“Home Is Where the Heart Is: Creating Home and a Life Worth Living for Elders who Live in Facilities,” an all-day conference, provided strategies for senior care providers to deliver person-centered care and to improve the quality of life for elders who reside in nursing homes and assisted living facilities.

“Culture change is critical as we face the challenges of an aging population in our community and is crucial for elders who reside in facilities, for caregivers and families, and for health care workforce retention and development efforts,” said Rhonda Rotterman, executive director of WNYAPCC.

Culture Change Pioneers in Attendance

The WYNAPCC event featured several speakers who are considered early pioneers in the culture change movement, including Carter Catlett Williams, a Pioneer Network founder. About 150 leaders from nursing homes and assisted living facilities attended the symposium.

Sponsors included the Western New York Association of Homes & Services for the Aging and the New York State Health Facilities Association.

“I hope Western New Yorkers who are not yet familiar with WNYAPCC will get in touch with the organization because state culture-change coalitions are among our most effective ways of growing the culture-change movement” says Susan Misiorski, PHI’s national director of training and organizational development, and a Pioneer Network board member.

Information on how to provide staff and resident education on person-centered care is available in “Getting Started, Pioneering Approaches to Long Term Care Culture Change,” written by PHI for the Pioneer Network.

– by Deane Beebe

Richard H. Chambers Courthouse, Pasadena, CA

A federal appeals court in California ruled against Gov. Arnold Schwarzenegger on March 3, invalidating past budget cuts that would substantially reduce wages for In-Home Supportive Services (IHSS) direct-care workers.

Schwarzenegger’s 2009 and 2010 budgets contained cuts that would reduce the state’s contribution to the IHSS home care workers’ hourly wage by $2 per hour — from $12.10 to $10.10, or a 17 percent decrease.

IHSS workers are independent providers (IP); they are employed directly by consumers, not by agencies that control the hourly wage. Consequently, these IP’s rely on government decisions to set their wage and benefit packages.

Decision Celebrated

“The court’s decision is most welcome, but not surprising,” said Donna Calame, executive director, San Francisco IHSS Public Authority.

“Governor Schwarzenegger has proposed multiple, egregious budget cuts for California’s model IHSS program, under the guise that the cuts are necessary and unavoidable,” Calame continued. “This ruling reminds us of what our nation stands for: fairness and public support for those most in need among us.”

IHSS is a Medicaid program, known as Medi-Cal in California, that helps low-income elders and people with disabilities live independently at home. The home care workers provide clients with needed services like bathing, dressing, cooking, shopping, and transportation.

The state-funded agency employs 370,000 direct-care workers and serves 440,000 consumers.

Cuts Violate Federal Medicaid Act

The U.S. Court of Appeals for the Ninth Circuit — in agreement (pdf) with decisions made by lower courts — continued to prevent the home care workers’ wages from being slashed on the grounds that the cuts did not comply with the federal Medicaid Act.

The state is required by law to first study the impact of the wage cuts on both the consumers’ ability to access the services provided by IHSS and the quality of these home care services.

California officials estimated that the state could save $79 million by cutting IHSS home care workers’ wages during the two-year period on which the appeals court ruled.

“The court’s decision means that IHSS consumers who have been approved to get home care will actually be able to find a worker to do it,” Calame said. “When wages fall or are exploitative of the workforce, consumers find it difficult — if not impossible — to get the services they need.”

The appeals court also handed down decisions that thwart the governor’s past budgets plans to cut the Medi-Cal reimbursement rate by 5 percent for adult day health programs, hospitals, and pharmacists.

Governor Plans Appeal

According to news outlets, Schwarzenegger does not plan to let the appeals court have the last say.

“We strongly disagree with the court’s decisions, which interfere with the state’s ability to manage its finances and reduce its spending to match its revenue,” said Schwarzenegger spokeswoman Rachel Arrezola. “We are confident the U.S. Supreme Court will overrule the Ninth Circuit’s rulings and reaffirm the state’s ability to make tough decisions to balance its budget.”

The recent appeals court’s decision does not bode well for the governor’s 2011 budget plan, which proposes to cut the IHSS budget by 87 percent.

– by Deane Beebe

The story confirms PHI’s findings that these workers are finding it difficult to afford employer-based coverage.

Passed in 2006, the Massachusetts health reform law requires all state residents to obtain health insurance. Full-time employees must enroll in their employers’ health plans, while residents earning less than 300 percent of the federal poverty level are eligible for state subsidies to purchase insurance.

As a result of health reform, nearly 98 percent of Massachusetts residents are insured, making it the state that has come closest to universal coverage.

Home Care Workers Face Difficulties

However, Massachusetts residents pay some of the highest premiums in the country. According to the PHI report Coverage for Caregivers: Lessons from Massachusetts Health Reform (pdf), home health care workers face especially high insurance premiums because they tend to be older, female, and prone to injury.

Mirlene Desrosiers, a Haitian-born home health care worker, knows first-hand just how expensive health care can be in Massachusetts.

The Workforce Management story describes Desrosiers’ struggle to maintain her insurance. She must pay a $287 premium each week, more than half of her $500 weekly gross income.

Desrosiers works 120 hours each week at four different health care agencies just to afford the basic necessities of rent, food, and health insurance.

‘Perverse Employment Outcomes’

One of the “perverse employment outcomes” of Massachusetts health reform is that some workers are willingly cutting their hours so they won’t be obligated to purchase insurance from their employers, according to PHI Government Affairs Director Carol Regan, who is quoted in the article.

“These disincentives to work are problematic in the home health care industry,” Regan said. “It’s a fast-growing industry. How do you get enough people to work there?”

Massachusetts’ experience with health reform should provide a valuable lesson to federal policymakers as they work on finalizing national health reform, the Workforce Management article concludes.

– by Matthew Ozga

In 2007, CNA training and certification programs were offered in just 24.4 percent of nursing homes containing 20 beds or more, the report shows, down from 37.6 percent a decade before. This means that more nursing assistants are receiving training in community colleges, high schools, vocational technical schools, and proprietary training facilities.

The report, written by members of Brown University’s Center for Gerontology and Health Care Research, analyzed nursing home administrative data for more than 15,000 nursing homes throughout the contiguous 48 states. It also used data from the National Nursing Assistant Survey (NNAS) to determine where CNAs are receiving their training and who is paying for it.

Who’s Paying for Training?

A much higher proportion of CNAs trained outside nursing homes are paying their own training costs. For example, more than half (51.3 percent) of CNAs trained in community colleges paid for their entire training.

The authors of the Gerontologist report write that CNA training outside of nursing homes can cost as much as $1500.

“This seems an unfair burden for CNAs who will go on to relatively low wage jobs,” says Denise Tyler, Ph.D., a co-author of the paper.

In sharp contrast, over 80 percent of CNAs trained in nursing homes paid none of their training costs, according to the NNAS. Training programs offered in nursing homes are reimbursable under state Medicaid programs, although at less than full cost in most states. More than four in ten CNAs receive their training in nursing homes.

Recruitment, Monitoring, and Training Quality Are Issues

Because CNA training is shifting away from nursing homes and into expensive outside settings, employers will have an increasingly difficult time recruiting new workers, the report states. Recruitment of CNAs — who provide 80 to 90 percent of care in nursing homes — is already a significant problem in the direct-care field.

“Allowing the cost of training to become a barrier for individuals who would like to work as nursing aides in long-term care facilities makes no sense given the recruitment needs of these facilities,” said Dorie Seavey, director of policy research at PHI.

An additional concern is whether the quality of training offered outside of nursing homes is lower than that provided in the homes. While more research is needed, the authors find that “[t]he few studies that have examined this issue suggest that this may be the case.”

The authors further note that states will have a more difficult time monitoring the quality of the training programs now that they are being scattered throughout the state.

– by Matthew Ozga

California, for example, has proposed ending its Adult Day Program, and for all practical purposes, eliminating its In-Home Supportive Services program. Proposed budget cuts in Virginia would reduce personal care assistants’ pay by five percent, as well as freeze for one year the Medicaid waiver programs that help Virginians with disabilities and elders live independently in the community.

According to a new report issued by Health Care for America Now, the combined result of three pieces of legislation — the American Recovery and Reinvestment Act (ARRA) and pending comprehensive health reform and jobs bills — will provide much-needed fiscal relief to the states.

“This report again reinforces how we need to take action now and pass these bills to ease the financial burden on states and provide affordable health coverage for so many American families struggling to make ends meet,” said PHI Government Affairs Director Carol Regan.

Easing the States’ Burden

The report, “Federal Health Reform Provides Critical Long-Term Help to States: Passage of Jobs Bill Needed for Additional Short-Term Relief” (pdf), documents how each of the bills provides assistance to states and individuals. The report also explains how together the bills would ease long-term pressures on state budgets, while ensuring coverage for tens of millions of people who would otherwise look to the states for help:

• The health reform bill would provide $849 billion in new federal funding for health coverage over the next ten years — $460 billion to help families purchase private health insurance and $389 billion for state Medicaid programs.
• The ARRA of 2009 provided a temporary increase in the federal share of Medicaid costs and the last installment of funds – $343 billion — is slated to go to the states by the end of this year.
• Finally, the jobs bill, which has passed the House but not the Senate, would extend the higher federal Medicaid match rate to states into early 2011, providing another $23.5 billion to the states.

The authors of the report argue that passage of comprehensive health reform, as well as the enactment of immediate relief through higher federal share of Medicaid costs, would provide an enormous boost to states, “relieving states of significant budgetary pressures while addressing the rising health care needs of American families.”

– by the PHI Policy Team

Maryland State House

Legislation introduced into the Maryland State Senate proposes to exempt home care workers from collecting unemployment insurance, under certain criteria.

The bill, introduced on January 27, would prohibit home care workers from collecting unemployment insurance if the home care worker:

• signs an agreement with a home care agency that states she/he is an independent contractor;
• is not restricted to the number of home care agencies that she/he may work for; and
• is permitted to negotiate the rate of pay.

Jeopardizes Workplace Protections

“Exempting a whole class of low-wage home health care workers from unemployment insurance based just on their signing an independent contractor agreement with their agency employer is a terrible idea, from a policy and moral standpoint,” said Catherine K. Ruckelshaus, legal co-director,National Employment Law Project (NELP).

The proposed law “would permit home health care agencies to condition employment on signing such an agreement, and would potentially deprive these critical workers of other workplace protections, like minimum wage and workers compensation,” said Ruckelshaus.

NELP joined two other organizations — the American Federation of State, County and Municipal Employees (AFSCME) and Service Employees Interntaional Union (SEIU) — in submitting joint testimony against the bill (pdf). The testimony emphasizes that to meet the rapidly increasing demand for skilled and dedicated home care workers, “it is essential that home care workers are afforded the same minimum protections enjoyed by other workers under state and federal law.”

The organizations dispute the proposed legislation on several grounds, including:

• Maryland unemployment law already exempts “true independent contractors”;
• few if any home care agencies prevent their employees from working for other agencies — nor would such a provision be enforceable; and
• all workers are permitted to negotiate a rate of pay with their employer.

Harmful to Workforce and Industry

The testimony argues that if the Senate bill were to pass, it would:

• undermine the purposes of unemployment insurance;
• exacerbate the worker shortage and high turnover already plaguing the industry;
• exclude the very workers who need unemployment insurance the most; and
• encourage abuse and undermine other minimum labor standards and tax laws.

In Maryland, the demand for home health aides and personal and home care aides is projected to increase by 45 and 40 percent, respectively, by 2016 (pdf).

Home care workers throughout the nation are currently excluded from federal wage and hour protections.

The legislation, Senate Bill 303 (pdf), was introduced by State Senator Allan Kittleman (R). It had no co-sponsors.

– by Deane Beebe

Members of the CHCA Policy Action Group (PAG)

Members of the Cooperative Home Care Associates‘ Policy Action Group (PAG) met with New York state legislators in Albany on February 23 and 24 to discuss the unfair treatment of home health aides.

Cooperative Home Care Associates (CHCA), an affiliate of PHI, is the largest worker-owned home care company in the country. Its PAG consists of a group of approximately 30 home health aides who advocate for better wages and benefits while learning about issues important to their work and developing themselves as leaders.

“This offers a great and unique opportunity for home health aides to have their voices heard and to participate in the legislative process,” said Michael Elsas, president of CHCA. “We pride ourselves on being the only home care provider in the state with a Policy Action Group that offers a forum for workers to advocate on behalf of themselves.”

PAG’s Message to State Legislators

The main message of the PAG was to ensure that home care workers would not have to bear the brunt of state budget cuts. In fact, the advocates asked the legislators to consider directing more money towards the workers. Currently, Medicaid pays certified agencies in New York an average of $18 for an hour of home health aide services, yet the average starting wage for a home health aide is $8 an hour.

The PAG members also asked their representatives to improve contracting standards and state workforce data collection. More specifically, they want to make certain that Medicaid favors those agencies that can demonstrate the majority of the rate goes to worker compensation.

These issues are currently being evaluated as part of the New York Department of Health’s Home Health Care Reimbursement Work Group (pdf), which assesses how home care providers and workers are paid.

PAG members encouraged the legislators to pay close attention to the recommendations of this work group — which will continue to meet throughout 2010 — in order to ensure more transparency and accountability in the system.

Many Policymakers Involved

The PAG members met with Assemblyman James Brennan and State Senator Ruben Diaz Sr. They also met with staff for Assemblyman Richard Gottfried, chair of the Health Committee, and State Senators Ruth Hassel-Thompson, Eric Schneiderman, Tom Duane, and Jeff Klein.

In addition to visits with their legislators, PAG members were introduced to the entire New York State Assembly by Assemblywoman Carmen Arroyo, the state representative for CHCA’s district.

– by Meghan Shineman

Below is the full text of Lee’s testimony:

Thank you for the opportunity to comment on the reauthorization of the Older Americans Act. My name is Allison Lee and I am the Federal Policy and Campaign Manager for PHI — formerly the Paraprofessional Healthcare Institute.

PHI works to improve the lives of people who need home care and residential care — by improving the lives of the workers who provide that care.

As Congress takes up the reauthorization of the Older Americans Act, we urge consideration of policies that invest in and support the nation’s direct-care workers — a workforce that provides 70 to 80 percent of the hands-on long-term services and supports received by our nation’s elder population and people living with disabilities. The majority of these staff work in consumers’ homes, or in residential or community-based settings such as nursing homes, assisted living facilities, and group homes.

The size of the direct-care workforce is stunning: it now numbers over 3 million and over one million new positions are needed by 2018, according to the U.S. Bureau of Labor Statistics. Home care workers are projected to be the third fastest-growing occupation in the country — increasing by 50 percent over the decade. By 2018, direct-care workers in the U.S. will outnumber teachers from kindergarten through high school (3.9 million) and registered nurses (3.2 million).

This vast and underleveraged workforce is essential to efforts to expand our system to meet the growing demand for long-term services and supports, and to reorient service delivery toward home and community-based models of care. Unless we invest in frontline workers over the next decade, this workforce will fall short of the capacity needed to ensure access to these services for our aging population.

The reauthorization of the Older Americans Act offers an important opportunity to make necessary changes to modernize the aging services network and its programs. PHI recommends several areas for innovation and improvements:

• First, we need to upgrade and improve training standards as well as invest in state infrastructure for recruiting and training one million new direct care workers. Federal nurse aide training requirements have not been updated in over 20 years, and do not reflect the more complex needs of today’s older and frailer consumers. Furthermore, while there are no federal training requirements for personal and home care aides, AoA could play an important role in developing consensus training standards for personal care workers based on core competencies.
• Second, we must build a 21st century infrastructure for self-directed services by creating effective labor market intermediaries — job banks, registries and matching services — that help consumers and workers find each other. Today’s consumers often wish to have greater control over how services are provided and who provides them, but without these intermediaries, consumers and their families are limited to searching for independent providers on their own.
• And third, more must be done to incorporate an explicit focus on workforce within the aging services network. Working together, government and service providers should, on an ongoing basis, assess the adequacy of the workforce for meeting the demand for services, and for monitoring workforce vital signs needed for sound policymaking.

The quality of care for our nation’s elders depends on the quality of the jobs of those who provide these services and supports. We urge the Administration to build into the OAA reauthorization an explicit focus on the frontline healthcare workforce, and PHI is prepared to work with you to identify ways to accomplish this goal.

Thank you.

His proposal makes significant improvements in making health care more affordable for low-wage workers, seniors, and state government. In addition, he reiterated his support for the Community Living Assistance Services and Supports (CLASS) Act, which will allow workers to pay into an insurance program for long-term services and supports.

The full proposal is available on the White House website.

New and Revised Policies Proposed

The proposal includes a number of important new or revised policies that would advance the goals of making health care more affordable:

(1) Making coverage more affordable: Compared with the legislation passed by the Senate, the President’s proposal would significantly improve health care affordability for most low-and moderate income families by reducing both premiums and out-of-pocket costs for most families earning less than $44,000. This is critical for direct-care workers because:

• One in every five nursing home workers and more than a third of personal and home care aides lack health coverage.
• In 2008, annual earnings for direct-care workers averaged $17,000 (pdf).
• About 44 percent of direct-care workers live in households earning below 200 percent of the federal poverty level income (pdf).

(2) Reducing the cost of prescription drugs for seniors: The proposal would also make prescription drugs more affordable for seniors by closing the Medicare Prescription Drug Plan’s “donut hole,” which currently leaves some seniors unable to afford the medicines they need to remain healthy.

(3) Regulating excessive insurance rate increases: In addition to adopting the House and Senate ban on insurance companies denying people coverage for pre-existing conditions, the proposal would create federal oversight of excessive rate increases by private insurers.

(4) Increasing federal support for state Medicaid programs: The President’s proposal eliminates a special deal negotiated for Nebraska, and instead increases federal support to states to defray the cost of enrolling people who will be newly eligible for coverage under health reform. The federal government will provide states 100 percent support through 2017, 95 percent support for 2018-2019 and 90 percent support for 2020 and beyond.

This will help hard-pressed states expand coverage to low-income households, including those of direct-care workers. Two in five direct-care workers live in households that receive one or more public benefits (pdf) such as food stamps; Medicaid; and housing, child care, energy, or transportation assistance.

Additional Information

A side-by-side brief prepared by the Pico Network gives a comparison of the status quo, the Republican House plan, and the President’s plan, as well as what will be discussed at today’s Health Care Summit.

If you missed today’s live broadcast of the summit, visit HealthReform.gov.

– by Carol Regan

Iowa direct-care workers with State Senator Jack Hatch (D, Des Moines)

Forty-five direct-care workers and their supporters participated in the Iowa Caregivers Association’s (ICA) annual Direct-Care Worker Day at the State Capitol.

Blizzard-like conditions the previous night made for hazardous travel conditions on the morning of February 15, 2010. Still, more than half of the 70 pre-registrants were able to attend and made the day a tremendous success.

Direct-Care Worker (DCW) Day featured a legislative briefing in the morning led by John Hale, the Association’s policy director. Hale discussed the day’s theme — Iowa’s growing “care gap.” State Senator Jack Hatch spoke to the group about the importance of building a relationship with their legislators.

Building Relationships with State Policymakers

“We had a great talk with our Senator about the care gap in Iowa,” said Becky Johnson, a participating direct-care worker. “[State Senator] Amanda Ragan was very cordial and took great interest in what we had to say.”

Johnson continued:

This experience was awesome and well-received. Senator Ragan made us feel very comfortable, which gave us the confidence to voice our concerns to her. This is my second visit to the Capitol. Since my first visit, I have been to local forums, sent e-mails, and am friends on Facebook with Senator Ragan. I feel that I actually have a good relationship with her.

Cindy Ramer, an ICA Direct-Care Worker Leadership Council member who has participated in most of the DCW Days at the State Capitol, said, “I was pleased to be able to talk with both my representative and senator.”

Ramer added:

[State Representative] Andrew Wenthe had a picture taken of him and me and is sending it to my local newspapers. Both he and [State Senator] Bill Heckroth understand what the care gap means and agree to continue to work for legislation that will improve those problems. They both would also be willing to do a ‘Come Care with Me Day’ at my workplace.

Each time that I contact these legislators, they show interest in the needs that other direct-care staff and I share. I have learned that by continuing to communicate with them, they remember me and what my needs are. They show an honest effort to help by keeping me informed of the legislation they are working on, e-mailing me their newsletters, and notifying me of local listening posts. I can respond on whether I feel it is good or not. Every year these events get bigger and better!

Quantity and Quality

The day was not just about the quantity of conversations that occurred, according to Hale:

The thing that impressed me was the quality of the conversations. A lot of legislator education occurred about the duties of direct-care workers, the distinctions between the jobs of nurses and direct-care staff, and the fact that direct-care jobs exist in locations other than nursing and assisted living facilities. Many legislators made the time to really listen and engage the workers in conversation. That made the day particularly valuable.

This was the fifth DCW Day sponsored by the ICA. The Association’s Leadership Council, a group of 15 direct-care workers who help guide the Association’s work, has already begun the process of evaluating the day to identify how it can be improved for next year.

– by the Iowa Caregivers Association