PHI National Policy Recommendation: Training and Support (pdf)

Summary

As the April 14, 2008, Institute of Medicine’s report, Retooling for an Aging America: Building the Health Care Workforce, makes clear, improving training for direct‐care workers is critical to preparing greater numbers of workers for direct‐care jobs as well as to ensuring quality of care.

As detailed below, PHI recommends that policymakers take action in three critical areas:

1. Curricula content and training supports: Enhance the content of entry-level training for direct‐care workers, by identifying the competencies required for workers to provide quality services to elders in any setting.
2. Training requirements: Revise federal and state training requirements to align with competencies and to set consistent standards across occupations requiring similar skills.
3. State training infrastructure: Expand and improve state infrastructure for training direct‐care workers.

Problem

The rapid growth in the number of Americans over age 65 is fueling an accelerating need for long‐term care services and supports. At the same time, changes in consumer preferences and public policy are increasingly shifting the site of care from institutions to consumers’ homes and other residential settings, making service delivery more labor intensive. These twin dynamics are driving an unprecedented demand for direct‐care workers to assist individuals with activities fundamental to daily life. Yet our systems for training direct‐care workers—to provide quality care to all long‐term care consumers—have not kept pace.

First, we have not invested enough to build the capacity to train the one million new direct‐care workers needed over the next 10 years. Second, federal training requirements, which have not changed since they were established 20 years ago, do not reflect the more complex needs of today’s older and frailer consumers, nor do they reflect the greater difficulty that workers face providing services in the community without benefit of on‐site supervision or support. Further, outdated training curricula reflect requirements that focus too much on tasks and too little on teaching communication and relational skills that help workers deliver person‐centered care.

The quality of instruction itself is also quite variable. Many educators rely too heavily on passive formats like lectures and videos, rather than adult learner‐centered methods that engage students with discussions, role plays, and small group work. In addition, there is often too great a divide between the classroom and the workplace, with inadequate on‐the‐job support for new workers to continue their learning and perfect their skills.

These limitations often leave workers feeling unprepared for the challenges of caring for people with complex emotional and physical needs. This fuels the high turnover rate in direct care‐‐ new workers often cite inadequate preparation as one of the reasons they leave the field for other occupations. And when the structure of training requirements limits the ability of workers to move between long‐term care settings or advance along a career path, we lose experienced workers as they pursue other opportunities. Ultimately, poor training and inadequate training systems that lead to high rates of turnover undermine access to care, erode the quality of care for hundreds of thousands of consumers around the country, and waste scarce public dollars and provider resources.

Solutions

Good training ensures that direct‐care workers can perform their jobs with competence and confidence. When workers feel well‐prepared for their jobs, research shows that they are more likely to stay on the job.

A significant investment in our training infrastructure is critical to preparing greater numbers of workers for direct‐care jobs as well as to ensuring quality of care.

To improve direct‐care worker training, PHI recommends that policymakers take action in three critical areas:

1. Curricula content and training supports: Enhance the content of entry‐level training for direct‐care workers, by identifying the competencies required for workers to provide quality services to elders in any setting.
   • Develop competency–based curricula based on a system‐wide review of the skills and knowledge needed to provide quality services to older Americans and individuals with disabilities.
   • Create career pathways that allow workers to advance from entry‐level through higher levels of mastery by identifying core competencies necessary for all direct-care workers, additional competencies needed by nursing assistants and home health aides, and advanced competencies to support consumers with particular health conditions.
   • Improve on‐the‐job supports to foster continued learning beyond initial training, including peer mentoring programs and enhanced in‐service training.
   • Encourage investment in coaching supervision training and other supportive management approaches for supervisors, administrators, and others who shape the quality of direct‐care jobs.
2. Training requirements: Revise federal and state training requirements to align with competencies and to set consistent standards across occupations requiring similar skills.
   • Update federal training requirements for certified nursing assistants and home health aides to align with the competencies identified as necessary for providing quality long‐term care.
   • Develop consensus training standards for personal care workers (for whom there are no current federal training requirements) based on the core competencies.
   • Require a greater emphasis on communication and interpersonal problem-solving skills, to strengthen caregiving relationships and ensure delivery of person‐centered services.
3. State training infrastructure: Expand and improve state infrastructure for training direct‐care workers.
   • Foster an array of training entities—community colleges, employer‐based programs, employer consortia, and new regional private/public partnerships.
   • Fund train‐the‐trainer programs to improve the ability of nurse educators and others to use adult learner‐centered methods in delivering direct‐care worker training.
   • Establish a national joint venture of the Centers for Medicare and Medicaid Services and the Department of Labor to identify and promote best practices in direct‐care worker training and training system design, to support state efforts and sponsor large‐scale state demonstrations based on an apprenticeship training model.
   • Encourage state and local workforce investment boards to support the expansion of training for direct‐care workers, particularly through the Workforce Investment Act (WIA) public workforce investment system.
   • Align government payment policies—in order to expand the availability of quality home and community‐based services—by establishing parity across different types of direct‐care workers for the reimbursement of training costs (currently, only CNA training costs are eligible for repayment by the federal government).