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The PHI State Data Center, the first web-based tool to provide comprehensive, state-by-state profiles of the direct-care workforce, is now live at the PHI PolicyWorks website.

The PHI State Data Center profiles nursing home aides, home health aides, and personal care assistants (including direct support professionals) in every state.

It provides easy-to-read charts with up-to-date, key direct-care workforce statistics, which can be easily downloaded and reproduced, featuring information on:

• workforce size and projected employment growth
• trends in wages for each direct-care occupation, and
• information on health insurance coverage rates and reliance on public assistance.

The state data on wages, benefits, and occupational growth are compared to all occupations in that state.

The new web-based data tool also features links to:

• legislation and regulatory developments pertaining to the workforce, such as summaries of pending or passed bills and regulatory actions
• notable state-based initiatives such as training programs, demonstration projects, matching service registries, person-centered care programs, and other efforts to improve the quality of care and direct-care worker jobs
• employer best practices, and
• resources, including state-specific surveys, demonstration projects, reports and recommendations.

States Hampered by Lack of Information

Despite the direct-care workforce’s central role and importance to the ability of states to provide long-term services and supports, a recent white paper from the National Direct Service Workforce Resource Center (sponsored by the Centers for Medicare and Medicaid Services) reported that states are hampered by a lack of on-going, reliable state-based information about this critical workforce.

The PHI State Data Center aims to begin to address the growing need that states have for better tools to monitor key vital signs of their direct-care workforces.

The data center compiles and analyzes the most recent data from multiple sources, including the U.S. Census Bureau’s Current Population Survey and the Occupational Employment Statistics and Employment Projections Programs, run by the U.S. Department of Labor/Bureau of Labor Statistics.

The development of the PHI State Data Center was supported by the CMS/National Direct Service Workforce Resource Center and a grant from The SCAN Foundation, dedicated to creating a society in which seniors receive medical treatment and human services that are integrated in the setting most appropriate to their needs.

CMS to Host Webinar to Introduce PHI State Data Center

The CMS/National Direct Service Workforce Resource Center will unveil the PHI State Data Center at a webinar that will feature a discussion with PHI Director of Policy Research Dorie Seavey and other presenters on strategies that states can use to impact workforce size, wages, and benefits:

September 19
3:00 PM – 4:30 PM EDT
Call-in Number: (800) 260-0702
Code: 213233
There is no charge for the webinar but registration is required.

– by Deane Beebe

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

With the Workforce Investment Act (WIA) due for reauthorization, the Senate Committee on Health, Education, Labor and Pensions (HELP) released a draft of the reauthorization bill for public comment in June.

HELP holds jurisdiction over WIA programs, which coordinate and support the nation’s workforce development system.

PHI submitted comments (pdf) on the reauthorization bill that emphasize the challenge our nation faces: building an adequate, stable, and trained direct-care workforce that will meet the increasing demand for long-term services and supports for people living with disabilities and our rapidly aging population.

PHI also identified opportunities where WIA programs can help to meet this challenge.

In a letter to the HELP Committee, PHI Government Affairs Director Carol Regan wrote, “The case for incorporating direct-care workforce strategies for the eldercare and disability services industry into WIA is compelling. Employers such as home care agencies, adult day centers and nursing and assisted living facilities face enormous difficulty in hiring and retaining an adequate supply of direct-care workers.”

The letter states that PHI acknowledges that direct-care jobs typically do not pay “family-sustaining wages and benefits that enable workers to achieve economic self-sufficiency,” a fact that has led some workforce investment boards to shy away from investment in the direct-care workforce.

But the letter goes on to note that “nonetheless, these occupations represent such a large proportion of available employment — in an otherwise job-starved economy — that they cannot simply be ignored.”

PHI’s Recommendations

PHI has recommended that:

• the definition of “in-demand industry sector or occupation” should be modified in such a way as to encompass direct-care occupations, perhaps by modifying the definition to include occupations which, with investment, could lead to economic self-sufficiency.
• states be directed to include specific analysis of the knowledge and skills needed to meet the employment needs of long-term care employers, the current status of the state’s direct-care workforce, and an articulation of a strategic vision and goals for building an adequate direct-care workforce in their four-year strategic plans.
• the state’s rate of disability and percent of population over the age of 65 be incorporated into the statistical model to revise state measures of performance.
• the Secretary of Labor include strengthening the direct-care workforce among the priorities for demonstrations and pilot projects.
• direct-care workforce training programs should be noted as a preferred recipient of retention grants.
• the two-year plan formulated by the Bureau of Labor Statistics for the workforce and labor market information system include data about the direct-care workforce as a priority.

The complete set of recommendations (pdf) is available in Regan’s letter to the Committee.

Groups Urge HELP to Move Forward

The effectiveness and efficiency of WIA programs has been criticized in several reports (pdf) published by the Government Accountability Office this year.

In a letter to the HELP Committee, which was drafted by the National Skills Coalition and signed by 40 organizations including PHI, the organizations urge the committee to move forward with the reauthorization process despite some Congress members’ concern “about the effectiveness and efficiency of the current workforce development system.”

The Committee is scheduled to mark-up the draft bill on July 20.

Federal funding for WIA was cut by almost $1 billion in the Fiscal Year 2011 Continuing Resolution, which was finalized last April. WIA programs face the threat of additional funding reductions as Congress works on appropriations for FY 2012.

“In view of these significant cuts, it is all the more reason that direct-care workforce development is prioritized because Workforce Investment Boards will be forced to make tough choices about where to place investments,” said PHI National Policy Director Steve Edelstein.

– by Gail MacInnes and Deane Beebe

Sen. Bob Casey (D-PA)

On May 26, the U.S. Senate Special Committee on Aging, chaired by Senator Herb Kohl (D-WI), hosted a hearing on the pending reauthorization of the Older Americans Act of 1965 (OAA).

The law governs a nationwide network of agencies and programs to deliver social services to older adults to help them maintain independence in their homes and communities.

The hearing, entitled “Meals, Rides, and Caregivers: What Makes the Older Americans Act So Vital to America’s Seniors,” featured testimony by:

• Kathy Greenlee, assistant secretary, Administration on Aging (AoA); U.S. Department of Health and Human Services [testimony];
• Rosalynn Carter, former First Lady and president of the Rosalynn Carter Institute for Caregiving; and
• others, including an advocate, a service provider, a state long-term care ombudsman, and a beneficiary of OAA programs.

The witnesses addressed a wide range of topics, including:

• the needs of family caregivers;
• new programs to be administered by AoA (the CLASS program, the State Health Insurance Assistance Program, and the Senior Community Service Employment Program);
• increased responsibilities of long-term care ombudsmen; and
• options for administering OAA programs more efficiently.

Specialized Training Necessary

Senator Bob Casey (D-PA), a member of the Committee, asked Carter to comment on evidence-based programs for the specialized training necessary for caregivers –- especially direct-care workers.

Casey paid tribute to the commitment of direct-care workers, saying “I have been…overwhelmed by the kind of care that is delivered by direct-care workers — how strong they are, how dedicated they are — willing to do back-breaking and sometimes seemingly impossible work on behalf of those who need that care and on behalf of their families.”

Carter responded by sharing information about approaches the Institute is testing to provide training to family caregivers of individuals with Alzheimer’s Disease, referred to in their October 2010 report, “Averting the Caregiving Crisis: Why We Must Act Now.”

Supporting the Direct-Care Workforce

Responding to the same question from Senator Casey, Assistant Secretary Greenlee commented that it “will take many different federal organizations working together” in order to address how the U.S. will “support the public programs — the CLASS Act, Medicare and Medicaid programs, the programs we have under the OAA, disability programs — with a paid workforce and provide enough support to that workforce so that they have meaningful career ladders, but also so that they have the skill set to serve an increasingly aging population.”

The Leadership Council of Aging Organizations, of which PHI is a member, submitted recommendations (pdf) on the reauthorization of OAA, some of which will bolster the direct-care workforce.

– by Gail MacInnes, PHI National Policy Analyst

Dozens of workforce development experts, policymakers, providers, funders, researchers, and advocates gathered in Washington, D.C., on May 26 for an in-depth examination of innovations in practice and policy for bolstering the direct-care workforce in the eldercare and disability services sector.

“Building Ladders and Raising the Floor,” which was organized by Jobs for the Future (JFF) and PHI, aimed to engage all stakeholders in dialogue to identify strategies and opportunities for both creating career advancement opportunities and improving the quality of direct-care jobs.

PHI President Steven Dawson noted that in the last 20 years, the workforce development field has invested a great deal in creating ladders to good jobs for direct-care workers, but far less in strategies to raise the floor of entry-level jobs.

Dawson highlighted the impact that the direct-care workforce has on elders and disabilities, saying, “The direct-care worker is the face, hands, and voice of long-term care for literally millions of elders and people with disabilities. The quality of this job undeniably determines the quality of their care.”

Two direct-care workers — Darlene Scott of Porter Hills Green House and Ancil Alexander of Cooperative Home Care Associates (CHCA), a PHI affiliate — shared their love for their work and desire to stay on the front line while receiving better training, compensation, support, and good supervision.

Best practices, such as those implemented at Porter Hills and CHCA, offer direct-care workers more time, control, authority, and pay, and encourage access to and sharing of information.

Stakeholders Express Concerns, Suggest Strategies

Participants included a wide variety of stakeholders concerned about the direct-care workforce.

“An elder and disability services sector strategy aimed at building the direct-care workforce is essential,” said Olga Merchan, director of workforce strategy for YouthBuild USA. “A common strategy will help YouthBuild and other workforce programs to achieve placement goals, ensure higher retention in employment and training opportunities, and position participants for higher wages.”

The keynote speaker, Gerri Fialla, deputy assistant secretary, employment and training administration, U.S. Department of Labor (DOL), detailed DOL’s commitment to investing in the direct-care workforce and to partnering with other federal agencies to do so. In an environment of budget cutting, she emphasized strategies to “do more with less.”

PHI National Policy Director Steve Edelstein noted how one state was handling the budget crunch:

Responding to the need for budget cuts in New York, stakeholders recently hammered out an agreement on unprecedented reforms of the Medicaid program. Without a doubt, budgets at both the federal and state level are challenging, but I hope that, working together, we can use these challenges as an opportunity for improvements and reform.

Participants at the event began a conversation about how to meet the challenge. Henry Claypool, director, Office on Disability, U.S. Department of Health and Human Services, offered one strategy for meeting the challenge: engagement with the 15 states that received grants from the Federal Coordinated Health Care Office at the Centers for Medicare and Medicaid Services to improve coordination of services for individuals who are dually eligible for Medicare and Medicaid.

Participants discussed this and other partnerships and strategies for growing and strengthening the direct-care workforce.

– by Gail MacInnes, PHI National Policy Analyst

“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