Check out the newest additions to PHI’s National Clearinghouse on the Direct Care Workforce:

Increasing staff retention – A fact sheet from the Advancing Excellence in America’s Nursing Homes campaign.

The interplay of CNAs’ views of residents and nursing home environments – Identifies CNAs’ perspectives of nursing home residents and how these perspectives translate into care practices.

Growing your staff – Reports on several nursing homes’ efforts to address the nursing and direct-care workforce shortages.

An information-based approach to staff efficiency – This article advocates reorganization of workflow and realignment of workload to address retention and attendance problems in nursing homes.

PHI’s National Clearinghouse on the Direct Care Workforce is a national online library for people in search of solutions to the direct-care staffing crisis in long-term care. It houses  over 800 articles, reports, issue briefs, and fact sheets on the direct-care workforce.

The Institute for the Future of Aging Services (IFAS) just released more materials. Available at bjbc.org, they include a catalog of tools and resources based on the work of BJBC grantees and a report that includes practical applications for key research findings.

Solutions You Can Use: Transforming the Long-Term Care Workforce takes the major findings and examines how aging-services providers can use them to build a quality workforce. The booklet is organized by WHAT WE LEARNED and WHAT IT MEANS TO YOU.

The findings are organized around four themes:

• Where to find new pools of workers
• What interventions improve retention
• The training direct-care workers and nurse supervisors want and need
• How to develop cultural competence

A Crisis With A Solution: Tools and Resources for Transforming the Long-Term Care Workforce is a compilation of the tools and resources used and developed by BJBC and the grantees.

An accompanying 9-minute video features several BJBC providers sharing their journey from a workplace in crisis to one that empowers direct-care workers and is transforming the way they do business. Narrated by Robyn Stone, BJBC national program director and IFAS executive director, it shares the overall lessons learned during the four-year project.

“Our wish is that you use the tools to invest in your staff,” Stone wrote in an opening letter to the catalog.

The multi-state project began in 2002 and ended in 2006 and was funded by the Robert Wood Johnson Foundation and The Atlantic Philanthropies. IFAS and PHI conceived of BJBC and provided technical assistance to the grantees.

PHI’s Health Care for Health Care Workers (HCHCW) campaign invites direct-care workers and their allies in Pennsylvania to a conference on October 3. Conference registration is open through September 19. Exhibitor registrations will be accepted through September 12 or until exhibit space is sold out.

Empowering Our Future will bring together an emerging network of workers, worker-advocates, and others concerned about the future of long-term care in Pennsylvania. Workshops and activities for personal care attendants, nursing assistants, and other direct-care workers will cover a range of topics, including:

• Working with clients with dementia;
• Resolving conflicts;
• Managing your personal finances; and
• Communicating effectively with policymakers

“The conference is a rare opportunity to develop leadership skills, become an effective advocate for change in long-term care settings, and discuss the issues confronting the long-term care system with your peers,” says Tracy Lawless, Pennsylvania State Campaign Coordinator for HCHCW.

It also gives organizations that support or employ direct-care workers a chance to reach them through exhibiting or advertising in the brochure.

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

Home health agencies that want to improve staff retention and client outcomes will find some unexpected results and useful lessons in a report recently posted to the US HHS/ASPE Office of Disability, Aging and Long-Term Care Policy website.

Home Health Aide (HHA) Partnering Collaborative Evaluation: Final Report (pdf) assesses the impact of an effort to truly incorporate home health aides into care teams. The initiative was implemented in 2003 by the Visiting Nurse Service of New York (VNSNY) and several of its licensed agency partners.

“It’s working because the aides feel more involved in the team, and they appreciate that,” says Daisy Diaz, supervising coordinator for Cooperative Home Care Associates (CHCA), one of the participating agencies. “They work hard, and it’s good for them to get acknowledged.”

It’s also good for the agency and its clients to get more regular and immediate input from the aides, Diaz adds. “They call us right away now to let us know about any issues with the patients. They also call the nurse.”

The Five Promises

One of the main tools for improving relationships between nurses and aides is The Five Promises. A set of five activities that the nurse and HHA working on a case promise to go over every time they are together, they start with “Introduce yourself and show your I.D.” and include “Discuss any observations or concerns about the patient that you have today.” The Five Promises were conceived as “reminders to everyone involved – particularly the nurses, but the aides as well – to have a face to face interaction when they’re in the home together, to share observations and to troubleshoot,” says Miriam Ryvicker, VNSNY research associate and the project manager for the HHA Partnering Collaborative.

That may sound obvious, says Sally Sobolewski, director of practice improvement for VNSNY, but most agency staff need to start with the basics in improving their communication, whether they realize it or not. “Most care team members assume there is little or no dissatisfaction on their immediate team,” she says. “Recognizing how communication and inclusion is perceived is the first step to improving the process.”

Lessons Learned

In addition to improving relationships between nurses and HHAs to incorporate the aides more fully into the care team, the initiative was aimed at getting aides more involved in helping the people they assist become more functionally independent. “We did see some modest improvement in patients’ ability to walk and get in and out of bed, but I want to emphasize the ‘modest’ part of that statement,” says Ryvicker. “The impact wasn’t quite enough to be clinically meaningful, but we did learn a lot from it.”

One of main lessons learned, she says, was the importance of communication – not just between nurses and aides but among the nurses and supervisors involved in the project. “As the initiative grew, it became more of a challenge to maintain the peer-to-peer communication that was driving the process,” she says. “This is a very large agency. A group of nurses and aides had become champions of the initiative early on. They communicated regularly for a while with their peers on other teams, but as the initiative grew, that was difficult to maintain.”

Another important finding was that best way to improve retention was to work on scheduling in order to give HHAs full-time work, or close to it. “It was a powerful finding: having enough hours contributed much more than any of the other things we looked at in explaining whether people stayed on the job,” says Ryvicker. “We found there was a jump in retention at something close to full-time hours – around 35 hours a week, I think, but we’re still doing the analysis, so I’m not sure. So there’s been a lot of talk about scheduling, and the structural issues that keep aides form getting a full workload.”

“Change Does Not Occur through Implementing Best Practices”

Another important lesson learned, says Sobolewski, is that “change does not occur through implementating best practices. Best practices are just the beginning tools to introduce a change in the process of how teams and licensed agencies, or clinicians and HHAs, will work together.”

In order to tend that process, she says, organizations need to answer questions like “How will we check in to see how these changes are holding? What is working well? And when things break down (and they will!), do we treat that as a failure or an opportunity?”

VNSNY “incorporated the process into the fabric of the organization,” Sobolewski says, by making one of its staff members responsible for providing feedback to teams, managers, and clinical directors. Participating coordinators like Diaz also provide peer-to-peer support, holding conference calls every two weeks to share progress reports and help each other solve problems as they arise.

Significant progress has been made, all agree, but there’s more work to be done before HHAs are fully integrated into the care team and the quality improvement process. One of the main challenges, Ryvicker notes, is the nature of home care work. “It can be difficult to integrate people into the team when, by definition, it’s a very dispersed workforce.”

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

Experts including long-term care consultants Barbara Frank and David Farrell, Marguerite McLaughlin of Quality Partners of Rhode Island, and more will discuss the variables affecting recruitment and retention and describe a variety of interventions and best management practices that can improve retention. Among the presenters is Doug Motter of Homestead Village in Lancaster, Pennsylvania, who will talk about how staff has been affected by the culture change process his facility is going through, which includes implementing the coaching model of supervision.

The Staff Stability webinar is the last in a series of three webinars offered by the Advancing Excellence in America’s Nursing Homes campaign. The others focused on reducing restraints and assessing resident satisfaction.

Details and registration information (pdf)

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

ANCOR continues its advocacy work for direct support professionals (DSPs) with two announcements this month: It has selected the winners of its 2008 DSP TV Online video contest, and it has won the unanimous support of the U.S. Senate for its National Direct Support Professionals Week.

The six DSP TV Online winners — all both by and about DSPs and the people they work for – are now available for viewing on ANCOR’s website. (Above, see the winning video.) All six are full of heart. They convey the pride and joy dedicated DSPs take in their profession, the difference they make in the lives of the people they work with, and the mutual respect and affection that develop between workers and clients. They also contain calls for better pay and benefits, along with a lot of singing, dancing, and enthusiastic expressions of gratitude. ANCOR calls them “part of a greater effort to raise awareness of the workforce wage issue and give DSPs the ability to tell their stories in their own words, and as only they can.”

In addition, the U.S. Senate has recognized the week of September 8 as National Direct Support Professionals Recognition Week. (pdf) The unanimously approved resolution is timed to coincide with ANCOR’s annual Governmental Activities Seminar and its DSPs to DC event in Washington, D.C.

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

Recommendations for Establishing a Credentialing System for Iowa’s Direct Care Workforce,

The report documents work to be done to implement recommendations published by the task force in December 2006.  Work began on the project last month.

Iowa’s proposed three-tiered credentialing system is intended to ensure that all direct-care workers are adequately prepared for the job. It also aims to make workers’ duties and qualifications clear to the consumers and family members who hire them, to acknowledge their special skills, and to correct the inequities of the current system, which requires training in some settings but not in others even when the same set of services is delivered in both.

The report includes 17 recommendations, a timeline, and detailed lists of criteria, qualifications and resources needed to create:

• A standardized curriculum for all new direct-care workers, regardless of setting
• Educational equivalency with other health care professions
• Standardized qualifications for educators and trainers
• Continuing education requirements for direct-care workers, educators and trainers
• Governance

It also includes an extensive list of specialty skills that should be eligible to receive “endorsements.”

A 16-page implementation plan (pdf) will guide the group’s work, with adjustments as needed as the project progresses.

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org

Many of the barriers that stand in the way are systemic – boulders that no one person can shoulder aside on his or her own. But a self-published, spiral-bound booklet created by an aging services specialist gets long-term care consumers closer to that goal by giving them a way to keep track of their vital information — and share it with direct-care workers and other health care professionals.

The Personal Health Care Passport (PCHP) includes tips on how to communicate with caregivers, but most of its 18 pages are devoted to forms for listing key information. Forms include:

• Family contact information
• Medical histories
• Current medications and other treatments
• Favorite doctors, pharmacists, and hospitals
• Special nutritional needs
• Daily activities

“The whole point of this is, I want to see people empowered,” says Melissa Kahn, who created the PCHP. “Whether it’s the person receiving care or a paraprofessional who’s caring for a new client or a relative who’s caring for someone, maybe long-distance, and doesn’t know anything about their health care needs, the PHCP was designed to foster a dialogue between all parties and encourage a person-centered approach to care.”

Visit Kahn’s website for more information or to order copies.

Elise Nakhnikian, Senior Online Editor
enakhnikian@phinational.org