Below are a list of background material provided at the National Symposium. Found will be the abstract, introduction, executive summary and/or full report (and a link to another site) depending on the Internet availability or release approval. At the end of each "handout" is information about where the full report can be obtained.
National Center for Health Workforce Analyses, Bureau
of Health Professions, Health Resources and Services Administration
February
2004
Nursing aides and home health aides are two of the major occupations responsible for providing patient care of a paraprofessional nature to chronically ill, disabled, and elderly persons in nursing homes and other institutional or community-based settings as well as at home. The challenges faced by long-term care facilities in recruiting and retaining these workers have been increasing in recent years, resulting reduced services for many Americans.
Recognizing the importance of this segment of the health workforce in meeting the care needs of an increasing percentage of the population, the National Center for Health Workforce Analysis (NCHWA) in the Health Resources and Services Administration's (HRSA) Bureau of Health Professions (BHPr) has commissioned and directed this study. The study concludes that informed workforce planning is needed to document the extent of existing shortages in these occupations and thereby assist states and institutions in addressing them, as well as to assess the impact of present and future initiatives to balance supply and demand.
The comprehensive assessment presented in this report was based on a review of eight key Federal datasets, certified nursing aide registries in 45 states, and fieldwork in four states (California, Illinois, New York, and Wyoming). The fieldwork included interviews and focus groups with long-term care providers and State officials to assess both their current data collection activities and the data needed for future program and policy development. The project was guided by an expert advisory panel and interviews with leaders in the long-term care field. These efforts, along with a review of the literature, resulted in (a) confirmation that there exists a widespread shortage of long-term care paraprofessionals and (b) affirmation that the shortage is likely to be far more severe in the future. The report concludes with a series of suggested strategies for improving data collection relating to these occupations, building on existing datasets and data collection activities.
Introduction
This report focuses on nursing aides and home health aides, two of the major occupations responsible for providing patient care of a paraprofessional nature to chronically ill, disabled, and elderly persons in nursing homes and other institutional or community-based settings as well as at home. Faced with an aging population and a material shift of patient care to non-hospital venues, the Nation is experiencing an unprecedented demand for individuals with the training and experience needed to provide such care. There is a high turnover rate associated with these occupations, the result of a variety of factors relating to job satisfaction, such as low pay, lack of a career ladder, and occasional less than ideal treatment by supervisors. As a consequence, the supply of these individuals, while continuing to grow, has been slipping relative to demand, a situation likely to continue well into the future.
Because of the importance of this segment of the health workforce in meeting the care needs of an increasing percentage of the population, the National Center for Health Workforce Analysis (NCHWA) in the Health Resources and Services Administration's (HRSA) Bureau of Health Professions (BHPr) has commissioned and directed this study. The study concludes that informed workforce planning is needed to document the extent of existing shortages in these occupations and thereby assist states and institutions in addressing them, as well as to assess the impact of present and future initiatives to balance supply and demand. Current data systems were found to be limited in their ability to assist in such planning efforts. They do not, for the most part, accurately estimate the supply of individuals working in these occupations, including their numbers, locations, characteristics, and qualifications.
The comprehensive assessment presented in this report was based on a review of eight key Federal datasets, certified nursing aide registries in 45 states, and fieldwork in four states (California, Illinois, New York, and Wyoming). The fieldwork included interviews and focus groups with long-term care providers and State officials to assess both their current data collection activities and the data needed for future program and policy development. The project was guided by an expert advisory panel and interviews with leaders in the long-term care field. These efforts, along with a review of the literature, resulted in (a) confirmation that there exists a widespread shortage of long-term care paraprofessionals and (b) affirmation that the shortage is likely to be far more severe in the future. The report concludes with a series of suggested strategies for improving data collection relating to these occupations, building on existing datasets and data collection activities.
Nature of the Problem
Across the United States, there is growing concern about current and projected shortages of frontline, direct care workers who provide care and services to the elderly, chronically ill, and disabled. National studies cite annual turnover rates in nursing homes ranging from 45 to 105 percent (Stone, 2001). In 1999, Ohio's nursing assistant turnover rate ranged from 88 to 137 percent while in Florida, only 53 percent of the state's certified nursing aides (CNAs) were working in a health-related field one year after certification. Long-term care provider organizations have either reduced services due to shortages of permanent staff or, alternatively, hired temporary replacement staff at significantly higher hourly rates (Forschner et al., 2001). In areas where levels of service have been reduced, elderly or chronically ill persons deprived of access to care must either remain in more restrictive, more costly environments (notwithstanding the Supreme Court Olmstead decision affirming the right of nursing-home-eligible people to live in the "least restrictive" setting) or seek care from family or friends. Both quality of care and quality of life suffer as people are denied services, or services are provided by persons less qualified or experienced.
Over the next several decades, as population aging and advances in medicine increase the number of persons living with chronic medical conditions, the need for long-term care workers will continue to grow. The Bureau of Labor Statistics (BLS) projects that between 2000 and 2010, an additional 1.2 million nursing aides, home health aides, and persons in similar occupations will be needed to (a) cover the projected growth in long-term care positions and (b) replace departing workers. This rapid increase in demand--over half the year 2000 supply--can be expected, for similar reasons, to continue well beyond 2010. The pool, however, from which such workers have traditionally been drawn--largely women between 25 and 50 without post-secondary education--continues to shrink. It is questionable, therefore, whether the Nation will have an adequate supply of workers in these occupations to meet the expected increase in demand.
Nursing aides and home health aides provide much of the care in long-term care settings, both in nursing homes and in the community. Policymakers and the health care community have sought to understand the problems in maintaining an adequate supply of such healthcare workers. While some studies have led to an improved understanding of these occupations and the causes of the shortages, they have tended to rely on case studies, focus groups, and data that are incomplete. The lack of system-wide data has weakened efforts to understand the scope of the problem and to develop programs and policies that could address it.
Characteristics of Long-Term Care in the United States
Recipients. Long-term care recipients in the United States numbered about 12.1 million in 1995 (Kaiser Commission on Medicaid and the Uninsured, 1999). A diverse population with a wide age range and variety of service needs, the common element linking these individuals is their need for assistance with activities of daily living (ADL). Most received services at home or in community-based settings such as adult day care facilities, although about 12 percent (1.5 million) were cared for in nursing homes or other institutional residential facilities (ibid.).
As shown in Table ES-1, persons 65 or older constituted slightly over half (6.4 million) of the estimated 12.1 million long-term care recipients in 1995. Within that group, 1.3 million (20 percent) received care in nursing homes; the rest were cared for at home or in community settings. Of those receiving care at home or in the community, about two-thirds relied exclusively on unpaid caregivers, i.e., family and friends (Stone, 2001).
| TABLE ES-1. Recipients of Long-Term Care in the U.S., 195 | |||
|---|---|---|---|
| Age Group | Setting in Which Care Was Received | All Settings Combined | |
| Nursing Home | Home or Community | ||
| 65 or Older | 1.3 million | 5.1 million | 6.4 million |
| Under 65 | 0.2 million | 5.5 million | 5.7 million |
| All Ages | 1.5 million | 10.6 million | 12.1 million |
| SOURCE: Kaiser Commission on Medicaid and the Uninsured, 1999 | |||
The dichotomy between nursing home and community-based care is even more pronounced for persons under 65. Of the nation's long-term care recipients below the age of 65, well over 95 percent--all but about 0.2 million--received care at home or in community settings. Of these, roughly three-fourths relied exclusively on family and friends for care. Long-term care recipients below the age of 65 include persons with mental retardation and serious mental illness, as well as adults living with AIDS or other chronic disorders and children with developmental disabilities.
Providers. The three major categories in the latest (1998) Standard Occupational Classification (SOC) system whose members provide long-term care of a paraprofessional nature are as follows:
| Nursing aides, orderlies, and attendants (SOC 31-1012) | Provide basic patient care under the direction of nursing staff. Perform attendants duties such as feeding, bathing, dressing, grooming, moving patients or changing linens. |
|---|---|
| Home health aides (SOC 31-1011) | Provide routine personal health care such as bathing, dressing, or grooming, to elderly, convalescent, or disabled persons at patient's home or residential care facilities. |
| Personal and home care aides (SOC 39-9021) | Assist elderly or disabled adults with daily living activities at person's home or daytime non-residential facilities. Duties may include keeping house and preparing meals. May also provide meals and perform supervised activities at non-residential care facilities. |
The number of individuals employed in these categories, based on year 2000 BLS data, are as follows:
| Nursing aides, orderlies, and attendants | 1,262,000 |
|---|---|
| Home health aides | 577,700 |
| Personal and home care aides | 366,600 |
| Total | 2,206,300 |
Table ES-2 shows their percentage distribution by industry group in which employed.
| TABLE ES-2. Paraprofessional Workers by Industry Group: 2000 | |||||
|---|---|---|---|---|---|
| Occupational Category |
Industry Group | ||||
| Home Health Care |
Nursing and Personal Care |
Residential Care |
Other | Total | |
| Home Health Aides | 32.9% | 5.4% | 22.3% | 39.4% | 100% |
| Nursing Aides, Orderlies, and Attendants | 2.7% | 51.9% | 4.5% | 40.9% | 100% |
| Personal and Home Care Aides | 30.8% | 3.5% | 24.1% | 41.6% | 100% |
| SOURCE: BLS Occupational Employment Survey | |||||
Approximately 60 percent of the workers in each occupational category are seen to be employed in the three industry groups most clearly associated with the delivery of long-term care (home health care, nursing and personal care, residential care). In addition, a significant portion of those in industries classified as "Other" may also be assumed to have been engaged in the delivery of long-term care. For example:
There also exists a substantial "gray market" of individuals hired directly by individuals and families, who do not show up as employed in either BLS or other government data systems. One national study found that 29 percent of workers providing assistance to the Medicare population in the home were self-employed (Leon and Franco, 1998a).
Workers in the described occupational categories earn relatively meager wages. In 2000, the median wage for each of these categories was less than $9 an hour, an annualized salary of less than $19,000 for a full work-year of 2,080 hours (BLS, National Occupational and Wage Estimates for 2000). Many of these individuals work only part-time. Long-term care paraprofessionals are reported to work only about 30 hours a week on average, reducing their annualized earnings to well below $15,000. A high percentage (28 percent) live in poverty, and are more likely than other workers to rely on public benefits to supplement their wages (Himmelstein et al., 1996). Among single-parent nursing home and home health aides, 30 to 35 percent receive food stamps (General Accounting Office, 2001). Many also rely on publicly funded health care.
Data from the BLS Current Population Survey (CPS) March Supplement indicate that over 90 percent of the two specific occupations "nursing home aide" and "home care aide" are female, with the vast majority falling between the ages of 25 and 54. A significant percentage of these individuals (12 to 23 percent) are foreign-born, of whom only about a third are naturalized. Contrary perhaps to public perception, a substantial proportion (28 to 35 percent) reported at least some college education.
Provider Organizations. Organizations that draw upon long-term care paraprofessionals to provide needed services include:
There were approximately 120,000 such organizations in the United States in 1998 (Harrington et al., 1999), of which roughly 43 percent (51,200) were residential facilities for adults or the aged and another 20 percent (23,300) were home health care agencies. Nursing facilities accounted for 15 percent (17,500) and residential facilities for the non-aged for 11 percent (13,300).
In addition to these types of organizations, there are a growing number of alternative organizational and service configurations as consumers and providers seek to expand the options for both health services and housing arrangements for the elderly and chronically ill. Many states have developed Home and Community Based Services (HCBS) options, with a sharp increase in assisted living arrangements and options. In addition, many states are promoting approaches to giving individuals more control over the selection of caregivers under programs generally referred to as "consumer-directed care".
Shortage Issues
Factors affecting supply. The high turnover and vacancy rates associated with these occupations are consistently found to be the result of job dissatisfaction stemming from the following:
Factors affecting demand. Factors responsible for the increased demand for long-term care include:
Population aging, in and of itself, might present less of a problem if the supply of care providers were growing at approximately the same rate. Unfortunately, it is not. It is growing at a significantly lower rate--not only are providers leaving the field for reasons of job dissatisfaction but the pool from which such providers have typically been drawn in the past has been dwindling compared to the growth in demand due to aging. In 2000, there were 1.74 females between the ages of 25 and 54 for every person 65 and older; by 2030, that ratio is projected to drop to 0.92 (calculations based on Census Bureau National Population Projections). Since women provide the majority of both paid and family-provided long-term care, this "care gap" will increase. Families unable to care for their loved ones by themselves will find, when they turn to the formal system for assistance, relatively fewer paid staff available.
Data Issues
Need for Data. Data that are clear, comprehensive, current, and correct are needed in the case of long-term care paraprofessionals, as they are for any other health occupation. Such data are a valuable tool for meeting the following purposes:
Relevant Data Sources. As noted earlier, the data systems reviewed in this study, although helpful in many respects, were limited in their ability to present an accurate and timely picture of nursing aides, home health care aides, and related occupations in the United States. The datasets reviewed included six maintained by the Bureau of Labor Statistics, one on nursing homes maintained by the DHHS Centers for Medicare and Medicaid Services (CMS), one maintained by the Bureau of the Census, and 45 certified nursing aide (CNA) registries maintained at the State level. A brief summary of these datasets follows:
Bureau of Labor Statistics. The six BLS datasets cover six separate aspects of the Bureau's data collection activities:
Centers for Medicare and Medicaid Services. The CMS dataset, labeled Online Survey Certification and Registration or OSCAR, consists of staffing data and associated facility characteristics for approximately 17,000 CMS-certified nursing homes. The data are self-reported and updated once a year as part of the CMS annual recertification process.
Bureau of the Census. The decennial Census collects limited data on the occupation of residents of the United States. These data, updated every 10 years, provide estimates of the numbers of persons employed in different occupations by Census tract. The data are tabulated by place of residence rather than employment.
State CNA Registries. Registries of this nature, mandated by the Omnibus Budget Reconciliation Act of 1987, are maintained by every State and the District of Columbia. Used for background checks and other relevant purposes, they contain information on certified, licensed, or registered nursing aides working in skilled nursing facilities (SNFs), although some states have gone beyond the legislative mandate to include other direct care paraprofessionals. Of the 45 State registries reviewed, nine include home health aides as well.
Data Limitations. The limitations presented by these data sources, in terms of meeting the purposes of this study, fall into three categories: data exclusions, inconsistency of definitions, and categorizations that are in some cases excessively broad.
Data exclusions. Important data exclusions are as follows:
Inconsistency of definitions. Occupational and industry classifications used have differed by dataset and varied over time. However, as announced in the Federal Register Notice of September 30, 1999, all Federal agencies that collect occupational data are now required to use the 1998 Standard Occupational Classification, the largest revision to the SOC in two decades. In addition, all State and local government agencies, as well as private sector organizations, that gather occupational data are strongly encouraged to use the 1998 SOC. In the words of the announcement, "This national system ... provides a common language for categorizing occupations in the field of work."
While the Federal government has attempted to standardize classifications through the SOC, inconsistencies among state-reported data remain; this includes differing definitions of workers and different methods used to quantify the number of workers.
Excessively broad categorizations. The occupational category "nursing aides, orderlies, and attendants", retained in the 1998 SOC, includes three separate occupations, each with its own set of demographic characteristics, work settings, and job responsibilities. Similar problems exist with respect to the classification of industries: some industry codes contain work settings irrelevant to the provision of direct care, e.g., medical laboratories, youth services, crisis centers, food banks, etc.
Making Workforce Data More Useful
The limitations noted above apply not only to the present study but also to future attempts to achieve a comprehensive assessment of the long-term care paraprofessional workforce at national, state, and local levels. To assure the accurate, comprehensive, timely data needed to support workforce planning in this area and offset possible future shortages, the following options are identified:
Upgrade and augment existing CNA registries. Possible options in this area include:
Adopt and implement state-level workforce data collection systems for nursing aides, home health aides, and related health care occupations. Such systems, using standard definitions and terminology, would permit useful totals and subtotals to be collected from facilities and agencies, to be shared and compared across states. A proposed data collection instrument of this form is shown in Appendix B of this report.
Involve long-term care provider organizations and professional associations in data collection efforts. Such groups would be a valuable source of information. Organizations that collect and maintain informative workforce data report fewer recruitment and retention problems than their relatively data less counterparts.
|
Department of Health and Human Services and Department
of Labor
May 14, 2003
In the FY 2002 Senate Appropriations Subcommittee for Labor-HHS Education and the Conference Committee Report for the FY 2002 Labor-HHS Appropriation, Congress requested that the Secretaries of Health and Human Services and Labor identify the causes of the "shortage" of frontline workers (registered and licensed practical nurses, certified nurse aides and other direct care workers) in long-term care settings such as nursing homes, assisted living and home health care. The Subcommittee and Committee requested that the Department of Labor (DOL) and Department of Health and Human Services (HHS) make comprehensive recommendations to the respective Committees to address the increasing demand of an aging baby boomer generation.
This report is a product of collaboration between HHS and DOL in response to the requests from the U.S. Congress. Staff at these Departments worked collaboratively to share information and data pertaining to direct care workers in long-term care settings and to develop a joint set of recommendations for the future. The results of those efforts are presented in this unified Report to Congress. In addition, HHS and DOL included information from the following activities:
One of the challenges facing the U.S. in the 21st Century will be to ensure that individuals throughout their life will have the supports they need and will be treated with dignity. For the growing population of the elderly and people with disabilities, ensuring the adequacy and availability of direct care workers is key to meeting this ideal. As this report shows, the aging "baby boomer generation" will be the most significant factor increasing the demand for long-term care services over the next half century. The number of individuals using either nursing facilities, alternative residential care, or home care services is expected to increase from 15 million in 2000 to 27 million in 2050. Most of this increase will be driven by the growth in the number of elderly in need of such care, which is expected to double from approximately 8 million in 2000 to 19 million in 2050.2
In 2000, approximately 1.9 million direct care workers (defined in this report as including registered nurses (RNs), licensed practical and vocational nurses, nurse aides (NAs), home health and personal care workers) provided care to 15 million Americans in long-term care settings (defined in this report as including nursing and personal care facilities, residential care facilities, and home health care services).3 The Bureau of Labor Statistics (BLS) estimates that by 2010, direct care worker jobs in long-term care settings should grow by about 800,000 jobs, or roughly 45 percent.4 Paraprofessional long-term care employment will account for 8 percent of the estimated increase in the nation's jobs for workers in occupations generally requiring only short-term on-the-job training.
According to estimates developed by HHS's Office of the Assistant Secretary for Planning and Evaluation (ASPE), after 2010, the demand for direct care workers in long-term care settings becomes even greater as the baby boomers reach age 85, beginning in 2030. ASPE estimates project the demand for direct care workers to grow to approximately 5.7-6.6 million workers5 in 2050, an increase in the current demand for workers of between 3.8 million and 4.6 million (200 percent and 242 percent respectively). This increase in demand will be occurring at a time when the supply of workers who have traditionally filled these jobs is expected to increase only slightly.
These projections indicate that it is critical to retain existing long-term care workers and attract new ones. Since many industries will be competing for the supply of workers, pay and working conditions will play a key role in attracting new workers and consequently influencing the supply of long-term care services. Providing adequate levels of high quality, compassionate care will require sustained effort by many actors. While the Federal Government has an important role to play, much of what needs to be done will require action on the part of current and new employers who will expand and alter the market itself and shape new solutions. Other solutions will inevitably be crafted by state and local governments, health care providers and industry associations, education and training institutions, workforce investment systems, faith-based organizations, and workers themselves.
Recommendations
HHS and DOL identified a comprehensive set of recommendations to address potential imbalances between the future demand for and supply of direct care workers in long-term care settings. The recommendations are geared to address key issues relating to:
The recommendations include:
National Dialogue With Employers: Engage employers and employees as well as medical professionals and state and local government, in a dialogue on issues relating to improved pay, benefits, career ladders, and working conditions in long-term care.
Outreach to Faith and Community-Based Organizations: Explore with faith and community-based organizations their potential roles in addressing shortages in labor imbalances through strengthening relationships with the workforce investment system, and in recruiting volunteers for respite care for family members, "back-up" services, and home-based support.
Enhanced Use of Technology: Explore use of new technology in recruitment, education and training, recordkeeping and patient care. Expand and work with industry to market CareCareers.net.
State and Local Initiatives: Encourage and support state and local efforts, involving both the private and public sectors to explore use of business partnerships with individual employers or consortiums of employers, training providers and public agencies.
Enhanced Training and Education: Support multiple initiatives including implementation of the newly passed Nurse Reinvestment Act, expanding efforts to leverage private sector funds similar to DOL's Partnerships for Jobs, encouraging states to expand training slots for nurses and paraprofessionals, promoting registered apprenticeship training programs to paraprofessional occupations, and others.
New Sources for Workers: Seek ways to broaden the supply of frontline long-term care workers by reaching out to older workers, former Temporary Assistance for Needy Families (TANF) recipients, military personnel transitioning to civilian life, individuals with recent experience providing care to family members, dislocated workers from other industries and young people.
Support for Informal Caregivers: Continue efforts to support informal caregivers, such as through tax incentives and grants to state and local organizations (e.g., the Administration on Aging's (AoA) National Family Caregiver Support Program), provide information and referral resources, and explore the effectiveness of respite care demonstrations.
Regulatory Changes: Explore areas for potential federal and state regulatory changes, which could include enhanced information sharing and policy coordination among states, and possible federal requirements on patient recordkeeping.
Worker Safety: Continue to support worker safety education and outreach to employers, such as through DOL's National Emphasis Program, and through enhanced safety training within schools of nursing and within the paraprofessional training curriculum.
Research Efforts: Continue to support research and evaluation activities on such subjects as wages, benefits, worker characteristics, and workplace cultures.
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Paraprofessional Healthcare Institute and North
Carolina Department of Health and Human Services
March 2004
The Paraprofessional Healthcare Institute (PHI) and the North Carolina Department of Health and Human Services (NCDHHS) have once again collaborated to survey states about direct-care workforce issues. The 2003 survey updates and expands upon information collected from states in prior surveys to examine public policy actions taken by states to strengthen the direct-care workforce. Specifically, the purpose of this survey was to:
This is the fourth national survey on the direct-care workforce developed by PHI and NCDHHS. Surveys were sent to all state Medicaid agencies and state Units on Aging in September 2003; some surveys were redirected to a more appropriate state entity for completion. Completed surveys were received between October and December 2003; clarification was sought as needed. Responses were received from 44 states, representing an 88% response rate.
A summary of results from the 2003 survey is available in Table 1 and detailed comments are described in Table 2. A snapshot of each state’s existing or enacted direct-care worker initiatives is presented in individual charts in Appendix A, reflecting information collected from this and prior national surveys conducted by PHI and NCDHHS. New information provided from the 2003 survey is reflected in bold type.
Data Caveat: All analyses and percentages reported are based on the 44 states responding to this survey.
Employment Growth:
Many states continued to indicate that
high rates of vacancies exist among direct-care workers occupations. This is
not surprising given the growth in demand nationally for direct-care workers as
projected by the US Bureau of Labor. Between 2002 and 2012, the Bureau of Labor
projects employment growth of direct-care workers to more than double (33.8%)
the projected growth in overall employment nationally (14.8%).
Wage Rates:
The national average of median hourly wages for
the three major categories of direct-care workers (nurse aides, orderlies, and
attendants; home health aides; and personal and home care aides) has increased
from $7.97 in 1999 to $8.70 in 2002. This represents a 9.15% increase over the
four-year period for an average annual increase of 2.28%. Wage rates for
direct-care workers in 2002 are presented below:
| National Wage Data for Direct-Care Workers, 2002 | |
|---|---|
| Median Hourly Wage | |
| Nurse Aides, Orderlies, and Attendants | $9.59 |
| Home Health Aides | $8.70 |
| Personal and Home Care Aides | $7.81 |
| Average median wage across 3 categories | $8.70 |
| See Table 3 for state unemployment data from 2001 to 2003. Also included in Table 3 are average median hourly wages, by state, across direct-care worker categories from 1999 to 2002. | |
During calendar year 2003 the national unemployment rate peaked at 6.3% in June and dropped to 5.7% by December. When examining individual state unemployment rates, however, twelve states had unemployment rates at, or in excess of, 6.0% in November 2003. Of these, three states (Alaska, Michigan, and Oregon) had unemployment rates of 7.0% or higher.
Information collected during the 2003 survey continued to show that, generally, vacancies of direct-care workers continued to be a serious workforce issue for most states. This trend has continued since the first survey conducted in 1999 and in subsequent surveys conducted during both strong and declining economic periods. It is worth noting that the severity of direct-care worker vacancy rates did diminish for some states: in 2003, 79% of the 44 states responding to the survey indicated that high vacancy rates continue, compared to 88% of states in 1999 and 86% of states in 2002. Thus, the recent high unemployment rates may have contributed to improved vacancy rates in some states. It will be interesting to observe whether those workers who were attracted to enter (or re-enter) direct care during the recession because of limited job opportunities, remain in the field once the overall job market significantly improves.
However, responses received from states re-affirm that the economy is not the primary factor impacting serious vacancies of direct-care workers. Repeating trends found in previous surveys, both the state with the highest unemployment rate as of November 2003 (Alaska at 7.5%) and the state with the lowest unemployment rate (North Dakota at 3.2%) reported serious direct-care workforce vacancies.
In spite of the unemployment rate and continued slow job growth during 2003, there were clear signs an economic recovery was underway. Indications that state economies were improving were welcome news for states, which have struggled to balance their budgets over the past several years. A November 12, 2003 article in USA Today reported that state and local spending increases were annualized at 1% for the two consecutive quarters ending September 2003.2 This growth rate represented the smallest growth spending during back-to-back quarters reported since 1952. In contrast, the good news for states during this same period was that revenue collection was picking up, increasing to a 9.2% annualized rate during these same two quarters. However, much of these increases was reportedly due to increased federal payments to states, a significant portion of which was one-time money to offset Medicaid costs, and increased tax collections.
The December 2003 Fiscal Survey of States published by the National Governors Association and the National Association of State Budget Officers confirmed that while the economy was improving, states continued to have difficulty balancing their budgets during State Fiscal Year 2003.3 Medicaid is a major expense for states, and the report indicates that every state has taken at least one step to control Medicaid costs during State Fiscal Years 2002-2004. The report listed the following key actions:
Some of these actions have had a direct impact on direct-care workforce issues. Detailed Medicaid policy actions taken by states during the 2003 fiscal year are described in Section D below.
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Charissa R. Raynor
August 2003
Across the country, long-term care providers are facing a shortage of qualified and committed direct care workers--those certified nursing assistants (CNAs), home health aides and personal care workers who provide hands-on care to millions of older adults and individuals with physical disabilities. Vacancy rates in excess of 10 percent and turnover rates in excess of 100 percent are not unusual.2
Over the next 10 years, the country will need an estimated 874,000 additional direct care workers to meet growing demand.3 At the same time, the supply of workers traditionally relied upon to fill these positions--middle-age women--will fall by about half by 2030.4 To address this emerging "care gap," providers, policy-makers and consumers are likely to consider a broad range of strategies: improving wages and benefits of direct care workers, tapping new worker pools, strengthening the skills that new workers bring at job entry and providing more relevant and useful continuing education and training. A key strategy in this mix will be a focus on workforce development--providing workers with the knowledge and skills they need to perform their jobs.
The purpose of this report is to describe five federal workforce development programs and how some long-term care agencies and service providers use them to improve the recruitment and retention of direct care workers. The five programs are:
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Alexander, Wegner, & Associates
February
2004
The following is a report prepared by Alexander, Wegner, & Associates for the U.S. Department of Labor, Employment and Training Administration’s Business Relations Group. This report details what the U.S. Department of Labor, Employment and Training Administration (DOL ETA) has learned from employers, employees, educators, workforce professionals, and researchers about health care workforce challenges and solutions. It provides the basis for developing strategic partnerships that include industry, education, and the public workforce system.
At the federal level alone the public workforce system invests over $15 billion each year providing employment and training services to people who need them. ETA is always looking for more effective and efficient ways to use these resources. The Initiative, of which this report is a part, is directed toward forging these partnerships and making these improvements.
To address workforce needs in health care and other industries, ETA created the Business Relations Group. Recognizing that workforce development is part of economic development, the Business Relations Group’s focus is on the education, employment, and economic development partnerships that are needed to fuel our nation’s economy. ETA’s goal is to prepare the workforce system to better serve the needs of business, and to connect businesses with the workforce system through targeted initiatives.
Based on ETA’s review of major areas of job growth, the health care industry was selected as one of 12 industries for the High Growth Job Training Initiative.
The reality of the situation allows employers the opportunity to reach out and offer jobs in health care that are enticing to potential job seekers. Health care occupations are attractive because they are located across the nation, provide a professional work environment, and are portable. The health care industry needs greater diversity among its workforce, and therefore may be attractive to new labor pools. There is an increased building of career ladders and lattices that are available to workers so they can shape their careers.
Meeting the short-term needs and the projections for the coming decade is only part of the challenge. The long-term care sector alone will see an increase of 5.7 to 6.6 million direct-care workers by the year 2050.2 Even the most optimistic hopes for increased technological solutions or improvements in the health of Americans will not prevent this increased need for direct care workers.
ETA heard from employers, and others associated with health care, of some of their actions to identify challenges and implement effective workforce strategies. ETA heard of the pressures they experience to do much more, to do it quickly, and to do it in a way that is sustainable over a long period of time. Health care leaders are committed to dealing with major workforce issues. However, the challenges they face are far too complex for any one institution or sector to solve alone. It has never been more important for ETA to build partnerships between employers, employees, educators, workforce professionals and government.
The Employment and Training Administration and the public workforce system will now move to partner with industry and education institutions to act on solutions from this report that highlight innovative ways that the workforce system can be a catalyst for meeting the health care industry’s workforce needs.
To those who gave generously of their time, effort and other resources for this initial work -- thank you for your thoughtful contributions. To those reading about this initiative for the first time -- ETA looks forward to your contributions to building a responsive and sustainable health care workforce system throughout the country.
As ETA heard from different industries, it found several workforce challenges that are common throughout different sectors. ETA will look to partner to address these workforce problems across industries. Solutions will be categorized under the following categories: pipeline, competency models, post-secondary and alternative training, new labor pools, retention, transitioning/declining industries, and small businesses.
A top priority for the Department of Labor’s (DOL) Employment and Training Administration (ETA) is serving America’s workers through effectively meeting the workforce needs of business. The High Growth Job Training Initiative of ETA and its Business Relations Group recognizes that workforce development is not separate from economic development but an integral part of it.
The health care industry was selected as one focus within the High Growth Job Training Initiative. Health Services comprised 5.8 percent ($589.9 billion) of Gross Domestic Product in 2001.3 In 2002, the total employment in health services was 11,529,000.4 The Labor Department’s Bureau of Labor Statistics projects that the industry will add 3.5 million new jobs, or 16 percent of all wage and salary employment, between 2002 and 2012. Nine out of the twenty fastest growing occupations will be in health care.5
Significant workforce supply and demand gaps currently exist across the U.S. that affect acute care, long-term care and primary care health care provider sectors. These gaps are even more significant across all three sectors in rural America.
This report provides the results of information gathering from key health care informants regarding workforce issues as reported by the ‘demand’ side of the workforce. The provider or owner/operator associations employing the greatest numbers of health care workers are the primary employer informants. Parallel to meetings and interviews with employers, relevant workforce reports and information were sought from the DOL Bureau of Labor Statistics, the Department of Health and Human Services Health Resources and Services Administration, health care workforce researchers, reports of provider associations, educators, public and private workforce professionals -- including Workforce Investment Boards, and the contacts suggested in interviews with members of these sources.
The initial analysis of the information generated concluded with a clustering of the workforce issues or challenges by topic and by sector within the health care industry:
The majority of the workforce issues reported are the same or similar across primary, long-term care and acute care sectors. For example, all types of provider groups report that the current number one problem in occupational vacancies is for registered nurses. There are, however, some identifiable differences among the provider sectors. For example, long-term care providers identify a serious concern regarding the current and projected supply/demand gap of senior managers, while neither acute nor primary care providers share the same degree of concern. The acute care providers’ vacancies include a significant number of direct care workers, medical diagnostic and treatment technologists and support workers. The rural health vacancies across a wide spectrum of occupations are of continuing concern and made more problematic with the current vacancy rates nationally.
A second step in information gathering and analysis was performed prior to and during the course of three Workforce Development Industry Forums held in October 2003. The 126 forum participants were selected from a pool developed through nominations from owner/operator associations, the National Association of State Workforce Agencies, the National Association of Workforce Boards, the American Association of Community Colleges, and other workforce leaders from whom project staff had previously sought information. Some of the participants represented health care workforce projects currently funded by the Employment and Training Administration. Participants were asked to complete a validation tool containing challenges gathered in Phase I and invited to suggest additional issues. In addition, at the forums they were presented with an overview of the challenges and issues and asked for additional input. No changes in the challenges were made.
Participants in the forums were assigned to one of four groups. They clarified challenges or issues, generated 1001 solutions, and ranked the solutions by a voting procedure. For the 83 highest-ranked solutions, small teams worked to develop a matrix that includes the challenge, the solution, critical attributes for a successful solution, key stakeholders, resources required, policy barriers at the local, state and national or federal level, and any other needed clarifications.
The highest-ranked solutions include recommendations in the following areas:
The Department of Labor Employment and Training Administration’s Business Relations Group reviewed the solutions generated during the Workforce Development Industry Forums. The purpose of the review was to:
The solutions anticipated to have the clearest impact include the following program areas:
The majority of the solutions identified by forum participants are not sector specific. However, many solutions can be adapted to the particular needs of a sector or a community.
National, State and Local Partnerships for Implementing Workforce Solutions
Dealing with workforce challenges in the health care industry requires collaboration at the national, state and local levels, and between these levels. Executive and Workforce Development Industry Forum participants recommend a national, systemic approach that aligns the workforce resources available with the challenges facing the health care industry today and well into the future. This direction is consistent with the thinking behind the High Growth Job Training Initiative.
A central role of the Employment and Training Administration is that of identifying and communicating effective workforce solutions that can be replicated to respond to national challenges such as management training or youth-related recruitment programs. A second aspect of that role is the funding of pilot programs, by ETA alone or in partnerships, that are most effective in dealing with some aspect of workforce challenges, and that are replicable by other entities. At the national level, providers and others also identify the need for a national warehouse of sound and effective workforce interventions with a search engine that makes it possible for a local Workforce Investment Board, a human resources manager, or others to identify solutions that have worked elsewhere.
The actions of state governments and state-level entities are pivotal to any national workforce effort. State government decisions direct how some federal funding is used to support some workforce programs. For example, the Workforce Investment Act provides funding to states, and through the states to local Workforce Investment Boards and workforce-related programs. These funds and others, such as Temporary Assistance to Needy Families and Medicaid, are used to provide training, support, and placement for many occupations including those in health care. It is at the state level that policy and funding decisions are made about higher education, licensing and regulation. Medicaid programs that directly affect employment conditions and delivery of care, worker training, collection of information for programs and policy development, and other initiatives that directly influence the implementation, are among many of the solutions recommended in the Executive Forums and Workforce Development Industry Forums. A sustainable, adaptive and effective workforce strategy in health care requires strong public and private partnerships in every state. Without these partnerships ETA cannot respond adequately to current problems or prevent future ones.
Local partnerships, including Workforce Investment Boards, employers, employees, educators and other community members, are needed to implement workforce solutions closest to health care delivery sites, and to potential labor pools. Through such partnerships, both the workforce demand and supply sides can identify the needs in their own communities. Partners can use their state and national networks to find solutions to better manage their particular challenges.
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Employment and Training Administration, U.S. Department of Labor
The New Americans in Nursing Program, a $1.4 million grant to Florida International University’s School of Nursing, retrains unemployed or underemployed foreign-educated physicians to become registered nurses. ($60,150 in leveraged funds)
Efficacy of Tutoring to Reduce Health Care Occupation Bottleneck, a $224,088 grant to Capital IDEA, Austin, Texas, fills the health care pipeline by offering tutoring to students who fail a key course required for graduation in a nursing or allied health occupation. (over $700,000 in leveraged funds)
Oregon Governor’s Healthcare Workforce Initiative is a $300,000 grant to the State of Oregon to enhance the capacity of educational institutions to provide health care clinical requirements by funding seven Sim Man® real-time interactive human patient simulators. This technology will be used by faculty and over the state’s broadband Internet network. ($450,000 in leveraged funds)
Grow Our Own, a $4 million grant to the Rio Grande Valley Health Training Alliance for the region surrounding McCallum, Texas, will enroll students in Post-Licensures Specialty Training, create a Skills Workforce Academy, and develop a comprehensive Faculty Sharing Program. ($4.5 million in leveraged funds)
Specialty Nurse Training is a $4 million grant to a partnership between the Hospital Corporation of America (HCA) and Broward Community College in Ft. Lauderdale, Fla., and Austin Community College in Austin Tex. To address the nursing shortage, the Florida program will create a distance learning model; the Texas fellowship program will create an intensive, hands-on, accelerated learning setting similar to a medical residency program. Both programs provide approaches that produce quicker results than traditional on-the-job training. (over $6 million in leveraged funds)
The Hospice and Palliative Care Certificate Program, a $516,154 grant to Excelsior College, Albany, N.Y., will develop curriculum and deliver an online hospice and palliative care certificate program that can be accessed from any location.
Johns Hopkins Health System’s Incumbent Worker Career Acceleration Program, a $3 million grant to the Johns Hopkins Health System, Baltimore, Maryland, provides a continuum of solutions for incumbent workers to move up the health career ladder starting at entry-level. ($3.9 million in leveraged funds)
Healthcare Career Lattice: A Model for Enhanced Learning, a nearly $1.9 million grant to Evangelical Lutheran Good Samaritan Society (ELGSS), addresses the need to attract more youth and other alternative labor pools into health care occupations, including non-nursing occupations. The project, which will operate in North Dakota, South Dakota and Minnesota, will also build the capacity of education providers. ($1,204,000 in leveraged funds)
The Maryland Healthcare Workforce Initiative is a $1.5 million grant to the State of Maryland and the Governor’s Workforce Investment Board. The grant provides strategies, including scholarships, to enhance the skill levels of nurses along the career ladder and to back fill the gaps left by nurses transitioning into teaching. ($700,000 in leveraged funds)
Developing Partnerships and Initiatives to Resolve Long-Term Care Workforce Challenges, a $113,296 grant to the American Health Care Association Foundation, will provide a practical “How To” or “Cookbook” for nursing home managers and administrators combating the nursing shortage in long-term care. The information can be used to spearhead the formation of partnerships across the country.
Recruitment and Retention of Direct-Care Workers, a nearly $1 million grant to the Paraprofessional Healthcare Institute, will focus on multiple workforce challenges related to recruitment and retention of direct care workers in the long-term care industry. The project, operating in New York, North Carolina and Pennsylvania, will demonstrate problem-solving training curriculum and publish a series of guidebooks and teaching manuals in both English and Spanish on effective paraprofessional workforce development practices. ($999,902 in leveraged funds)
Three-Year, Hospital-Based Degree Nursing At a Rural Community Hospital is a $200,000 grant to the Berger Health System in Circleville, Ohio. To increase the number of trained nurses, Berger Health System will provide instructors, space for training, and clinical experiences; Ohio University will supply curriculum and faculty for a three-year, university-based Associate Degree nursing program. ($405,939 in leveraged funds)
Pueblo Project HEALTH, a $715,402 grant to Pueblo Community College, Colorado, will assist counties designated as Health Professional Shortage Areas and Medically Underserved Areas. The program delivers training to rural areas through traditional classroom instruction, distance learning, and mobile clinical experiences.
The Contextualized Literacy Pre-LPN Program is a $192,500 grant to 1199 SEIU League Grant Corporation, New York. The grant will help entry-level health care workers, out of school for a long period of time, to enter LPN training by providing literacy and pre-LPN classes. ($100,000 in leveraged funds)
Rural Health Care Job Training Pilot Economic Recovery Demonstration Project is a $1.2 million grant to Columbia Gorge Community College, Oregon. The grant will implement a health care career ladder program with multiple entry points to enable individuals, at any place in their career, to enter or move ahead in the health care field. ($870,982 in leveraged funds)
Healthcare Services Business Connection is a $762,659 grant to the Tacoma-Pierce County Workforce Development Council in the State of Washington. Ten regional health care organizations are partnering with the public workforce system to develop of Western Washington Invasive Cardiovascular Technologist Program, a Healthcare Educator Network, and strategies to reach out to minority populations and youth. ($751,000 in leveraged funds)
Project H.E.A.L.T.H., a $1.5 million grant to the North Carolina Department of Commerce, is designed to help transition North Carolina workers in declining industries into health care jobs experiencing shortages. ($170,504 in leveraged funds)
Meeting America’s Healthcare Employment Needs: The Job Corps/Community College Solution is a $1.5 million grant to Management and Training Corporation. The grant will link Job Corps health care training with advanced training in community colleges leading to certification for health care occupations. It also provides easy access for Hispanic youth to take advantage of English courses and become part of a high-demand bilingual workforce.
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Employment and Training Administration, U.S. Department of Labor
U.S. Secretary of Labor Elaine L. Chao is pleased to announce a series of investments totaling more than $24 million to counter health care labor shortages. For the past nine months, the U.S. Department of Labor has taken part in forums with health care industry leaders, educators, and the public workforce system.
DOL has sought to understand and implement industry-identified strategies to confront critical workforce shortages. It has listened at sessions conducted by associations representing thousands of health care institutions, and considered viewpoints expressed in-person by over 300 health care leaders. Solutions that have been adopted as a result of eight forums will act as national models through the President’s High Growth Job Training Initiative.
This set of solutions cuts across the national labor needs of the health care industry in acute care, long term care, allied health care professions, as well as the unique challenges facing rural areas. It focuses on specific as well as the broader range of challenges in the health care arena, including:
Overall, grants totaling more than $24 million are being funded across the nation. They are intended to provide genuine solutions, leadership, and models for partnerships that can be replicated in different parts of the country. The U.S. Department of Labor anticipates offering additional grants in a competitive process later this year.
Grant amount: $4,000,000 Total (Florida: $2,000,000; Texas: $2,000,000)
Leveraged amount: $6,076,930
Grantee: Hospital Corporation of American (HCA)
Key partners: Broward County Community College, Ft. Lauderdale, FL; Austin County Community College, Austin, TX; St David’s HealthCare Partnership, Austin, TX
Grant activities will take place in South Florida and Austin, Texas
Challenge
A shortage of critical care nurses threatens the
nation's health care system. In addition, without sufficient patient contact,
inexperienced graduate nurses cannot fill openings in critical care areas
quickly enough. Unless innovative solutions are developed, this lack of
experienced nurses will continue to adversely affect health care services in
the U. S.
Addressing the Challenge
With its $4,000,000 grant from ETA,
this Specialty Nurse Training pilot program will implement two approaches to
address the lack of experienced nurses and set standards that can be replicated
across the country. The Florida program will create a distance learning model,
and the Texas fellowship program will create an intensive, hands-on,
accelerated learning setting similar to a medical residency. Both programs
furnish the specialized training nurses need to perform at higher levels more
quickly than traditional approaches.
Projected Outcomes
Florida: At least 100 students will
enter the critical care core program during the grant's first year. In their
second year, these students will specialize in either critical care or the
emergency department. Meanwhile, another 100 students will enroll in the
critical care core program. When their clinical rotations end, students will be
able to provide care on their own. Texas: Eighty candidates will
complete a year in the Nursing Apprenticeship/Fellowship program, qualifying
them to work in specialty areas such as intensive care units, emergency
departments, and surgical services.
Sustainable Impact
This grant's partners are committed to
these activities beyond the grant period. A new, self-supporting Specialty
Training Institute that will offer courses and technical expertise nationally
will assure the sustainability of the program. Grant funds will offset start-up
costs associated with curriculum development for both programs.
Grant amount: $4,000,000
Leveraged amount: $1,620,000 cash and $2,837,200 in-kind from participating hospitals.
Grantee: Rio Grande Valley Allied Health Training Alliance -- Weslaco, Texas
Key partners: 10 hospitals, five educational institutions, four counties, two workforce development boards, and one faith-based community organization.
Grant activities will take place in Cameron, Hidalgo, Starr, and Willacy Counties, Texas.
Challenge
Multiple barriers contribute to the severe nursing
and allied health professionals shortages occurring in rural border
communities. If these barriers are not addressed, the skills shortage will
worsen, jeopardizing health care services in these communities.
Addressing the Challenge
With its $4,000,000 grant, the Rio
Grande Valley Allied Health Training Alliance will assist area businesses and
community leaders to develop, attract, and retain homegrown talent. Key
objectives include enrolling students in Post-Licensures Specialty Training,
creating a Skills Workforce Academy for Nursing and Allied Health candidates,
retaining them through tuition assistance, and developing a High School
Concurrent Enrollment Program and comprehensive Faculty Sharing Program while
drawing from Alliance hospitals' supply of Masters of Science in Nursing.
Projected Outcomes
Grow Our Own will: a) Enroll 135
participants in Post Licensure Specialties with a completion rate of 95
percent; b) Prepare 70 students annually in academies; c) Write curricula and
learning objectives so that 90 high school juniors and seniors have the annual
opportunity to take college classes d) Expand comprehensive case management
services to 360 participants with retention rates for all students reaching 90
percent; e) Utilize online coursework by Fall 2005 as part of the Faculty
Sharing Program for one allied health specialty; and f) Develop an online,
regional scheduling system in 2004 for coordinating 400 students' clinical
rotations in Fall 2005.
Sustainable Impact
The members that comprise the Alliance are
well positioned to ensure the sustainability of this project beyond the
cessation of federal funds.
Grant amount: $3,000,000
Leveraged amount: $3,900,000 in-kind from Johns Hopkins Health System
Grantee: Johns Hopkins Health System
Key partners: Baltimore City Community College; Community College of Baltimore County
Grant activities will take place in Baltimore, Maryland
Challenge
There is an immediate, severe shortage of skilled
health care workers, and a wide range of evidence exists that the demand for
these workers will increase while the number of individuals enrolled in
accredited programs to receive training for the most critical skills is
decreasing. If unaddressed, this problem will continue to threaten the
availability and quality of health care in the United States.
Addressing the Challenge
Under its $3,000,000 grant from ETA,
Johns Hopkins Health System will develop and execute an Incumbent Worker Career
Acceleration Program, which will be comprised of five components: (1) An
initiative for addressing retention and growth of at-risk workers; (2) A GED
and diploma preparation program; (3) An initiative for retraining of employees
in declining jobs for emerging jobs; (4) A high-potential worker assessment and
skills training program; and (5) An initiative to upgrade training of incumbent
workers into critical skills shortage positions.
Projected Outcomes
Johns Hopkins projects an 80% success rate
in employment retention for 100-150 employees participating in the Retention
and Growth of At-Risk Workers initiative. It also expects to achieve a 70%
retention rate among 50 incumbent workers receiving a GED or diploma through
this initiative. In addition, of those 70% at least 50% are expected to go on
to further skills training and higher-skilled positions. 75 of Johns Hopkins'
workers will be assessed, counseled, and provided skills-based training for
emerging new jobs. High-Potential Worker Assessment will result in an estimated
200- plus workers entering either remedial education or various skills-based
training programs leading to the staffing of more critical skilled
positions.
Sustainable Impact
Johns Hopkins is strongly committed to
share all initiatives of its Incumbent Worker Career Acceleration Program with
the health care industry and the public workforce system.
Grant amount: $1,877,517
Leveraged amount: $910,000 in cash and $294,000 in-kind from Evangelical Lutheran Good Samaritan Society (ELGSS)
Grantee: The Evangelical Lutheran Good Samaritan Society, Sioux Falls, South Dakota
Key partners: In South Dakota: Lake Area Technical Institute, Watertown; South Dakota State University, Brookings; University of South Dakota, Vermillion; Sioux Valley Hospitals and Health System, Sioux Falls; pullUin software/South Dakota Health Technology Innovations Inc., Vermillion. In Nebraska: Bellevue University, Bellevue.
Grant activities will unfold through the use of distance learning technology. Mentoring will be delivered at 25 sites mostly in Minnesota, North Dakota, and South Dakota.
Challenge
Recruitment and retention of health care
professionals is especially challenging in rural communities where educational
opportunities are limited. Without more access to education, the health care
industry's labor pool will keep shrinking.
Addressing the Challenge
With its $1,877,517 grant, ELGSS
will recruit from high schools and non-traditional labor pools such as
displaced workers, and collaborate with Sioux Valley Hospitals and Health
System to raise public awareness of health care career opportunities. To
increase retention, ELGSS will start a Mentor project for entry-level workers
and develop Management Certificate training. To build the capacity of education
and training providers, ELGSS will deliver online nursing programs up through
the Master's degree level. Training will be offered in employees' own ELGSS
long-term care facilities -- 50% of which are located in Minnesota, South
Dakota, North Dakota, Iowa, and Nebraska -- through an innovative blend of
distance learning, mentoring, and clinical experience in health care sites near
the employees' homes.
Projected Outcomes
ELGSS will implement an apprenticeship
model program for Management Certificate Training with DOL and Bellevue
University. ELGSS also will partner with Lake Area Technical Institute to
develop and deliver an online LPN program, as well as with South Dakota State
University to deliver online BSN and MSN programs, with an emphasis on
geriatrics. Each part of the overall project is replicable for use throughout
the nation's health care industry.
Sustainable Impact
ELGSS has made a strong commitment sustain
this project. Tuition and fees generated by education providers involved in
this initiative will sustain their established history of producing qualified
nurses.
Grant amount: $1,500,000
Leveraged amount: $700,000 from State of Maryland Employer Matching Fund
Grantee: State of Maryland
Key partners: To be determined during grant activities
Grant locations: Statewide
Challenge
There are two major challenges facing the health
care industry: (1) lack of nurses and allied health professionals; and (2) lack
of qualified academic and clinical health care faculty. The lack of faculty is
preventing the admission of applicants into nursing and allied health programs
which ultimately affects the number of qualified nurses and allied health
professionals available for employment. If these two challenges are
unaddressed, this worker shortage will have severe and damaging impacts upon
the availability and quality of health care services in the United States.
Addressing the Challenge
Under its $1,500,000 grant from ETA,
the Maryland Governor's Workforce Investment Board (GWIB) will address the
faculty capacity problem by implementing a scholarship program for nurses who
pursue credentials to teach nursing and allied healthcare professions. The GWIB
will also implement a scholarship program for Licensed Practical Nurses (LPNs)
and other incumbent workers that are seeking their Registered Nurse (RN)
credentials to backfill the RNs that pursue their Master's Degree.
Additionally, an Incumbent Worker Training strategy will be implemented to
assist health care employers to upgrade the skills of existing workers.
Projected Outcomes
The "Teaching for the Health of It"
scholarship program will provide 40 one-time only scholarships in the amount of
$10,000 each for nurses pursuing teaching credentials. The other scholarship
program will provide 40 one-time only scholarships in the amount of $10,000 for
LPNs and other incumbent workers who are seeking their RN credentials.
Partnerships between employers and the community college system will be created
to provide allied health care training for incumbent workers.
Sustainable Impact
The GWIB has established a Governor's
Healthcare Workforce Steering Committee that consists of members from industry,
economic development, employment services, and education to develop and
implement collaborative solutions. Currently the health care industry in
Maryland spends over $11,140,000 to educate, attract, and retain health care
workers because of the faculty shortfall. The GWIBs and the Maryland Healthcare
Workforce Steering Committee are committed partners for continuing and sharing
the model throughout the nation.
Grant amount: $1,500,000
Leveraged amount: $170,504 in-kind contributions from most key partners listed below
Grantee: North Carolina Department of Commerce, Commission on Workforce Development -- Raleigh
Key partners: NC Hospital Association, NC Community College System, University of North Carolina System, NC Department of Health and Human Services, NC Area Health Education Centers, JobLink Career Center system, and local Workforce Development Boards
Grant activities will take place in the western, eastern, and piedmont regions.
Challenge
Since the mid-90's, North Carolina's health care
industry has experienced severe shortages of registered nurses and direct care
workers due to the aging of nurses and nursing educators. Meanwhile, the state
has been devastated by worker dislocation.
Addressing the Challenge
With its $1,500,000 grant, Project
H.E.A.L.T.H.: Helping Employers and Labor Transition to Health Care will
address North Carolina's critical nursing and direct care worker shortages. It
targets the state's large and diverse labor pool of dislocated workers, and
will test and expand innovative approaches to worker education, training, and
employment in the nursing and direct care workforce sectors. In this model,
H.E.A.L.T.H. will work to enhance health career development and employability
of dislocated workers and provide the needed support for an education and
training institution for nursing.
Projected Outcomes
Up to 450 displaced workers are projected
to enroll in Human Resource Development Plus pilot sites that support other
initiatives addressing direct care shortages. Additional outcomes include 300
workers expected to enroll in further training, 200 placed in jobs -- of which
120 will be direct care workers. Thirty-three individuals will be placed in
degree programs to increase the availability of instructors and applicants for
health care programs.
Sustainable Impact
An advisory team drawn from hospitals, the
long-term care industry, and key Project H.E.A.L.T.H. partners will build the
foundation for sustainability. Project H.E.A.L.T.H. will provide innovative
models that can be replicated throughout North Carolina and the nation.
Grant amount: $1,500,000
Grantee: Management & Training Corporation, Centerville, Utah
Key partners: In Illinois: City Colleges of Chicago and the Metropolitan Chicago Healthcare Council; In Ohio: Cincinnati State Technical and Community College and Sinclair Community College; In Pennsylvania: Luzerne County Community College and Lehigh/Carbon County Community College
Grant activities will take place at the Paul Simon Chicago Job Corps Center, the Cincinnati Job Corps Center, the Dayton Job Corps Center, and the Keystone Job Corps Center in Drums, Pa.
Challenge
The health care industry faces three key problems:
a shortage of qualified health care employees, a lack of bilingual employees,
and available, yet untrained out-of-school youth.
Addressing the Challenge
Management & Training
Corporation will unite the efforts of Job Corps Centers with community colleges
to address the health care workforce challenges in Illinois, Ohio, and
Pennsylvania. Job Corps students finished with their vocational training in
basic health will be recruited to pursue advanced training and certification at
the community college. Additionally, this project provides instruction,
assessment, career development, academic training, and support services. It
also provides easy access for Hispanic youth to take advantage of English
courses, and become part of a high-demand bilingual workforce.
Projected Outcomes
Management & Training Corporation's
projects will affect four Job Corps Centers and 125 students, who will
ultimately be employed in health care.
Sustainable Impact
Management & Training Corporation, Job
Corps Centers, and participating community colleges will provide a firm
foundation for sustainability once federal funding has been expended. The model
will be documented so that it can be replicated in Job Corps Centers across the
nation.
Grant amount: $1,421,639
Leveraged amount: $500,000 in cash from the Hospital Corporation of America (HCA) and 60,150 in-kind from Florida International University (FIU)
Grantee: Florida International University School of Nursing
Key partners: Hospital Corporation of America, Nashville, TN
Grant activities will take place in Miami-Dade County and Tallahassee, Florida
Challenge
Nurse shortages left unaddressed will have severe
and damaging impacts upon the availability and quality of health care services
in the United States.
Addressing the Challenge
With its $1,421,639 grant, the New
Americans in Nursing Program will address the challenges by retraining
unemployed or underemployed foreign-educated physicians to become registered
nurses.
Projected Outcomes
One hundred nursing students with prior
clinical knowledge and experience will graduate during the grant period. Under
this grant, FIU also will test distance education through the use of
interactive television, with 70 students in Miami and 30 in Tallahassee. The
grantee will also share data on the program's effectiveness as a retraining
model for other areas of the country.
Sustainable Impact
FIU's School of Nursing, through its
strong track record of attracting financial support, will ensure the
sustainability of this project. FIU will evaluate this program's impact and
effectiveness for foreign physician students and the overall nursing workforce.
Because of the large applicant pool of foreign-educated physicians and the
worsening nursing shortage, there will be lasting interest from various
hospital and corporate entities to support the continuation of this program.
Grant amount: $1,250,000
Leveraged amount: $542,501 from four local hospitals, four long-term care facilities, foundations, and Columbia Gorge Community College; $328,481 in-kind from health care businesses and Columbia Gorge Community College
Grantee: Columbia Gorge Community College, The Dalles, Oregon
Key partners: Eight area hospitals and health care providers, Region 9 Workforce Investment Board and its One-Stop Career Centers, K-12 school districts, Oregon Health and Science University, and city and county governments
Grant activities will take place in Gilliam, Hood River, Sherman, Wasco, and Wheeler Counties in Oregon; Klickitat and Skamania Counties in Washington.
Challenge
Economic downturns have left high numbers of
displaced workers requiring education and retraining to transition into health
care positions. Without programs, the health care industry will not be able to
draw from this non-traditional labor pool to fill vacancies.
Addressing the Challenge
With its $1,250,000 grant, Columbia
Gorge Community College and its partners will create a Health Occupations
Career Ladder Nursing Program to train 200 new workers. CGCC will expand its
offerings and opportunities for an Associate Degree in Nursing and a distance
learning option for a Bachelor Degree of Nursing Program.
Projected Outcomes
Trainees will emerge from the Health
Occupations Program with the skills, licenses, and experience needed for health
care employment. Of the 200 trainees who enter the Career Ladder, 85 percent
will pass licensing exams, and 85 percent will achieve employment at their
target career level within the grant period. Further, 90 percent of incumbent
workers will receive pay raises as a result of their additional credentials.
Forty nurses of 200 total trainees will have the opportunity to earn a BSN
through Columbia Gorge's dual admission agreement with Oregon Health and
Science University.
Sustainable Impact
Besides the matching funds already
supplied, regional businesses have committed financial support to the program
for at least one year after the grant. Also, the Healthcare Demonstration
Project grant will be replaced with Oregon State Reimbursement Funds at the end
of the grant period.
Grant amount: $999,902
Leveraged amount: $999,902 cash from the Charles Stewart Mott Foundation and The Atlantic Philanthropies
Grantee: Paraprofessional Healthcare Institute, Bronx, New York
Key partners: Lehman College of New York; North Carolina Foundation for Advanced Health Programs; Workforce Investment Board of Lancaster County, Pennsylvania; local community colleges and workforce investment boards
Grant activities will take place in New York City, in and around Lancaster County, Pennsylvania, and at sites to be determined in North Carolina.
Challenge
The long-term care industry's shortage of
direct-care workers is particularly acute in home-based care. Long-term care
providers realize that they must transform standard practices regarding
recruitment, training, supervision, and support in order to effectively attract
and retain new workers as paraprofessionals.
Addressing the Challenge
With its $999,902 grant, the
Paraprofessional Healthcare Institute will provide a range of technical
assistance, training initiatives, and materials for the long-term care
workforce. Emphasis will be placed on Hispanic caregivers and supporting the
nation's Workforce Investment Boards and community colleges in recruiting and
training.
Projected Outcomes
The Paraprofessional Healthcare Institute
will: (1) develop a recruitment and apprenticeship career-lattice model; (2)
create a coaching approach for front-line supervisors, with a curriculum
designed for employer-based community colleges; (3) demonstrate a problem
solving training curriculum, in partnership with Lancaster's Workforce
Investment Board; (4) publish a series of guidebooks, curricula, and teaching
manuals -- written in English and Spanish -- on effective paraprofessional
workforce development practices; (5) create strategic relations with
faith-based health systems capable of bringing about nationwide change.
Sustainable Impact
Well-established partnerships of The
Paraprofessional Health Institute, The Charles Stewart Mott Foundation, and The
Atlantic Philanthropies along with local community colleges and Workforce
Investment Boards will provide a firm foundation for replicating the model
throughout the nation after the federal funds have been expended.
Grant amount: $762,659
Leveraged amount: $200,000 in cash and $500,000 in-kind contributions from multiple partners
Grantee: Tacoma-Pierce County Workforce Development Council
Key partners: More than 20 organizations ranging from health providers to universities, community colleges, and workforce boards
Grant activities will take place in Pierce County, Washington.
Challenge
Serious health care workforce shortages exist
throughout the United States. Without a multi-pronged, regional approach, gaps
in the health care workforce will not be filled.
Addressing the Challenge
With its $762,659 grant, the
Tacoma/Pierce County Workforce Development Council will implement four distinct
projects to improve and expand the pool of qualified professionals in
high-demand health care jobs. The first project confronts a clear need to train
invasive cardiovascular technologists; the second targets current health care
workers through a Comprehensive Career Coaching Program; the third seeks to
establish connections through a Healthcare Educator Network; and the fourth
project incorporates multiple strategies to reach out to minorities and
youth.
Projected Outcomes
Tacoma/Pierce County Workforce Development
Council will (a) admit 15 students to the Invasive Cardiovascular Technologist
Program; (b) develop and launch the Healthcare Educator Network website; (c)
translate Healthcare Occupations Workshop materials into Spanish, Korean, and
Russian; (d) increase the Medical Rotation Program participants by eight; (e)
start a Health Summer Camp for youth; (f) increase minority youth participation
in job shadow and volunteer programs by 10 percent.
Sustainable Impact
At least 10 regional health care
organizations will commit to ongoing funding of the Invasive Cardiovascular
Technologist Program. At least 10 organizations, including regional colleges,
universities, and the Washington State Nursing Association, will be approached
for resources for the Healthcare Educator Network beyond the grant period. The
partners involved in the Targeted Populations Outreach Program -- community
colleges, the local workforce system, and health care providers -- already have
a strong history of collaboration and will continue to work together after the
grant ends.
Grant amount: $715,402
Leveraged amount: $595,062 from grantee and state and local governments
Grantee: Pueblo Community College, Pueblo, Colorado
Key partners: Pueblo Work Link (One-Stop Career Center), Trinidad State Junior College, Parkview Episcopal Medical Center
Grant activities will take place in Colorado's Pueblo, Costilla, Conejos, and Alamosa Counties.
Challenge
A shortage of medical personnel in rural Colorado,
communities is compounded by two key challenges. First, many rural communities
have Emergency Medical Services comprised of volunteer personnel, who often
leave to pursue paid employment elsewhere. In addition, there are no training
programs in rural Colorado to prepare health care practitioners.
Addressing the Challenge
With its $715,402 grant, Pueblo
Project HEALTH addresses this shortage by bringing training opportunities to
outlying areas, and helps volunteer medical personnel secure paid employment.
Pueblo Project HEALTH combines the Emergency Medical and Respiratory Care
positions into one hybrid curriculum, and administers their training through
traditional classroom instruction, distance learning technology, and mobile
clinical experiences. Graduates will be able to secure employment in
Respiratory Care and serve as volunteer Emergency Medical Technicians. This
project will assist counties that have been designated as Health Professional
Shortage Areas and Medically Underserved Areas, and will target
minority/disadvantaged individuals.
Projected Outcomes
The hybrid curriculum will prepare
individuals for both the Intermediate Emergency Medical Technician and the
Respiratory Care Practitioner positions. The number of minority/disadvantaged
individuals enrolled in the program will increase significantly during the
second and third years of the project.
Sustainable Impact
Pueblo Project HEALTH will result in an
innovative curriculum that can be used by community colleges throughout the
state. Further, local WIA funds can continue to be a source of funding after
ETA demonstration funds expire. Third, Pueblo Project HEALTH is committed to
expanding the program throughout the state using the community college system.
Grant amount: $516,154
Leveraged amount: $80,556 in-kind from Excelsior College
Grantee: Excelsior College, Albany, New York
Key partners: Fourteen hospices in New York state, along with one each in Montana, North Carolina, Rhode Island, South Carolina, and Texas
Grant activities will take place at locations determined immediately following implementation. Local hospices will be identified in Montana, New York, North Carolina, Rhode Island, South Carolina, and Texas.
Challenge
Many hospices and their associations have reported
that the shortage of nurses is having a significant impact on access to hospice
services, and that hospices have had to deny services to eligible patients
because they do not have adequate staff to provide nursing care. Without
immediate solutions to the hospice nurse shortage, dying patients and their
families will increasingly face abandonment by the health care delivery
system.
Addressing the Challenge
With its $516,154 grant, Excelsior
College will develop a Hospice and Palliative Care Online Certificate Program
(HPCC) that includes a period of practical experience and training supervised
by an expert or specialist. In doing so, HPCC will directly address two major
national health care workforce needs: (1) expanding the number of registered
nurses (RNs) working in the health care field; and (2) creating a stable,
highly skilled RN workforce for hospices throughout the nation.
Projected Outcomes
Excelsior College will operate HPCC for 16
months as a pilot program in Montana, New York State, North Carolina, Rhode
Island, South Carolina and Texas. The program will serve 60 interns and
approximately 30 preceptor supervisors affecting the quality of care of over
15,000 patients from 19 hospice partners.
Sustainable Impact
Excelsior College has over 30 years of
experience in developing educational programs for working adults. While other
organizations have educational materials for hospice and palliative care, none
are online and easily accessible. By the 17th month, the HPCC program will be
offered nationally and will be self-sufficient.
Grant amount: $300,000
Leveraged amount: $200,000 in cash and $250,000 in-kind from the State's Employer Workforce Training Fund
Grantee: Governor's Healthcare Workforce Initiative, Salem, Oregon
Key partners: In Portland: Oregon Consortium for Nursing Education (OCNE); Oregon Center for Nursing; Northwest Health Foundation. In Tualatin: Oregon Health Career Center; Community College Healthcare Action Plan.
Grant activities will take place statewide.
Challenge
Overcoming nursing shortages requires that the
education system devise ways to supply clinical facilities and faculty.
Otherwise, the education system will be unable to fill the pipeline with
qualified nurses.
Addressing the Challenge
With its $300,000 grant, the Oregon
Governor's Healthcare Workforce Initiative will purchase seven SimMan,®
real-time interactive human patient simulators made by Laerdal Medical
Corporation. The simulation technology will be integrated into health care
curricula for use by well-prepared and networked faculty, available over the
state's broadband Internet network, and affordable for all education and
service groups in the state.
Projected Outcomes
The Governor's Healthcare Workforce
Initiative will report on the use of simulators to ensure that they: (a)
Increase the capacity of educational programs; (b) Increase access to
simulation-based education; (c) Increase simulation technology expertise
statewide; and (d) Prove satisfactory as a quality educational tool.
Sustainable Impact
Firm commitments from community colleges,
universities, high schools and health care organizations will help to ensure
this project's long-term sustainability. This project's major stake-holding
partners have each demonstrated their continuing efforts to meet the demand for
a qualified health care workforce.
Grant amount: $224,088
Leveraged amount: $456,091 in cash contributions from public and private sources.
Grantee: Capital IDEA, Austin, Texas
Key partners: In Austin: Austin Community College; Seaton Healthcare Network; St. David's Healthcare Partnership; Austin Heart; Worksource-Greater Austin Area Workforce Development Board; In San Marcos: Central Texas Medical Center.
Grant activities will take place in Central Texas.
Challenge
A Department of Labor-funded research project in
Central Texas found that candidates for health care occupations had a very high
failure rate in a key prerequisite course, Anatomy and Physiology I (A&P
I). About one-third of students interested in health care careers were
eliminated by A&P I. Taking A&P I multiple times delays admission for
approximately one-quarter of the students.
Addressing the Challenge
With its $224,088 grant, Capital
IDEA will test a strategy that starts tutoring the first week of classes in
order to: (a) Increase the success rate of students, thereby reducing the extra
expense of tuition, counseling, child care, and time associated with students
repeating the course; (b) Accelerate graduations; and (c) Increase the success
rate of disadvantaged students. Rather than take remedial action after students
fall behind, the tutoring will raise their chances of enrolling in a nursing or
allied health occupation.
Projected Outcomes
The Capital IDEA project will increase the
percentage of students achieving a C or better in A&P I from 50 percent to
at least 70 percent. Students achieving a B or better will rise from a baseline
of 25 percent to at least 45 percent. Removing this bottleneck will then enable
students and lower-skill hospital employees to advance to the career training
courses much more quickly, thus addressing recruitment and retention issues of
health care employees.
Sustainable Impact
Capital IDEA is a joint effort of Austin
Interfaith and leaders in the business community, including the area's two
largest hospital systems. Along with Austin Community College and local
Workforce Investment Boards, a firm foundation for continuing the model will be
in place after federal funds have been expended.
Grant amount: $215,600
Leveraged amount: $196,000 in cash and in-kind contributions from key partners listed below.
Grantee: Telelink Consortium Network, Ashland, Wisconsin
Key partners: Burnett Medical Center, Grantsburg; Flambeau Hospital, Park Falls; Memorial Health Center, Medford; Memorial Medical Center, Ashland; Northwest Wisconsin Workforce Investment Board, Ashland
Grant activities will take place in Northwest Wisconsin.
Challenge
Small, rural health care providers often do not
have the resources to implement the continuous training and skills-upgrading
programs necessary to keep employees.
Addressing the Challenge
With its $215,600 grant, the
Telelink Consortium Network (TLC) will establish ongoing, collaborative
relationships among rural health care providers in Northwest Wisconsin and the
One-Stop Career Center system. TLC will pool financial, material, and human
resources of small, remote hospitals and clinics for the purposes of increasing
the supply and retention of health care professionals.
Projected Outcomes
TLC's efforts will concentrate on
delivering higher skills training using appropriate, cost effective, web-based
means. Training topics will include continuing professional development,
managerial subjects, and skills upgrading in such areas as sonograms, Xrays,
CAT scans, and MRIs -- all of which have a significant impact on worker
retention. Under the project, 300 incumbent workers will complete at least one
professional development/skills upgrading module, and a 15 percent larger pool
of candidates interested in training for higher skilled health care occupations
will be created.
Sustainable Impact
Four of the region's largest hospitals
form the core of the TLC Network, and have agreed to take responsibility for
the sustainability of this project. A combination of TLC Network membership
fees and access fees will be the specific method for achieving
self-sustainability.
Grant amount: $200,000
Leveraged amount: $405,939 cash and in-kind contributions from Berger Health System
Grantee: Berger Health System, Circleville, Ohio
Key partners: Ohio University
Grant activities will take place in Pickaway County and adjacent counties and small cities in Ohio.
Challenge
The acute care sector in rural areas experiences
nursing shortages due to up-front costs for education and books, lack of role
models, and a lack of knowledge of career opportunities. Hence, rural citizens
often do not take advantage of the opportunity to attain the professional goal
of becoming a registered nurse. There is also a lack of capacity at the local
university to educate all qualified nursing school applicants.
Addressing the Challenge
With its $200,000 grant, the Berger
Health System and Ohio University will meet the needs of the rural community
hospital by holding all classes and clinical rotations at the Berger Hospital
facilities for the three-year, university-based Associate Degree nursing
program. Berger Health System agreed to sponsor one instructor, provide space,
and accept students into clinical rotations. Ohio University agreed to supply
the curriculum, faculty, and degrees.
Projected Outcomes
The Berger Health System and Ohio
University will educate 30 incumbent employees and non-traditional students to
become registered nurses in a community hospital versus a university setting.
They also will document their progress and results so that the program can
serve as a framework for other rural communities and hospitals.
Sustainable Impact
The project provides new and innovative
ways to meet educational and workforce needs in rural regions. Due to the
strong partnerships of the Berger Health System, Ohio University, and the local
community, the project will serve as a model and be able to be repeated
throughout the nation.
Grant amount: $192,500
Leveraged amount: At least $100,000 in matching funds from Service Employees International Union's Training and Upgrading Fund (TUF)
Grantee: 1199 SEIU League Grant Corporation -- New York City
Key partners: NYC Department of Education; the Consortium for Worker Education
Grant activities will take place in New York City, Nassau, and Westchester Counties.
Challenge
Shortages of nursing and affiliated health care
workers will have severe impacts upon the availability and quality of services
if they are not addressed. One strategy for addressing the need for Licensed
Practical Nurses (LPNs) calls for low-level health care workers to complete LPN
training programs and secure employment. However, the challenge of the
work-family balance, as well as other issues, make it difficult for workers who
are new to academic environments to perform well on training programs' entrance
exams.
Addressing the Challenge
SEIU's TUF will expand its
Contextualized Literacy Pre-LPN Program, which combines literacy and job
training in preparation for LPN programs. This pre-LPN program has been
designed for low-level health-care workers who have been out of school for a
long period of time and have had difficulty passing entrance exams. TUF will
provide 10 classes and train instructors, enabling New York City area health
care workers to enter LPN programs and find employment.
Projected Outcomes
Pre-LPN classes will prepare 250 students
to pass entrance exams and enroll in LPN programs. 90 percent of the 250
participants will complete the pre-LPN program and advance to LPN programs
within six months. The number of students in pre-LPN classes that successfully
complete the LPN program will increase by 80 percent over last year.
Sustainable Impact
The Contextualized Literacy Pre-LPN
Program will have a sustained impact on the LPN shortage because additional
instructors will increase the TUF's training capacity. In addition, the pre-LPN
program will have a sustained impact because the TUF has demonstrated its
commitment to the program, providing at least $100,000 in matching funds to
expand the program. Finally, the program will serve as a replicable model for
other entities, with recommendations and best practices disseminated through
papers and conferences.
Grant amount: $113,296
Leveraged amount: $7,615 from the American Health Care Association
Grantee: National Foundation for the Advancement of Elder and Disabled Care in America (part of the American Health Care Association) -- Washington, D.C.
Key partners: George Washington University's Center for Health Services Research and Policy and Wertlieb Educational Institute for Long Term Care Management.
Grant activities will take place at locations determined through research proposed as part of this grant.
Challenge
Adequate staffing of facilities is essential for
providing quality nursing home care. Without an infrastructure for this
high-growth sector, nursing homes are challenged in building their
workforce.
Addressing the Challenge
With its $113,296 grant, the
American Health Care Association will develop an infrastructure of "Best
Practice" models that can be expanded, evaluated, replicated, and transported
to other areas of the country.
A major objective of this effort includes the development of a practical "How To" or "Cookbook" to build partnerships for combating the nursing shortage in long-term care. Another major objective calls on long-term care providers to develop ways to effectively team up with the public workforce system and take actions that will make the profession an attractive employer.
Projected Outcomes
The American Health Care Association will
develop the infrastructure of "Best Practice" models for long-term care
facilities along with a "How To" book of best practices, and partner with the
public workforce system to make the long-term care sector an attractive
employment option.
Sustainable Impact
The American Health Care Association
(AHCA) and the National Commission on the Nursing Workforce for Long-Term Care
have the foundation to communicate and implement the "Best Practice" models
identified by the project.
|
102nd American Assembly, Columbia
University
February 2003
On February 6, 2003, seventy-fi ve men and women representing business, labor, academia, government, workforce intermediaries, academia, nonprofit organizations and the media gathered at Arden House in Harriman, New York, for the 102nd American Assembly entitled “Achieving Worker Success and Business Prosperity: The New Role for Workforce Intermediaries.” For three days, participants examined policies, approaches and actions that need to be taken to assure that workers have access to economic opportunity and to assure that employers have access to the skilled workforce required for them to be globally competitive.
This project was directed by Robert Giloth, director, The Annie E. Casey Foundation; John Colborn, deputy director, Economic Development Unit, The Ford Foundation; and Betsy Biemann, associate director, Working Communities, The Rockefeller Foundation. The project was also ably assisted by a steering committee of distinguished leaders from around the country, whose names and affi liations are listed in the appendix to this report.
Background papers were prepared for participants under the editorial supervision of Robert Giloth and will appear as chapters in a book tentatively entitled Workforce Intermediaries for the 21st Century, to be published by Temple University Press in fall 2003. The chapters are listed on the inside back cover.
During the Assembly, participants heard formal addresses by David Ellwood, Lucius N. Littauer Professor of Political Science, John F. Kennedy School of Government, Harvard University; and Jeremy Nowak, president/CEO, The Reinvestment Fund. Richard M. McGahey, managing vice president, Abt Associates, Inc., moderated a panel of Timothy M. Barnicle, co-director, Workforce Development Program, National Center on Education and the Economy; Steve Crawford, director, Employment and Social Services Policy Studies, National Governors Association; and Jackie Edens, Commissioner, Mayor’s Office of Workforce Development, Chicago. Mr. Giloth also moderated an introductory panel that included Cynthia E. Marano, director, National Network of Sector Partners, National Economic Development and Law Center; Marlene Seltzer, president, Jobs for the Future; and Julie Strawn, senior policy analyst, Center for Law and Social Policy.
Following their discussions, participants issued this report on February 9, 2003. It contains both their findings and recommendations.
The text of this report is available on both The American Assembly’s website (http://www.americanassembly.com) and the project’s webpage (http://www.opportunitiesatwork.org), which also contains links to many of the organizations involved in this project.
We gratefully acknowledge the support of The Annie E. Casey Foundation, The Ford Foundation, The Rockefeller Foundation, The John D. and Catherine T. MacArthur Foundation, and the Open Society Institute, Baltimore.
The American Assembly takes no positions on any subjects presented here for public discussion. In addition, it should be noted that participants took part in this meeting as individuals and spoke for themselves rather than for their affiliated organizations and institutions.
We would like to express special appreciation for the fi ne work of the discussion leaders, rapporteurs and advisors in helping to prepare the final draft of this report: Daniel Berry, Paul Brophy, Terri Feeley, Lisa Kaplan Gordon, Ed Hatcher, Cynthia Marano, Richard McGahey, Julie Strawn, and Orson Watson.
David H. Mortimer
The American Assembly
Over the past decade, a set of workforce development policies and strategies has emerged to meet the needs of both businesses and low-wage, low skilled workers. In some cases, the results have been nothing less than remarkable: employers are finding a well-trained competitive workforce while at the same time workers are being placed in jobs that can sustain their families.
The opportunity exists to spread this workforce intermediary approach, as this Assembly has named it, to a wider array of existing institutions in order to achieve greater impact. Achieving this impact will not be easy. Employers and job training providers simply adopting “promising workforce practices” won’t get the job done.
The challenge ahead is about transforming workforce development practices in a variety of institutional settings, such as community colleges, workforce boards, labor unions, employer associations, and community organizations. It is about creating and sustaining entrepreneurial organizations that have the commitment and capacity for innovation and to build partnerships, learn, change directions, and relentlessly pursue results.
Transforming workforce development practices, however, will only occur if there is top-level leadership committed to this agenda. Public and private workforce development resources must lay the groundwork to support the pursuit and achievement of substantial results.
The report of this American Assembly provides hope and, most importantly, direction for a broad spectrum of workforce practitioners, business organizations, and advocates who are ready to take on this challenge. Given the current and impending workforce crises that threaten the future of America’s families and businesses, the time is right.
We are proud to have supported and participated in this important civic dialogue. But this is just the beginning. We look forward to working in collaboration with our workforce development colleagues to advance this critical agenda in the months and years to come.
Betsy Biemann
John Colborn
Robert Giloth
Co-directors
The 102nd American Assembly
At the close of their discussions, the participants in the 102nd American Assembly on “Achieving Worker Success and Business Prosperity: The New Role for Workforce Intermediaries,” at Arden House, Harriman, New York, February 6-9, 2003 reviewed as a group the following statement. The statement represents general agreement; however, no one was asked to sign it. Furthermore, it should be understood that not everyone agreed with all of it.
Introduction
As the 21st century begins, the prosperity of the United States depends increasingly on the strength of its workforce. The world is becoming one economy, and nations that fully utilize their workers are more likely to thrive than those that do not.
There is a crisis emerging in America: workforce. The future worker shortage in the United States, the lack of worker skills, the increasing wage gaps, the disjointed public programs, and the absence of business participation all contribute to the crisis. But most importantly, it is the failure of our nation to recognize and respond to these challenges that presents the greatest risk.
Over the past twenty years, a dramatic increase in the size and skill of America’s labor force has driven its economic growth. Baby boomers were in their prime employment years, and large numbers of women entered the labor force. New workers emerged far more educated than those they replaced. The number of college-educated workers more than doubled.
These trends have ended. More than one third of the nation’s current workforce lack the basic skills needed to succeed in today’s labor market. During the next twenty years, the American workforce is expected to grow by only half of its earlier pace: there will be no growth of native-born workers in their prime working years; the percentage of the labor force composed of four-year college graduates is predicted to stagnate over the next two decades; the number of workers with two-year degrees and skill certificates will fall far short of the economy’s needs.
These labor force trends are exacerbated by globalizing competition and accelerating technological requirements in both domestic and export sectors. Taken together, these trends will lead to severe consequences for the vibrancy of the American economy and businesses. Problems on the horizon include:
However, these problems can create opportunities to better involve overlooked labor market pools in the United States.
A strong economy depends on labor force growth and increased productivity. But if the nation’s labor force does not grow, then we must find ways to increase the productivity of all American workers to meet the demands of future jobs.
Today, U.S. tax dollars support workforce development through a fragmented and under-funded patchwork system. In many communities, employers indicate that the workforce development system does not meet their needs and their engagement in workforce development programs has been superficial; publicly funded workforce programs have been constrained by funding that follows individual personal eligibility and political boundaries rather than regional economies; and systems improvements have proved elusive. As a result, employers still struggle to find workers who can help their businesses succeed, and workers still struggle to find and keep jobs that can sustain their families.
A new strategy -- what this Assembly calls a “workforce intermediary” strategy -- seeks to help workers advance, help businesses fi ll critical job shortages, and, ultimately, change systems to bolster regional and national economic development. This approach does not require creating a new category of organization or overhauling public systems but it does require the transformation of existing policies and programs so that they are more adaptable to the local labor markets. It challenges existing organizations and systems to redefine whom they serve and how they do business through the forging of new partnerships and building the capacity to do so.
Workforce intermediary approaches are practiced by a variety of organizations -- including community colleges, federally mandated Workforce Investment Boards (WIBs), state and local government agencies, unions, employer organizations, community development corporations, community development financial institutions, faith-based organizations, and community-based organizations. Groups using workforce intermediary approaches have these goals:
This intermediary approach is results-driven, entrepreneurial and flexible, trusted by employers and workers, and collaborative.
A Promising Start
More and more organizations in places as diverse as Wiscasset, Maine and San Francisco are showing encouraging results by using workforce intermediary approaches to help workers and business. But what exactly are these practices?
This approach arose in response to some of the limitations of the present workforce system. The current system is characterized by single customer focus on job applicants; a lack of knowledge of employers and their needs; a focus on limited employability training and initial placement and little post-placement retention and advancement services; and the fragmentation of the workforce community and its funding streams.
The “workforce intermediary” approach has several common characteristics. At their core, workforce intermediaries:
Business organizations, labor supported programs, nonprofit community organizations, the public workforce investment system, and community colleges all can pursue workforce intermediary strategies. The number of such efforts has risen from a handful in the early 1990s to several hundred today. Although they approach their tasks in different ways, successful intermediary organizations bring together key partners and functions to advance careers for all workers -- recognizing the special needs of low-skilled, low-wage workers -- increase business productivity, and improve regional competitiveness. (For descriptions of groups that perform workforce intermediary functions, go to http://www.opportunitiesatwork.org.)
Results
“There aren’t too many programs for people like me who have worked all their lives and never had a chance to move up… You need training in this world to survive and stride forward, and this program gives people that chance. I see a career path that’s open to many new things” -- Worker
“We have found that partnerships allow us to save money on a cost-per-hire basis. Our partners are actually pre-screening candidates for us and pre-training them.” -- Employer
The workforce intermediary approach promises to improve the economic well being of job seekers, workers, and their families. Outcomes, where they have been measured, are positive especially when compared to the impacts of other more traditional workforce development activities.
Early research indicates that businesses reap economic benefits from partnering with workforce intermediary organizations. These benefits include:
By attending to business concerns and increasing productivity, workforce intermediary organizations also bolster regional competitiveness. For example, in New York City, the Garment Industry Development Corporation introduced production changes that enabled area firms to increase profits while maintaining decent wages and benefit packages.
What Types of Organizations Use Intermediary Approaches?
More than 200 organizations in thirty-nine states responded to a recent survey that described their use of workforce intermediary approaches. Most organizations participating in the survey are just a few years old, but two-thirds of them each serve more than 500 job seekers and workers annually.
While workforce intermediary organizations take many forms, not every education, training, or economic development entity plays this role. Efforts that are single-purpose in character -- attend to one particular activity or attend to the needs of a single employer -- do not meet the workforce intermediary definition. The power of the workforce intermediary approach is its multifaceted nature, and its potential impact goes beyond the sum of its component parts.
Indeed, many public workforce development agencies -- including local Workforce Investment Boards (WIBs), economic development agencies and community colleges-act as workforce intermediaries. More often, however, workforce intermediary efforts work to complement these public systems by expanding their reach through new partnerships and adding depth in industry sectors.
Consistent with the mission of the public workforce development systems, workforce intermediary efforts seek to:
A Call To Action
A workforce intermediary strategy seeks to help workers advance, businesses fi ll critical job shortages, and ultimately boost regional and national economic growth and productivity. Such ambitious goals require a “high impact” strategy, one that results in quality services to a greater share of workers and employers and meaningful changes to local and regional labor markets. The challenge is to get beyond what one Assembly participant called “pockets of unreplicable greatness” to a wider scale.
This strategy is an important response to the larger workforce crisis confronting this nation.
The severity of the impending workforce crisis requires nothing less than a major transformation in how the workforce system and workforce organizations go about their business. This change will require that intermediary functions and practices should be widely adopted by thousands of existing organizations -- Workforce Investment Boards, community colleges, employer associations, labor programs, community development venture capital funds and community-based organizations. New partnerships between these groups can increase effectiveness in serving employers.
To accomplish this transformation, the system will require:
Implementing the workforce intermediary approach is itself a challenge. For example, finding common ground between business and worker/jobseeker interests is a challenge. At times, these two perspectives have been assumed to be in opposition. However, finding the intersection between these two is essential in order to ensure business productivity, worker advancement, and regional competitiveness in the new skills economy. In addition, intermediary organizations operate in a fragmented policy and institutional environment and must often negotiate new roles and relationships while sidestepping destructive turf battles. This requires trust, credibility, and influence -- as well as careful diplomacy.
Further, the intermediary approach often faces all the challenges of an emerging business venture. Financial instability, limited resources, strained leadership, and the risks of taking success to scale must be successfully managed.
Many organizations have struggled with the constantly changing landscape of public workforce funding. Public funds have been cut and strict eligibility requirements, short-term timelines, and disparate performance measures have negatively affected outcomes. In general, some level of funding has been available for recruiting and training, but limited funding has been available to help businesses retain new workers and to help workers advance to higher quality jobs. In addition, there is no dedicated public funding for research and planning efforts that bring together stakeholders within specific industries to implement long-term strategies that address changing skill standards and related business needs. More and smarter funding is needed.
Workforce intermediary organizations and employer partners need flexible capital to create innovations in the public or private sector. Several states have created bond financing tools and investment tax strategies to support efforts of intermediary organizations to meet skill shortage demands and wage advancement goals. Other intermediary organizations have created blended financing strategies that include public funding and revenue-generating businesses. Based on the experience of these intermediary organizations, flexible financing options are needed to expand the impact of these strategies as well as support their efforts to increase capacity.
In addition to financial challenges, a variety of environmental forces constrain the emerging workforce intermediary efforts. A sometimes rigid policy environment and long-standing practices limit the acceptance of this new approach. Furthermore, slow decision making, inappropriate outcome measures, and cumbersome rules impede the attainment of positive outcomes for workers, firms, and regions.
The crisis facing America’s labor market is not widely recognized. This American Assembly recommends the following:
Raise the Nation’s Awareness
Faced with the immediate threats-of international tensions and economic recession-it is easy for the nation to overlook future workforce conditions that threaten the health of our economy. This American Assembly calls on America’s civic, education, labor, and business leaders to understand and address this looming crisis, which threatens the nation’s prosperity and democratic future.
This Assembly thinks it is especially important for private business to play a leading role in this effort. For more than thirty years, a variety of efforts have attempted to increase support for traditional workforce development activities. Those efforts have experienced, at best, mixed success, in part because the business sector did not perceive that the system met its needs for trained and productive workers and small and medium-sized firms were not organized and supported to participate effectively in the system. If there is one lesson that successful workforce intermediary efforts have taught us, it is that business sector involvement is critical to success. This has been demonstrated by Project QUEST in San Antonio and elsewhere, and will prove true for any national effort to address these issues.
Business leaders, who create jobs, must be actively and immediately approached, invited and tasked to become key actors in local, state, and national consciousness-raising efforts. This effort could take the form of a national commission, a business-led summit, a major public awareness and media campaign, or any and all of these. This Assembly thinks these issues should be immediately debated and made part of the public policy agenda.
At the same time, given the realities of competing pressures that make it hard for this issue to be heard, this Assembly also recommends the following steps.
Develop an Effective Workforce Intermediary Policy for Business, Workers, and Regions
The current disjointed policy environment creates a multi-faceted problem, including funding streams that are not aligned, and have difficulty achieving meaningful results. Concerns have been expressed from many fronts, including businesses, community-based organizations, educational institutions, unions, and government agencies.
Addressing this workforce development problem will require:
Promoting Smarter Financing
Although coordinating existing public and private funding will help make progress towards growing the workforce intermediary approach, coordination alone is not enough. There is a need for more resources to help intermediary organizations meet the pressing demands of businesses, especially small businesses and workers. Even the most exemplary organizations, which juggle multiple funding streams and provide high performing services to businesses and workers, face a daily struggle to finance their work. Because of limited resources, public agencies also face impossible choices between supporting required core activities, and intermediary approaches like strategic planning and employer engagement that would strengthen their work and the critical need for training.
Federal, state, business, and philanthropic dollars all need to be expanded, and new types of financing mechanisms should be developed. Specifically, this Assembly recommends the following financing improvements:
Build Capacity
Organizations that successfully carry out these strategies conduct a dizzying range of activities to achieve their mission. They coordinate or provide training, work closely with employers, study their local and sectoral economies and labor markets, and link workers with support services like childcare. They do this in an environment where they must constantly seek funds from a variety of sources, each of which has its own demands for accountability and reporting. These demands would challenge the most sophisticated organization. Achieving higher impact, both for the specific organizations and for the system as a whole, will require investments in capacity building, like the following:
Build a Constituency for Action
Although it is critical for the nation’s future economic success, workforce development has not been a national priority. In part, this is because of competition for public funds and attention, but also because of a perception of poor training results and little understanding or knowledge of the emerging successes. Paradoxically, the broad tasks of advancing workers, increasing business productivity, and enhancing regional competitiveness span so many institutions and stakeholders that they inhibit the necessary attention and public support. As the nation strives to build a more effective workforce development system, the workforce intermediary strategy can serve as an effective way to simplify the system for both business and workers, and foster their long-term advancement. Part of the strategy for achieving this success is building a broad constituency for action. Building that constituency requires:
This report builds upon twenty years of innovation, practice, and research in workforce development. It calls America to action and challenges the nation to use the workforce intermediary approach as a strategy to solve the nation’s workforce crisis. There is a great deal at stake. Without aggressive action to expand the labor force in ways that increase productivity for employers, the nation’s long-term economic health will be challenged. Workforce intermediary approaches can make a major contribution to meeting this national need.
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Lauren Harris-Kojetin, Debra Lipson, Jean Fielding,
Kristen Kiefer and Robyn I. Stone
May 2004
The purpose of the synthesis paper is to review, summarize, and discuss the significance of available research findings on the frontline long-term care (LTC) workforce since 1999, in both home and community-based and nursing home settings. This paper builds on the review article by Stone (2001) that reviewed the seminal practice and policy research related to recruitment and retention of frontline workers in LTC. Writing in 2001, Stone noted the lack of empirical research and, in particular, of evaluations to determine the effectiveness of programs and polices intended to recruit and retain LTC direct care workers.
This paper provides an updated review of the status of empirical findings, focusing on what has been learned between 1999 and 2003. The primary goal is to learn what initiatives have worked to reduce LTC direct care workforce recruitment and retention problems. A secondary goal is to provide empirically-based insights on the factors that contribute to recruitment and retention problems. This paper is intended to help policymakers, providers, worker and consumer groups, and researchers create a framework for future evidence-based policy, practice, and applied research initiatives to address LTC direct care workforce shortages.
The paraprofessional LTC workforce -- over 2.4 million nursing aides, orderlies, and attendants, home health aides, and personal and home care aides (USBLS, 2004a) -- forms the core of the formal LTC system.2 Direct care workers serve as the eyes and ears of the formal LTC system and provide most of the care in this system. Even with relatively high unemployment rates, LTC providers and state agencies responsible for LTC services are reporting unprecedented vacancies and turnover rates among direct care workers, ranging from 45 percent to over 100 percent annually for nursing homes. Most states consider direct care worker recruitment and retention major issues (NCDFS, 1999; PHI and NCDHHS, 2004).
Significant societal factors are converging that will likely result in a 21st Century LTC direct care workforce crisis, or “care gap,” in the US. These dynamics include an unprecedented increase in the elderly population and those with chronic medical conditions, a decrease in the traditional pool of women available to provide formal care, fewer adult children available to provide care, and a potential increase in the need for paid care for elderly parents of dual-income and single-parent households. Policymakers and providers need to know what workforce initiatives have been shown to work to address the direct care workforce shortage.
Previously reported research (discussed in Stone, 2001 and Stone and Wiener, 2001) highlights a variety of factors associated with LTC direct care workforce recruitment and retention problems. These factors include but are not limited to: inadequate training; poor public image of the LTC direct care workforce; low pay; insufficient benefits; inadequate job orientation and lack of mentoring; little or no opportunities for continuing education and development within the position; poor supervision; emotionally and physically hard work; workplace stress and burnout; personal life stressors, such as problems with housing, child care, and transportation; lack of respect from residents’ families; and, short staffing. In the past several years, states, providers, and worker groups have developed, implemented and, in some cases, evaluated a variety of initiatives to address these challenges. This paper gives an overview of the most recent evidence base on both problems and possible solutions, to inform future investment choices and initiatives.
We review both published reports and articles, unpublished conference presentations and working papers reporting results of research and evaluations on recruiting, retaining, and sustaining a quality frontline workforce in nursing homes, home care, and assisted living facilities. The review updates research findings reported in a seminal piece by Stone (2001) to better understand the problems facing the frontline LTC workforce and to identify effective solutions to chronic shortages, high turnover, and training needs. Studies on the relationship between LTC staffing levels and quality of care were not included, as they are beyond the scope of this paper; however, studies that examine links between staffing levels and worker satisfaction or turnover rates are included in this review.
Research and evaluation reports and articles completed or initiated between 1999 and 2003 were identified using Internet searches, personal communication with researchers, and database searches (e.g., PubMed). Search terms used when conducting web site and database searches included: LTC workforce, recruiting, labor force, nurse aides, job tenure, employment practices, work environment, aging services personnel, paraprofessional personnel, and intervention strategies. While published articles in peer-reviewed journals generally were preferred, unpublished reports and interim progress reports were included if based on sound research methods. We include studies that use qualitative and/or quantitative methods. Initiatives that were at an early stage of development in the Stone (2001) article were investigated to determine if the research or evaluation was now complete. We also obtained relevant working papers and presentations at professional conferences (e.g., American Society on Aging, Gerontological Society of America) and made personal communications.
The studies abstracted and analyzed for this report fall into two main categories: (1) empirical research (i.e., results of surveys and qualitative studies) on direct care workers that describe their working conditions or further elucidate the causes of turnover; and (2) evaluations of the implementation and impact of public and private initiatives designed to improve the recruitment and retention of direct care workers (e.g., wage and/or benefit enhancements, new training programs, and revised certification requirements).
Section IV reviews studies on characteristics of direct care workers and the wages and health insurance benefits available. Section V synthesizes research on factors contributing to high turnover and chronic shortages. Section VI summarizes findings from evaluations of interventions designed to improve recruitment and retention of direct care workers. Section VII discusses the implications of these recent findings for public policies and provider practices that seek to expand and stabilize the labor pool of direct care workers, and for future research intended to support these initiatives.
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Michael E. Fishman, Burt Barnow, Asaph Glosser and
Karen Gardiner
May 21, 2004
This paper sets the stage for an ongoing conversation between representatives of the long-term care sector and the workforce investment system. The long-term care sector provides care to chronically ill, disabled, and elderly persons in a variety of care settings such as individual homes, residential care, nursing homes, and other institutional settings. Long-term care consists of an array of services and supports for persons with functional limitations whose needs range from limited personal assistance to total care. The workforce investment system supports both employers and workers by providing -- at the local level -- labor market information, job placement services, and training.
This conversation is critically important for our nation. In 1995, there were approximately 12.1 million long-term care recipients in the United States (Kaiser Foundation, 1999.) As the baby boom generation ages and technological advances extend life, these numbers will grow rapidly in the coming decades. The elderly population in the United States is expected to increase by over 130 percent between 2000 and 2050 (ASPE, 2003). Much of the formal care for these populations is provided by paraprofessional workers: certified nurse assistants (CNAs), home health aides, and personal and home care aides. For a variety of reasons described later in this paper, there is a growing shortage of these workers.
In addition to the care needs of our nation’s elderly and disabled population, there is an economic imperative to support the viability of long-term care services. Spending on institutional and home care for adults -- including Medicare, Medicaid, private long-term care insurance, family resources, and other payers -- is expected to more than double between 2000 and 2025, from $98 billion to $208 billion. By 2050, spending is projected to reach $380 billion (ASPE/Lewin, 2001). The majority of long-term care is provided by unpaid, informal caregivers. Often, formal long-term care services support the care provided by informal caregivers -- typically adult children -- enabling some informal caregivers to enter paid work. Exploring the costs of informal caregiving to employers, MetLife (1997) found that the cost to business through lost productivity as a result of informal caregiving is over $11 billion per year. In short, developing a long-term care paraprofessional workforce is an economic development issue for communities and individuals. The workforce investment system is well-positioned, through its network of One-Stop Career Centers, to serve as a valuable resource for both long-term care providers and workers.
This paper provides the fundamental context of both the long-term care sector and the workforce investment system in order to build understanding among members of each system. It is not intended to be comprehensive but to provide enough information to stimulate dialogue. Section II briefly describes the characteristics of the long-term care paraprofessional workforce. Section III outlines the growth in the long-term care sector. Section IV discusses workforce shortages from an economic perspective and why they exist in the long-term care sector. Section V describes the response of the long-term care sector to the shortage of paraprofessionals. Section VI describes the Workforce Investment Act (WIA) and the role of the workforce system. Section VII provides some examples of workforce investment initiatives in the long-term care sector. Finally, Section VIII presents some opportunities for collaboration.
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Robyn I. Stone, DrPH, Steven L. Dawson and Mary
Harahan
October 2003
Since the Nursing Home Reform Act of 1987, public policy makers, consumers and providers have expressed growing interest in the quality of long-term care in nursing homes and other long-term care settings. The Nursing Home Reform Act, known as “OBRA 87,” transformed federal oversight of nursing home quality from its traditional emphasis on structure and process indicators to a focus on maintaining and improving resident outcomes. Since the passage of that landmark federal legislation, consumers, providers, regulators, insurers, and researchers have continuously struggled with how to define measure, assess and ensure long-term care quality.
The purpose of this paper is to introduce a largely overlooked feature of the long-term care system -- direct-care workers -- into the long term care quality debate. For the typical nursing home resident, direct-care staff -- not nurses or doctors -- provide eight out of every ten hours of the care they receive (McDonald, 1994). For home care clients, every hour of non-skilled nursing service is provided by paraprofessional workers. Our thesis is that the quality of long-term care -- the recipients’ clinical and functional outcomes and quality of life -- is significantly influenced by the attributes these workers bring to their caregiving jobs, the education and training they receive, and the quality of their jobs. The attitudes, values, skills and knowledge of these workers, how they are compensated and rewarded, and the way their jobs are organized and managed, all have a role to play in determining long-term care quality. Workforce development activities designed to increase the capacity of these individuals to participate effectively in long-term care settings should be integrated into all ongoing and new long-term care quality improvement and quality assurance initiatives.
The paper addresses the following topics:
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Robyn I. Stone
Journal of Social Work in
Long-Term Care, Volume 2, Issue 3/4, 2003
In this article the author reviews the practical issues related to implementing culture change in nursing homes. The merits of model replications are discussed and the barriers to creating and sustaining culture change in nursing homes are highlighted. This is followed by a description of the various dimensions of culture that must be changed including the approach to clinical training and practice, the nature of management and job design, the approach to caring, and the characteristics of the residential environment. The article then identifies the major elements required to maximize the potential for nursing homes to create and sustain cultural change.
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