Getting real about retention

This is the fourth in a series of PHI Expert Interviews, which bring you insights from four senior PHI staff. They’re an impressive group — among the nation’s leading experts on long-term care’s direct-care workforce — and collectively they’ve spent decades studying the challenges facing the workforce and how to address them. We think you’ll be interested in what they’ve learned.

When Steven Dawson came out of the workforce development field in 1992 to join Peggy Powell in heading up the Paraprofessional Healthcare Institute, PHI’s sole purpose was to raise funds and provide technical support for Cooperative Home Care Associates. Over time, Steven led PHI into the broader long-term care arena, where its policy and practice experts work with employers and lawmakers to support and stabilize the nation’s direct-care workforce.

Steven has written about the impending direct-care workforce crisis (pdf) and the link between quality jobs for direct-care workers and quality care for long-term care consumers. Through the years, his emphasis has been on creating workplaces that are intentionally re-designed to retain direct-care staff.

“A constantly churning workforce is the enemy of quality care — ask anyone whose mother has had to deal with five different home health aides within a month, or with a blur of CNAs in the nursing home. The industry still manages to attract hundreds of thousands of skilled, caring workers every year, but once hired, these frontline staff are too often treated as if they were invisible. So, of course they leave,” he says.

A low-investment, high-turnover employment strategy

The revolving door that keeps an ever-changing cast of direct-care workers circulating through long-term care organizations has never been ideal for workers, consumers, or employers. Still, from a business standpoint, it has worked well enough to be the norm within the industry for several decades.

It started in the 1970s, Steven says, when the baby boomers began to transform the workforce – partly because of the sheer size of the baby boom generation, and partly because women entered the workforce at a much greater rate than they ever had before. “The long-term care industry was able to count on an endless supply of low-income women willing to do this work,” he says, “so the business model for direct-care work was built around a low-investment, high-turnover strategy, with low expectations of quality.”

Decades of an over-supply of labor created little pressure to make jobs more attractive, and so direct-care wages stayed low and benefits spotty. “The logic was — and typically still is — ‘Why invest in people if in six months they’re just going to leave?’ But low investment nearly guarantees high turnover, and so it is self-fulfilling — and has helped the industry avoid the difficult task of building a stable care staff.”

On the fast track to a true labor crisis

However, over the past ten years the supply of young and middle-aged women in the workforce — the group that has traditionally supplied about 90 percent of all direct-care workers — has started to flatten. And soon the baby boomers will age out of the workforce and into the long-term care system, causing demand for services to increase relentlessly. “That is the expanding care gap the nation is now facing,” says Steven.

The current weakness in the economy may buy employers a little time, by boosting unemployment and slowing job growth. “But once the economy strengthens, we’ll be on the fast track to a true labor crisis. No industry should rely on recession as the answer to its labor force challenge,” Steven says.

That challenge grows every day. “The Bureau of Labor Statistics is predicting that we’ll need a net one million more workers in the next 10 years — rising from three million to four million direct-care workers by 2016. Add to that the numbers of new caregivers required to replace the workers who leave, and the result is a magnitude of challenge the industry has never faced before. And this challenge will take place precisely at the wrong time, when the traditional supply of caregivers is no longer flooding the labor market.”

Direct-care workers want the same thing as you and me

So how do you get workers to stay in a tight labor market? “PHI has developed a very simple analysis of the nine elements it takes to have a quality job,” says Steven. “Those elements are pretty much the same as what you or I want in our jobs: things like a livable wage, health insurance, decent training, a chance to move up, supervisors who know what they’re doing and can help when you need support.

“It’s all pretty self-evident, and yet for policymakers argued that these workers were different from you and me, that home care aides and CNAs loved the act of caregiving so much they were quite content with minimum wages. We now have research to document that’s not true, as if we needed research to prove the obvious: Direct-care workers will never form a stable workforce until they are truly valued as an essential member of the care team-by being provided all nine elements of a quality job.”

Employers can implement many of the nine elements on their own, but some elements require additional governmental investment. Medicaid pays for more than half of the long-term care provided in the U.S., and its reimbursement rates leave no room for major outlays like generous raises or increased benefits. That’s why PHI also fields a policy agenda, doing work like its Health Care for Health Care Workers campaign, which provides tools and technical assistance to people working to expand health care coverage. “We know health coverage is an essential part of the solution,” says Steven. “We’ve seen the analysis that says affordable health insurance improves retention — in some cases even more than raising wages. But even more importantly, it is a national embarrassment that we ask people to serve our health care system, and yet don’t even guarantee them health insurance.”

Providing a solid grounding for new workers

Improving training and on-the-job support for new workers also improves retention, since direct-care worker turnover is rampant during the first six months on the job — largely because new workers are faced with challenges they’re unprepared to meet.

PHI’s entry-level training provides a solid grounding. “We’ve developed a specialty at PHI in creating employer-based training programs,” says Steven. “Recently, to address the demand for direct-care staff, organizations across the country are developing more and more direct-care training programs. We are increasingly asked to help these entry-level programs design adult learner-centered curricula, especially for workers who will be providing services and support within a consumer-directed setting.”

In addition, a good peer mentoring program picks up where effective training leaves off, pairing new workers with a senior colleague to provide advice, answer questions, and clue them in on the culture of their new workplace.

Teaching supervisors how to manage people

Finally, one of the primary causes of turnover is the punitive and inconsistent supervision that plagues long-term care. PHI’s coaching supervision model addresses that problem by giving supervisors the management skills and support they need. “Nurses within long-term care constantly come to us and say, ‘Nobody taught us how to manage people. We’re trained as clinicians, and we came to this work to care for patients, not manage staff. And yet we’re told just to go out on the floor and start supervising 25 CNAs,’” reports Steven.

In response, PHI has developed a skill-based approach to person-directed care: “The ability to really listen to another person, the ability to offer feedback without judgment or blame, the ability to manage one’s emotions in difficult settings – these are not easy skills, but PHI’s Center for Coaching Supervision and Leadership is showing that these are skills that can be learned, and are enormously valued once mastered.”

What it takes to make it happen

“The good news is that there are several industry leaders who are taking very seriously the challenge of creating a ‘high investment-low turnover’ business model,” says Steven. “They range from rural home care agencies like the VNA of Indiana County, Pennsylvania, to very large home care agencies like the Visiting Nurse Service’s Partners in Care in New York City, and to family-owned nursing homes like the Edgewood Center in Portsmouth, New Hampshire, to Genesis Health Care New England.

“So, please don’t tell me we don’t know what to do to retain workers. Don’t hold another national conference calling for more analysis of the direct-care ‘crisis.’ Sure it’s is a crisis, but it’s an unnecessary one, because the problem isn’t not knowing what to do.

“The problem is that we have yet to build the political will in this country necessary to invest adequate resources into long-term care. Words probably won’t change that — but perhaps trying to find and keep one million more direct-care workers over the next decade will.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org