The more than three million direct-care workers (home health aides, personal care attendants, certified nurse assistants) are an underutilized resource in our health care system. These workers are ideally positioned for improving the lives and care of individuals with multiple chronic conditions and functional limitations. If properly supported and trained, direct-care workers could provide timely information to members of the health care team and offer an enhanced level of support to the individual receiving care. The result? Better care at lower cost.
One strategy for improving the quality of direct-care jobs—which continue to be poorly supported and compensated--is to provide real opportunities for advancement. Currently, a direct-care worker is likely to earn much the same hourly wage during her first year of employment as ten years down the road. Other than nursing, which takes considerably more education, there are few, if any, advancement opportunities. What is needed is an advanced role that builds on the knowledge of experienced aides, offers an opportunity for additional skill development, and provides a significant increase in compensation.
Contact UsSend us your comments and suggestions on the advanced aide concept, especially any information on advanced aide models currently being developed. Contact Robert Espinoza at respinoza@PHInational.org.
Greater Value for Health Care System
With rapid changes in the organization of health care, there is a genuine opportunity to develop advanced aide roles that offer greater value to the health care system and thus allow for increased compensation. The shift from fee-for-service toward capitated payments and managed care places more responsibility on long-term care organizations to provide quality care in the most cost-effective manner. This requires new delivery models, which if thoughtfully implemented, could employ experienced direct-care workers in supporting better chronic care management and care transitions, and ensuring fewer re-hospitalizations for individuals with multiple chronic conditions.
At the same time, these advanced roles would help to fill in a gap – or a missing “rung” – in the career ladder between the direct-care worker and more highly paid and skilled occupations. The truly advanced role we envision would be a significant career step for a select number of workers. It in no way replaces the need to invest in improved skills and compensation for all workers, but that effort is distinct from advanced role training described here.
Advanced Aide Functions
An advanced role would include a combination of three distinct direct-care functions, which in turn would support a fourth function, sharing knowledge gained through extensive daily contact with the consumer as an active participant in the care coordination team. Advanced role functions, thus, include:
- Clinical Observation, Monitoring, and Reporting: Observation of diseases and chronic conditions to recognize and report early-warning signs/symptoms or changes in the consumer’s clinical status. This would require a strengthening of observation and communication skills, as well as deeper knowledge of certain chronic diseases and post-hospitalization complications. Where available, this should include the use of remote monitoring technology.
- Health Education and Outreach: Through health coaching and navigation assist the consumer in achieving better outcomes. Appropriately trained aides could provide consumers with counseling on health promotion and prevention, generally, as well as help adhering to specific treatment plans. An aide might also assist a consumer in making and keeping medical appointments or facilitating healthy meal choices. When a direct-care worker is already providing care to a consumer, equipping her to take on these responsibilities may eliminate the need and expense of bringing another team member into the home.
- Medication Adherence: Assist in the timely adherence to medication schedules and, depending upon the Scope of Practice laws and regulations, either assist or administer medications as prescribed.
- Care Coordination: Participate in the Interdisciplinary Care Team, assisting the team to understand the needs of the consumer and problem-solve issues that arise, including those related to transitions in care and services in the home.
Examples of current programs and models which include some elements of the advanced responsibilities and training an Advanced Aide might encompass are listed below.
- A demonstration project in New Jersey tested expanding the scope of practice for home health aides to include assistance with administration of medications.
- The Service Employees International Union Healthcare NW Training Partnership works to professionalize the home care field by building career ladders and deepening support for home care workers by implementing a Peer Mentoring program for home care aides, with a particular focus on newly employed home care aides and those employed for less than one year.
- Independence Care System launched a Senior Aide Program in 2011 to incorporate an advanced home health position into its interdisciplinary care management team.
- The “I CARE-4-Healthcare Transition Project” at the University of Medicine & Dentistry of New Jersey (UMDNJ) includes an integral role for certified home health aides in efforts to prevent re-hospitalizations.
- Projects funded by the Center for Medicare and Medicaid Innovation aimed at testing advanced roles for aides in Arkansas and California.
- In the 113th Congress, U.S. Senator Robert P. Casey, Jr. (PA) and Representative Matt Cartwright (D-PA-17) introduced legislation to support the testing of new models of care (pdf) that draw on the strengths of direct-care workers to improve care and reduce cost.
- New York’s Medicaid Redesign Team Workforce Flexibility & Scope of Practice Work Group made recommendations to expand the scope of practice for home health aides and create a platform for advancement for these aides. In 2015, a workgroup of stakeholders issued recommendations (pdf) for the creation of an Advanced Home Health Aide occupation. These recommendations have been included in bills in the past few legislative sessions, but have yet to fully pass the legislature.
- Forum on Innovations in Care Coordination: Rethinking the Role of Home Care Workers – On March 1, 2012, over 100 home care stakeholders, health care policy experts, and national policymakers gathered to discuss the opportunities and challenges presented by the concept of advanced roles for home care workers. And, on April 22, 2013, a Home Care Summit was held in New York City under the sponsorship of the Speaker of the City Council, Christine Quinn. That Summit included a panel on “Expanding the Aide’s Role to Meet Consumer Need,” with the recommendation for a pilot or demonstration to begin in New York.
The Affordable Care Act (ACA) offers numerous opportunities for states and health care providers to design and implement initiatives to better coordinate and manage the health care needs of beneficiaries. These provisions may also allow for the development and testing of advanced roles for direct care workers.
- Advanced Direct Care Worker: A Role to Improve Quality and Efficiency of Care for Older Adults and Strengthen Career Ladders for Home Care Workers (pdf), a brief from the Eldercare Workforce Alliance, September 2014
- Innovations in care coordination: Rethinking the role of home care workers, Senate briefing by PHI President Steven Dawson, March 2012
- Making the most of direct-care workers with a new role on the care team, Aging Today, Jan-Feb 2012
- Achieving Better Chronic Care at Lower Costs Across the Health Care Continuum for Older Americans, Brookings
- PHI Workforce and Curriculum Development Services
- Envisioning Enhanced Roles for In-Home Supportive Services Workers in Care Coordination for Consumers with Chronic Conditions (pdf), Janet Coffman and Susan Chapman
- “Enhancing the role of home health aides as congestive heart failure and diabetes disease management coaches,” Catherine Kelleher
- "A National Survey of Medication Aides: Education, Supervision and Work Role by Work Setting," Jill Budden
|PHI||New York Governor Announces Support for Advanced Aide Legislation||January 13, 2016|
|The Eldercare Workforce Alliance||Alliance Brief Highlights Untapped Labor Potential in Time for Labor Day||September 2, 2014|
|The Brookings Institution||What Payment Reform Means for the Frontline Health Care Workforce||August 5, 2014|
|The Brookings Institution||Part of the Solution: Pre-Baccalaureate Healthcare Workers in a Time of Health System Change||July 24, 2014|
|PHI||New York Gov. Cuomo Proposes Advanced Position for Home Health Aides||June 9, 2014|
|Concord Monitor||Reform Health Care? Start with Home Health Care||February 28, 2013|
|San Jose Mercury News||Coordinated Care Key to Saving Health Care for Seniors||April 24, 2012|
|Forbes||The Role Home Health Aides Should Play in Caring for the Frail Elderly||March 1, 2012|