LongTerm Care: Workforce Issues for States in a Changing Society

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Long-Term Care Workforce Issues for Statesin a
Changing Society

• Robyn I. Stone Dr.P.H.
• NASHP
• 15TH Annual Health Policy Conference
• Philadelphia, PA

Institute for the Future of Aging Services
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Who are the Frontline Workers?

• Nursing assistants, home care aides, personal
  care workers form centerpiece of formal LTC
  system
• Care is intimate, personal and physically and
  emotionally challenging
• Eyes and ears of the care system high touch

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Who are the Frontline Workers?continued

• Accurate estimate of number of workers is
  difficult to ascertain
• Typical worker is middle-aged, single mother with
  low level of education living at or just below
  poverty
• Large portion of African-American, Asian or
  Hispanic workers, particularly in urban centers

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Disadvantaged Status

• 1/4 of NAs and 38 of home care workers have less
  than a high school education
• Median income was 19,960 for NAs and 25,600 for
  home care aides in the late 1980s

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Disadvantaged Statuscontinued

• Median hourly wages in 1998 - 7.50 for NAs in
  nursing homes 7.20 for NAs in residential care
  7.20 for home health aides 6.00 - 7.00 for
  professional/home care aides
• Hazardous position (16.5/100 FT NAs and 9/100 FT
  home health aides had occupational injuries in
  1996 compared with 6/100 service workers)

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Implications for Stakeholders

• Expensive for employers
• Poorer quality and unsafe care
• Reduced access to care and more pressure on
  family caregivers
• High worker stress increased injury and illness

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Current Problem

• Severe labor shortage w/geographic variation
• High turnover rates
• High vacancy rates
• Intra and inter-sectoral movement
• Long time to fill positions
• 37 states report significant recruitment and
  retention problems

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Long-Term Outlook

• Increased demand for LTC
• Potentially less informal care available
• Serious concern about future availability of
  workers
• Decreased pool of traditional caregivers
• Increased educational levels of minority women
• Little relief from softening unemployment

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Key Determinates of Job Satisfaction, Turn over
and Retention

• Status of local economy
• Management style of Supervisors
• Level of aide involvement and empowerment
• Wages/benefits not as important as expected
• Mixed training effect

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Meta-Level Factors Influencing Supply and Quality
of Workers

• Value of Frontline Caregiving
• Status of the Economy
• Health and LTC Policy (reimbursement, regulation,
  program design)
• Labor Policy
• Welfare Policy
• Immigration Policy

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What States are Doing to Address Recruitment and
Retention

• Improving wages and benefits
• Task forces/work groups
• Efforts to provide career ladder options
• Efforts to broaden the pool of potential workers
• Public education, awareness and recognition
• Training, pilot programs, staffing ratios, etc.

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Improving Wage/Benefits

• Wage pass throughs (WPT) / wage enhancement (most
  prevalent strategy)
• Increased reimbursement rates
• State set shift differentials
• Access to health insurance coverage
• Tying increased reimbursement to increased
  performance by providers/staff

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State LTC Workforce Initiatives
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State LTC Workforce Initiativescontinued

• Initiative
• Career Ladder/Training
• Health Insurance
• Task Forces/Commissions

• No. of States
• 20
• 14
• 25

Sources NGA compilation from 1999 and 2001,
North Carolina Division of Facility Services
Surveys, Stone and Weiner monograph,
2001. Proposed or implemented as of September
2001
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Major Career Ladder Initiatives

• CNA to LPN Training
• Medication Aide

• MN, MT, NV
• ME, NC, NJ, OR, WI

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Major Career Ladder Initiativescontinued

• Skill upgrade training
• Others
• Voluntary CNA program
• Collaboration with community college to create a
  career ladder

• MA, VA, WI
• DE
• MI

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Other Key Initiatives (since 2000)

• 1)Establishment of task forces/study commissions
  since June 2000
• 2)Health Insurance efforts
• 3)Increased reimbursement tied to on-site
  training, accreditation, etc.

• CO, GA, IA, KS, MI, MO, NV, NC, OR, PA, RI, VA,
  VT, WI
• GA, NC, NJ, PN, VT
• AK, GA, ME, MN, NC, RI

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Other Key Initiatives (since 2000)continued

• IA
• AK, ME, MA, MN, MO, MT, NJ, ND, PA, RI, VT, WA,
  WI
• ME, WI, WA

• 4)Case-mix reimbursement
• 5)Higher wage rate/wage pass through
• 6)Increased minimum training requirements

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Broadening the Pool of Potential Workers

• Consumer directed care models
• Use of single task workers in residential and/or
  nursing home settings
• Web-based training -- including efforts to
  accommodate immigrants, older workers, other
  non-traditional employees
• Recruit Welfare to Work participants
• New job categories, scholarships,
  promotional/recognition activities

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Training

• Increase minimum hours for NAs
• Standardize required training for personal care
  workers across settings and/or competency
  requirements
• Require orientation on specific topics prior to
  providing hands-on care
• Expand scope of duties for NAs under RN
• Web-based training, training scholarships

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Pilots

• MA -- career ladder pilot effort
• NC WI -- TEACH like program for aides
  combines training with financial and other
  incentives
• MD -- Wellspring model
• MI and CA -- funded innovation grants
  specifically for staff development and training

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Conclusion

• Its not just a money issue
• Many states are considering taking action through
  a variety of strategies to address this current
  and long-term workforce issue
• Need to continue data collection efforts
• Need to track and evaluate range of state efforts