Recommendation 5-2: State Medicaid programs should increase pay and fringe benefits for direct-care workers through such measures as wage pass-throughs, setting wage floors, establishing minimum percentages of service rates directed to direct-care labor costs, and other means.

The committee also supports efforts to address the issue of variable hours and unstable income among direct-care workers. For example, the Guaranteed Hours Program implemented by Cooperative Home Care Associates (a home-care staffing agency in New York City) aims to reduce turnover and vacancy rates (PHI, 2007). Under this program, home health workers are considered full-time employees, are guaranteed full-time wages, and effectively serve on an “on call” basis during work hours when no client visit is scheduled. Although it has not been evaluated in isolation, it is part of a set of workforce interventions that have been documented to reduce turnover to nearly half the industry average (PHI, 2007).

Improving the Work Environment

Besides pay and benefits, a number of other factors may increase job satisfaction among direct-care workers, such as participation in decisions related to care planning and workplace improvement, the availability of career advancement opportunities, and high-quality supervision. Research has shown that job satisfaction and changes in organizational culture are strong predictors of commitment to an organization (Sikorska-Simmons, 2005) and that improved job satisfaction can result in a greater intent to stay (Castle et al., 2007). A variety of approaches, including mentoring (Hegeman, 2005), use of self-directed work teams (Yeatts et al., 2004), and career ladders (Maier, 2002), have all been closely linked to employee satisfaction.

Improving Relationships with Supervisors

As discussed in Chapter 4, the relationship between nursing supervisors and direct-care staff plays a significant role in the development of a hospitable work environment that leads to increased job satisfaction (Bishop et al., 2006; Tellis-Nayak, 2007). Positive supervision (as opposed to more punitive approaches) can greatly increase the direct-care worker’s sense of value and ultimately can increase his or her level of job satisfaction and intent to stay. Evidence shows that perceived support by supervisors is also an important determinant in decreasing job-related stress (McGilton et al., 2007). A strengthening of the relationship between supervisors and staff may also enhance the practice of job delegation, as members of a workforce

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