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A new PHI analysis finds that — with over half a million workers — California is home to the nation’s largest direct-care workforce.

Personal care attendants, home health aides, and nursing aides together constitute the second largest occupational group in the state today, second only to teachers from K-12 (including special education), and larger than retail salespersons and all law enforcement/public safety workers, according to the analysis in PHI State Facts: California’s Direct-Care Workforce (pdf).

“This workforce is made up of jobs that are in very high demand and expected to add the most new jobs to the state’s economy over the next few years,” said PHI Director of Policy Research Dorie Seavey, Ph.D.

The new analysis projects that over the period 2008 to 2018, demand for direct-care jobs in California will increase by 260,000.

A Low-Wage, Diverse Workforce

Wages for direct-care jobs in California are so low that they place 42 percent of direct-care worker households below 200 percent of the federal poverty line, making them eligible to qualify for many state and federal assistance programs.

In 2009, the median hourly wage for all occupations in California was $17.92. Home health aides’ and personal care aides’ wages are among the state’s lowest at $10.12 and $10.28, respectively. The median hourly wage for nurse aides in the state is $12.42.

California’s direct-care workforce is the most diverse in the country. Minorities comprise 70 percent of the workforce and foreign born workers comprise 50 percent. Nationally, 51 percent of direct-care workers are minorities and 23 percent are born outside the U.S.

Hearing Addresses California’s Direct-Care Workforce

PHI State Facts was introduced at a joint hearing on long-term care conducted by the California Assembly Committee on Aging and Long-Term Care and Assembly Labor and Employment Committee on November 9.

Topics on the agenda included the shortage of direct-care workers, barriers to recruiting paraprofessionals to long-term care, and the training needs of the direct-care workforce.

“Policymakers in Sacramento have an unprecedented opening for reshaping these jobs and leveraging the vast potential of this workforce to improve care for elders, bolster job growth, and rein in health care costs by deploying new models of transitional and chronic care,” Seavey said.

“Direct-care service providers play a critical role in allowing older Americans to age with dignity and independence,” said Bruce Chernof, M.D., president and CEO of The SCAN Foundation, which provided testimony at the hearing. “California’s next governor has the opportunity to ensure that this workforce is prepared to meet the growing needs of our state’s aging population.”

PHI State Facts: California’s Direct-Care Workforce (pdf) was developed with support from The SCAN Foundation.

– by Deane Beebe

California state capitol building

One hundred days after California’s new fiscal year started, Governor Arnold Schwarzenegger signed the state budget containing cuts to the In-Home Supportive Services (IHSS) program on October 8.

While the cuts were not nearly as severe as the governor proposed earlier this year, the final budget includes a 3.6 percent across-the-board reduction to the number of hours that IHSS clients were assessed for being eligible for services.

This cut translates into IHSS direct-care workers receiving “15 minutes less work and pay each day,” according to the Sacramento Bee.

California’s 2010-2011 budget actually specifies reducing the IHSS program by $300 million but due to other calculations, the budget cut to IHSS is about $35 million.

The actual reduced cut is based on the state using “IHSS provider-generated revenue to draw down additional federal funds and offset General Fund expenditures in the program [by] $190 million,” according to the budget.

The $35 million figure also reflects an additional $75 million in savings to the state because the budget purports an “updated caseload estimate based on an actual decline in recipients as compared to the previous caseload projection.”

Any Cut Hurts Consumers

“The reduction in hours many not seem like a lot, but they are significant for our clients,” said Personal Assistance Services Council Executive Director Greg Thompson.

“The cuts could mean the difference between getting help bathing or out of bed and ready for work. Already our clients feel like they are getting by with minimum care. Every cut means a lot to the quality of these consumers’ lives.”

The budget also changes the law on background checks for IHSS workers, adding additional disqualifying convictions and crimes.

IHSS currently employs about 370,000 home care workers who provide services and supports to 400,000 low-income people aged 65 and over, and Californians who are blind or living with a disability, including children.

Line-item vetoes that Schwarzenegger made to the budget include $256 million for child-care subsidies for working parents, $132 million in mental health services for children, and $80 million for child welfare services.

– by Deane Beebe

A new case study in The Business of Caregiving, a PHI series that highlights exemplary employer practices in the eldercare/disability services industry, features the Los Angeles-based Ararat Nursing Facility.

Ararat Nursing Facility, Sustaining Excellence through Quality Improvement Systems, Trust, and Teamwork (pdf) explains how the not-for-profit, 196-bed skilled nursing facility has created an environment consistent with its core values of compassion, dignity, respect, integrity, self-determination/choice, empowerment, flexibility, and vision of excellence, according to the case study.

CNAs Are Instrumental to Achievements

Margo Babikian, RN, MS, the facility’s executive director, put into practice what she already understood: success depends upon high-quality staff and services.

CNAs are valued members of the care team at Ararat, empowered to do their own problem solving, the case study explains.

“I say, ‘Okay, you are closer to the resident, you are going to make that decision.’ They are responsible of course, accountable for the decisions that they make, but CNAs make a lot of decisions — more than I do,” Babikian says.

Initiatives for Success

During her tenure at Ararat, Babikian has focused on developing quality improvement systems as well as outstanding employment practices that encompass a coaching and mentoring leadership style, resident-centered care teams, and a CNA career ladder with associated wage increases.

All staff, from entry-level workers to managers, are invited to identify problems that interfere with quality care — and to help find solutions.

Outcomes Show Benefits for All

Creating an environment of support, trust, and respect, and establishing strong systems have resulted in successful outcomes for everyone involved with Ararat: the employer, employees, and residents and their families.

Among the outcomes are:

• consistently low turnover with just a 3 percent overall and 0 to 4 percent for CNAs
• consistently high employee satisfaction rates, as measured by annual surveys (95 percent on average)
• high resident and family satisfaction (98-100 percent family satisfaction on annual satisfaction surveys)
• patient outcome measures (e.g., pressure sores, pain, urinary tract infections) that outperform state and national averages
• five out of five stars on the Center for Medicare and Medicaid Services’ Nursing Home Compare rating system

Multimedia Components

An overview (pdf) of Ararat’s initiatives and outcomes, as well as multimedia materials that illustrate how Ararat has achieved success, accompany the case study.

Materials include a podcast in which Ararat’s director of clinical services discusses how coaching and mentoring are used to show respect for staff and bring out their best qualities, charts that compare Ararat’s patient outcomes with other facilities in the state and the nation, and a slide show.

The Business of Caregiving case study series was funded by the Hitachi Foundation, which also funded PHI’s ongoing series of best practices in long-term care.

– by Deane Beebe

Dr. Candace Howes

PHI, along with the Institute for Women and Policy Research (IWPR), released a report this week by Dr. Candace Howes, examining why California’s proposal to cut 444,000 elders and people with disabilities from the In-Home Supportive Services progam is short-sighted and fiscally irresponsible. Read the full story

A policy brief about proposals to close California’s $20 billion budget gap cautions that “all options for closing the budget gap are not equal.” Read the full story

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. Read the full story