A recent issue of the National Academy on an Aging Society’s Public Policy & Aging Report is devoted entirely to the evolution of long-term care and trend toward home- and community-based services.

The report, entitled “Advancing Home and Community-Based Services: Transforming Policies, Programs, and Service Delivery in Long-Term Care,” (pdf) contains articles by national long-term care experts, including articles on the history of long-term care, trends toward consumer-directed care, and the long-term care workforce.

The article “Strengthening the Direct-Care Workforce: Preliminary Recommendations from a National Panel of Experts in Long-Term Care” highlights the preliminary findings of a national panel convened by the Benjamin Rose Institute on Aging to “enhance the capacity of both the direct-care workforce and family caregivers to provide quality care.”

The national panel addressed four key issues:

• supply of direct-care workers and family caregivers;
• readiness or capacity of both direct-care workers and family caregivers to provide care;
• retention of direct-care workers and family caregivers in their roles; and
• quality or outcomes of direct-care workers’ and family caregivers’ care.

Increasing Supply

To increase the supply of direct-care workers and family caregivers, the panel highly recommends continuing the expansion of consumer-directed care programs. It also suggests drawing on these labor sources to build the direct-care workforce:

• immigrant populations;
• displaced workers over 55 years old who lost jobs in the current recession; and
• people with developmental disabilities.

Improving Worker Capacity

To better prepare direct-care workers for their jobs, the panel recommends the following:

• increase the federal and state training requirements for direct-care workers;
• expand training and education programs; improve their design, content, and delivery; and evaluate their effectiveness;
• design curricula around the core competencies needed;
• build training partnerships; and
• train family caregivers and develop and test models in which direct-care workers provide the training.

Retaining Workers

To improve the retention of direct-care workers, the panel advises improving wages and benefits as well as career advancement opportunities. Better supervision was also suggested as a proven strategy that helps keep direct-care workers on the job.

The panel addresses the relationship between staff turnover and the continuity and quality of care. It recommends tracking staff turnover and retention and disseminating and replicating best practices for retaining staff.

Best Practices

Several innovative practices that aim to improve the recruitment, training, and retention of direct-care workers across the spectrum of facility- and home- and community-based service are showcased in PHI’s Best Practice Profiles.

The Public Policy & Aging Report’s Winter/Spring 2010 issue was sponsored by the Benjamin Rose Institute on Aging.

– by Deane Beebe

The Arizona Direct Care Worker Association (ADCWA) will hold its annual fall conference in Tucson on September 29.

“A Celebration of Caring” (pdf) is the theme of the all-day conference, which is being co-sponsored by the Arizona Gerontological Nursing Association.

According to Henry Schemper, the ADCWA’s program director, the conference is intended to “recognize the vital contributions of professional caregivers in the lives of the elders in our state.”

Conference Agenda

The conference will cover a wide variety of topics, including:

• The dangers of bed rest
• Understanding dementia
• Compassionate communication
• Conflict resolution

Attendees will be asked to follow either the “Care Knowledge” track or the “Empowering the Caregiver” track.

Additionally, the award for the 2010 Professional Caregiver will be presented to the most outstanding caregiver of the past year.

Participants are eligible to receive up to six continuing education units (CEUs) for attending the entire conference.

For registration information, contract Henry Schemper at henryschemper@gmail.com.

– by Matthew Ozga

Jack Mills

A guest column by Jack Mills, Executive Director of the National Network of Sector Partners (NNSP), an initiative of the Insight Center for Community Economic Development.

NNSP released a brief last week that provides important lessons for health care providers and direct-care workers. From Hidden Costs to High Returns: Unlocking the Potential of the Lower-Wage Workforce (pdf) reports on the experience of dozens of health care organizations and manufacturing companies.

These employers have found that investments in lower-wage workers directly benefit their bottom lines while their workers move up to better jobs. The brief documents the benefits for employers and provides lessons to help other employers follow suit.

Companies highlighted in the brief include the Visiting Nurse Association of Eastern Massachusetts (VNAEM), which employs 160 people at its home care agency and two assisted living facilities for low- and moderate-income seniors and individuals with disabilities.

Aides Should Get the Pay and Respect They Deserve

As VNAEM CEO Linda Cornell points out, aides are low on the organization’s wage ladder, but they are “the people who have the most responsibility in our organization for the direct hands-on care that our patients and residents receive.” Their performance on the job consequently has a huge effect on service quality and customer satisfaction.

VNAEM’s goal is for every patient and resident to be treated as you would want your loved ones treated, and its ultimate goal is to have everyone in the association recognize and embrace direct-care workers as equal members of the care team. Their approach was that certified aides and nurses’ aides should receive high-quality training, and the pay and respect that they deserve.

Funding from the Commonwealth Corporation’s Extended Care Career Ladder Initiative (ECCLI) supported VNAEM’s early work toward its goals with B&F Consulting in 2004-2005. Over the next two years, VNAEM teamed up with other health care employers and a nonprofit workforce organization, called Employment Resources, Inc. (ERI), to form a collective recruitment and training program for entry-level aides.

Ms. Cornell and her staff had long felt that the standard training required for certified aides and nurses’ aides was too rudimentary to ensure the quality of care that the association wanted to be known for. “In the industry,” she says, “the training did not match what we need…. It was just a bare minimum, no real hands-on training.”

Industry-Focused Workforce Development

Fortunately, ERI was working on an approach to the broader, industry-wide change that Ms. Cornell had in mind. With an ECCLI grant, ERI designed a program specifically tailored for employers who — collectively — hired lots of aides every year. Since so many participated, the program could recruit widely, train large numbers of people, greatly improve the kind of training each candidate received, and yet keep the cost per worker low for each employer.

How the Program Worked

• The program took place at the participating companies’ facilities, so trainees received an immediate, firsthand experience of the working environment.
• A one-on-one assessment of each worker and assessments of supervisors’ and managers’ needs were performed at the outset.
• The employers paid 100 percent of their employees’ salaries while they were being trained.
• The training included various kinds of adult basic education and English as a Second Language, depending on the needs.
• The program paid for transportation and child care when needed.
• Employees who completed each stage of the curriculum got an immediate boost in wages.
• Wages rose from $10 to as much as $16 per hour for completing the full regimen.
• Graduates have become equal members of care teams.
• Several graduates have become Team Leaders and several others have become nurses.

The program also involved and trained supervisors and managers at every level to:

• ensure that the companies know how to get the best results from the newly trained workers;
• get every level to buy into culture change regarding how important all of the workers are at every level; and
• understand how they can better lead.

Given that the need for well-trained employees is common across the health sector, it was logical for ERI to reach out to a number of health care organizations in the region to form a program together. All of the employers worked together to design the training. ERI was at the “center of the wheel” in implementing the design. It brought together other organizations to deliver the services that employers and workers needed.

So-called “sector initiatives” like this one have been shown, in rigorous independent evaluations (pdf), to yield higher earnings and steadier work for participants with low incomes who also face multiple barriers. VNAEM and other employers that participate in sector initiatives receive major benefits too, as documented in other studies and as the brief describes in detail.

Funding for From Hidden Costs to High Returns: Unlocking the Potential of the Lower-Wage Workforce (pdf) was generously provided by the Hitachi Foundation.

The Patient Protection and Affordable Care Act will improve the health care of nearly 30 million women in the U.S., according to an issue brief published by The Commonwealth Fund.

By the time the law fully takes effect in 2014, up to 15 million uninsured women will be eligible for subsidized coverage, and an additional 14.5 million insured women will see improved coverage and/or reduced premiums.

Low-income women will especially benefit from the law, the issue brief states.

President Obama signed the Patient Protection and Affordable Care Act this past March as part of his administration’s effort to enact national health reform.

Implications for Direct-Care Workforce

Perhaps the most significant provision of the act will be an expansion of Medicaid eligibility to cover adults earning up to 133 percent of the federal poverty level (currently about $14,400 for a single adult).

An estimated 8.2 million uninsured women between the ages of 18 and 64 will be eligible for Medicaid when that provision takes effect in January 2014, The Commonwealth Fund report found.

A significant number of these millions of uninsured women are members of the direct-care workforce, which is 90 percent female, PHI research (pdf) suggests.

Approximately one out of four direct-care workers is uninsured, and many of them would be eligible for Medicaid under the new eligibility rules. The median annual income of direct-care workers is just $17,000; personal and home care aides make an average of $12,000 a year.

PHI has compiled a chart (pdf) on other health-reform provisions that will affect the direct-care workforce.

More Helpful Provisions

The Commonwealth Fund’s issue brief details several other provisions that will benefit women.

Beginning September 23, 2010

• Health plans will be required to cover a wide variety of services without requiring cost-sharing. Those services include screenings for breast cancer, and cervical cancer, as well as osteoporosis screenings for women age 65 and older.

Beginning January 1, 2014

• Insurance companies will be required to accept every individual who applies for coverage, and will be forbidden from charging higher premiums based on gender or pre-existing medical conditions.
• Health plans sold through state insurance exchanges will be required to cover maternity and newborn care.

– by Matthew Ozga

The National Center for Gerontological Social Work Education devoted its August newsletter to the role that social workers can play in improving the working conditions of direct-care workers, and by doing so, improving the care for older adults.

The bimonthly issue of Aging Times features two articles on this topic:

Are We Prepared to Care? — PHI President Steven Dawson explains that as Baby Boomers age, many are retiring from the eldercare workforce, leaving an even greater gap in care. Dawson calls for a system reform to recruit and retain direct-care workers and increase collaboration between the direct-care workforce and social workers.

Vital Yet Undervalued: Recruiting and Retaining Qualified Direct-Care Workers — Nancy Wilson of the Baylor College of Medicine and Jane Bavineau of Care for Elders provide recommendations culled from years of practice, policy work, and research for improving the supply and quality of direct-care workers.

Aging Times also references:

Social Work — Direct Care Partnerships Would Improve Care, a PHI Quality Care/Quality Jobs Guest Commentary by Nancy Hooyman, a gerontology professor and dean emeritus at the University of Washington’s School of Social Work.

Thank You, Iman, Hugo, and All of the Nation’s Other Direct-Care Workers, a personal account by The John A. Hartford Foundation Executive Director and Treasurer Corinne Rieder on how two home health aides make it possible for her elderly parents who have multiple health conditions to live at home. This blog post in the Hartford Foundation’s Health AGEnda calls for putting an end to the Fair Labor Standards Act’s companionship exemption.

The National Center for Gerontological Social Work Education’s newsletter also includes a Direct Care Workers Bibliography (Word doc), a 10-page list of suggested readings on direct-care workers.

– by Deane Beebe

Sen. Bob Casey (D-PA)

The U.S. Senate Special Committee on Aging held a field hearing on August 2 entitled “Taking Care of Mom and Dad: Why We Need a Quality Workforce to Serve Our Older Americans.”

“I called this hearing today to address a serious problem in our Commonwealth and across the nation: providing access to a quality workforce for an aging population,” said a press statement by Sen. Bob Casey (D-PA), who chaired the hearing.

Experts provided testimony on the shortage of health care workers, including physicians, nurses, and direct-care workers. They warned that with the baby boom generation turning age 65 in 2011, there will be an even greater demand for this workforce.

Witnesses included representatives of the federal government, academic medicine, a national advocacy organization, home care, and a direct-care worker association.

Senate Companion Bill to the Direct Care Workforce Empowerment Act Introduced

The day following the hearing, Casey introduced the Direct Care Workforce Empowerment Act, the companion legislation to the House bill (H.R. 5902) that was introduced on July 28 and sponsored by Rep. Linda Sanchez (D-CA).

“The number of Americans needing long-term care is expected to double in the coming decades from 13 million in 2000 to 27 million in 2050,” Casey said in a press statement about the bill. “The vast majority, 70-80 percent, of paid care will be provided by direct-care workers.”

“As a long-time leader on issues affecting direct-care workers, Senator Casey understands in a very personal way their vital role providing compassionate hands-on care and support to elders and persons with disabilities,” said PHI Pennsylvania State Policy Director Joe Angelelli. “His leadership and concern for fair treatment of home care workers is critical.”

Fastest-Growing Occupation is a Poor Paying Job

There were 3.2 million direct-care workers in the U.S. in 2008. It is projected that an additional 1.1 million new positions will be needed by 2018 (pdf).

The median hourly wage for direct-care workers in 2008 (pdf) was $10.42, compared with $15.57 for all U.S. workers that same year.

As in the rest of the nation, home health aides and personal and home care aides are among Pennsylvania’s top 10 fastest-growing occupations (pdf).

“Despite providing care and services that help millions of older citizens and people with disabilities maintain their dignity and autonomy and often remain in their homes, most direct-care workers receive low wages, little or no benefits, and insufficient training and professional development,” Casey said. “As a result, there are high turnover rates that can compromise the quality of care our older citizens and people with disabilities deserve.”

Testimony from the hearing will soon be available at the U.S. Senate Special Committee on Aging website.

– by Deane Beebe