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Massachusetts State House in Boston

Massachusetts lawmakers heard testimony on November 15 on a Senate bill to establish a task force to ensure that there is an adequate direct-care workforce to meet the rising demand for long-term services and supports in the state.

The proposed direct-care task force — comprised of representatives from state agencies that employ or contract for direct-care services — would seek to gather accurate data across the current workforce, including:

• the number of workers,
• turnover and vacancy rates, and
• wages and benefits.

The task force would also:

• assess the state’s current training and credentialing infrastructure;
• develop workforce policies that ensure an adequate supply of frontline caregivers, especially in home and community-based settings; and
• report their findings to the governor and legislature by December 31, 2012.

“We Need to Ensure These Are Good Jobs”

“Families depend on these workers to care for their loved ones — often so that they can work themselves,” said State Senator Pat Jehlen, co-chair of the Massachusetts Joint Committee on Elder Affairs, who introduced “An Act to Establish a Task Force Relative to the Commonwealth’s Direct-Care Workforce” (S.45).

“If Massachusetts is going to meet the rapidly growing demand for this workforce, we need to ensure that these jobs are good jobs with decent wages, health coverage, better training, and opportunities for career advancement,” she said.

Senator Jehlen Presents Case in the Globe

 
An op-ed by Senator Jehlen (left) entitled “Is Massachusetts Prepared to Care?” was published by The Boston Globe a day before the hearing.

Massachusetts’ nearly 104,000 direct-care workers comprise the largest occupational group in the state today. The demand for this workforce is expected to grow in the state by at least 21 percent by 2018.

Poor wages, however, will make it difficult to attract workers. The median hourly wages for home care aides and personal care attendants was $12.23 and $12.48, respectively, and $13.53 for nursing aides, in Massachusetts in 2010. The median hourly wage for all occupations in the state was $20.13.

“Not Able to Access Healthcare Ourselves”

In testimony (pdf) delivered to the Joint Committee on Children, Families, and Persons with Disabilities, Victoria Entzminger, a personal care attendant employed to care for her nephew with multiple disabilities, said:

“I am proud to provide him with this care, but I am struggling myself. Personal care attendants do not receive any health insurance through our jobs. While we provide healthcare supports to consumers, We often are not able to access healthcare ourselves.”

Also testifying on behalf of the bill were:

• Lisa Gurgone, executive director, Massachusetts Council for Home Care Aide Services
• Paul Dzialo, president/CEO, Affinity Home Health Care
• Russ Davis, executive director, Jobs with Justice

For more information about the bill — and the direct-care workforce in Massachusetts in general, including downloadable charts and graphs — visit PHI Massachusetts on the PHI PolicyWorks website.

– by Deane Beebe

In recent weeks, numerous media outlets — from daily newspapers to trade publications — have reported on issues relevant to the direct-care workforce.

San Antonio Paper Covers Looming Care Gap

On October 29, the San Antonio Express-News reported on the rising demand for direct-care workers, particularly home health aides.

However, most jobs in the direct-care field are of such low quality, it will be difficult to attract the estimated 1.1 million additional workers needed to meet that demand, wrote reporter Melissa Fletcher Stoeltje, who quotes PHI National Policy Director Steve Edelstein and Public Education and Media Relations Director Deane Beebe in the article.

In a letter to the Express-News, Beebe wrote that Stoeltje devoted a disproportionate amount of attention on the tiny number of direct-care workers who are unscrupulous.

The article “may have left an impression that because of low wages, home-care workers can be unreliable or, worse, thieves,” Beebe wrote. On the contrary, the vast majority are “dedicated, compassionate people,” she added.

Washington State Ballot Initiative Debated

An October 23 article in the Olympian reported on Ballot Initiative 1163, a measure to establish more rigorous training standards for home and residential care workers, which passed last week.

The initiative also requires that home and residential care workers undergo background checks and become certified. State certification for home care aides is “pretty uncommon at this point,” Edelstein is quoted as saying.

PHI Featured in Trade Publications

The October 10 issue of ADVANCE for Long-Term Care Management featured an article on cross-functional teams by PHI Regional Policy Specialist Alexandra Olins.

Cross-functional teams, which engage employees at all levels of an organization, are an effective means of directing culture change efforts in long-term care facilities, Olins wrote. This is a unique approach that PHI has tested with multiple clients.

Meanwhile, Long-Term Living on November 2 published the latest in a series of blog posts by PHI Training and Organizational Development National Director Susan Misiorski.

Misiorski’s newest post describes an evaluation of the PHI Coaching Approach^SM, which found that the coaching helps to improve job satisfaction among workers and frees up more time for supervisors, who no longer have to concentrate on resolving minor daily disputes.

In another article published online in September and in the October issue, Long-Term Living noted the debut of the PHI State Data Center.

The State Data Center compiles comprehensive workforce data for all 50 states, including trends in wages, health insurance rates, and legislative and policy developments pertinent to the direct-care workforce.

– by Matthew Ozga

Robyn Stone

Robyn Stone, senior vice president for research at LeadingAge, is the author of a new book entitled Long-Term Care for the Elderly. Stone notes that in her book — unlike many others that address long-term care policy — she “wanted to put the direct-care workforce front and center.” As she explained in a wide-ranging interview with PHI, “the long-term care delivery system is predicated on having a strong workforce to support the care.”

Below are excerpts from our discussion, which addressed the challenges and opportunities to ensure our nation has an adequate supply of qualified, trained direct-care workers to care for our growing population of elders.

PHI: What is so critical about the role of direct-care workers in providing care and support?

RS: In the book, I emphasize how important the relationships are between the care recipient — whether in a nursing home, assisted living facility, or home care setting — and the direct-care worker.

For elders who need long-term care, particularly people with cognitive impairment, it is not just the hands-on care that is provided, it is the ability to be with that person and to supervise the activities that they do. Making sure that they are eating, helping them with mobility — oftentimes it is a cue to walk, not necessarily making them walk. The role of the frontline person is essential — not only for the hands-on care but being there to support and enable the aging in place for as long as possible.

PHI: What do you see as the challenges to ensuring an adequate supply of direct-care workers as baby boomers age and need support?

RS: In the longer-term recession period that we are experiencing now, it is not as difficult to find a home care worker, personal care assistant, or even a CNA, but it will become more difficult when the economy is more robust.

But the shortage we face is not just numbers but also a shortage of people who are trained, educated, and supported to stay in the field. We know that there are a number of things that underlie that, including poor wages and lack of support in the workplace.

PHI: How do we address the poor quality of these jobs, especially in a time of fiscal austerity?

RS: What it is going to take is a public- and private-sector commitment to recognizing that these jobs are the most important part of the infrastructure for long-term care of the elderly. Both sectors must recognize that there has got to be support, education, training, and good compensation — competitive compensation that includes good wages and competitive benefits. And, we also need a healthy work environment.

I see the current situation as a challenge but also an opportunity to do things differently. We are on the cusp of aging — the first baby boomers have just turned 65 this year. With the proportion of elders moving from 14 percent of the population to one in five by 2025-2030, we have an opportunity to develop these jobs as real careers and real options.

PHI: What about the current political environment and the focus on cutting entitlement programs?

RS: The issue of what is going to happen to Medicare and Medicaid is critical to this workforce because so much of these services are publicly subsidized. The public policy, reimbursement policy, and financing policy really drive what is possible.

I am not sure that this current political environment bodes well. On the other hand, the demand is going to be there. Somehow we are going to have to meet these challenges. With home care being one of the fastest-growing jobs in the country, for example, this is an opportunity for economic development.

How do we reconcile the future of entitlement programs with the growing demand and also recognize that if we create good jobs they become an economic stimulus for communities? I don’t think people actually looking at Medicare and Medicaid program have the same lens in term of thinking about community economic development. Where it can happen much more so than at the federal level is the state and local level because that is where people really live.

PHI: How is the movement to provide services that better meet individual needs affecting the role of direct-care workers?

RS: Nursing homes are embracing the notion of person-centeredness and worker-centeredness. More and more providers are actually seeing — and some of this has to do with the empirical work that supports it — that if you create teams where the frontline is empowered, you end up with less turnover, better retention, better quality of care and life outcomes, and better job quality and satisfaction for the workforce.

The culture change movement, if nothing else, has created a stronger acknowledgement that supporting CNAs goes beyond just throwing a pizza party. It is really about integrating the direct-care workforce into the team effort. That I think is a sea change. As a result, we see more and home administrators focusing and involving the direct-care worker and CNAs in a lot of the decisions.

The other major transformation in delivery systems is the continuing shift from the nursing home into home- and community-based care, including consumer-directed care where you have truly independent providers who are being hired by individual consumers. Here the pendulum has shifted a little bit.

In the old days, when I worked at the Department of Health and Human Services, for example, home- and community-based, consumer-directed care was all about the client. In fact there was hardly any discussion about the worker. It was all about empowering the consumer. I think that since then, there has been an acknowledgement that there has to be an equal relationship between the consumer and the worker. And both the worker and the consumer need training and support so the system can work efficiently and effectively.

PHI: What role do families play? After all, they do the vast majority of caregiving.

RS: First off, it is important to realize that family caregivers may not be as able to do the work as they have in the past. There are a lot more women in the labor force, and more people — older women in particular — will have to remain in the workforce because of the economic situation. There is going to be more reliance on these frontline workers than ever before.

That’s why we need a strong partnership. I believe there is a need for finding more opportunities where direct-care workers and families can be trained together, and even having direct-care workers become trainers for family members because they tend to be doing a lot of the same jobs.

How do you create that mutual support and mutual education of each other’s roles, recognition of how important they both are, and how important those relationships are?

There is more recognition these days that families need to be involved in transitional care and the decision making, but oftentimes the aides are left out and they are the really important link in any coordinated care model.

Yet, there are a lot of optimistic signs for building the direct-care workforce into the transitional care model that came out of the Affordable Care Act. Many geriatricians and an expanding group of inter-disciplinarian, inter-professional team programs are now beginning to incorporate direct-care workers into their processes. These professionals recognize that integrating the direct care-worker into the team is essential to their success.

PHI: Do you have some final thoughts on where our eldercare system is going, and how we will meet the rising demand for support services?

RS: Both the shortages of direct-care workers and consumer preferences will drive a rise in consumer-directed care, but I don’t think that families will be the solution. We are going to have to look at other sources, especially since families are going to need to continue to work and won’t be able to retire.

I am hoping that if we ever get to a job strategy over the next couple of years, this is really part of that discussion, particularly for women, lower-income women. We can try and get more men in the field but it is going to remain 90 percent female. How do we make these viable careers? Direct-care jobs need to be made quality jobs.

The average age of the homecare aide is late 40s and many are over 65. How are we going to support an older workforce that can remain in these jobs, and do a good job? We also need to be looking at high schools and really encouraging young people to see these as viable careers.

Finally, I think that we are going to have to take on the immigration issue. Over a quarter of this workforce is immigrants and in some communities it is much, much higher. If and when we ever deal with immigration policy — this is a concern. We need to recognize that a large proportion of our workforce is immigrants and look at how to make the pathways to citizenship easier and more permanent.

– by Deane Beebe and Karen Kahn

“Building a Workforce to Care for an Aging Society: Challenges and Opportunities” was the topic of a Capitol Hill luncheon briefing where experts presented their research on the challenges we face as an aging nation and the opportunities for Congress to avert an eldercare workforce shortage crisis.

The May 25 briefing, hosted by the Eldercare Workforce Alliance (EWA) in partnership with the American Society on Aging (ASA) and with support from Senator Herb Kohl (D-WI), chair of the Special Committee on Aging, was attended by scores of representatives from Congressional offices.

EWA Leads the Way

“The Eldercare Workforce Alliance is leading the way with the type of cross-cutting and innovative work that our health care system needs to reinvent itself in the 21st century,” said Kohl, the Congressional supporter of the briefing.

“As chair of the Senate Special Committee on Aging, I have high hopes for their mission of promoting progressive workforce reforms. They should be the cornerstone of any new model of care,” Kohl said.

At the briefing, Anne Montgomery, senior policy advisor for the Committee, spoke about the critical need to build a workforce to care for our nation’s aging population.

Investing in Training and Expanding the Eldercare Workforce

The speakers authored articles in the most recent issue of Generations, the ASA’s peer-reviewed policy journal. The issue — which has the same focus and title of the briefing — was devoted entirely to:

• the current state of the nation’s eldercare workforce;
• the eldercare workforce’s makeup, deficiencies, and strengths; and
• strategies for much-needed workforce retention, recruitment, training and management, policy development, and fostering of cultural competencies.

“This briefing brought together representatives of the multidisciplinary care team to discuss the need for investments in training and expanding the eldercare workforce,” said Nancy Lundebjerg, American Geriatrics Society deputy executive vice president and COO who co-convenes the EWA with PHI President Steven Dawson.

“Making these investments is essential to providing quality, well-coordinated care to America’s older adults,” Lundebjerg said. “Our expert panelists were able to use this briefing as an opportunity to not only highlight the magnitude of the problem, but to also offer solutions.”

Lundebjerg highlighted public policy strategies to support a quality workforce, which is the topic of the Generations article that she co-authored with Dawson and Caitlin Connolly, EWA project manager.

Among the solutions Lundebjerg proposed were for Congress to:

• ensure that elements of the Affordable Care Act specific to geriatrics health professions and training of the direct-care workforce are adequately funded through the annual appropriations process.
• enhance workforce training during reauthorization of the Older Americans Act.

Building the Direct-Care Workforce

PHI Director of Policy Research Dorie Seavey (standing)

PHI Director of Policy Research Dorie Seavey, Ph.D., presented on the historic growth of the direct-care workforce, the quality of these jobs, and how federal and state governments need to work together to develop a stable, competent direct-care workforce to meet the nation’s rapidly growing demand for these workers.

Seavey’s research is reported in the Generations article, “Caregivers on the Front Line: Building a Better Direct-Care Workforce.”

“We appreciate legislative staff taking the time to attend a briefing on how the country can move forward with preparing America to care for an aging population,” Seavey said. “The common ground for alignment is broad and deep — in large part because the economic arguments for investing in a better caregiving infrastructure are so compelling.”

The full list of briefing speakers, slide presentations, and photos are available on the EWA website, where a video of the event will be posted soon.

– by Deane Beebe

A May 2011 report by Families USA says that the proposed federal cuts to Medicaid would put the health of older adults and people living with disabilities at risk by eroding the health care safety net that Medicaid was established to provide.

Cutting Medicaid: Harming Seniors and People with Disabilities Who Need Long-Term Care also discusses how slashing the Medicaid program would hinder the nation’s ability to build the direct-care workforce to meet the increasing demand for long-term services and supports.

Families reports on the projected shortage of direct-care workers and cites PHI data on the workforce growth needed in each state by 2016 (pdf). The organization expects that payments to long-term care providers will be reduced should the proposed Medicaid cuts be enacted, and says such measures will “hamper efforts to build up the direct-care workforce.”

A reduction in Medicaid provider payments will lower compensation for direct-care workers and further exacerbate the workforce shortage. Ultimately, everyone will suffer — even individuals whose long-term care is not covered by Medicaid — because a workforce shortage will lower the quality and availability of care for everyone, the report explains.

Key Findings

Families reports that many older adults and people with disabilities depend on Medicaid for health care and long-term services and supports:

• More than 16 million older adults (6.3 million) and people with disabilities (9.8 million) depend on Medicaid — in other words, more than one in four people who are over 65 or living with a disability rely on Medicaid.
• Medicaid is a critical source of coverage for people who need nursing home care; it is the primary payer for an estimated 63.6 percent of all nursing home residents.
• Medicaid services help older adults (3 million) and people with disabilities (2.8 million) to remain living in the community.

A series of State Fact Sheets that provide details on how the federal cuts to Medicaid would affect each state accompanies the Families USA report.

Bill Passed to Allow States to Reduce Medicaid Enrollment

There are several proposals in Congress on different measures to cut Medicaid:

• convert Medicaid to a block grant with much less federal funding
• cap federal spending
• allow states to significantly reduce Medicaid eligibility and enrollment

Under the Affordable Care Act (ACA), states are prohibited from making large reductions in Medicaid eligibility or changing the eligibility criteria to make it more difficult to enroll in the program.

Families explains that this ACA protection, known as the “maintenance of effort” (MOE) requirement, was included in the law to ensure that important health coverage remains in place until the new law is fully implemented in 2014. It reports that the effort to repeal this provision is likely to be taken up in Congress “very soon.”

In fact, CQ Weekly reports that on May 12, the Republican-led House Energy and Commerce Subcommittee on Health approved a bill (H.R. 1683) that would permit states to reduce Medicaid enrollment. The journal says that the bill is expected to be passed by the Energy and Commerce Committee but a date for the vote has not yet been set.

For more information on Medicaid block grants, read the PHI publication Medicaid Matters…for Long-Term Services and Supports.

– by Deane Beebe

The Affordable Care Act (ACA) contains numerous provisions that will help the U.S. meet the rising demand for eldercare-focused health care workers, according to a brief by the Alliance for Health Reform.

The brief points out several ACA provisions that are specifically designed to strengthen the direct-care workforce.

Causes of Rising Demand

The ACA itself will raise the demand for health care workers — physicians, nurses, and direct-care workers — by expanding coverage to approximately 32 million additional legal U.S. residents.

Additionally, demand will increase dramatically as the “baby boomer” generation ages into Medicare eligibility.

According to the brief, 78 million baby boomers will reach age 65 by 2030. That’s an average of 10,000 baby boomers turning 65 each day, according to the Pew Research Center.

These elders will increasingly rely on health care workers who specialize in caring for older individuals, the brief notes.

Direct-Care Workforce Provisions

“The ACA recognizes the value of direct-care workers to health care delivery and contains a number of initiatives that address current issues and future challenges,” the brief states.

These initiatives include:

• Grants and other financial incentives aimed at encouraging providers to enhance training, recruitment, and retention of direct-care staff.
• Grants to Geriatric Education Centers requiring that the centers offer courses on geriatrics, chronic care management, and long-term care.
• The Personal and Home Care Aide State Training (PHCAST) program, in which six states received grants to develop core competencies and certification programs for personal and home care aides.
• The establishment of a Personal Care Attendants Workforce Advisory Panel, which will advise the Department of Health and Human Services (HHS) and Congress on matters relating to the personal care attendant workforce.

Other ACA provisions that focus on the development of the direct-care workforce can be found in PHI Health Reform Facts 1: Workforce Development and Training Opportunities for Direct-Care Workers (pdf).

The Alliance for Health Reform brief was produced with funding from the Robert Wood Johnson Foundation.

– by Matthew Ozga