital partners and connects them with incumbent workers who are hoping to enhance their skills. The clients are guided toward the most applicable funding streams. For both employers and employees, the use of health career specialists creates a seamless connection between individuals and training. WIA ITAs are used for shorter-term training, while H1-B funds (resources generated from H1-B category worker visas that are used for training of the U.S. workforce) are usually used to support baccalaureate degree RN and associate degree RN training.
Funding sources: Career specialists, funded with WIA Adult funds, for training of eligible incumbent workers—primarily H1B, WIA Adult, Targeted Industry Program, or Industries of the Future Skills Training funds
Contact: Seattle-King County Workforce Development Council
(206) 448-0474

Building Health Workforce Educational Capacity

The educational capacity for many health workforce occupations does not produce enough health care workers to meet current demand. Qualified applicants to nursing schools are being turned away at institutions across the country, even as the Nation is experiencing an estimated shortage of nearly 140,000 RNs (National Center for Health Workforce Analysis, 2002).

In some states, there is unused capacity within the state's training facilities for high demand health workforce occupations, and alternatives to on-site education are needed to link students with the existing training programs. Distance learning via the internet is one popular approach, especially for rural areas. Another is through articulated education programs that link education facilities so that students can complete prerequisite coursework and other basic courses in local education facilities before enrolling in specialized courses at a more distant, or more expensive, facility.

Education costs for health care fields are more expensive than in most other education paths. Health workforce education capacity requires qualified faculty, classroom (or virtual classroom) capacity with appropriate equipment, clinical training sites (including facilities and supervisors), and funding for student enrollment. Salaries paid by educational institutions must compete with the wages that qualified faculty can receive in clinical care jobs. Classrooms must not only be functional for didactic teaching but also must have up-to-date equipment for hands-on training. To accommodate the need for students to have actual experiences with patients, clinical training sites must be negotiated and scheduled, appropriate supervision must be secured for students, and site surveillance and monitoring of student progress must be planned. Tuition seldom pays the full cost of education, so educational institutions must secure additional funding for any expansions to their program. Finding new funding is a difficult feat for many state-funded schools.

Many state and local WIBs and One-Stops encountered the educational capacity barrier when their clients attempted to use ITAs for health care education, particularly for nursing programs. Many schools already had long waiting lists of eligible RN program applicants when WIA was being implemented. Getting clients into the high-demand health care fields required innovative solutions, including bringing new partnerships to bear on the problem. Following are examples of health workforce capacity building programs that the WIA generated in eight states.

Program Highlight Arizona
RN Training Expansion
Goal: To expand the number of RNs graduating from community colleges and universities in Arizona.
Approach and status: This program seeks to expand community college RN training programs by 180 students for each of two years (2004 and 2005). It also works to implement accelerated BSN degree programs that take students who already hold bachelor degrees and provide them with intensive instruction in nursing programs at the three state universities. The BSN programs would increase the number of BSN graduations by nearly 200 over the two-year period.
Funding sources: WIA state discretionary funds ($1.7 million a year), plus tuition, state resources and private sector contributions
Contact: Arizona Board of Regents
(602) 229-2544

Program Highlight Colorado
Arapahoe/Douglas County Works!
Goal: To increase LPN training capacity.
Approach and status: This program creates a nursing skills lab to increase LPN training capacity by 64 LPNs per year in the Arapahoe/Douglas county WIB region.
Funding sources: WIA state discretionary funds.
Contact: Colorado Office of Workforce Development
(http://www.state.co.us/gov_dir/wdc/wdc.htm)

Program Highlight Colorado
RN Refresher Course
Goal: To encourage RNs who are licensed but not currently working to return to the workforce.
Approach and status: In the Arapahoe/Douglas county WIB region, this program is developing a technological infrastructure to support the delivery of an online RN refresher course. It will engage health care employers to provide paid on-site clinical work as part of the refresher course. Using online technology, a goal of this program is to increase the capacity of existing educational institutions to produce more nurses within a shorter period of time. The Mesa county WIB received a grant for a similar program.
Funding sources: WIA state discretionary funds (Arapahoe/Douglas WIB -$172,000, Mesa county WIB - $35,750)
Contact: Colorado Office of Workforce Development
(http://www.state.co.us/gov_dir/wdc/wdc.htm)

Program Highlight Colorado
Mesa County Workforce Center/Rural Consortium
Goal: To develop and promote models for coordinated long-term solutions to health care training in western Colorado.
Approach and status: This program is coordinating the delivery of associate degree RN training in Mesa County and other distance learning sites in western Colorado; assisting with identifying and developing clinical training sites for placement of associate degree RN students; and developing an articulation model for core health care training, such as anatomy/physiology, for many different types of health care professions. Through a separate grant, the Mesa County WIB is working to build capacity to deliver training for health care positions up to and including LPNs.
Funding sources: WIA state discretionary funds (Two grants: $89,545 and $118,500)
Contact: Colorado Office of Workforce Development
(http://www.state.co.us/gov_dir/wdc/wdc.htm)

Program Highlight Colorado
Weld County Nuclear Medicine Technologist Training Program
Goal: To develop and implement a model training program that will address the current workforce shortage for nuclear medicine technologists.
Approach and status: This project is developing a Level 1 certificate at the community college level for nuclear medicine technologists, with the possible development of a two-year degree program. Aims Community College is planning to start the first two-year program for nuclear medicine technologists in the region.
Funding sources: WIA state discretionary funds ($72,000)
Contact: Colorado Office of Workforce Development
(http://www.state.co.us/gov_dir/wdc/wdc.htm)
Weld County WIB
(970)353-3800
http://www.eswc.org

Program Highlight Georgia
New Nursing Faculty Loan Program
Goal: To provide graduate training for nurses intending to become nurse educators.
Approach and status: This program by the Georgia state WIB established 160 service-cancelable loans (up to $10,000 each) for RNs to pursue graduate nursing study (masters or doctoral degree) in any public or private program. Recipients must agree to teach in Georgia (one year for each $2,500 received).
Funding sources: WIA state discretionary ($1.1 million) and Woodruff Foundation ($500,000), that can be used more flexibly than WIA funds (e.g., for housing)
Contact: Georgia Department of Labor
(404) 232-3907

Program Highlight Oregon
Rural Nurse Training Capacity Program
Goal: To help alleviate rural nursing shortages.
Approach and status: This program by the Oregon state WIB, to be implemented in early 2004, will address rural nursing shortages by building education capacity. It will address the need for simulation labs, distance education technology, and faculty development.
Funding sources: WIA state discretionary and other Federal funds
Contact: Oregon State WIB
(503) 329-7356

Program Highlight South Carolina
WIA Critical Skills Gap Grant
Goal: To increase educational capacity in nursing.
Approach and status: This program at the University of South Carolina School of Nursing is designed to recruit 15 eligible adults to receive financial assistance to complete graduate studies in nursing. In return, the recipients make a two-year commitment to teach in a state-approved nursing program.
Funding sources: WIA state discretionary funds
Contact: South Carolina Employment Security
(803)737-3830

Program Highlight Texas
The Gulf Coast Workforce Board Faculty Salary Fundraising
Goal: To retain nursing faculty.
Approach and status: This program offers salary increases to faculty in area nurse training programs who are considering retirement or transfer. It also serves to increase offers to newly hired additional training faculty.
Funding sources: Two local foundations and private companies, coordinated by the Workforce Board
Contact: Gulf Coast Workforce Board
Health Industry Liaison
(713) 499-6651

Program Highlight Washington
Northwest Workforce Development Council
Goal: To increase capacity for LPN training.
Approach and status: In 2003, northwest Washington area community colleges were at capacity for health care training. The Northwest Workforce Development Council used WIA Adult funds (by pooling ITAs for eligible participants) to nearly double the LPN training capacity at Skagit Valley College. Washington state funds pay two-thirds of instruction costs at most community colleges. For the added LPN training capacity at Skagit Valley College, the pooled ITAs paid this portion (two-thirds) of instruction costs. Students, assisted by Workforce Development Council staff, sought other sources to pay the remainder of instruction costs (through Pell grants, Trade Adjustment Act Funds, etc.).
Funding sources: WIA Adult funds (pooled ITAs used to contract for additional capacity in training programs)
Contact: Northwest Alliance for Health Care Skills
(360) 676-3207

Program Highlight Washington
Pierce County Health Services Careers Council
Goal: To expand education and training for high-demand health care occupations.
Approach and status: The Pierce County Health Services Careers Council identified local education and training capacity in high-demand health occupations by surveying educational partners providing the training. They then advised the Workforce Development Council and others on health programs most in need of expansion. The Workforce Development Council distributed WIA funds to expand training capacity for RNs, radiology technologists, respiratory therapists (as well as pre-requisites for these three programs), registered health information technicians, medical billers, and those considering career changes to become baccalaureate degree RNs.
Funding sources: WIA Adult funds (pooled ITAs used to contract for additional capacity in training programs)
Contact: Tacoma/Pierce County Workforce Development Council
(253) 404-3932

Program Highlight Washington
Seattle-King County Workforce Development Council
Goal: To expand education and training for high-demand health care occupations.
Approach and status: The Workforce Development Council pools WIA ITAs to expand training capacity for CNAs, LPNs, RNs, and radiology technologists.
Funding sources: WIA Adult funds
Contact: Seattle-King County Workforce Development Council
(206) 448-0474

Program Highlight Wisconsin
Lakeshore and Northeast Wisconsin Technical Colleges/Bay Area Workforce Development Board
Goal: To increase the number of CNAs and LPNs and ensure higher graduation rates from these programs.
Approach and status: This program provides classroom and clinical training at a rural hospital, mentoring services, and occupational English and Spanish language curriculum. It recently added new CNA and LPN class sections at two community colleges. It also provides student advocates for recruitment and support services linked to expansion of a long-term care Retention Management System and coordination with job centers for placement service.
Funding sources: WIA Performance Incentive Grant
Contact: Green Bay Area Workforce Development Board
(920) 693-1168

Program Highlight Wisconsin
Southeast Workforce Development Board/Gateway Technical College
Goal: To help under-represented populations gain access to health workforce training, with emphasis on associate degree RN and CNA training.
Approach and status: This program emphasizes recruitment among non-English speaking and minority populations. It helped expand global English/bilingual CNA classes and the associate degree RN program by 20 students, initiate a new class in nursing skills renewal aimed at RNs whose licenses had lapsed, and purchase equipment needed for a new teaching lab. It also increased the associate degree RN program by 20 students over the previous year, started a bilingual CNA program by adding one section, and launched a nursing skill renewal class.
Funding sources: WIA Performance Incentive Grant
Contact: Southeast Workforce Development Board
(262) 564-2758

Program Highlight Wisconsin
Fox Valley WDB/Moraine Park and Fox Valley Technical Colleges
Goal: To increase instructional capacity for associate degree RN programs and introduce new paramedic technician and radiology technologist programs.
Approach and status: This program expanded associate degree RN training capacity through evening and weekend classes and clinical opportunities and through a defined training ladder by which students could obtain LPN training as a first step in their route to become RNs. It added a new radiology technologist program at Moraine Park Community College and is developing curriculum for a medical terminology course and a mentoring program. It formed new partnerships with health care providers and developed programs to increase student retention and placement through instructional and laboratory support, mentoring, ESL for medical terminology, and student focus groups and feedback sessions.
Funding sources: WIA Performance Incentive Grant
Contact: Fox Valley Technical College
(920) 735-2488

Program Highlight Wisconsin
WOW Workforce Development Board/Waukesha Technical College
Goal: To train certified nursing assistants or facilitate reentry into the nursing field.
Approach and status: This program provided seven CNA classes over 18 months, enrolling 70 students. It also supported three RN refresher courses enrolling 30 individuals, focusing on new technology. It enrolled 80 individuals in classes combining English as a second language training with CNA training and established 30 individuals in CNA on-the-job training.
Funding sources: WIA Incentive Grant from Wisconsin state WIB Grant is administered by the Waukesha Technical College.
Contact: Workforce Development Board of Waukesha, Ozaukee and Washington Counties
(262) 691-5526

Health Workforce Retention
Retaining workers in the health care industry can be as much of a challenge as recruiting them. Jobs in the health care system are often physically and emotionally demanding. Many employers require workers to cover 24-hour shifts, seven days a week. Patient care demands often compete with paperwork requirements, leading to frustration over job priorities. At the entry level and in some settings such as some long-term care facilities, health industry jobs can be low-paid, particularly for aides and paraprofessionals, and employees are easily attracted to other jobs within and outside of health care. And for occupations with supply shortages, employees at all levels of the pay spectrum may be attracted to other jobs by competing employers with higher pay and better benefits. Adding to the instability, supervisory and management positions in health care are usually filled by health professionals whose primary training is clinical and not managerial, which can exacerbate job frustration for both managers and those they manage (Salsberg, 2003). Turnover rates for nursing home staff in 2002 ranged from a national average of 36 percent for administrative RNs to 71 percent for CNAs (American Health Care Association, 2003). The cost of training new workers is expensive and is generally recognized by employers to be more expensive than retaining an employee.

Methods to retain employees include increasing compensation and benefits (e.g., higher pay, child care, parking) and increasing professional skills and status (e.g., professional development opportunities, continuing education, increased participation in clinical decision-making, etc.). WIA resources are best suited to retention programs that enhance employee skills through training. Promoting professional development through career ladders, as described in a previous section, can be used within an institution as an employee retention strategy. Providing mentors and preceptors to help employees overcome professional hurdles with practical training and tips may increase job satisfaction and retention. Opportunities for continuing education and certification, even if they do not lead directly to new occupations, are other ways to promote professional development and retain employees. Workplace models that include paraprofessionals in patient care decision-making have been shown to reduce employee turnover and increase job satisfaction (Stone and Wiener, 2001).

WIA-supported programs in four states with the specific goal of health workforce retention are described below.

Program Highlight California
The Preceptor Training Project
Goal: To retain the nursing workforce.
Approach and status: This program will train 300 RNs to be preceptors and 15 hospital-based educators to become preceptor trainers.
Funding sources: WIA state discretionary funds (through the Nurse Workforce Initiative)
Contact: Regional Health Occupations Resource Center
Saddleback College
(714) 991-9659

Program Highlight Michigan
Region 7B Michigan Works — Tendercare Clare and Tendercare Tawas City
Goal: To retain workers in long-term care occupations.
Approach and status: Two nursing homes have participated in incumbent worker training, providing "elder associate" certification for about 130 employees. The certification is awarded after the employee completes a three-day training course.
Funding sources: WIA Adult funds
Contact: Michigan Works
www.michworks4u.org
(989) 539-2173

Program Highlight Texas
The Gulf Coast Workforce Board Work Environment Workgroup
Goal: To increase satisfaction among nurses at area hospitals.
Approach and status: This program identifies "magnet" hospitals in the area. The workgroup is preparing an Ideal Work Environment Assessment Model to share best practices with other hospitals. The program includes an area survey to examine local turnover and vacancies among the nurse workforce.
Funding sources: Core staff are supported with WIA discretionary funds. Most of the program is supported through a grant from the HRSA Bureau of Health Professions.
Contact: Gulf Coast Workforce Board
Health Industry Liaison
(713) 499-6651

Program Highlight Wisconsin
Southeast Workforce Development Board/Gateway Technical College
Goal: To attract and retain health care workers.
Approach and status: The program supports a new class in nursing skill renewal aimed at nurses (RNs and LPNs) who have lost their licenses.
Funding sources: WIA Performance Incentive Grant
Contact: Southeast Workforce Development Board
(262) 564-2758

Program Highlight Wisconsin
WOW Workforce Development Board/Waukesha Technical College
Goal: To increase employment retention.
Approach and status: This program supports RN refresher training in new technology, ESL training in the workplace, and pre-assessment, case management, job placement, and follow-up services for newly trained CNAs. It supports three RN refresher courses, enrolling 30 individuals and focusing on new technology. Thirty individuals are receiving CNA on-the-job training through this effort.
Funding sources: WIA Incentive Grant
Contact: Workforce Development Center of Waukesha, Ozaukee and Washington Counties
(262) 544-5971

Direct Support for Health Careers Education and Training

In addition to using WIA resources to support health career ladder advancement programs, to build educational capacity, and to finance programs that are designed to increase employee retention in health care settings, states also use these resources to route individuals directly into health care education and training programs. Some state and local WIBs have earmarked WIA funds for health profession-specific tuition; others have used this resource to develop the health career One-Stop centers or to set up training programs to prepare groups of clients for entry-level health care jobs. WIA allows customized training for employers who are committed to hiring people who complete WIA-supported instruction.

Examples of programs in eleven states that provide direct WIA support for health careers education and training are described below.

Program Highlight California
Caregiver Training Initiative (CTI)
Goal: As part of the Governor's Aging with Dignity Initiative, to train geriatric caregivers, including CNAs.
Approach and status: Programs train WIA-eligible and welfare-to-work participants to become CNAs through existing training facilities. Competitive grants were awarded to 12 regional collaborative efforts statewide. The programs, now complete, trained from 4,800 to 5,900 individuals.
Funding sources: WIA state discretionary funds ($15 million) and state general fund ($10 million)
Contact: California Employment Development Division
Workforce Investment Division
(916) 653-6347
http://www.edd.ca.gov/wiaspnwiawtx.htm

Program Highlight Colorado
Accelerated BSN Worksite Incumbent Worker Program
Goal: To increase the number of skilled RNs in Adams County.
Approach and status: With a $250,000 grant from the Colorado state WIB, this program is training incumbent workers to become RNs through an accelerated BSN program.
Funding sources: WIA state discretionary funds ($250,000)
Contact: Colorado Office of Workforce Development
(http://www.state.co.us/gov_dir/wdc/wdc.htm)

Program Highlight Colorado
Health Care Center within a Workforce Center
Goal: To create a workforce center that focuses on health care.
Approach and status: This program is designed to create a health care center within a workforce center that will implement health workforce recruitment strategies, provide easy access to training in health care occupations, facilitate job placement in health care jobs, and offer workforce center customers career development strategies that are responsive to the health care industry needs of the Arapahoe/Douglas region.
Funding sources: WIA state discretionary funds ($49,999)
Contact: Colorado Office of Workforce Development
(http://www.state.co.us/gov_dir/wdc/wdc.htm)

Program Highlight Delaware
Nurse Scholarship Program
Goal: To train more RNs in the state.
Approach and status: In 2003, the Governor of Delaware earmarked $500,000 for nursing scholarships in a program managed by the Delaware Healthcare Commission. Candidates were required to be entering their final year of nursing education, and the scholarships paid for one year of tuition and accompanying education costs.
Funding sources: WIA state discretionary funds ($500,000)
Contact: Delaware Healthcare Commission
(302) 577-6202

Program Highlight Mississippi
Hinds County
Goal: To provide direct support for health occupations training.
Approach and status: The Mississippi Development Authority provided $1 million to create a Health Careers One Stop center, slated to open in 2004. This office is located near associated businesses and will offer multiple resources, all at one location, for job seekers who are interested in health careers.
Funding sources: WIA state discretionary funds
Contact: Hinds County WIB
(601) 368-3033

Program Highlight North Dakota
North Dakota WIB/Department of Public Instruction
Goal: To provide CNA training for students with limited English skills.
Approach and status: The North Dakota WIB contracted with the state Department of Public Instruction (responsible for state K-12 institutions and technical colleges) to provide CNA training for students with limited English skills. The funds, $180,000 for each of 2003 and 2004, pay for ESL training and CNA pre-requisite courses.
Funding sources: WIA incentive funds
Contact: North Dakota Department of Public Instruction
(701) 328-2398

Program Highlight Pennsylvania
Foundational Skills for Health Care Workers
Goal: To prepare candidates for health workforce training.
Approach and status: The Lancaster County workforce investment board developed programs to create a health care-related literacy program called Foundational Skills for Healthcare Workers, which provides a 40-hour training course for individuals not ready to enter training programs. In addition, the WIB created a remedial three-week course to prepare candidates for entrance to LPN training.
Funding sources: WIA Adult and TANF funds
Contact: Lancaster County Workforce Investment Board
(717) 735-0333

Program Highlight South Carolina
CVS Pharmacy Technician Training Program
Goal: To increase the skill level of pharmacy support staff by creating a three-tiered job with standardized training and certification for each level. Staff retention is a secondary goal of this program.
Approach and status: This program targets incumbent workers at CVS pharmacies. CVS technician-trainers conduct the training after receiving instruction from the CVS Training Department. These trainers report to CVS regional health care managers. Entry-level pharmacy employees, once trained in the first of seven training modules, assume the role of pharmacy services associates (PSAs). Pharmacy support staff members may continue training to become pharmacy technicians by completing and certifying in 10 additional training modules. The third-tier position is lead technician. To achieve this title, the technician must complete three additional modules and become nationally certified. The program is designed for 340 participants.
Funding sources: WIA state discretionary funds
Contact: South Carolina Employment Security
(803) 737-3830

Program Highlight Texas
Dislocated Worker Grants
Goal: To provide training for dislocated workers to become CNAs and LPNs.
Approach and status: This $1.5 million program, funded by a WIA demonstration grant, provides health workforce training to dislocated workers. Funds are split between the Dallas and the Gulf Coast WIBs.
Funding sources: WIA state discretionary funds
Contact: Texas Workforce Commission
(512) 463-2222

Program Highlight Virginia
Northern Shenandoah Valley Workforce Center and The Greater Peninsula Workforce Development Consortium
Goal: To provide training in health careers.
Approach and status: Several health career training programs have been implemented by local WIBs. The Northern Shenandoah Valley Workforce Center works closely with the Lord Fairfax Community College Nursing Department to help nursing students in LPN and RN programs complete their study by assisting clients with tuition expenses, especially during their last semester when Federal financial aid has been exhausted, and by assisting with the cost of the graduation pin, uniforms, equipment, and the cost of State Boards. Training assistance is also provided for clients to become CNAs, medical transcription/medical coders, and surgical technologists. The Greater Peninsula Workforce Development Consortium implemented a CNA program for out-of-school youth that provides an intensive 10-week occupational training course, case management, and supportive services to clients age 18 to 21.
Funding sources: WIA Adult and Youth funds
Contact: Northern Shenandoah Valley Workforce Investment Board
http://www.careerconnect.state.va.us/5noshenandoah
Greater Peninsula Workforce Development Consortium
http://www.careerconnect.state.va.us/14greaterpen/

Program Highlight Washington
The Olympic Health Care Alliance
Radiological Technologist Training Program
Goal: To increase the supply of radiology technologists in northwest Washington.
Approach and status: This scholarship program for radiology technologist training involves five community colleges that offer radiological training in other areas of the state, based on prerequisite training at the local Peninsula College. Letters of articulation were established among the participating colleges. Awardees sign an agreement that they will return to work for one of the employer-contributors to the scholarship fund.
Funding sources: WIA Adult, combined with contributions from health industry employers
Contact: Olympic Workforce Development Council
(360) 337-7185, or
Olympic Health Care Alliance
(360) 337-4883

Program Highlight Wisconsin
Fox Valley WDB - Moraine Park and Fox Valley Technical Colleges
Goal: To support collaborative workforce development planning through a task force.
Approach and status: The Fox Valley task force on health workforce shortages identified the need for a practical nursing program that trained LPNs who could easily gain the additional training to become associate-degree RNs. The first year of training developed under the partnership of this program provides LPN training and also satisfies the first-year requirements for an associate degree from which students can either enter the workforce or continue education toward an associate level RN degree. Remedial courses in nursing topics are also provided.
Funding sources: WIA Incentive Grant
Contact: Fox Valley Technical College
(920) 735-2488

Program Highlight Wisconsin
Lakeshore and NE Wisconsin Technical Colleges/Green Bay Area Workforce Development Board
Goal: To provide CNA training.
Approach and status: This program supports ESL instruction with a focus on nursing, while enrolling students in simultaneous training to become CNAs.
Funding sources: WIA Performance Incentive grant
Contact: Green Bay Area workforce Development Board
(920) 693-1168

Program Highlight Wisconsin
Western Wisconsin Workforce Development Board/Western Wisconsin Technical College
Goal: To increase the number of health care workers from populations traditionally under-represented in the health care workforce by increasing student success in CNA training.
Approach and status: This program supports remediation services, special admissions adviser services, job shadowing, special orientation sessions, case management, study skills training, and follow-up services for students studying to become CNAs.
Funding sources: WIA State Performance Incentive grant and special fund for assistance to economically disadvantaged populations
Contact: University of Wisconsin — Lacrosse
(608) 785-5148
Western Wisconsin Workforce Development Board
(608) 785-9211

Program Highlight Wisconsin
WOW Workforce Development Board/Waukesha Technical College
Goal: To train CNAs and to train RNs for reentry into the nursing field.
Approach and status: This program supports CNA training, refresher skill training, pre-technical skill training in job readiness, and communications and computer technology training. Seven CNA classes were conducted over 18 months, enrolling 70 individuals. The program also enrolled 80 individuals in classes combining ESL training with CNA training and supported three RN refresher courses enrolling 30 individuals, focusing on new technology.
Funding sources: WIA Incentive grant
Contact: Workforce Development Center of Waukesha, Ozaukee and Washington Counties
(262) 544-5971

One-Stop Center Referrals for Health Workforce Jobs and Education

With its work-first goal, WIA's original design was to route clients to jobs through core and intensive services and to limit the number receiving training services. But few health care jobs can be obtained without some specialized training or education. Clients who already have health care job skills use One-Stop center resources to find available jobs. For those who lack these skills, the role of the One-Stop center is to help clients navigate the various training and education resources for which they may be eligible. Clients who are eligible for WIA may be provided with ITAs to help them obtain training in job skills that are in high demand in the health care industry.

Linking clients to jobs through One-Stop centers are important to state and local health workforce development, but the extent of these linkages is not easily quantified. WIA performance measures document numbers of individuals becoming employed as well as their average earnings but not the industry sector in which employment occurs. We can nonetheless be certain that One-Stop centers across the Nation have linked many individual job-seeking clients with health care jobs, even without specific health care-related training and education programs as described above. Health care is one industry sector that has continued to experience a high rate of job vacancies in all states over the five years since WIA implementation.

VI. WIA Reauthorization

Congress authorized WIA in 1998 for five years. Continuation past September 30, 2003 required reauthorization or a continuing resolution. While the House and Senate passed reauthorizing legislation in 2003 (House Resolution 1261 and Senate 1627/Amended H.R. 1261), and the Bush Administration presented its reauthorization plans that year, Congress did not authorize WIA but extended it under a continuing resolution. WIA reauthorization remains in the House-Senate Conference Committee at the time this report was completed (Summer 2004).

Major Proposed Changes of WIA in Reauthorization Plans

Following are some of the major proposed changes in WIA through reauthorization (U.S. Department of Labor, 2003d).

Combined funding streams: The Administration and House proposals would combine Adult, Dislocated Workers, and Wagner-Peyser funds into a single formula grant for each state. The Senate proposal retains the current WIA formulas. Proponents of funding consolidation argue that it will increase states' flexibility.

State WIB membership and function: The proposals modify requirements for state WIB membership, adding the director of the state vocational rehabilitation program and removing requirements that organizations with expertise in youth activities and workforce activities be included. The proposals disagree about whether the business sector majority should be maintained and the extent to which elected officials should be included. They give state WIBs varying levels of increased policy-making authority over One-Stop centers.

Local WIBs: By removing the requirement that One-Stop centers have a seat on local WIBs, the House, Senate, and Administration proposals generally agree on changes that would make the WIBs more directed toward policy and planning and less toward service delivery. Local Youth Councils, mandatory under the original WIA, would become voluntary under reauthorization. Local plans would be submitted every two years instead of every five, with the intent of creating "living" documents.

TANF links: One of the major changes proposed by the Administration, House, and Senate would be closer linkages between WIA and the TANF. Noting that many states have already integrated services in their One-Stop centers, reauthorization would move TANF services to become one of the services required to be delivered at One-Stop centers (unless exemption were requested by a governor). Under such an integration, Individual Training Accounts could be combined with Individual Development Accounts (TANF funds that are set aside for basic services to help clients become self-sufficient).

Grandfathering: Grandfathering of JTPA systems (such as private industry councils) would be eliminated under the House version of the bill and would affect about half of the states. The Senate version leaves old systems intact unless they do not meet performance standards, in which case they would be replaced.

One-Stop center funding: The proposals take different approaches, all of which aim to improve infrastructure funding for One-Stop centers.

Access to training services: All three proposals contain modifications that would ease access to training services for those individuals whose needs are unlikely to be met through core and intensive services.

Performance measures: The 17 original performance measures would be reduced to 8 in both the House and Administration proposals. Customer satisfaction and adult credential measures are eliminated, but efficiency measures are added. The Senate proposal differs by retaining customer satisfaction and adult credential measures; it adds cost-per-participant language, but it does not include efficiency measures.

VII. Discussion

Clearly, WIA resources are used across the United States to build the health care workforce, especially for occupations with training requirements of two years or fewer. It would be difficult to say how much certain features of the law, versus the economic environment, have contributed to the significant emphasis many states and local workforce planning groups have placed on health industry jobs since 1999. A surge in demand for health care jobs occurred at the time WIA was implemented, making it difficult to estimate whether—had WIA not been enacted—similar amounts of DOL funding would have been channeled to the health care sector through programs of the JTPA.

Regardless of how DOL workforce development programs are delivered, health care would still be a high-demand, high-growth industry. With increasing demand for workers and crisis-level supply shortages within some occupations, members of the health care industry have banded together to work on solutions for the past several years. Many are leaders in programs and policy who have been working to develop the health workforce since long before WIA was enacted. The health care industry would have been represented at many WIA planning tables without the mandated involvement of business. But the WIA mandate undoubtedly helped provide new opportunities for the health care industry's involvement in workforce planning and increased awareness of the industry's high-demand, high-growth status.

One contribution of WIA that serves the overall health care workforce is the resources it has provided for data collection and state and local planning. These resources have been critical for some states, especially during a period of tight state budgets, for developing plans to alleviate health personnel shortages.

It was inevitable that health care's large quantity of relatively high wage jobs requiring training at the associate degree level or less would be an attractive focus for WIA programs. Our inquiries across the country found that health care has not been on every WIB's agenda, however. Many regions, and several states, had no specific WIA-funded programs to connect clients with health care jobs. A separate study would be needed to determine whether in those areas there was less demand for health care employees, whether health care was less involved in WIA planning efforts, if health care sector needs were being fulfilled with other resources, or if priority for WIA resources was given to another industry.

We did find that, in many cases, WIA has been a catalyst for developing the health workforce with pooled resources—mobilizing additional resources from both public and private sources. With restrictions on how WIA resources can be used, and limits to the quantity of WIA funds available, planners at the WIB table and One-Stop center staff were challenged to find complementary funds and partners for needed programs. With these additional funding sources, some programs have been able to support clients through baccalaureate, and occasionally, graduate training. In some cases, WIA resources were linked with funding allocated by state legislatures for health workforce development. WIBs have successfully sought Federal H1-B grants (workforce development grants derived from visa fees collected when skilled workers are imported by business) to fill gaps in health workforce development funding. Many business partners have contributed to programs developed by WIBs, as have private foundations. Certainly the WIA mandate that business, education, government, and labor meet at the planning table facilitated many of these successful collaborations. But the reauthorization debate about changes to WIB membership, which focuses on whether to decrease or increase the mandated number of business representatives and elected officials on WIBs, suggests that the current membership complement has not been productive in all sites.

Reauthorization may affect how WIA relates to the health care industry. If clients can be routed quickly to training programs (instead of first receiving core and intensive services), and if new performance measures are designed to support WIBs that encourage clients to receive training, more WIBs may target health industry jobs. Participation by health industry representatives in state and local WIBs will continue to promote awareness of the industry's needs. If WIA's mandate for business involvement is dropped or decreased at reauthorization, the health care industry's role in workforce planning will be determined by its level of activism in the community and/or the importance assigned by each state's governor.

In 2003, the DOL implemented "The President's High Growth Job Training Initiative." Under this initiative, the DOL Employment and Training Administration's Business Relations Group launched a series of forums with key industry stakeholders, including health care, to identify critical workforce issues and to discuss solutions. Since those forums were held, DOL has awarded $24 million in grants to "genuine solutions, leadership, and models for partnerships that can be replicated in different parts of the country" (U.S. Department of Labor, 2004). Many of these grants support health workforce development partnerships that grew out of WIB activities, and they include WIBs as partners. Health workforce development programs and partnerships across the Nation that started with WIA resources and that are perceived to be successful are serving as models through this initiative for potential replication and refinement.

For this report, we were able to identify many specific programs designed to promote health workforce development using WIA resources across the Nation. We found little information, however, on the success of those programs—although we acknowledge that assessing program outcomes was not an objective of this project. While WIA's performance measures track numbers of WIA-supported clients who become employed and stay employed for at least six months and the extent to which their earnings increased, they do not track this information by industry sector. The DOL-funded evaluations of WIA are process-oriented and describe various elements of WIA's implementation, but they do not provide information about outcomes such as jobs filled in the health care sector. As this report documents, WIA resources are being used through many different programs to prepare workers for health care occupations. The health care industry and other stakeholders would benefit from research and evaluations that identify which of these programs are successful at meeting that goal. We also need to increase our understanding of the components of workforce development programs, such as those described in this report, that contribute to successful outcomes.

The national workforce development structure that was put in place through WIA is not the sole vehicle for meeting our health workforce needs. WIA was designed for rapid job placement, and it is not suited for training physicians, dentists, pharmacists, and many other health professions requiring post-graduate training. The law provides, however, a multi-billion dollar infrastructure that can help the health care industry fill major gaps in many entry-level, allied health and nursing jobs. But the increased attention that WIA-funded programs bring to health careers may draw people into entry level health care occupations as a precursor to pursuing advanced professional degrees. And many of the gaps in the health care workforce can be filled by attracting underrepresented populations to these occupations—a solution that will help overcome the supply shortages and better serve patients. WIA can address these needs with job training resources for unemployed and underemployed individuals. To make the best use of WIA's resources, health care business, educators, policy makers, and workers need to understand how WIA relates to their needs and how changes will affect them in the future.

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