5
The Direct-Care Workforce

CHAPTER SUMMARY

This chapter describes the direct-care workforce—nurse aides, home health aides, and personal- and home-care aides—which is in many respects the linchpin of the formal health care delivery system for older adults. This collection of workers supplies a major portion of the direct care provided to older adults, including the provision of some clinical services plus assistance with bathing, dressing, housekeeping, and food preparation. Direct-care workers have rewarding but difficult jobs, and they are typically very poorly paid and receive little or no training for their duties. As a result, turnover rates are high, and recruitment and retention of these workers is a persistent challenge. In the context of rapidly increasing demand for direct-care services, the need for these workers is beginning to reach a crisis stage. This chapter discusses a range of approaches to improve the quality of direct-care occupations, including needed increases in pay and benefits. In addition, improvements in the education and training of these workers are needed to ensure that they have the knowledge and skills required to meet the care needs of older patients.

Direct-care workers, also referred to as paraprofessionals, are the primary providers of paid hands-on care, supervision, and emotional support for older adults in the United States. While not all direct-care workers care for older patients, they work primarily in settings important in the care of older adults, such as nursing homes, assisted living facilities, and home-care settings. According to the Bureau of Labor Statistics (BLS), about three



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5 The Direct-Care Workforce CHAPTER SUMMARY This chapter describes the direct-care workforce—nurse aides, home health aides, and personal- and home-care aides—which is in many respects the linchpin of the formal health care deliery system for older adults. This collection of workers supplies a major portion of the direct care proided to older adults, including the proision of some clinical serices plus assis- tance with bathing, dressing, housekeeping, and food preparation. Direct- care workers hae rewarding but difficult jobs, and they are typically ery poorly paid and receie little or no training for their duties. As a result, turnoer rates are high, and recruitment and retention of these workers is a persistent challenge. In the context of rapidly increasing demand for direct-care serices, the need for these workers is beginning to reach a crisis stage. This chapter discusses a range of approaches to improe the quality of direct-care occupations, including needed increases in pay and benefits. In addition, improements in the education and training of these workers are needed to ensure that they hae the knowledge and skills required to meet the care needs of older patients. Direct-care workers, also referred to as paraprofessionals, are the pri- mary providers of paid hands-on care, supervision, and emotional support for older adults in the United States. While not all direct-care workers care for older patients, they work primarily in settings important in the care of older adults, such as nursing homes, assisted living facilities, and home-care settings. According to the Bureau of Labor Statistics (BLS), about three 

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00 RETOOLING FOR AN AGING AMERICA million workers were employed in direct-care occupations in 20061 (BLS, 2008c,d). Still, the current number of direct-care workers is insufficient to meet demand (GAO, 2001a,b; Stone, 2004). The need for direct-care workers is expected to increase in the coming decades, mainly because of the aging of the population but also because the number of females aged 25 to 54—the typical direct-care worker demographic—is projected to remain flat (PHI, 2001). A further trend that may exacerbate this unfulfilled need, especially for personal- and home-care aides, is a shift away from institutional care to home- and community-based care. Policy makers and payers are increas- ingly implementing home- and community-based care programs in response to consumer preferences and legal mandates and with the hope that costs will be lower for at least some types of services. However, caring for older adults in these settings may require proportionately more direct care-level staff than in institutional facilities (National Center for Health Workforce Analysis, 2004). The workforce providing non-institutional personal as- sistance and home health services tripled between 1989 and 2004, and Medicaid spending for these services also increased significantly during that time (Kaye et al., 2006). Over that same time period, the workforce providing similar services in institutional settings remained relatively stable. In fact, the BLS predicts that personal- and home-care aides and home health aides will represent the second- and third-fastest growing occupa- tions between 2006 and 2016 (BLS, 2007b). This trend will not only lead to an increase in demand for services in non-institutional settings but will also require home-based workers to deliver more skilled care to patients with more complex needs (Seavey, 2007b). In home- and community-based care settings, carers work more independently and rely on personal skill and judgment; however, many direct-care workers do not receive the education or training they need in order to be prepared for the care of older patients with complex care needs. A major factor in the deficit of direct-care workers is the poor quality of these types of jobs. Direct-care workers typically receive very low salaries, garner few benefits, and work under high levels of physical and emotional stress. In 2005 the median hourly wage for all direct-care workers was $9.56, about one-third less than the median wage for all U.S. workers (Dawson, 2007). Direct-care workers are more likely to live in poverty, to lack health insurance, and to rely on food stamps than other workers (GAO, 2001b). Additionally, these workers have high rates of job-related injury, most often due to overexertion in the care of a patient (BLS, 2007a). All of these factors contribute to the unacceptably high rates of vacancies 1 Itis important to note that this figure does not include the many workers who are hired privately by patients and their families.

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0 THE DIRECT-CARE WORKFORCE and turnover among these occupations, which can, in turn, lead to poor quality of care for patients. Much of this chapter focuses on issues concerning direct-care workers in general because there is relatively little data on the group of direct-care workers solely involved in the care of older adults; whenever possible, how- ever, issues related specifically to the care of older adults will be highlighted. The chapter begins with descriptions of direct-care occupations and the basic demographics of the current workforce, followed by an overview of the current state of education and training of these workers. The chapter then discusses challenges to the recruitment and retention of direct-care workers, including financial disincentives and difficulties in work environ- ment. The chapter concludes with an examination of strategies to improve the recruitment and retention of direct-care workers, including enhancing the quality and quantity of basic education and training, increasing overall job satisfaction (including expanding roles and responsibilities), improv- ing economic incentives, and broadening the labor pool. Overall, in order to create a more effective and efficient direct-care workforce, much more needs to be done to educate and train these workers to care for older adults, and much more needs to be done to enhance the quality of these jobs. DIRECT-CARE OCCUPATIONS Direct-care workers are often grouped into three categories: nurse aides (also known as nursing assistants); home health aides; and personal- and home-care aides (Harmuth and Dyson, 2005). Forty-two percent of direct- care workers care for patients in the home setting, 41 percent work in nurs- ing homes, and the remaining 17 percent are employed in hospitals (Smith and Baughman, 2007). Table 5-1 provides details about the various types of direct-care workers, including their most common employers, the types of services they provide, and typical supervision requirements. Nurse Aides and Home Health Aides The occupation of nurse aide goes by a number of job titles which vary by state, setting, and situation; these titles include certified nursing assistant (CNA), geriatric aide, orderly, and hospital attendant (BLS, 2008c). Nurse aides are employed primarily in nursing homes but also work in other insti- tutional settings, such as hospitals and assisted living facilities. They assist residents with activities of daily living (ADLs), including bathing, dressing, eating, and toileting, and they can perform such clinical tasks as taking blood-pressure readings and, in some states, administering oral medications (Reinhard et al., 2003). These workers have a major role in institutional

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0 RETOOLING FOR AN AGING AMERICA TABLE 5-1 Comparison of Direct-Care Occupations Nurse Aides (Assistants), Orderlies, Personal- and Home- and Attendants Home-Health Aides Care Aides Common Nursing and Home health care Home-care agencies; employers residential-care agencies; social assistance individual and family facilities; hospitals agencies; nursing and services; private residential-care facilities households Examples Answer patients’ Administer oral Help clients get out of typical call lights; deliver medications; take vital of bed, bathe, dress, services messages; serve meals; signs; help patients bathe, and groom; assist with provided make beds; help groom, and dress; assist housekeeping, grocery patients eat, dress, with prescribed exercises shopping, and cooking; and bathe; escort accompany clients to patients to medical doctors’ appointments appointments; take or on other errands vital signs; observe patients’ physical and mental conditions Supervision On-site nursing and Periodic check-ins/visits by Periodic check-ins/visits medical staff supervisors (e.g., nurses, by supervisors (e.g., physical therapists, social case managers, patients’ workers, case managers) families, nurses) SOURCE: BLS, 2008c,d; Fishman et al., 2004. settings, providing 70 percent to 80 percent of direct-care hours to those older Americans who receive long-term care (Harmuth and Dyson, 2005). Home health aides (HHAs) are generally hired through a home health agency and assist individuals with ADLs in their homes. They may also as- sist with food preparation and housekeeping. Both nurse aides and home health aides provide a degree of clinical services (e.g., wound care) and work under the supervision of a registered nurse (RN). Personal- and Home-Care Aides Personal- and home-care aides may work in group or individual home settings and are somewhat more difficult to classify. These aides may be referred to as personal-care attendants, personal assistants, or direct sup- port professionals, and they may be employed through an agency or hired directly by an individual (BLS, 2008d; Harmuth and Dyson, 2005). They help older adults maintain their independence and remain in their homes and communities by providing assistance with both ADLs and instrumental

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0 THE DIRECT-CARE WORKFORCE activities of daily living (IADLs), such as meal preparation and transpor- tation. Personal-care services have been growing and all states now have waiver programs through Medicaid that provide these services to seniors and people with disabilities (Kitchener et al., 2007; Seavey and Salter, 2006). Whereas home health aides who provide Medicare-certified home care perform their jobs under the supervision of a registered nurse (RN), personal- and home-care workers frequently have no supervision, even though they may perform many of the same services. Furthermore, many personal- and home-care workers may be hired privately by patients, with- out the involvement of an agency. Because of these hiring practices, little can be done to track the workers in this “grey market,” which makes it difficult to create a demographic profile of the workers or to regulate their work practices (Seavey, 2007b). As patients move rapidly away from institutional long-term care and toward home- and community-based settings, they are increasingly relying on direct-care workers to provide needed care, including more complex services than previously provided in these settings. Assisted-living facili- ties, which are community-based facilities that provide more services than a typical home setting but less than a nursing home, are a rapidly growing option for the residential care of older adults (Lyketsos et al., 2007), and the workers serving patients in these settings (including the patients with more complex needs) are typically personal- and home-care aides rather than home health or nurse aides. There is little to no federal regulation regarding the training or staffing requirements for assisted-living facilities; instead, each state regulates workers in these settings. WORKFORCE DEMOGRAPHICS Direct-care workers are overwhelmingly female (89 percent) and are typically between the ages of 25 and 55, unmarried (including those who are widowed, divorced, or separated), without college degrees, and citizens of the United States (Montgomery et al., 2005; Smith and Baughman, 2007; Yamada, 2002). Approximately 30 percent of direct-care workers are African American and 15 percent are of Hispanic or Latino origin (BLS, 2008a), although this can vary by setting and job title. In 2005 Montgomery and colleagues examined data from the 2000 Census to create a profile of home-care aides who provide direct long-term care services, including those who are hired privately (Montgomery et al., 2005). The study revealed that as compared to hospital aides and nursing home aides, home-care aides are on average older, more likely to be of Hispanic or Latino origin, more likely to be self-employed, and less likely to have steady year-round employment (Table 5-2).

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0 RETOOLING FOR AN AGING AMERICA TABLE 5-2 Characteristics of Direct-Care Workers, 1999 Hospital Nursing Home Home-Care Characteristic Aides Aides Aides Demographic Characteristics Gender (% female) 81.2 91.3 91.8 Average age (years) 40.5 38.0 46.2 White, non-Hispanic (%) 48.4 55.6 50.3 Hispanic or Latino (%) 10.7 7.8 15.9 U.S., native-born (%) 81.5 85.5 75.1 Marital status (% married) 46.2 42.7 44.2 Education—less than high school (%) 17.6 26.3 30.9 Employment Characteristics Year-round, full-time employment (%) 52.4 48.3 34.3 Part-year, part-time employment (%) 13.0 14.8 24.3 Self-employed (%) 0.0 0.3 16.8 SOURCE: Montgomery et al., 2005. A recent study found notable differences between female direct-care workers and the female workforce overall (Table 5-3) (Smith and Baughman, 2007). Black women, for example, make up a disproportionately large per- centage of the female direct-care workforce relative to their presence in the female workforce overall (29 percent versus 13 percent). A second differ- ence is that female direct-care workers are more likely to be single mothers than are female workers in general (24 percent versus 14 percent); of those who are single parents, 35 percent to 40 percent are below the poverty line (GAO, 2001b). EDUCATION AND TRAINING REQUIREMENTS The education and training of the direct-care workforce is insufficient to prepare these workers to provide quality care to older adults. Although there are a number of state and federal requirements for the education and training of nurse aides, home health aides, and personal- and home-care aides, these requirements are minimal (Table 5-4). Many direct-care work- ers have no more than a high school education, and some have even less (Montgomery et al., 2005; Smith and Baugham, 2007). Minimum train- ing requirements for these workers are often inadequate or non-existent, and they vary across occupational categories and settings of care as well as among states. A number of other training-program characteristics vary among states as well, including the specific qualifications that instructors are expected to have, maximum student/instructor ratios, and the required program approval and oversight processes (AARP, 2006).

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0 THE DIRECT-CARE WORKFORCE TABLE 5-3 Demographic Characteristics of Female Direct-Care Workers Versus All Female Workers, 2006 All All Female Female Female Female Female Direct-Care Hospital Nursing Home Health Characteristic Workers Workers Aides Home Aides Aides Average age (years) 42 41 40 38 45 Race and Ethnicity (%) White, non-Hispanic 70 51 55 51 49 Black, non-Hispanic 13 29 30 35 24 Other, non-Hispanic 6 5 5 4 7 Hispanic 11 15 11 10 21 Foreign-born 13 20 19 17 22 Marital Status (%) Married 54 38 35 38 39 Previously married 21 31 27 27 37 Never married 25 31 38 36 24 Children under 18 years 41 43 32 50 40 Single mothers 14 24 17 28 22 NOTE: The direct-care worker category consists of the three types listed in the last three columns (hospital aides, nursing home aides, and home health aides). The table excludes the 11 percent of the direct-care workforce that is men. Percentages listed are based on weighted data for female workers aged 19 years and older. Percentages may not sum to 100 because of rounding. SOURCE: Smith and Baughman, 2007. This section describes the current requirements for education and training of direct-care workers. Where possible, direct-care education and training issues that are particularly relevant to the older patient popula- tion are highlighted. TABLE 5-4 Education and Training Requirements for Direct-Care Occupations Nurse Aides, Orderlies, Personal- and and Attendants Home Health Aides Home-Care Aides Federal requirements of Per federal rules, if employer Dependent on state, with 75 hours of training (for receives Medicare/Medicaid some requiring no formal nurse aides); competency reimbursement, workers training; high school evaluation results in state must pass competency test diploma and previous work certification; high school (75 hours of classroom and experience not always diploma and previous work practical training suggested); required experience not always high school diploma and required previous work experience not always required SOURCES: BLS, 2008c,d; Fishman et al., 2004.

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0 RETOOLING FOR AN AGING AMERICA Nurse Aides The Omnibus Budget Reconciliation Act of 19872 established the Nurse Aide Training and Competency Evaluation Program, which created mini- mum federal requirements for the education and training of nurse aides (OIG, 2002). Nurse aides working in Medicare- or Medicaid-certified nurs- ing homes or home health agencies are required to successfully complete the following: • At least 75 hours of state-approved training by, or under the general supervision of, an RN with at least 2 years of experience in nursing and at least 1 year of experience in a long-term care environment (or in home health care for training of home health aides) • A competency evaluation (state certificate exam to become a certi- fied nursing assistant) • At least 12 hours per year of continuing education; for nursing homes, this must include training on providing services to indi- viduals with cognitive impairments and on aide-specific areas of weakness identified in performance reviews Many states have established additional requirements beyond the fed- erally mandated minimums. For example, 27 states and the District of Colombia require more than 75 hours of initial training and 12 states plus the District require 120 hours or more (Seavey, 2007a). Under federal rules the initial 75 hours of nurse aide training must cover a number of specific subject areas (Box 5-1). That time must include 16 hours of supervised practical, or “hands on,” training in a clinical setting, and the trainee must demonstrate the ability to perform specific tasks, such as taking vital signs. The 75-hour training requirement is low compared to other service profes- sions. For example, California requires significantly more hours of training for manicurists (350 hours), skin-care specialists (600 hours), and hair stylists (1,500 hours) (Harrington, 2007a). States are responsible for ensuring compliance with educational require- ments and administering (or contracting with someone who administers) competency exams. Subject to the 75-hour minimum, states have flexibility in developing training programs. These training programs can be offered by vocational schools, nursing homes, or home health agencies as long as the institution maintains its certification requirements. Instructional facili- ties that are judged to be providing substandard care can lose their right to 2 Omnibus Budget Reconciliation Act of . Public Law 100-203. 100th Congress. De- cember 22, 1987.

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0 THE DIRECT-CARE WORKFORCE BOX 5-1 Federal Requirements for Nurse Aide Training, by Subject Area • Basic nursing skills, such as monitoring vital signs and height/weight; reporting abnormal changes in body functioning; and caring for the dying resident. • Personal-care skills, including activities of daily living such as bathing, groom- ing, dressing, toileting, and skin care; feeding and hydration; and transferring, positioning, and turning. • Mental health and social service skills, such as responding to a resident’s behavior; allowing the resident to make personal choices; and drawing upon the resident’s family to be a source of emotional support. • Caring for cognitively impaired residents, such as addressing the behav- iors of dementia patients and responding to residents with other cognitive impairments. • Basic restorative skills, such as training the resident in self-care; use of assis- tive devices; maintaining range of motion; eating, dressing, and ambulation; and bowel and bladder training. • Residents’ rights, such as maintenance of privacy and confidentiality; promot- ing residents’ rights to make personal choices; helping to resolve grievances and disputes; reporting any instances of abuse, mistreatment, and neglect. SOURCE: OIG, 2002. offer a nurse-aide training program, which generally makes it more difficult and more costly to recruit new aides. Home Health Aides Home health aides must meet federal requirements only if their em- ployer receives Medicare or Medicaid reimbursement. Specifically, home health aides in such institutions must pass a competency test that covers 12 subject areas (Box 5-2). Federal law suggests that home health aides be provided at least 75 hours of classroom and practical training that is supervised by an RN. These training programs vary by state. Personal- and Home-Care Aides Since residential-care services, such as those provided in assisted-living facilities, are not paid for under the Medicare and Medicaid programs (ex- cept under some state Medicaid waivers), there are no federal requirements for residential-care personnel, and states have the primary responsibility

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0 RETOOLING FOR AN AGING AMERICA BOX 5-2 Subject Areas Covered in Home Health Aide Competency Tests • Communication skills • Observation, reporting, and documentation of patient status and the care or services furnished • Reading and recording vital signs • Basic infection-control procedures • Basic elements of body function and changes • Maintenance of a clean, safe, and healthy environment • Recognition of, and procedures for, emergencies • The physical, emotional, and developmental characteristics of the patients served • Personal hygiene and grooming • Safe transfer techniques • Normal range of motion and positioning • Basic nutrition SOURCE: Home Health Aide Training. 2006. 42 C.F.R. § 484.36. for regulating residential-care facilities (IOM, 2001). When aides are hired directly by individuals (i.e., through consumer-directed programs), the pa- tient or the patient’s family member assumes responsibility for deciding what the worker needs to know and for providing training for those tasks, most often through direct observation (PHI and Medstat, 2004). In turn, patients may need to learn training and supervisory skills (as was discussed in Chapter 4 for the case of professionals), including effective communica- tion and problem-solving. While no federal requirements exist for personal-care attendants who work outside a nursing home or home health agency, states may conduct checks on the background, training, supervision, age, health, and literacy of these service providers if they receive Medicaid reimbursements (OIG, 2006). Training checks may include verification of instruction in topics such as first aid, assistance with ADLs, and basic health and hygiene. In 2006 the Office of Inspector General (OIG) found that the median number of training hours required of personal-care attendants was 28 hours, but state requirements ranged from 2 hours to 120 hours. As more personal-care attendants are hired privately by patients, making sure that these workers have the appropriate abilities will become an even more complex task.

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0 THE DIRECT-CARE WORKFORCE RECRUITMENT AND RETENTION CHALLENGES Health care workers serving older patients have high rates of turnover, and maintaining adequate levels of staffing within the industry overall is a persistent challenge. This challenge is especially pronounced among direct- care workers, who have a number of immediate, less stressful job alterna- tives, such as those offered by the food and hospitality industries. In 2006, for example, personal- and home-care aides had median wages of $8.54 per hour while counter attendants in cafeterias, food concessions, and coffee shops had median wage-and-salary earnings of $7.76 per hour (including tips) (BLS, 2008b). One study found that 40 percent to 60 percent of home health aides leave after less than 1 year on a job, and 80 percent to 90 percent leave within the first 2 years (PHI, 2005). Staff turnover in assisted-living set- tings ranges from 21 percent to 135 percent, with an average of 42 percent (Maas and Buckwalter, 2006). In nursing homes CNA turnover averages 71 percent per year, and the turnover rate in many states is much higher (Decker et al., 2003). Turnover may have negative effects on the quality of patient care and may also increase employer costs because of the need for continuous recruitment and training. A study of direct-care workers in Pennsylvania estimated annual recurring training costs due to turnover to be almost $24 million for nursing homes and almost $5 million for home health and home-care agencies (Leon et al., 2001). It has been estimated that turnover among direct-care workers in the United States costs provid- ers a total of $4.1 billion per year (Seavey, 2004). While many direct-care workers find the work of caring for frail older individuals to be rewarding, the appeal of these professions is weakened by a number of other factors including low wages, few (if any) benefits, high physical and emotional demands, and a significant potential for on- the-job injury (Newcomer and Scherzer, 2006; Pennington et al., 2003). Job dissatisfaction among these workers can also result from factors related to the work environment including poor relationships with supervisors, a lack of respect from other health professionals, and few opportunities for advancement (Fleming et al., 2003; Stone, 2000). Not surprisingly, high job dissatisfaction has been associated with increased turnover (Castle et al., 2007). Conversely, improved job satisfaction can result in a greater intent to stay. Researchers examining the predictors of high turnover in nursing homes have identified a number of key variables, including low staffing ratios, for- profit ownership, and higher numbers of beds (Castle and Engberg, 2006); low reimbursement rates, a high Medicaid census, low wages, and low ad- ministrative expenses (Kash et al., 2006); and inadequate benefits and not having a good social environment at work (Grau et al., 1991). One study

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0 RETOOLING FOR AN AGING AMERICA large-scale efforts, including those of the federal government, are detailed below. In addition, there have been several large-scale efforts to build an evidence base for the best practices in the recruitment and retention of direct-care workers. These efforts are also described below. Better Jobs Better Care The Better Jobs Better Care national program, which was completed in 2007, supported five state-based coalitions (in Iowa, North Carolina, Or- egon, Pennsylvania, and Vermont) that designed and tested practice-based interventions and policy changes over a 4-year period. These coalitions attempted to reduce turnover and vacancy rates and improve the working environment of direct-care staff in long-term care (BJBC, 2007). Since each state used different approaches to reach these goals, no single method can be fairly highlighted over the others. All of the participating states demon- strated a range of positive results from this effort, including improvement in worker satisfaction and increased recruitment (BJBC, 2008). To accom- plish this, the program improved employee pay and also pushed employ- ers to demonstrate respect for direct-care workers in a variety of ways: by providing supervision, peer mentoring, and team building; by offering opportunities for educational advancement; and by encouraging greater communication and understanding (McDonald, 2007). Employment and Training Administration Programs A number of efforts to bolster the direct-care workforce have been un- dertaken by the Employment and Training Administration (ETA) within the DOL, which has invested hundreds of millions of dollars in grants aimed at strengthening the pipeline of needed workers. The ETA’s efforts to improve career lattices through the programs of its Office of Apprenticeship were discussed above. Many of the ETA’s grants focus on long-term care work- ers (Freking, 2007). For example, since 2004 the Community-Based Job Training Grants have funded a number of programs to prepare students for careers in high-growth industries (DOL, 2008b). In March 2008 the DOL awarded $125 million to 69 community colleges, and 24 of these grants (totaling almost $40 million) were for developing workers for the health care industry (DOL, 2008a,d). The ETA’s High Growth Job Training Initiative is aimed at giving work- ers the skills necessary to build a career in one of several different indus- tries, including health care. Under this initiative, the ETA is investing more than $46 million to address health care workforce shortages, particularly among long-term care workers (DOL, 2007). The initiative will focus on such things as increasing the number of younger workers entering the mar-

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 THE DIRECT-CARE WORKFORCE ket, identifying alternative labor pools, developing new educational tools and curricula, increasing faculty, and improving recruitment and retention. The initiative intends to develop approaches that can be replicated across the country. Centers for Medicare and Medicaid Programs CMS has also funded several initiatives to strengthen the quality of direct-care work and its services. In 2003, for instance, CMS initiated the Direct Service Workforce Demonstration, which provided grants to 10 states to test the effectiveness of various workforce interventions on the re- cruitment and retention of direct-care workers in the communities. Accord- ing to an assessment of this program, the grants were shown to decrease worker turnover and increase retention rates. For example, over a 2-year period Kentucky reported a decrease in turnover rates from 43 percent to 29 percent and an average increase in retention rates of 5 months (Univer- sity of Minnesota and The Lewin Group, 2006). Such improvements were primarily achieved by increasing the visibility of available positions and by using more accurate selection strategies to hire well-matched workers to those positions. Later, in 2006, the National Direct Service Workforce Resource Center was created by CMS, and it continues to address the recruitment and reten- tion challenges of direct-care workers by providing information, resources, and assistance to all relevant stakeholders (e.g., policy makers, researchers, employers, workers, and patients) involved in the provision of quality care to older adults at the state and local levels (CMS, 2008a). Another effort by CMS to improve health services to older popula- tions in all 50 states is its Real Choice Systems Change Grants. Since 2001 CMS has provided a total of approximately $270 million in these grants to provide support for community living (CMS, 2008b). This funding has helped build effective foundational improvements in community-integrated services and long-term care systems by allowing states to address issues regarding personal assistance services, direct-care worker shortages, and respite service for caregivers and family members, along with many other issues. Several states improved their support of the direct-care workforce by targeting the areas of recruitment, training and career development, and administrative activities (CMS, 2005). Some of the more common or effec- tive strategies used by states to achieve better recruitment and retention of this workforce were altering training strategies, allowing for more flexibility in worker responsibilities, and broadening the definition of who can serve as a personal assistant (CMS, 2007). The funding provided to the states by this grant program has been put to use effectively, CMS reports, and “the infrastructure that has been developed enables individuals of all ages to

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 RETOOLING FOR AN AGING AMERICA live in the most integrated community setting suited to their medical needs, have meaningful choices about their living arrangements, and exercise more control over the services they receive” (CMS, 2008b). The PAS Workforce Project The 5-year PAS Workforce Project, run through the Center for Personal Assistance Services, has the goal of building and disseminating an evidence base for best practices concerning the personal assistance workforce. The information collected includes data on individual interventions as well as related legislation and policy efforts. The project pays particular atten- tion to strategies to improve worker retention in consumer-directed pro- grams, including issues related to wages, training, safety, and supervision, as well as to the development of infrastructures that facilitate consumer- directed programs (CPAS, 2008). To be included, a program must have documented operational experience as well as evidence of program success and replicability. National Clearinghouse on the Direct-Care Workforce PHI’s National Clearinghouse on the Direct-Care Workforce is a na- tional, online library of information regarding the direct-care workforce for long-term care. The clearinghouse collects government and research reports, fact sheets, briefs, and other information on issues such as career advancement, education and training, recruitment and retention, job envi- ronment, and best practices (National Clearinghouse for the Direct-Care Workforce, 2008). The clearinghouse also produces original research and analysis, including monitoring of state-based initiatives. CONCLUSION Because direct-care workers provide the bulk of paid direct-care services for older patients in nursing homes and other settings, it is vitally important that the capacity of this segment of the workforce be enhanced in both size and ability to meet the health care needs of older Americans. However, the recruitment and retention of sufficient numbers of these workers is chal- lenging due to serious financial disincentives and job dissatisfaction as well as high rates of turnover and severe shortages of available workers. As it exists today, the education and training of direct-care workers is inadequate to impart the necessary knowledge, skills, and abilities to these workers, especially as the complexity and severity of older adults’ needs increase and as more adults are cared for in home- and community- based settings. The government should raise the federal minimum training

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 THE DIRECT-CARE WORKFORCE requirement for nurse aides and home health aides to 120 hours and states should establish minimum standards for personal-care aides if they have not already done so. All direct-care workers should be required to demonstrate that they possess the competencies necessary to engage in this type of work. More research is needed to determine the appropriate content of training programs, which needs to be individualized for the needs of workers based on their responsibilities and the settings in which they provide care. Improving the quality of these jobs will demand significant effort. Direct-care workers typically receive low wages and have limited access to other benefits, including health insurance. Economic incentives should be bolstered to improve the desirability of these jobs. Additionally, much more needs to be done to improve the workforce environment. Evidence shows that increased job satisfaction and decreased turnover rates may be associated with increasing worker responsibilities (including the develop- ment of new roles or career lattices), increasing the recognition of the work- ers’ current contributions, improving safety, and improving supervisory relationships. Given all these factors, it is clear that a change in culture is needed—that both health care workers and health care organizations need to change the way they think about direct-care workers and, in particular, that direct-care workers need to be seen as a vital part of the health care team. REFERENCES AARP. 2005. International forum on long-term care: Deliering quality care with a global workforce. Washington, DC. October 20, 2005. AARP. 2006. Training programs for certified nursing assistants. http://assets.aarp.org/rgcenter/ il/2006_08_cna.pdf (accessed February 20, 2008). ASA (American Society on Aging). 2008. Innoations in recruitment, retention and promo- tion of nursing assistants in long-term care awards: 00 winners. http://www.asaging. org/awards/awards01/extendicare.html (accessed February 24, 2008). Banaszak-Holl, J., and M. A. Hines. 1996. Factors associated with nursing home staff turn- over. Gerontologist 36(4):512-517. Baptiste, A. 2007. Technology solutions for high-risk tasks in critical care. Critical Care Nurs- ing Clinics of North America 19(2):177-186. Barry, T., D. Brannon, and V. Mor. 2005. Nurse aide empowerment strategies and staff stabil- ity: Effects on nursing home resident outcomes. Gerontologist 45(3):309-317. Benjamin, A., and R. Matthias. 2004. Work-life differences and outcomes for agency and consumer-directed home-care workers. Gerontologist 44(4):479-488. Bishop, C. E., D. B. Weinberg, L. Dodson, J. H. Gittell, W. Leutz, A. Dossa, S. Pfefferle, R. Zincavage, and M. Morley. 2006. Nursing home workers’ job commitment: Effect of organizational and indiidual factors and impact on resident well-being. http://www. academyhealth.org/membership/forum/uploads/kmetter/BishopBJBCDisc2.pdf (accessed February 25, 2008). BJBC (Better Jobs Better Care). 2007. Who we are. http://www.bjbc.org/Page.asp?SectionID=1 (accessed December 5, 2007).

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