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Three brief stories on direct care:

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Consumer Voice Launches Home Care Survey

Consumer Voice

In an effort to improve the quality of home care, the Consumer Voice is conducting a survey of:

• consumers who have received home care services and supports in the past year or two, and
• families and friends who have arranged these services for others.

The survey is available online. The deadline to complete it is September 1.

The Consumer Voice represents consumers in issues related to long-term care, helping to ensure that consumers are empowered to advocate for themselves.

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Book Examines Home Care Workers’ Lives

A new book explores the deep, often profound impact that the daily routine of caregiving has on the lives of home care workers.

Clare L. Stacey, an assistant professor of sociology at Kent State University, drew upon interviews with home health aides and personal and home care aides to write The Caring Self: The Work Experiences of Home Care Aides.

The book examines the meaningful ties that many home care workers make with the elders and people with disabilities for whom they provide care.

It also details the difficult and often unfair conditions under which home care workers must work, and the emotional and physical toll those conditions can take.

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New York State Person-Centered Care Initiative to Expand

The Western New York Alliance for Person-Centered Care (WNYAPCC) has created a membership program in an effort to expand its person-centered care initiative.

The program is designed to enhance collaboration and synergy among organizations and health care professionals that provide long-term care and geriatric services in an eight-county region in New York State.

More information on the membership program is available on the WNYAPCC website.

– by Deane Beebe and Matthew Ozga

Robyn Stone

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

– by Deane Beebe and Karen Kahn

PHI President Steven Dawson

PHI President Steven Dawson argues that both a flagging economy and efforts to move toward new models of care provide the opportunity for the health care industry to redefine the role of the home health aide.

In a guest blog post for the Collaboration for Homecare Advances in Management and Practice (CHAMP), Dawson writes that “greater person-centered, cost-effective care is standing before us.”

He recommends that home health aides be given the tools they need to practice at the top of their license.

The CHAMP Program, based at the Center for Home Care Policy & Research of the Visiting Nurse Service of New York, is a national initiative to advance home care excellence for older people. The online site provides home care clinicians with evidence-based tools, e-learning opportunities, and expert advice.

– by Deane Beebe

Fifteen states have received federal contracts from the Centers for Medicare and Medicaid Services (CMS) to design new ways of providing coordinated care for individuals receiving both Medicaid and Medicare benefits, also known as “dual eligibles.”

The chosen states will receive up to $1 million each, which they will use to develop creative, person-centered strategies that will promote simplified care models for “dual eligible” individuals.

The project’s funding stems from a provision in the Affordable Care Act.

Costly and Complicated Care

Of the approximately 100 million individuals enrolled in Medicare and Medicaid, nine million are dual eligible (pdf).

Providing and coordinating care for those nine million beneficiaries can be complicated and costly.

According to CMS, for example, dual eligibles account for 27 percent of Medicare spending and 39 percent of Medicaid spending each year — percentages that far exceed their proportional representation within those two programs.

In addition, the care infrastructure for dual-eligible individuals tends to be unnecessarily complex, according to CMS.

“The more than 9 million dual eligibles in the U.S. are more likely to have mental illness and/or multiple chronic disorders than recipients of either Medicaid or Medicare,” said Michigan Medicaid Director Stephen Fitton. “Yet because of their unique status, they tend to face the most complicated and uncoordinated care models of anyone in the U.S.”

Many dual eligibles have to contend with multiple sets of benefits; multiple providers, which may or may not coordinate their patients’ care; and several different identification cards — one each for Medicaid, Medicare and a prescription-drug benefit.

Simplifying Care for Dual Eligibles

The 15 states have been tasked with integrating and coordinating person-centered care for dual-eligible beneficiaries across multiple spectrums: primary, acute, behavioral, and long-term care.

Michigan, for example, has received $1 million to help make its Medicaid and Medicare infrastructures more complementary for dual eligibles. Representatives from PHI Michigan will help advise that state on constructing its proposal.

“Integrating care for those who are eligible for both Medicaid and Medicare really is a win-win for our state,” Michigan Governor Rick Snyder told Crain’s Detroit Business.

“Vulnerable recipients will benefit through better coordinated and higher quality care, and Michigan taxpayers will benefit by ensuring resources are spent wisely.”

Presenting Proposals

States will present their proposals to CMS’s Federal Coordinated Health Care Office, also known as the Duals Office. The Duals Office was established in December as part of the Affordable Care Act.

The Duals Office will work with the 15 states to flesh out their most promising proposals.

In addition to Michigan, the states chosen for the contracts are California, Colorado, Connecticut, Massachusetts, Minnesota, New York, Oklahoma, Oregon, South Carolina, Tennessee, Vermont, Washington State, and Wisconsin.

– by Matthew Ozga

Nursing Home Compare's star rankings

The National Quality Forum (NQF) has endorsed a slate of 21 measures designed to assess the quality of nursing home care.

Three of the measures are based on survey data gathered from current and former residents as well as residents’ family members.

Most of the other measures are quantifiable resident health outcomes that are known to correlate with care quality, including the incidence of pressure ulcers, moderate-to-severe pain, and urinary tract infections among residents.

The 21 measures will be integrated into Nursing Home Compare, a searchable online database of more than 17,000 U.S. nursing homes. Nursing Home Compare is operated by the Centers for Medicare and Medicaid Services (CMS).

Survey Assesses Person-Centered Care

One of the three survey-based measures uses responses from people who have resided in a nursing home for at least 30 days.

That survey asks respondents to rank, on a scale of 1 to 10, the comfort of their surroundings and the professionalism of the staff.

It also asks residents whether their facilities are person-centered by asking questions such as, “Can you choose what time you go to bed?” and “Can you choose what activities you do here?”

“These sorts of questions demonstrate that the concept of person-centered care has positively impacted nursing home care throughout the country,” said PHI Director of Training and Organizational Development Services Susan Misiorski. “We applaud NQF and CMS for advancing person-centered practices through their nursing home assessments.”

A second survey asks relatives of nursing home residents to give their impression of the care their loved ones are receiving. A third survey is designed to be answered by recently discharged residents and is administered by mail only.

The surveys used in the NQF-endorsed measures were created by the Consumer Assessment of Health Providers and Systems (CAHPS).

Long-term care stakeholders who are dissatisfied with any of the 21 measures should notify NQF, via its website, by April 1.

NQF is a nonprofit organization that establishes and disseminates voluntary standards designed to improve the quality of U.S. health care.

– by Matthew Ozga

The Ohio Department of Job and Family Services and Ohio Department of Aging are sponsoring a summit to gather input for a unified health and human services strategy to improve the state’s long-term direct service workforce in the state.

At the session, core competencies that can be shared across disciplines and service sectors will be identified, as well as collaborative solutions aimed at leveraging costs and creating efficiencies.

“Cultivating a Workforce for Person Centered Long-Term Services and Supports”

Stakeholder Summit for Ohio’s Long-Term Direct Service Workforce Initiative

April 8, 2011
9:00 am – 4:30 pm

Northeast Conference Center
4140 Executive Parkway, Westerville, Ohio

Featuring:

• John McCarthy, Medicaid Director, Ohio Department of Job and Family Services
• Bonnie Kantor-Burman, Sc.D., Director, Ohio Department of Aging
• Sheryl Larson, Ph.D., National Direct Service Workforce Resource Center

The registration deadline is April 5.
Space is limited.

Key representatives from the following stakeholder groups are encouraged to attend:

• Providers
• Employees
• Training programs
• Local Workforce Boards
• College and university faculty and students in degree programs in health and human service shortage areas
• State agency program and policy staff
• Advocates, service recipients, and family members

For more information, contact Dushka Crane-Ross, Ohio Colleges of Medicine Government Resource Center, by e-mail or phone (614-366-3126).