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 recruitment and retention of direct-care workers in the communities. According 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 (University 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 retention 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 populations 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 effective 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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