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A study published in Seniors Housing & Care Journal examines the relationship between The Green House model of long-term care and the empowerment of the direct-care workers who provide that care.

The authors of the report, Barbara Bowers and Kim Nolet of the University of Wisconsin School of Nursing, interviewed more than 100 employees at 11 Green House–affiliated facilities throughout the country — including 68 “Shahbazim,” the Green House term for certified nursing assistants.

Their findings offer “some insight into direct-care staff empowerment as experienced in The Green House model of culture change,” including both the benefits and the challenges of empowerment, the authors write.

They note that many providers believe that direct-care worker empowerment is connected to better quality of care and better quality of life for residents, and is an important strategy for promoting worker satisfaction and retention.

Benefits and Challenges of Empowerment

For example, Bowers and Nolet report that Shahbazim at Green House facilities derive positive feelings of empowerment and respect from the fact that they do not have supervisors constantly “checking up on them.”

They also report that Shahbazim feel empowered to initiate contact with consumers’ family members about specific care practices.

However, the empowerment that comes with greater independence in the workplace can also pose challenges, Bowers and Nolet write. For example, Shahbazim found that dealing with conflicts between co-workers is more difficult without close supervision.

“Many of the Shahbazim did not feel adequately prepared to deal with interpersonal conflicts,” Bowers and Nolet write.

“This report substantiates the positive impacts on job quality of the Shahbazim role,” said PHI National Director of Training & Organizational Development Services Susan Misiorski. “It also highlights why conflict resolution skills, which PHI offers as part of our suite of coaching and communication training, are so important.”

Green House Background

The Green House Model is a model of care designed to create a greater sense of community among long-term care staff, residents, and residents’ families.

In addition to empowering workers, the Green House model strives to build a sense of community by implementing physical changes to create small homes and restructuring staffing hierarchies.

The Green House model has been adopted by many skilled nursing homes throughout the country, including at The Cottages at St. Martin’s in the Pines, in Alabama, which was the subject of a PHI case study earlier this year.

– by Matthew Ozga

Direct-care workers in training

A new PHI analysis found that only 15 states require home health aides to have more training hours than are federally mandated, yet 30 states and the District of Columbia require certified nurse aides (CNAs) to have more training hours than the federal requirements.

In 1987, the federal government set a training standard of 75 hours, including a minimum of 16 hours of clinical training, for both home health aides and CNAs who are employed by Medicare-certified nursing homes or home care agencies.

“Our analysis shows that state home health aide training requirements have not kept pace with their nursing home aide training requirements, even though these direct-care workers provide essentially the same care and services,” said Steve Edelstein, PHI national policy director.

“Although it is clearly time to revisit the federal standards, having states move ahead on their own to upgrade training requirements is a step in the right direction.”

In Retooling for an Aging America, a 2008 report, the Institute of Medicine (IOM) recommends that the federal minimum training requirement be raised to at least 120 hours for both CNAs and home health aides and that competency in elder care be demonstrated as a criterion for certification.

Other Findings

The PHI analysis also found that:

• 4 states meet the IOM recommended training standard for home health aides;
• 14 states meet the IOM recommended training standards for CNAs;
• 13 states require more than 16 hours of clinical training for home health aides — the federal minimum training requirement; and
• of the states that exceed the federal training standard, 9 require home health aides to be CNAs, and 4 allow CNAs to become home health aides with supplementary training.

Trend Toward Home and Community-Based Care

Today, the majority of direct-care workers, including personal care aides, are employed in home and community-based settings (pdf).

By 2018, home and community-based direct-care workers are likely to outnumber facility workers by nearly two to one.

“Current federal training standards have not kept pace with changes in public policy and services delivery and do not adequately prepare the direct-care workers who provide the lion’s share of paid hands-on long-term care,” Edelstein said.

“The federal government must modernize training requirements for direct-care workers to help them gain the skills and knowledge they need to help elders with chronic and complex medical conditions live as independently as possible where they prefer — in their homes and communities.”

To compare the training requirements for home health aides and certified nurse assistants in each state, visit the PHI PolicyWorks website.

– by Deane Beebe

Just as the Green House Project® announced the completion of the nation’s 100th Green House home in September, Seniors Home & Care Journal published an article concluding that the Green House model’s operations are “comparable in cost to traditional nursing homes as well as nursing homes that are implementing other culture change practices.”

The article, “Financial Implications of The Green House Model,” explains that several published studies have already shown that the Green House Model of licensed nursing homes “provides significant and sustained satisfaction and clinical improvements when compared to traditional nursing homes,” but that questions remain as to the model’s initial and long-term financial viability.

The authors review past studies on the financial performance of the Green House Model and report on two recent studies that look at the 1) costs of Green House administration and organizational staffing, and 2) environmental costs, overall financial performance, and benchmarks of Green House homes.

The first study found that the total estimated personnel costs of the Green House homes and traditional models are “essentially equal.”

While there is an increase in the number of full-time direct employees in the Green House homes compared with traditional facilities, this increase is offset by a reduction in the number of both administrative and support staff (housekeeping, laundry, and food service staff), the authors report.

Shahbazims’ Larger Role Reduces Other Costs

In the Greenhouse model, the certified nurse assistants known as Shahbazim are responsible for the tasks of these support staff in addition to their typical direct-care duties.

The authors attribute the reduction in administrative full-time employees to the increased role of both the nursing staff and the Shahbazim who coordinate care and maintain patient records in the Green House model rather than having unit secretaries or charge nurses do so.

The second study compares the overall costs — including food costs, plant operations, ancillary costs and administrative expenses — of Green House homes to traditional nursing homes. It also compares their capital costs, both per square foot and per unit.

In this study, the authors conclude that the capital costs of the Green House homes are equivalent or less than similar culture change models but higher than traditional facility designs. They note that the increased occupancy and more private-pay days that are associated with the Green House model may offset these capital costs.

Tripling the Number of Green House Homes

The Robert Wood Johnson Foundation, a partner of the Green House Project, announced the organizations’ mutual goal of tripling the number of Green House homes in the next three years.

PHI, also a partner with the Green House Project, has worked with the project to imbed its Coaching Approach^SM in the educational offerings for all Green House staff, including the formal leadership team, nurses, and the self-managed work team of Shahbazim.

– by Deane Beebe

In a reversal of a 20-year-old decision, the National Labor Relations Board (NLRB) issued a rule on August 26 regarding what constitutes a bargaining unit in nursing homes, rehabilitation centers, and other non-acute health care facilities.

The NLRB decision (pdf) in the Specialty Healthcare and Rehabilitation Center of Mobile and United Steelworkers, District 9 case concluded that the 53 certified nursing assistants (CNAs) employed by this facility had the right to form a bargaining unit that does not include other “nonprofessional” staff such as maintenance workers, cooks, dietary aides, and clerical workers.

New “Community of Interest” Standard Applied

The ruling makes it possible for employees that share a “community of interest,” such as employees with the same job title, to form collective bargaining units, regardless of the size of the unit.

The “community of interest” standard that will now be applied to employees of non-acute health care facilities is the standard used in other workplaces, according to a NLRB press release.

Under the traditional “community of interest standard,” factors such as common supervision, interchange of employees, geography, job classifications, departments, functions, and skills are considered.

Under the new rule, should an employer make the case that “the proposed unit inappropriately excludes certain employees, the employer will be required to prove that the excluded employees share an ‘overwhelming community of interest’ with employees in the proposed unit,” the NLRB release explains.

According to a New York Times article, the lone dissenter on the NLRB “asserted that the new approach would encourage the unionization of units as small as possible, which he said conflicted with the labor act’s aims.”

Majority Calls Precedent “Obsolete”

Referencing the 1991 case that the NLRB reversed, the 3-1 majority opined that “we have concluded that the Park Manor approach to determining if a proposed bargaining unit in a nursing home is an appropriate unit has become obsolete.”

– by Deane Beebe

Three brief stories on direct care:

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Standards Lowered for Some Hawaii Caregivers

Hawaii has reduced its qualification requirements for part-time caregivers working in community-based adult foster homes.

As a result of legislation signed by Governor Neil Abercrombie (D) in July, nurse aides who provide less than five hours of care daily (or less than 28 hours weekly) in adult foster homes no longer have to be certified.

To become certified, nurse aides must take a state-administered test every two years to demonstrate continued mastery of their skills. Uncertified nurse aides are trained but not tested.

Advocates for the elderly say that the degraded qualifications could lead to worse quality of care in adult foster homes.

The lowered qualifications apply only to adult foster homes with three residents, the maximum allowable in Hawaii’s Community Care Foster Family Homes program.

The changes to the qualifications are set to expire in June 2013, at which point lawmakers will decide whether to extend them permanently.

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Boston College Receives HHS Grant to Improve Home- and Community-Based Care Competencies

The Department of Health and Human Services (HHS) has awarded $2.25 million to Boston College’s Graduate School of Social Work to bolster consumer direction in home- and community-based care settings.

The grant will fund a three-year program called Accelerating Participant Direction Philosophy and Models in the Aging Network.

The program’s overarching goals are to identify the skills necessary to jobs that help people obtain home- and community-based services, and to enhance providers’ ability to ensure consumer direction.

Announcing the grant on July 26, HHS Assistant Secretary for Aging Kathy Greenlee said that the grant is “an investment that will help strengthen our commitment toward providing home- and community-based services…based on both the needs and preferences of the consumer.”

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PHI Board Member Calame Honored in San Francisco

San Francisco Mayor Edwin Lee (D) proclaimed July 21, 2011, to be “Donna Calame Day” in honor of the executive director of the San Francisco In-Home Supportive Services (IHSS) Public Authority.

Calame, a PHI board member, was honored for her career-long dedication to helping people with disabilities exercise their right to “the widest range of choices possible for [living] outside of institutional settings with appropriate assistance,” according to the city’s proclamation.

Since 1996, the San Francisco IHSS Public Authority has served as the employer of record for the city’s home care workers, fighting for better wages, benefits, and supports.

– by Matthew Ozga

Massachusetts State House in Boston

PHI Massachusetts lent its support to two bills at a July 19 hearing on home and community health care provider policies, held by the Joint Committee on Public Health.

“An Act Relating to Training for Certified Nurses’ Aides and Direct-Care Workers,” Senate Bill 1121, calls for a review of current training standards for home health aides and certified nurse aides (CNAs) in the state.

“An Act Relative to Home Health Aides,” Senate Bill 1138, would expand the current role of home health aides (HHAs) in the state and, with appropriate training and oversight, allow them to administer some medications.

Facilitating a Career Lattice

Passage of the training standards bill would be well-timed: Massachusetts is one of six states to receive a Personal and Home Care Aide State Training (PHCAST) demonstration grant from the Department of Health and Human Services.

“The PHCAST demonstration grant will position Massachusetts as a leader on training standards for personal care attendants and personal care aides nationally — and also lay the foundation for a portable credential in the state,” said PHI Massachusetts State Director Amy Robins in her hearing testimony.

“A close examination of training standards for CNAs and HHAs could help facilitate the creation of a clearly articulated and intentional career lattice among direct-care occupations. This would allow workers to advance to new positions and move across settings — keys to cultivating, recruiting, and retaining the direct-care workforce Massachusetts will need in the coming years,” Robins’ testimony (pdf) concluded.

Medication Administration

Senate Bill 1138 provides a very attainable advancement opportunity for HHAs who are interested in medication administration.

“The experience of others demonstrates that this can be done safely and effectively — and that this strategy also helps ensure the best value for our health care spending, with all working to the top of their training and licensing,” Robins’ testimony (pdf) said.

The bill “would send a clear signal that the state recognizes the importance of this vital workforce and the need to do more to improve these jobs and create meaningful advancement opportunities,” her testimony continued.

There are nearly 100,000 direct-care workers in Massachusetts. Direct-care jobs are the second largest occupational grouping in the state and are expected to grow by 22 percent by 2016, dramatically outpacing the growth of other jobs.

Home and community-based direct-care jobs are among the state’s lowest-paying jobs, paying wages that fall below the state’s low-wage threshold.

“Quite simply, the state must do more to cultivate a high-quality, well-trained and stable workforce,” Robins says. “These two bills are important steps in the right direction.”

For more information on the direct-care workforce in Massachusetts, see State Facts: Massachusetts’ Direct-Care Workforce (pdf).

– by the PHI Policy team