May 14, 2004 — With vacancy and turnover rates of direct-care workers still at crisis levels, adopting “employer of choice” strategies could help providers ease the problem, believes Steven L. Dawson, president of the Paraprofessional Healthcare Institute. “It’s like a bucket with 12 holes in it: You can’t fix just two, or six or even ten of the holes and still expect to retain a stable direct-care staff — you have to pay attention to every aspect of the problem,” he says in this snalfnews.com interview. Dawson is the author of numerous papers analyzing the direct-care labor crisis, including “Direct Care Health Workers: The Unnecessary Crisis in Long-Term Care,” and “Long-Term Care Financing and the Long-Term Care Workforce Crisis: Causes and Solutions.” To access these articles and a wide range of additional resources available from the National Clearinghouse on the Direct Care Workforce, click here.
First, what is the Paraprofessional Healthcare Institute (PHI)?
Our mission at PHI is twofold — to improve the quality of the direct-care worker’s front-line jobs, and in doing so improve the quality of care for long-term care consumers. We focus our work on re-designing systems around the relationship between the consumer and her caregiver — we believe that only a respected and valued workforce will be able to provide quality care to residents. We do this work at both the practice level, consulting directly with provider agencies, and at the policy level.
Bring us up to date on the direct-care staffing crisis. How bad is it right now, and what are some of the contributing factors?
The staffing situation is slightly better than it was a couple years ago when the economy was at its hottest, but vacancy rates are still severe — and among paraprofessionals, it worsens the lower down the job quality ladder you get. Nursing homes are having somewhat less trouble than before, in terms of CNA vacancy rates — but only slightly. The American Health Care Association (AHCA) still reports turnover rates of CNAs above 70 percent, and vacancy rates above 8 percent. And home care and personal care providers, particularly where the jobs tend to be part time with no benefits, continue to have even greater difficulty in finding staff. Also, those geographic areas that have the highest immigration rates are doing better than those that don’t have an influx of non-native born workers.
However, as the economy begins to heat up again and the employment rates begin to strengthen, I believe we’re going to not just see high turnover rates, but return to the high vacancy rates that the industry experienced just a few short years ago — and that’s when the industry and the political policy makers will again begin to pay even more attention, when workers stop showing up. The system has been built around an assumption of fairly high turnover and churning of the workforce, and while that’s a serious problem, everything becomes far more difficult when workers don’t show up at all. So higher vacancy rates will trigger a more intense look at the direct-care workforce, and, assuming the economy continues to strengthen, I think we’ll see those vacancy rates back up to 11 and 12 percent again within just the next year or two.
The problem will continue to deepen because of the demographic issues. Most people in the industry are aware of the increasing demands of higher prevalence of disabilities and an aging population will place on long-term care services, but what’s less understood is that the traditional supply of long-term care workers has changed substantially. The long-term care system was built assuming an endless supply of women entering the workforce between the ages of 25 and 44, but since 2000 or so, that pool of workers has remained relatively unchanged — it’s not increasing the way it used to because now the smaller “Post Baby Boom” generation is entering the workforce. That means that as the economy heats up, a relatively fixed pool of women entering the job market will have more choices for employment — as they did in the late 1990s — and so long-term care providers will be forced to compete aggressively again in the labor market for their CNAs and home health aides.
Let’s talk about turnover first. If so many CNAs feel the work they do is a special calling, why do so few stay?
It’s like a bucket with 12 holes in it: You can’t expect to fix just two, or six or even ten of the holes and still expect to retain a stable direct-care staff — you have to pay attention to every aspect of the problem. There are a number of factors all along the employment chain — from recruitment and selection through supervision and support — and unless you attend to all of them, you still lose people. It starts with having good selection criteria, and includes obvious things like decent wages and benefits and how people are treated.
Unfortunately, I think we see too much “either/or” thinking in the industry. It’s either “If we just pay people more that’s all we need to do,” or “If we just paid attention to people more, and trained them better, we wouldn’t have to worry about wages and benefits.” But it’s not either/or, it’s always both. It’s one thing to be greeted in the morning and feel appreciated, but if you’re still making $6.50 an hour, don’t have health insurance and are worried about your kids being cared for by a neighbor, it’s hard to do your best work. Similarly, if you’re making $12 an hour, but you’re treated like you are invisible, that’s not enough to keep you in your job either.
Another reason for the high turnover of direct-care staff is the high turnover in administrative and professional staff. If you have constant churning at the higher level, you’re certainly not going to have a stable environment or a positive culture in which direct-care workers are going to feel supported and stable. Finally, I think we have to also acknowledge that there is a broad, societal backdrop in our industry in terms of who is providing care to whom — it’s primarily low-income women providing care to low-income women — and in addition, the direct-care workforce is disproportionately women of color. That’s the norm of long-term care. It’s just a reality that these are people whose work society has not traditionally acknowledged or fully valued — they are too often invisible — and at the same time they’re working within an industry where the administration and professional staff are primarily white and middle class. It’s a framework that needs to be acknowledged, because it’s always there — and is likely to become more true as our workforce in this country is drawn increasingly from non-native born workers.
You’ve talked and written about the importance of being an “employer of choice.” How does that concept help fill some of those holes in the bucket?
It’s a phrase we use to help employers understand that they are dealing within a labor market. They didn’t have to worry about that back when they had an endless supply of women willing to work under pretty much any conditions that were offered. But as the labor market shifts, employers have to understand that they have to offer competitively attractive jobs. Just as they are trying to compete for consumers, just as they have to compete for finance capital, they also now have to compete for workers in order to have a successful business, and that really changes the power dynamic within the organization.
That means that as providers, we must make a longer term investment in staff resources, and that’s a worthy investment only if we achieve a more stable workforce. If we’re still constantly churning, there’s no sense in investing up front. It’s good business logic that if I become an employer who invests in the work force up front in training, support, higher wages ands benefits, the result will be a more stable, longer-term workforce — and in return I won’t have to pay the other costs of constantly paying top price for temporary workers, and constantly hiring, terminating and disciplining staff. In simple terms, it’s a “high road” versus “low road” kind of strategy, and whether it’s because of a lack of resources, the regulatory climate or other factors, long-term care has typically taken the low road of simply assuming high turnover, and managing the workforce accordingly.
Are you talking about the high road from a mission perspective as well? It sounds like doing the right thing for people is also good business.
Although more research is required to prove conclusively that better jobs do in fact create better care — it’s intuitive. PHI and other practitioners work on the belief that a more stable workforce gets to know their clients better, and at least has the opportunity to provide a higher quality of care. It still amazes me that some things that seem pretty obvious are often ignored in our industry — for example, “consistent assignments” in which the CNA is assigned to the same unit or client as much as possible. If we know that CNAs are attracted to this work mostly because they value caring for their client, but we still structure the job so they can’t form good relationships with clients, then it should not surprise us when they leave in frustration. So, consistent assignment is one of the very fundamental, and yet relatively simple and low-cost restructurings that can be done to recognize who your workforce is and why they show up for work each day.
Another example is that people in low-wage jobs typically, by definition, have relatively few financial assets, and therefore it’s harder for them to deal with problems before they turn into crises. When a car breaks down, or there’s child care difficulty, they just have fewer assets to fall back on, and that becomes an obstacle to getting to work or doing a good job while at work. Employers don’t have to become a social service center and take on that level of responsibility, but they can certainly help their employees gain access to community-based resources, whether it’s to address domestic violence at home, or transportation needs, housing, or child care. For instance, many of our direct-care workers are eligible for the federal Earned Income Tax Credit — increasing income, in some cases, by several thousand dollars — and employers could easily help organize support to help their employees apply for and receive that tax-related income.
Think of it almost like a “case management” approach to your direct-care staff. At Cooperative Home Care in New York — which is an 800-worker, employee-owned home care agency affiliated with PHI — we have several counselors who work with our employees on those types of issues. And they now have very effective relationships with all sorts of different community organizations that act as an additional safety net for staff as they deal with the realities of direct-care work.
Are there providers or organizations that are making significant progress with “employer of choice” type programs?
There are countless examples now, across the country. The Direct CareGiver Association, in Tucson, Arizona, is a consortium of providers who came together to recruit and train direct-care workers for a variety of home care, nursing home and hospice positions. The Loomis House, a skilled nursing facility in Holyoke, Massachusetts, participated in a state-funded career ladder initiative — they cut their CNA turnover in half and saved more than $100,000 in staff recruitment, replacement and training costs over the past three years. And Ararat Nursing, in Mission Hills, California, has created a multi-level career path for their CNAs — their system has even shown a link between their very comprehensive approach to staffing and improvements in resident outcomes — of increased physical activity and decreases in use of antipsychotic drugs and sleeping pills. Your readers can learn details of these and more than fifty other examples by visiting the National Clearinghouse on the Direct Care Workforce, at www.directcareclearinghouse.org, and clicking on “practice profiles.”
One broader example that is particularly exciting is within the “Better Jobs, Better Care” initiative, which is the national direct-care demonstration program funded by The Atlantic Philanthropies and the Robert Wood Johnson Foundation. One of the demonstration states is North Carolina, where they are creating a set of standards for how direct-care staff are supported, trained and supervised within long-term care facilities. Eventually, they hope employers will be rewarded for those behaviors in the State’s reimbursement rates — that’s the type of system change that I think is very important. We know employers can’t do this just on their own. There has to be change both at the practice level, in terms of day-to-day management and structure of the facilities, but also at the policy level, in financially rewarding “good behavior” that results in a high-quality, stable workforce.
What kinds of progress are you seeing at the policy level?
There’s a lot happening at both the state and federal level. It is encouraging that both CMS [Centers for Medicare and Medicaid Services] and the Department of Labor [DOL] have begun to focus on this workforce in a way they never have before. HHS and the DOL are now talking to each other, which had not happened much before, and are in fact sponsoring a national symposium on the direct-care workforce in May. It’s really the first time the two agencies have agreed that direct-care employment is an opportunity — both to create decent jobs, and provide high-quality care.
At the state level, we continue to see both practice and policy initiatives across the country. This is where providers can more easily become involved in policy matters. In partnership with the North Carolina Department of Health and Human Services, PHI co-publishes each year a survey of those state activities — in April we published the most recent survey, which also can be accessed at the National Clearinghouse website. I urge your readers to find out what is happening in their state, and then participate in the demonstration programs and task forces that are becoming active across the country.
But with so much focus on government initiatives to keep people out of nursing homes, will much attention be given to staffing in institutional settings?
It’s just logical. You can’t invest in a whole lot of staff training on how to ensure quality outcomes, and then go back six months and find that 50 percent of those staff members you trained aren’t there anymore. Maintaining a stable staff is essential to having a strategy where quality is improved and measured over time, so I think it is through the “quality improvement” processes where you’ll see increasing focus on facility-based staffing — that is why I expect that the Quality Improvement Organizations (QIOs), with encouragement from CMS, will focus increasingly at the direct-care, paraprofessional staffing level.
From your observation, is the “employer of choice” concept resonating with providers?
Yes. The State of Maine, for example, is encouraging long-term care providers to adopt the “employer of choice” model, and is providing technical assistance to do just that. What I think is most interesting is that organizations like the Pioneer Network and others who have been working a long time on “culture change” initiatives are now taking an even stronger and more blended approach in terms of understanding that the consumer can’t get what she needs, unless her caregiver is also receiving the support she needs.
Copyright snalfnews.com 2004. Reprinted by permission.
