Robert Jenkens

Robert Jenkens was at boarding school in Exeter, New Hampshire, when, in order to fulfill community service, he chose to volunteer as a buddy to an elder in a nursing home. He soon discovered he enjoyed listening to the personal stories of those who lived there, and he marveled at their rich, interesting lives.

Still, he remembers, “Every time I walked in, I thought, ‘How can anyone live here?’ It was the last area where I saw society accepting a bad quality of life, where rights were really denied. People didn’t have the ability to make choices or lead lives the way they wanted to. I thought it was a civil rights issue.”

Jenkens determined then and there that people need multiple options in their communities for long-term care. So he became an architect and for eight years tried to change the look and feel of typical nursing homes. Then he realized that nursing homes are actually creatures of finance and policy, so he studied public policy at Harvard’s Kennedy School of Government and worked at AARP as a policy analyst.

Finally, he discovered an affordable alternative to the institutional nursing home model called the THE GREEN HOUSE®. This model, he discovered, made full use of Medicaid dollars, innovative design ideas and the principles of culture change. Individuals living in Green House homes have rights: they maintain independence, direct their own care, and live with dignity.

Originally a volunteer working with Bill Thomas, developer of the project, Jenkens now serves as its director.

A new world for workers

The Green House model departs from traditional nursing home principles at every turn. In addition to replacing the institutional care model with small homes that accommodate no more than 8 to 10 people, the Green House model offers a new role for the direct-care worker. That role is to protect and nurture those living in the Green House. Together with the elders, direct-care workers run the household; they also provide personal care, cook, and clean. Nurses are on-call to provide clinical care, when needed.

Each home has a self-managed work team of CNAs who receive 120 hours of extra training in Green House philosophy and skills, including the principles of culture change. These caregivers are even given a new name, the Persian word Shahbaz (plural, Shahbazim),which originally derives from Hebrew. The Shahbazzim report to the Guide, who provides overall administrative support and coordination for residents and staff. PHI developed a leadership training program for Green House Guides , who having previously directed staff in traditional, hierarchical institutions, needed a different set of skills to support the Shabahzim self-managed work teams.

You can go to Lincoln, Nebraska in the middle of the heartland, says Jenkens, and find that Green House CNAs love the term Shahbazim. “In Tupelo at our first pilot site, you can hear them say ‘Shahbazim’ with a strong southern accent,” he says.

If a CNA “is drawn to that word and cares about the importance of language,” says Jenkens, they are probably open to the Green House philosophy.

Studies are finding that turnover drops when people transition to this new role. Sometimes, it drops dramatically. Before the original Tupelo home transitioned into a Green House, it reported a 70 percent turnover rate for the direct-care workforce. That dropped to 10 percent after the transition.

This may be due in part to the greater depth of personal care and contact in the Green House model. According to Jenkens, workers “have reported better job satisfaction,” saying they get to know residents better in this intimate setting and can better care for them. Just outside Albany, New York, where six new houses have recently opened, despite the rigors of new training and the challenges of getting up and running, 97 percent of staff said they didn’t want to go back to their jobs in the traditional nursing home.

Looking ahead

Since the first pilot project opened in Tupelo, the Green House models have expanded to 18 operating campuses today, containing one to 10 houses each, with another 20 sites in development.

“We hope the Green House model is home as people know it from their experiences, preferences and needs,” Jenkens says. “And that may be different in Alaska than it is in Tupelo, Mississippi.”

The GREEN HOUSE® Project is now a program of NCB Capital Impact, a Washington, D.C., based non-profit that works to bring innovation to low-income communities in order to improve the lives of those living there. Established by an act of Congress in the late ‘70s, the organization works in health care, education, affordable housing, and long-term care. Since its inception, NCB Capital Impact has put nearly $1.2 billion into low and moderate-income communities, supporting health care centers, charter schools and affordable homeownership. In 2005, the Robert Wood Johnson Foundation committed to supporting NCB in implementing 50 Green House projects over a five-year period.

“As we go well beyond the grant, we expect the real benefit will be to grow and evolve from what we learn from each other, from our best practices and collective wisdom,” says Jenkens. “We hope the project looks totally different in ten years because it’s grown and because we’ve gotten much better.”

– Story by Dinah Cardin

Nathan Herman and Dylan Marriner

Nathan and Dylan could be any two dudes in their early 20s, hanging out beneath band posters in their hoodie jackets and ironic T-shirts, chatting away their afternoons about music, video games, and cult-classic films.

They certainly don’t look like the future of caregiving in America — but that’s exactly what they could be. 

Suffering from a degenerative spinal cord disease called Spinal Muscular Atrophy, 25-year-old Nathan Herman has had several personal care assistants in his lifetime. But while most of them have been older women with kids and lives unlike his, Dylan Marriner is Nathan’s demographic peer: a young, self-described “geek” who shares Nathan’s pop cultural interests.

Perhaps a younger generation with strong arms and open minds represents an untapped pool of workers who can not only help to fill the country’s enormous care gap for elders but can also identify with, and assist, the many young people who suffer from disabilities.

A case in point is Nathan, who says having a young male work with him makes more sense for a number of reasons, including the delicacies of personal grooming and, most importantly, his and Dylan’s ability to relate to each other on a personal level.

The two of them explain the process of dressing Nathan for a cold New England day, getting Nathan into body and leg braces and then into his motorized wheelchair with the finishing-each-other’s-sentences way of conversation used by people who spend a lot of time together. This is because they spend nearly 40 hours a week in each other’s company.

Nathan having his hair washed by Dylan.

With expressive dark brown eyes and long lashes, Nathan lives in a reclined position, using his thumb to manipulate a computer touchpad to draw comic book action heroes and soft, lovingly embracing and nuzzling figures – a new addition to his work since he met and married Ali Neenan in 2005.

While Ali goes off to work, Dylan assists Nathan with bathing, dressing, eating; positions him to use his computer; and performs all the other daily tasks that those without disabilities take for granted. But what makes Dylan’s role in Nathan’s life special is that he is Nathan’s perfect companion. Discussing their shared interests of movies, TV shows, video games and music brings Nathan into the world.

A serendipitous moment

Before hiring Dylan one year ago, Nathan had gone three years without a personal care assistant, instead relying on his new wife to care for him.

“I dragged my heels because it’s such a pain to find someone who is competent and then train them to be more competent,” he says.

Dylan has turned out to be more than competent. Last February, when Dylan looked around Nathan’s living room and commented on certain cult movies and action figures, Nathan knew that the interview was over. He had found his new personal care assistant.

Dylan brushing Nathan's teeth.

“It was a serendipitous moment,” says Dylan, between feeding Nathan bites of a feta omelet. “I don’t think it would have worked out if we didn’t get along so well.”  “It was, ‘You’ve got the job, now let’s just talk,’” remembers Nathan.

The two of them have since gone to Dylan’s home to hang out with his friends who wanted to meet Nathan – no easy task since it involves meticulous preparation.

For Dylan, entry into the direct-care world represents a dramatic change of direction. The past year has been unlike any other time in his life. He was out of work for a couple of years prior to working with Nathan. Before that he worked at a Toys R Us. He began seeking work with a local non-profit disability service organization only after talking with an acquaintance who worked as a personal care assistant.

“Mostly it was opportunity,” he says. “I was out of work for a couple of years.”

Dylan recently got a slight raise to $11.40 an hour. He has been told that he may be eligible for health insurance next year. But he lives with his parents and has no children of his own and no big bills to pay. He says he’d like to get married some day and have a family, and he knows he could never do it on his current pay.

“If I had to live completely independently, I couldn’t,” he says. “I think it would be pretty hard. I’d have to find more people in need of services.”

(go to part two)

- Story by Dinah Cardin

Steve Shields

Steve Shields’ journey from heading up a long-shore drilling operation in the Middle East to becoming a key player in the eldercare culture change movement began with the loss of his mother.

In the mid-80s, his mother had advanced Alzheimer’s and his father had Parkinson’s, two “headline diseases,” as he calls them. So, Shields went home to Kansas to help.

“The options available to them were dismal,” he remembers.

Shields saw his mother, a former dancer, deteriorate in a nursing home. He blamed the facility’s strict schedules and clinical feeling for her rapid decline.

One day she pirouetted down the hallway. A janitor knocked her down and injured her. The nursing home staff told Shields that his mother should not have been dancing in the first place. Shields gave some thought to it and then decided that his mother, and for that matter all of the other residents in the nursing home, should be dancing.

He transferred his mother to what was considered a better option, Meadlowlark Hills, a nursing home in Manhattan, Kansas, and took a job there. When she later died, he vowed to change the way nursing homes operate.

Since 1994, Shields has been CEO of Meadowlark Hills. In 2000, Shields and other Meadowlark personnel began conducting extensive research, gathering detailed input from residents, staff, architects and industry professionals on what would make Meadowlark Hills a better place to live. They transformed the 24-hour care center from its traditional institutional model into a new model based around homes where people live and thrive.

Complete transformation

Meadowlark Hills was a culture change pioneer. Advocates for culture change a decade ago were viewed as outsiders. But today the idea of smaller households with a consistent staff is firmly established as an alternative to traditional nursing homes.

Because of groups like Pioneer Network, the Green House project, PHI, and Meadowlark Hills, says Shields, the movement has become mainstream. These efforts have helped the household model grow from fewer than 30 small houses in America ten years ago to more than 800 today.

“It doesn’t need to have a brand name,” says Shields. “The vocabulary fits the local culture. In the long run, it’s been better for people to grapple with this and let it reflect local culture and local organizations. If there were 800 with a name like McDonald’s, the understanding of policymakers would be deeper and higher, but nonetheless, there are 800 where there was once none. “

At Meadowlark the use of clinical call lights, massive nursing stations, and metal meal carts was discontinued. Residents were given back their right to direct their own schedules and lives. The nursing home physical plant was redesigned to create the feeling of a true home. Since then, Meadowlark, with Shields at its helm, has become an international model of transformation in retirement communities.

“The rate of change is not going to slow,” says Shields, who speaks on the subject of culture change around the world. “It’s going to exponentially increase. We are now past the time when facilities are waiting to see if it’s a good move for them. Now is the time to actively plan for transformation or you’re not going to be here. By 2015, you’re gone.”

Meadowlark Hills is now a learning site for other organizations across the country, and Shields is an international consultant. Every week during the past decade, they have had visitors from around the globe “who want to begin their own journey,” he says.

Moving ahead

Shields’ staff recognized in the early ’90s that if others failed to move in the same direction, they wouldn’t sustain their own transformation.

“It takes constant vigilance to preserve and maintain and grow,” he says.

In addition to teaching other organizations how to make the changes, they have “penetrated” their area’s education system to ensure that their own area colleges and universities teach culture change.

“If we don’t, they are already tainted,” says Shields.

For instance, at Kansas State University, Meadowlark Hills has concurrently coordinated 20 different internships in various departments, including nursing, human resources, architecture, and landscape architecture, so that students in each area understand how their piece connects with the whole.

Shields says that smart decisions and further advancements in culture change can only help positively reform the health care system overall.

“I believe,” he says, “that elder services can really drive cost down in America. I think we can significantly drive down costs for the Medicare system,” by changing the focus from acute care to prevention and chronic disease management for eldercare and disability services.

He notes his excitement about the Obama administration’s recent nomination of  Kansas Governor Kathleen Sebelius as Secretary of Health and Human Services. “She’s a very competent individual,” he says. “Most importantly, she’s a very grounded, yet a practical visionary leader. I think she’s going to bring a great deal to the table at this critical time, at what appears to be the first allowable departure from the status quo not only in health insurance but in how we view health. I’m thrilled about it. . . . Whether she’s first or second pick, she’s the person for the job.”

As for his recommendations for future policy developments, Shields says policymakers should focus on reducing the number of nursing facilities and transforming those that remain into the household model. “Not only because it’s the only fiscally responsible way to deal with the problem,” he says, “but it’s also a wonderful solution that allows people their fundamental rights of driving their own lives despite the fact that they have 24-hour needs. They eat when they want and they sleep when they want and they make their own decisions.”

- Story by Dinah Cardin

Rep. Gwen Moore (D-WI)

Along with many economists and advocacy organizations, Rep.  Gwen Moore (D-WI) wants to see women’s poverty placed at the very top of the nation’s agenda. And she has exerted her political power as a U.S. representative to pursue this goal by advocating for the inclusion of women in President Obama’s economic stimulus package.

Moore’s passion for supporting low-income women is not just political but personal — She was a teenaged mother who lived on government assistance. Now she’s fighting to narrow the wage gap and increase post-secondary education for women on welfare. Thanks to a writeup at WomensEnews.org, we caught wind of the comments she delivered at the Democratic National Convention on women and poverty, and we tracked her down this week as she was on her way to cast votes in the House.

“One of the things I was concerned about when looking at the stimulus package was making sure it does not leave women and children behind,” she said. “I agreed that we needed to rebuild our crumbling infrastructure. Some of the oldest school buildings in the country are in my state. Obama needed to provide tax cuts, but I’m very concerned that many of the jobs — building roads and so forth — were not things women customarily did.”

Moore briefly invoked a comparison between the levels of responsibility shared by a nurse and a bank CEO — and highlighted the stark contrast between their respective levels of pay.

“They have people’s lives in their hands. It’s that nurse and the nurse’s aide who summon the resident from their sleep to let them know if things aren’t going well. If we start paying women comparable to the level of responsibility they have, you’re going to see greater income equality.”

She wants to increase money for food stamps and head start programs, as well as to emergency shelter grants that help women avoid eviction.

When it comes to the stimulus package, she supports the proposed federal aid to state Medicaid programs because she believes it will benefit women living in poverty and expects the savings from the proposed $20 billion for new health care information technology can be used to pay health care workers.

“Education and training dollars are vital and critical for women and children,” said Moore. “We were at risk of creating a permanent underclass because women (on welfare) couldn’t get educational opportunities. I think this is a big ticket item and the package has been calculated and calibrated to produce some results in the next 18 months that people can get their arms around. I think women are going to be huge beneficiaries of that.”

Training, coupled with equal pay for equal work, is what it’s going to take to care for a generation of aging Baby Boomers like her, says the Congresswoman.

“There’s going to be a whole lot of us that are elderly at the same time. It’s going to create a number of jobs. This man (Obama) is serious about it. It’s not just a talking point.”

Dr. Jack Resnick

While making house calls for the past decade on Roosevelt Island, a small planned community famous for the aerial cable car that connects it to Manhattan,  one doctor has come to understand the importance of direct-care workers.

Dr. Jack Resnick believes that home-based care, especially with one doctor, looking out for us throughout our lives, can be done more competently and at a lower cost than institutional care.

“People live longer.  They have fewer complications. They’re happier and it costs a lot less…Much better healthcare,” he explained, when we recently caught up to him.

One of the challenges, says Resnick, is the impact direct-care worker turnover has on older patients who need assistance to stay in their homes. He has seen these patients deteriorate when their usual day to day contact is no longer there.

“They’re crucial,” he says of the workers. “They are there every day. They’re more important than me or the nurses, really.”

Resnick says he would like to set up a structure on Roosevelt Island that would mean more responsibility and better pay for direct-care workers, as well as more training and some kind of career ladder.

“We can utilize them much more effectively. By doing that, you create so much savings for the government. Everybody comes out way, way ahead.”

In December, Resnick hosted one of the Obama transition team’s community health care forums where he shared his ideas about home-based care including a short video.

Find out more about Dr. Resnick by reading this recent post at the New Old Age or by visiting his personal website.

Dr. William Thomas

Bill Thomas calls himself “a nursing home abolitionist.”

“I want them to go away,” he says. “Our greatest adversary is the institutional mindset. That must go.”

Talk of culture change doesn’t matter as long as people retain an attitude of elders as “the helpless inmates of total institutions,” he says.

Looking back on the last decade of the culture change movement, Dr. William “Bill” Thomas, an international authority on geriatric medicine and eldercare, says it has progressed from the point of “being laughed at” to the subject of serious criticism.

An increasing number of organizations, regulatory bodies, corporations, non-profits, and unions are now seriously considering what happens when the concept of a nursing home is less of an institution and more of a real community where elders can thrive.

Now a professor at the University of Maryland’s Erickson School of Aging Studies, Thomas is a medical doctor who left the emergency room for geriatrics, surprising himself when he fell in love with elders and those who provide their care. It was then that he discovered he could make life better for them.

“I feel that’s what I was born to do,” he said, by phone from Maryland this week.

Direct Care Worker in Culture Change

When we asked him where the role of the direct-care worker fits into his vision, Thomas said, “Older people are held in low esteem in this country, so people who work with them are held in low esteem. First, we have to tackle ageism in this society in general, because it bears directly on the quality of life of those who work with elders.”

Thomas founded The Eden Alternative,  a philosophy and program that has worked to de-institutionalize nursing homes worldwide over the past 20 years. As we featured on our blog last month, he most recently developed the Green House, a radically new approach to long-term care where nursing homes are torn down and replaced with small, home-like environments where people can live a full and interactive life.

There are now 54 Green Houses around the country, either open or in development. While some are built from the ground up, others are transformed from the old model of the nursing home, receiving “bulldozer therapy,” says Thomas.

This means good things for both consumers and direct-care workers, when meaningful relationships are built on a foundation of dignity, equality, and mutual respect.

“One of the tragedies of long-term care,” says Thomas, “is you take big hearted, compassionate people and put them into itty, bitty little jobs. Culture Change holds promise to the extent that it’s willing to envision bigger jobs for the people doing this work – jobs that offer more decision-making autonomy and authority, better training and better pay. That’s what we’re fishing for out here.”

Better jobs and diversity of skills

The workforce you get is based on the jobs you have to offer, he says.

“Without attractive jobs, you can’t wake up and say we have a magnificent workforce. I oppose the idea of attracting new people into the field to take jobs that are not worthy of them. I don’t want to recruit people to work in the current authoritarian regime. I want people to be attracted to our field because we offer tremendous jobs with great fulfillment and personal growth.”

When we asked Thomas what skills workers will need in the future, he said, presuming the success of the culture change movement, those who work with elders will have the wellbeing of elders in mind. They’re going to need a wider range of skills because the focus will be on the people they care for and not on service to their department.

Workers will need to work cooperatively. With a more team-based system, they will need to carry out plans together, have greater communications skills, a wider range of technical skills, and community building skills.

“Healthy communities help those who live there and those who work there,” he says, adding, “we’ve got a big challenge to upgrade the workforce to match the philosophy of culture change. That’s going to take decades of work, actually.”

– Story by Dinah Cardin

For more information on how to ensure your workforce has the necessary skills to support culture change, contact Susan Misiorski, PHI Director of Organizational Culture Change, smisiorski@PHInational.org.

This is the fourth in a series of PHI Expert Interviews, which bring you insights from four senior PHI staff. They’re an impressive group — among the nation’s leading experts on long-term care’s direct-care workforce — and collectively they’ve spent decades studying the challenges facing the workforce and how to address them. We think you’ll be interested in what they’ve learned.

When Steven Dawson came out of the workforce development field in 1992 to join Peggy Powell in heading up the Paraprofessional Healthcare Institute, PHI’s sole purpose was to raise funds and provide technical support for Cooperative Home Care Associates. Over time, Steven led PHI into the broader long-term care arena, where its policy and practice experts work with employers and lawmakers to support and stabilize the nation’s direct-care workforce.

Steven has written about the impending direct-care workforce crisis (pdf) and the link between quality jobs for direct-care workers and quality care for long-term care consumers. Through the years, his emphasis has been on creating workplaces that are intentionally re-designed to retain direct-care staff.

“A constantly churning workforce is the enemy of quality care — ask anyone whose mother has had to deal with five different home health aides within a month, or with a blur of CNAs in the nursing home. The industry still manages to attract hundreds of thousands of skilled, caring workers every year, but once hired, these frontline staff are too often treated as if they were invisible. So, of course they leave,” he says.

A low-investment, high-turnover employment strategy

The revolving door that keeps an ever-changing cast of direct-care workers circulating through long-term care organizations has never been ideal for workers, consumers, or employers. Still, from a business standpoint, it has worked well enough to be the norm within the industry for several decades.

It started in the 1970s, Steven says, when the baby boomers began to transform the workforce – partly because of the sheer size of the baby boom generation, and partly because women entered the workforce at a much greater rate than they ever had before. “The long-term care industry was able to count on an endless supply of low-income women willing to do this work,” he says, “so the business model for direct-care work was built around a low-investment, high-turnover strategy, with low expectations of quality.”

Decades of an over-supply of labor created little pressure to make jobs more attractive, and so direct-care wages stayed low and benefits spotty. “The logic was — and typically still is — ‘Why invest in people if in six months they’re just going to leave?’ But low investment nearly guarantees high turnover, and so it is self-fulfilling — and has helped the industry avoid the difficult task of building a stable care staff.”

On the fast track to a true labor crisis

However, over the past ten years the supply of young and middle-aged women in the workforce — the group that has traditionally supplied about 90 percent of all direct-care workers — has started to flatten. And soon the baby boomers will age out of the workforce and into the long-term care system, causing demand for services to increase relentlessly. “That is the expanding care gap the nation is now facing,” says Steven.

The current weakness in the economy may buy employers a little time, by boosting unemployment and slowing job growth. “But once the economy strengthens, we’ll be on the fast track to a true labor crisis. No industry should rely on recession as the answer to its labor force challenge,” Steven says.

That challenge grows every day. “The Bureau of Labor Statistics is predicting that we’ll need a net one million more workers in the next 10 years — rising from three million to four million direct-care workers by 2016. Add to that the numbers of new caregivers required to replace the workers who leave, and the result is a magnitude of challenge the industry has never faced before. And this challenge will take place precisely at the wrong time, when the traditional supply of caregivers is no longer flooding the labor market.”

Direct-care workers want the same thing as you and me

So how do you get workers to stay in a tight labor market? “PHI has developed a very simple analysis of the nine elements it takes to have a quality job,” says Steven. “Those elements are pretty much the same as what you or I want in our jobs: things like a livable wage, health insurance, decent training, a chance to move up, supervisors who know what they’re doing and can help when you need support.

“It’s all pretty self-evident, and yet for policymakers argued that these workers were different from you and me, that home care aides and CNAs loved the act of caregiving so much they were quite content with minimum wages. We now have research to document that’s not true, as if we needed research to prove the obvious: Direct-care workers will never form a stable workforce until they are truly valued as an essential member of the care team-by being provided all nine elements of a quality job.”

Employers can implement many of the nine elements on their own, but some elements require additional governmental investment. Medicaid pays for more than half of the long-term care provided in the U.S., and its reimbursement rates leave no room for major outlays like generous raises or increased benefits. That’s why PHI also fields a policy agenda, doing work like its Health Care for Health Care Workers campaign, which provides tools and technical assistance to people working to expand health care coverage. “We know health coverage is an essential part of the solution,” says Steven. “We’ve seen the analysis that says affordable health insurance improves retention — in some cases even more than raising wages. But even more importantly, it is a national embarrassment that we ask people to serve our health care system, and yet don’t even guarantee them health insurance.”

Providing a solid grounding for new workers

Improving training and on-the-job support for new workers also improves retention, since direct-care worker turnover is rampant during the first six months on the job — largely because new workers are faced with challenges they’re unprepared to meet.

PHI’s entry-level training provides a solid grounding. “We’ve developed a specialty at PHI in creating employer-based training programs,” says Steven. “Recently, to address the demand for direct-care staff, organizations across the country are developing more and more direct-care training programs. We are increasingly asked to help these entry-level programs design adult learner-centered curricula, especially for workers who will be providing services and support within a consumer-directed setting.”

In addition, a good peer mentoring program picks up where effective training leaves off, pairing new workers with a senior colleague to provide advice, answer questions, and clue them in on the culture of their new workplace.

Teaching supervisors how to manage people

Finally, one of the primary causes of turnover is the punitive and inconsistent supervision that plagues long-term care. PHI’s coaching supervision model addresses that problem by giving supervisors the management skills and support they need. “Nurses within long-term care constantly come to us and say, ‘Nobody taught us how to manage people. We’re trained as clinicians, and we came to this work to care for patients, not manage staff. And yet we’re told just to go out on the floor and start supervising 25 CNAs,’” reports Steven.

In response, PHI has developed a skill-based approach to person-directed care: “The ability to really listen to another person, the ability to offer feedback without judgment or blame, the ability to manage one’s emotions in difficult settings – these are not easy skills, but PHI’s Center for Coaching Supervision and Leadership is showing that these are skills that can be learned, and are enormously valued once mastered.”

What it takes to make it happen

“The good news is that there are several industry leaders who are taking very seriously the challenge of creating a ‘high investment-low turnover’ business model,” says Steven. “They range from rural home care agencies like the VNA of Indiana County, Pennsylvania, to very large home care agencies like the Visiting Nurse Service’s Partners in Care in New York City, and to family-owned nursing homes like the Edgewood Center in Portsmouth, New Hampshire, to Genesis Health Care New England.

“So, please don’t tell me we don’t know what to do to retain workers. Don’t hold another national conference calling for more analysis of the direct-care ‘crisis.’ Sure it’s is a crisis, but it’s an unnecessary one, because the problem isn’t not knowing what to do.

“The problem is that we have yet to build the political will in this country necessary to invest adequate resources into long-term care. Words probably won’t change that — but perhaps trying to find and keep one million more direct-care workers over the next decade will.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

This is the third in a series of PHI Expert Interviews, which bring you insights from four senior PHI staff. They’re an impressive group – among the nation’s leading experts on long-term care’s direct-care workforce – and collectively they’ve spent decades studying the challenges facing the workforce and how to address them. We think you’ll be interested in what they’ve learned.

Marcia Mayfield, PHI’s director of evaluation, helps PHI document its successes for policymakers, employers, funders, and anyone else who needs to know what works and what doesn’t. As she explains it, her evaluation team does three things:

• Helps PHI learn from what it has done, to make its work more effective;
• Documents PHI’s work and measures its impact, “both for our own purposes and to share what we’ve learned with others in the field”; and
• Develops evaluation tools and approaches for use by anyone interested in improving direct-care jobs. For example, providers can use a business investment calculator due out this fall to calculate their turnover costs, comparing that figure to the cost of various retention or culture change initiatives.

Hired last year by PHI  after 12 years as an evaluator for an international women’s  health organization, Marcia says her goal at PHI is “to demonstrate in a measurable way that what we’re doing works. We essentially have to make the business case for the initiatives we’re promoting.”

PHI works on two tracks, so she does too. Her training and organizational development (TOD) work measures whether and how PHI helps employers improve workforce practices. And her policy work measures the progress made by PHI and its allies in improving public policy to support direct-care workers.

Training and Organizational Development: Documenting process as well as outcomes

PHI’s Center for Coaching Supervision and Leadership (CCSL) is in the midst of a four-year initiative to introduce PHI’s coaching supervision model in nursing homes and home health agencies. Marcia’s team is an integral part of figuring out what is and isn’t working.

They’re collecting both quantitative and qualitative data to determine whether coaching supervision affects things like turnover, absences, and job satisfaction. And they’re evaluating the process itself, documenting how the program is being implemented.

Process evaluation, says Marcia, is an important and often overlooked step. “In CCSL, for instance, there was research that said if you improve supervision you improve retention, but there’s not a lot of evidence about how to do it, or how to sustain such an effort. So it’s important to document program implementation as you’re going along, rather than just collecting outcome data.”

On the most basic level, Marcia says, documenting the process provides evidence that people really did what they say they did. It also makes it easier to identify and change things that aren’t working well. For example, CCSL’s evaluation helped clarify who should attend the train-the-trainer sessions. “In the first year, people were selected who had a huge amount of other responsibilities within the organization, so pulling them away to do training was very difficult,” says Marcia. “In the second year, the CCSL team was much clearer about what was required – the skills and the amount of work and the commitment to the project. They also increased the number of people trained as trainers, to create depth in the organization and to mitigate the problem of trainer turnover, which had been an issue the first year.”

Policy: evaluating the interim steps

Changes in organizational practices may come slowly, but they seem lightning-fast compared to the process of passing a piece of legislation or changing a regulation. And so, with policy evaluations, the team starts by measuring what’s being done to prime the political pump.

“For Health Care for Health Care Workers our ultimate goal is for direct-care workers to receive needed health care coverage, but before legislative policies can be enacted work must be done just to increase awareness,” says Marcia. “So we look for things like increased media coverage and hits on our website, then measure whether that raises awareness.

“Alliances are also important, so we’re measuring things like how many partnerships we’re forming, who’s writing letters to legislators, and so on,” she adds. “You’re building evidence that there is a base of support for your issue, which often is a prerequisite for needed policy change.”

Making evaluation part of the process

Whether she’s measuring a policy or a TOD initiative, Marcia’s process is the same.  “At the start of all projects, we develop a logic model that engages staff and other stakeholders in thinking about the connections between inputs – the resources you put in and the activities you do and so on – and the results you expect, not just immediate outputs but intermediate and long-term outcomes as well.”

Any new program or project would benefit from that kind of evaluation, Marcia says. “It helps make sure that what you’re doing will lead to some kind of measurable outcome. And if there’s a certain outcome the staff want to see but their inputs are not addressing that in a straightforward way, it helps them engage in a discussion about what else might be needed.”

Last but not least, evaluation helps the field move forward, using the wheels other people have forged rather than constantly stopping to reinvent them. “You want to look at the existing empirical data and evidence, read the existing literature, before you start something new,” says Marcia. “You want to know what has worked in the past.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

This is the second in a series of PHI Expert Interviews, which bring you insights from four senior PHI staff. They’re an impressive group – among the nation’s leading experts on long-term care’s direct-care workforce – and collectively they’ve spent decades studying the challenges facing the workforce and how to address them. We think you’ll be interested in what they’ve learned.

Peggy Powell is one of the founders of Cooperative Home Care Associates, the worker-owned home health agency that started PHI, where she served as director of education. Since joining PHI in 1991, she has worked with CHCA and other employers to develop strategies for recruiting, training, supervising, and supporting direct-care staff.

One of those strategies, peer mentoring, is gaining in popularity – and no wonder. Done right, a peer mentor program helps new direct-care workers get oriented to the job and the organization, bolstering their skills and their confidence. It also creates a career ladder for experienced workers.

And that’s not all, as Peggy has learned.

Moving away from the blame game

Since helping CHCA launch its peer mentor program in 2002, Peggy has helped turn the program into a published curriculum and adapted it to two other organizations. The PACE CNY program at Loretto, a large, multi-setting elder services provider in central New York, started peer mentoring with funding from a grant to improve workforce practices. The Center for Nursing and Rehabilitation (CNR), a Brooklyn nursing home with subacute care and short-term rehabilitation units, established peer mentoring as part of its culture change initiative.

CHCA’s leaders got interested in peer mentoring when they looked at why turnover was so heavy during the first few months their aides spent on the job and concluded that new workers needed more support.

“We wanted to move away from the blame game,” says Peggy. “You often had the newer workers complaining that they needed more support. Meanwhile, the coordinators complained that the new workers needed too much of their time – and that they didn’t seem to know the procedures and tasks they should have learned in training. That led the coordinators to blame the trainers. And then the trainers blamed the recruiters, for not screening candidates adequately.

“The idea behind the peer mentor system was that the problem was with the system, not with the people. People need time to learn their jobs and to learn the culture of the places where they work. New workers need someone they can ask questions of – someone they can trust.”

If you’ve seen one program, you’ve seen one program

Each mentor program needs to be tailored to the needs of the organization, Powell stresses. “I always say: If you’ve seen one mentor program, you’ve seen one mentor program.”

Before an organization writes job descriptions or starts recruiting its mentors, Peggy and her PHI colleagues interview staff at all levels, from aides to operations managers. In part, they’re generating buy-in and making sure everyone understands how peer mentoring will work, but they’re also gathering valuable information about particular needs that may affect how the program is structured.

For example, both CHCA and PACE have used their mentor programs to change the way they assigned cases. Rather than assigning a challenging case to a new aide and expect her to manage the case competently on her own, they alert the aide’s mentor, to make sure someone will check in to offer support and answer questions. In the past, Peggy says, tough cases contributed to high turnover rates amonth new aides at both organizations. “They’d get overwhelmed and they wouldn’t have anyone to turn to for advice, so they would just leave.”

To handle the volume of new workers at their fast-growing organization, CHCA also amended its program to create a two-tiered mentor structure. Level 1 mentors work full-time as aides and do 10 hours of mentoring a month. Level 2 mentors work as mentors full-time and handle more complicated cases.

Key elements

PHI has identified 10 elements of a formal peer mentor program. Peggy singles out five as crucial:

• Create a clear program design. Explain the role mentors will play and how it fits in with your existing orientation.
• Get buy-in from management. Make sure the mentor program will solve a business problem in the organization – e.g., improving job satisfaction or reducing turnover – to ensure that management invests the time and money needed.
• Compensate mentors adequately, either through a raise in their hourly wage or through a monthly stipend. “A lot of organizations will say, ‘We’ll pay 20 or 25 cents more an hour,’ because that’s all they feel they can afford – and because they’re not really looking at the cost of turnover,” says Powell. She recommends that raises be at least 50 cents an hour.
• Train and support mentors adequately. PHI starts its mentors with a two-day training session, followed by two booster sessions within the first two months. In addition, the program director checks in regularly to offer support as needed.

The payoff

“You can get a mentor program up and running in four to six months, and if you do it right you’ll see changes very soon,” says Peggy.

Done right, she adds, peer mentoring helps residents and other staff, not just direct-care workers. “A good peer mentor helps the relationships thrive between the residents, the nurses, the other workers, and the aides. They help the system achieve its goals around quality care and staff satisfaction.”

At CNR, a survey of workers, residents, and family members before and after the intervention found that ratings rose significantly on many key indicators. Residents and their relatives were much more likely to recommend CNR to others, for example, and far more satisfied with the “friendliness and skill of CNAs.” And in the PACE program, the turnover rate for new hires dropped from 48 percent in the first six months in 2005, just before the program was implemented, to 12.5 percent in 2007.

Peggy points to ECCLI, LEADS, and the Foundation for Long Term Care as initiatives that have fostered successful peer mentor programs.

Developing leaders

One unexpected bonus of peer mentoring for Peggy has been its capacity to create new leaders within an organization. “The outcome is a more confident and empowered worker who’s willing to take greater risks, to grow,” she says. “As these mentors begin to see the growth in people they’ve worked with, it allows them to grow in their own self-confidence about what they’re capable of doing.

“At CHCA, after about a year and a half of CHCA organizing their support meetings, the mentors decided they could do it themselves. Now they organize every meeting, with a check-in on where people are at and a skills piece where people are learning something new. It’s been the most amazing thing for me to see.”

Peggy built that new knowledge into her recent collaboration with CNR, whose peer mentor program is called Mentors as Leaders. The home, which had restructured its units into neighborhoods, wanted CNAs to be leaders in its culture change initiative as well as mentors for workers in the neighborhood.

“Peer mentoring can be a powerful tool for building leaders,” says Peggy.

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

The One Thing You Need to Make Culture Change Work

Sue Misiorski, PHI’s Director of Organizational Culture Change, has been making nursing homes better places to live and work for more than 20 years. A registered nurse, she started her career as a CNA and later became a director of nursing and vice president of nursing for an innovative nursing home chain.

Sue is also one of the pioneers of the Pioneer Network, the people behind the concept of culture change. She was president of the Pioneer Network for three years, and she wrote its handbook on how to implement culture change: Getting Started: A pioneering approach to culture change in long-term care organizations.

The Pioneers have worked hard to keep the concept of “culture change” flexible. They say that it’s a journey, not a destination, and that it can start almost anywhere. In keeping with that philosophy, Sue and her PHI colleagues start with an organizational assessment when they work with an employer, learning about that particular organization’s needs and goals rather than trying to impose a cookie-cutter solution.

But Sue has learned that one thing must be in place before an organization can embark on its culture change journey. “Relationships have to be healthy and strong, with a high level of trust and honesty and respect,” she says. And that means all relationships – between frontline workers and the people they assist, between workers and their supervisors, and between workers in different departments.

No teamwork, no change

“We often get called into an organization as consultants after changes have already been attempted and met with a lot of resistance,” says Sue. “We hold focus groups with all kinds of staff in all departments, all shifts. We ask them a series of open-ended questions, and we listen. And based on what we hear, we can often figure out that there’s a problem with relationships that need to be grown and healed in order to move forward.”

“Let’s say, for example, that you want to change how you serve food in your nursing home – away from institutional tray service to a more homelike dining style. If your nursing assistants and your nurses are not in a good relationship with the dietary department, the teamwork that’s required just isn’t in place.”

Developing a core set of skills

Building good relationships “isn’t simply intuitive,” says Sue; it requires a core set of skills. Sue and her PHI colleagues have identified those skills and developed adult learner-centered ways of teaching them, working some into published curricula.

Communications skills, says Sue, boil down to “a combination of self-awareness and self-management.” PHI’s communication skills training for direct-care workers and other non-management staff includes:

• Active listening, or making sure you truly understand what someone else is saying;
• Pull-back, which means maintaining emotional control in stressful situations;
• Problem-solving by exploring options; and
• Appreciative inquiry, which is a means of approaching other people and one’s work from a positive perspective, identifying strengths and opportunities rather than weaknesses and problems.

Supervisory and management staff learn coaching supervision, which includes all the same skills as well as “how to present a problem without blame or judgment,” says Sue.

Cross-functional teams, where direct-care workers, supervisors, organization leaders and others work together to implement a change, can also foster better relationships – though not without a little assistance. Team members from different levels of the organizational hierarchy are generally unused to working together, so a newly formed team often requires support and training in order to learn how to communicate with one another. “Otherwise, what often ends up happening is that a couple of people do most of the talking,” says Sue.

From that, great ideas are born

Once good relationships have been formed, everything else becomes possible, says Sue.

To keep people talking, she and her colleagues often help organizations start learning circles, bringing staff from all departments together with clients to talk about how they want to live and work together. “From that, great ideas with a lot of energy behind them are born,” says Sue.

“There are so many wonderful opportunities: consistent assignment, changing caregiving practices and routines to be person-directed and less institutional, breaking the larger organization into smaller neighborhoods, changing how you serve meals, changing how you bathe people, changing how you administer medications, changing how activities happen.

“There isn’t a department that can’t be included in what happens next.”

Interview by Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org