U.S. Department of Health and Human Services

Linking TANF Recipients with Paraprofessional Long-Term Care Jobs

Jacqueline Kauff, Gretchen Kirby, and LaDonna Pavetti

Mathematica Policy Research, Inc.

March 2005

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This report was prepared under contract between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and Mathematica Policy Research, Inc. For additional information about the study, you may visit the DALTCP home page at http://aspe.hhs.gov/daltcp/home.htm or contact the ASPE Project Officer, Charlene Liggins, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. Her e-mail address is: Charlene.Liggins@hhs.gov.

This brief is based on Mathematica's study of Temporary Assistance for Needy Families (TANF) recipients as long-term care (LTC) workers. The study examined the suitability of TANF recipients for employment as certified nurse aides (CNAs) and home health aides and the feasibility of training recipients for these paraprofessional jobs. We used two data sources: (1) a survey of single-parent TANF recipients in three states and the District of Columbia; and (2) in-person visits to five programs that train TANF recipients and other low-income individuals for these jobs. The study shows that more than half of those on the TANF caseload have the potential to succeed in paraprofessional LTC jobs and that there are many different ways to design and implement successful LTC training programs for TANF recipients.

The LTC Crisis and TANF Environment

Attracting and retaining CNAs and home health aides to care for elderly, disabled, and chronically ill people is a growing concern for the LTC industry and health care policymakers. Demographic and economic factors combined with issues specific to the LTC industry--such as low wages, few benefits, and the physical and emotional demands of the work--are making it challenging for providers to ensure the adequacy and availability of these paraprofessional employees, and the problem is expected to increase dramatically over the next several years as baby boomers begin to enter their sixties. At the same time, TANF recipients are seeking opportunities to move from welfare to work within an environment marked by strict work requirements and time limits on receipt of aid. In 1996, welfare reform legislation required states to engage a substantial portion of their TANF caseloads in work or work-related activities for 30 hours per week; some recent proposals for reauthorization of the legislation would require states to engage an even larger share of their caseloads for 40 hours weekly.

If such TANF proposals become law, states will need innovative strategies to help recipients find employment. The LTC industry's lack of workers and TANF recipients' need for jobs could create a mutually beneficial opportunity if (1) the characteristics of recipients match the requirements of the available jobs; (2) available jobs offer the hours and pay that recipients need to move toward self-sufficiency; and (3) workforce development programs can createroutes to the LTC industry that are accessible and attractive to recipients.

Can TANF Recipients Fill LTC Jobs?

Through an analysis of the match between the characteristics of TANF recipients and those desired in paraprofessional LTC workers, we found that 56 percent of TANF recipients in Illinois, Maryland, South Carolina, and the District of Columbia had moderate to high potential for entry into LTC employment. To conduct this analysis, we used data from the three states and the District of Columbia collected through a common survey of TANF recipients. Note that the findings presented here apply only to the sites analyzed and cannot be generalized to all TANF recipients or states.

Demographic characteristics. Both the TANF population and the LTC paraprofessional workforce are made up mostly of women with low education levels. About 9 of every 10 LTC paraprofessionals are female; almost all single-parent TANF households are headed by a female (Table 1). Three out of four CNAs and two out of three home health aides have a high school diploma or less. Similarly, 70 percent of TANF recipients have no more than a high school education. However, compared with LTC employees, a much larger proportion of TANF recipients have less than a high school diploma or GED.

The two groups differ somewhat in age distribution, racial and ethnic composition, and marital status but they are still more similar to each other than to the workforce in general. On average, the TANF population is younger with a larger percentage of African Americans than the LTC workforce. Unlike TANF recipients, most CNAs and home health aides are white and have been married at some point, but they are more likely than the workforce in general to be nonwhite, unmarried, and have a child under age 18. For example, the Government Accountability Office found that 26 percent of the general workforce was nonwhite, compared with 43 percent of CNAs and home health aides (Scanlon 2001).

Job characteristics. Paraprofessional LTC jobs generally offer low wages, limited benefits, and little opportunity for wage growth and career advancement. Nonetheless, they may provide decent entry-level opportunities for TANF recipients who are not working, and better wages and benefits than the current jobs of those who are employed. Employed TANF recipients generally have lower median wages--$7 per hour in the study sites--than LTC paraprofessionals, who earn between $7 and $9 per hour nationally (DHHS and DOL 2003). And, only 40 percent of currently or recently employed TANF recipients are offered employer-sponsored health insurance, while 47 percent of home health aides and 57 percent of CNAs in nursing homes nationally receive health insurance coverage from their employer (Scanlon 2001).

Potential pool of LTC workers. TANF recipients in the four sites appear suited for LTC jobs, based on their demographic and current job characteristics. However, we also need to consider personal characteristics that are prerequisites for LTC employment. At the very least, LTC workers cannot have a criminal record that would disqualify them from LTC employment in their state, and they cannot be dependent on drugs or alcohol (virtually all LTC employers require potential employees to pass a drug screen). These two personal challenges could be major impediments to LTC employment for the TANF population. Twelve percent of all recipients in the four sites have one or both of these liabilities. LTC workers also should not have poor English skills or poor physical and mental health. On average, 37 percent of recipients have at least one of these more moderate liabilities to LTC employment.

Using a multivariate model, we predicted high, average, and low probabilities of substantial employment (30 hours or more per week) in any job for each recipient in the four sites. We then combined these probabilities with information on major and moderate liabilities for LTC employment in order to estimate the potential pool of new LTC workers.

We found that 38 percent of recipients--27,467 recipients combined across the sites--have high potential for LTC employment because they (1) have a high or average probability of substantial employment generally and no major or moderate liabilities to LTC employment specifically, or (2) are employed in a job that is less attractive than a LTC position (Table 2). An additional 18 percent, or about 13,000 recipients, have moderate potential for LTC employment because they have a high or average probability of substantial employment generally and only moderate liabilities to LTC employment specifically. The total potential pool of new LTC workers was 56 percent of recipients--just over 40,000 TANF recipients--in the four sites. An additional six percent reported either current or recent employment in an LTC job.

How Is LTC Training Structured?

To assess the feasibility of training TANF recipients for paraprofessional LTC jobs, we visited five programs that have tried to link recipients with the LTC labor market. The programs are in the District of Columbia; Tucson, Arizona; Dakota County, Minnesota; Bronx, New York; and Richmond, Virginia. Most provide participants with job readiness or life skills instruction in the classroom, some offer hands-on learning through job shadowing or work experience, and all provide or pay for CNA or home health aide training lasting between 3 and 13 weeks.

The programs had common goals but many structural differences (Table 3). For instance, each was run by a different type of organization--a private for-profit organization; a hospital; a technical college; a worker-owned collaborative; and a housing authority. Some recruited participants directly from TANF agencies, and others recruited participants from other social service systems or by word-of-mouth. Funding sources also varied, from local TANF funds to federal grants from the U.S. Department of Labor and the U.S. Department of Housing and Urban Development, contributions from private organizations, and grants from foundations. In addition, programs had varied success with respect to graduation rates and participant employment in the LTC field (Table 4).

Despite differences in structure and outcomes, programs had common experiences that provide the following lessons about designing LTC training programs for TANF recipients:

• Strong linkages between training providers and employers are critical. Training is only one step in the process of linking TANF recipients to LTC jobs. Recipients are also likely to need help accessing job opportunities. Successful links to employment are facilitated when the training provider and employer are the same entity. In this environment, a seamless transition can occur between training and employment, helping to capitalize on the momentum participants have when they graduate from training and ensure that trainees do not stagnate or get lost in the system. Two of the five programs in the study had this structure. When the training provider and employer are not the same entity, strong relationships between the two can improve trainees' access to jobs. Employers that are connected to and invested in training programs might consider trainees as "first-source" job candidates, get to know them during training, and ensure that trainees know about current openings. Three of the five programs in the study had this structure.
• Job shadowing or work experience components are beneficial. A job shadowing or work experience component exposes trainees to the realities of a paraprofessional LTC job and puts employers in contact with a qualified pool of job candidates. Through these components, trainees can also refine their skills and gain confidence to become permanent employees. Prospective employers can observe and evaluate trainees' technical skills, soft skills (such as motivation and workplace etiquette), and personal characteristics prior to extending job offers. Three of the five programs in the study use job shadowing or work experience immediately before job search or employment and consider it an essential part of training.
• Multiple funding streams help reduce risk and expand services. Tapping into multiple sources of funding can reduce the risk of programs folding when individual funding streams dry up. Two of the programs observed rely exclusively on one source of public funding to support all program activities, and the future of these programs is entirely dependent on the renewal of a contract with the supporting agency. By contrast, the programs that rely on multiple sources of funding have some recourse when grants expire or public budgets are cut. They also have used various funding streams to expand their array of program services or target population and to avoid being beholden to a specific set of rules or requirements set forth by a specific funder.

• Linkages with the TANF system can provide vital supports and services. Linkages between LTC training programs and the TANF system can provide funding for trainees as well as access to supportive services. All but one of the programs in the study used TANF funding to support program staff and activities; two relied on TANF funding exclusively. Contracting with TANF agencies gives training programs access to staff who can provide case management services, such as in-depth assessments, links with supportive services, and help addressing personal issues. Perhaps more importantly, trainees who are TANF recipients can lay claim to the full range of financial support--such as transportation stipends, child care subsidies, and reimbursement for uniforms and other equipment for employment--that TANF agencies provide, saving training programs substantial resources.
• Retention services to help graduates maintain jobs must be a central program component. Most programs in the study last between 5 and 12 weeks, and administrators agree that it is misguided to expect trainees to become self-sufficient in this time. Barriers to successful employment do not disappear when an individual becomes employed. Some barriers that have been addressed may resurface; others may worsen under the demands and stresses of the LTC workplace. For this reason, programs have invested in post-employment peer mentoring or support groups for their graduates. In addition, many trainees had previous training and/or experience in health care but left the field because of personal issues. This suggests that supportive services, such as case management and continued child care or transportation assistance, might help to reduce employee turnover and ensure more continuity in patient care. Finally, one program observed provided jobs that offered steady pay increases and guaranteed full-time employment. Because lack of stability in hours and wages is another major contributor to attrition in the LTC workforce, other programs should try to create or identify jobs with these characteristics as well.

What Challenges Do Programs Face?

Designing and implementing an LTC training program for TANF recipients and other low-income individuals may be a daunting task, particularly for organizations with little experience in the LTC field or with disadvantaged populations. Although the five programs in the study experienced a range of successes, all encountered challenges as they entered uncharted territory. We highlight three of these challenges here:

Program selection criteria can limit the pool of trainees. As discussed, many TANF recipients may not be suited for employment in LTC jobs because of personal characteristics that disqualify them (criminal convictions or drug use) or limit their ability to carry out the job (physical or mental health problems). Training programs often use additional selection criteria, however, to help reduce staff burnout, use resources efficiently, and maximize results. For example, three of the four programs that provide CNA training accept only applicants who provide proof of reliable child care and/or transportation, to reduce logistical problems that can disrupt program attendance and, ultimately, patient care. Furthermore, because most LTC employers require CNAs to have a high school or equivalent degree, individuals lacking this credential are often not accepted into training. And, a few programs use extensive application processes designed to mimic the employment application experience and identify the most motivated and capable applicants. These selection criteria have resulted in trainees with higher skills and fewer personal challenges relative to TANF recipients as a whole. They also have excluded somewhat less qualified recipients who might, with a greater level of support, be successful in training and subsequent employment.

Programs interested in reaching a wider group could seek additional resources to enable them to hire more staff (particularly with expertise in personal and family issues), further train current staff, and ensure links to consistent child care and transportation assistance. They could also add a GED component for applicants lacking a high school education.

"Work first" may limit training opportunities. Since the mid-1990s, "work first" has been the dominant philosophy in welfare-to-work programs. In this environment, programs focus on engaging TANF recipients in employment immediately or in activities that lead directly to employment, rather than encouraging them to meet federal work participation requirements through a broader range of activities. Education and training are rarely allowed as the principal initial activity. The shift away from education and training can create recruitment problems and low enrollment in LTC training programs that rely on referrals from TANF case managers, who may be reluctant to refer recipients to any education and training activity regardless of its content, duration, or potential outcomes. "Work first" can also delay training program entry for recipients characterized as job-ready because they have few barriers to work.

A potential solution is to educate TANF administrators and staff about the short-term nature of LTC training; most programs last less than 12 weeks, can count toward the federal TANF work participation rate, and can rapidly lead to employment. However, programs that provide prevocational instruction might need to be creative in ensuring that they do, indeed, meet federal participation guidelines. For instance, one program in the study worked diligently with TANF program administrators to certify its eight-week prevocational component as a community work experience activity that could count toward the federal requirements. Alternatively, program staff could develop relationships with TANF case managers who may be able to exempt recipients from work-first requirements.

Few take advantage of advanced training opportunities. Four of the five programs in the study offer opportunities to pursue additional education and training in the nursing/LTC field, yet few trainees or graduates have done so, primarily for two reasons. First, many are not aware the opportunities exist; second, advanced training is often not accessible. For example, it may be offered in inconvenient locations or at times, such as in the evening, when it is difficult to find child care and program graduates are either tired from their daytime employment or busy working evening jobs. In addition, they may not have the prerequisites for advanced training (such as a high school diploma or GED, or minimum Test for Adult Basic Education--TABE--scores) and thus may view it as a lengthy commitment involving remedial education.

To encourage greater participation in advanced training, programs could educate trainees about available options and ease access to training. For example, trainees could be informed about opportunities early on and also periodically throughout their tenure. Programs might also make use of peer motivation and invite former TANF recipients or others who started in entry-level positions and then got additional training to talk with current trainees about their experiences. Training could be made more convenient if offered on site, or if child care and transportation were provided. Additional flexibility could be afforded if classes were offered during the day as well as in the evening. Finally, programs operated by employers might think creatively about providing advancement opportunities within CNA or home health aide positions, rather than or in addition to training for more advanced job titles.

Implications for the Future

The LTC industry represents a realistic opportunity for employment for a substantial portion of TANF recipients facing work requirements, time limits, and sanctions. While linking TANF recipients with LTC jobs is not the entire solution to the current staffing LTC staffing crisis, our study shows that policymakers and LTC employers should tap TANF recipients to help meet the growing demand for workers. Yet, while the majority of TANF recipients in the four sites analyzed could be suited for LTC employment, there is still the question of how many among this potential pool will consider entry into the field. One avenue to promote LTC employment among TANF recipients is through the type of workforce development programs we discuss in this brief. This study found that it is not only feasible to create programs to help recipients obtain and maintain paraprofessional LTC jobs, but in fact, there are many different ways to design and implement such programs.

Although the study offers important information on different ways in which LTC training programs can be structured, it does not answer questions about how programs affect participant outcomes--such as employment and retention, earnings, and self-esteem--or about the costs of these programs relative to their benefits. Before policymakers and program administrators invest heavily in linking TANF with the LTC industry, it may be wise to first rigorously evaluate existing programs or to design, implement, and evaluate smaller-scale demonstration projects. Evaluations and pilot tests can answer questions about the added values of individual program components and the effectiveness of a program overall. They can also help policymakers and administrators design the most optimal programs cost-efficiently. In addition, it could be useful to examine how to support current and former TANF recipients and eligible nonrecipients already in LTC jobs with an array of TANF-funded services, such as specialized case management or extended child care and transportation assistance.

References

William Scanlon. "Nursing Workforce: Recruitment and Retention of Nurses and Nurse Aides Is a Growing Concern." Washington, DC: GAO, 2001.

U.S. Department of Health and Human Servicesand U.S. Department of Labor. "The Future Supply of Long-Term Care Workers in Relation to the Aging Baby Boom Generation." Washington, DC: DHHS, 2003. [http://aspe.hhs.gov/daltcp/reports/ltcwork.htm]

This study was funded by the Office of the Assistant Secretary for Planning and Evaluation at the U.S. Department of Health and Human Services (DHHS). The opinions expressed here are those of the authors and do not necessarily represent the views of DHHS. The full reports on which this brief is based, "TANF Recipients as Potential Long-Term Care Workers: An Assessment of the Prospects in the District of Columbia, Illinois, Maryland, and South Carolina," and "Training TANF Recipients and Low-Income Populations for Long-Term Care Paraprofessional Jobs" are available at http://www.mathematica-mpr.com. For more information, contact Gretchen Kirby at (202) 484-3470 or gkirby@mathematica-mpr.com.

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