The Future of the Long-Term Care Workforce: It

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The Future of the Long-Term Care Workforce
Its Not Just the Economy, Stupid

• Presented By
• Robyn I. Stone, Dr.P.H.
• Institute for the Future of Aging Services
• UNC Institute on Aging Distinguished Lecture
  Series
• Chapel Hill, NC
• December 7, 2000

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Objectives

• To provide an overview of the issues related to
  the paraprofessional LTC workforce
• To identify major research and findings related
  to recruitment and retention of workers
• To highlight federal, state, and provider
  initiatives in this area
• To highlight areas for research and demonstration

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LTC Workforce Concerns

• Need for a qualified, prepared professional and
  paraprofessional workforce
• Concerns throughout the provider continuum
  (physicians, nurses, administrators, therapists,
  aides)
• Turnover and retention problems at all levels
  compromise quality
• Concerns have been heightened by worker shortages
  in economic prosperity cycle
• How systemic is the problem?

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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?

• Typical worker is middle-aged, single mother with
  low level of education living at or just above
  poverty
• Large proportion of African - American, Asian or
  Hispanic workers, particularly in urban centers

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Poorly Trained Paraprofessional Workforce

• Limited training
• Inadequate supervision
• Missed core competencies (e.g., interpersonal
  communication, clinically informed problem
  solving, critical thinking)
• Inadequate trainers
• Less qualified labor supply
• No incentives for ongoing training

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Consequences Diminished Quality of Care

• Poorer quality of care
• High turnover and poor quality job
• Potential abuse and neglect
• Higher rates of injuries to staff and clients

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Paraprofessional Demographics
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Average Wages for Nursing Staff1998 Nursing
Staff Survey
Source Who makes what Contemporary Long Term
Cares 1998 nursing staff survey. Contemporary
Long Term Care, May 1998.
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Wages of Long-term Care Paraprofessionals 1996
Source U.S. Bureau of Labor Statistics, 1997.
1996 National occupational employment and wage
data.
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Nonfatal Occupational Injury and Illness per 100
Full-time Workers 1996
Source Occupational Safety Health
Administration, U.S. Department of Labor
(Internet). Nonfatal injury and illness incidence
rates per 100 full-time workers by industry, 1996.
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Lost-worktime Injuries per 10,000 Workers 1994
474
326
277
Source U.S. Bureau of Labor Statistics, 1997.
Injuries to caregivers working in patients
homes.
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Seminal Research Studies

• Paucity of empirical and analytical research
• Last profile of workers in early 1990s
• Most work done in nursing homes little activity
  in residential care/assisted living
• Most work is anecdote and best practice little
  evaluation

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Conceptual Framework

• Success depends upon a variety of interactive
  factors at different levels
• demographics and economics
• health and LTC policy
• labor policy
• immigration policy
• workplace level

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Workplace Level Framework

• Organizing arrangements
• goals
• administrative policies
• reward systems
• Social factors
• management style
• employee interactions
• individual personalities

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Workplace Level Framework

• Physical settings/environment
• Technology
• job design
• training
• clinical tools
• information systems

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Descriptive Models Nursing Homes

• Nursing Home Pioneers
• Eden Alternative
• Mt. Saint Vincent Nursing Home
• Wellspring Nursing Homes Quality Consortium
• Genesis Eldercare
• Amhert Wilder Foundation

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Descriptive ModelsHome Care

• Cooperative Home Care Associates
• VNS Choice
• Huntington Memorial Hospital Senior Care Network

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Empirical Nursing Home Research

• Waxman, et al. (1984) - most important prediction
  of job satisfaction and nursing assistant
  turnover was management style allowing worker
  autonomy
• Tellis-Nayack and Tellis - Nayack (1988) -
  skilled people managers differentiating factors
  in 8 exemplary homes

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Empirical Nursing Home Research

• Brannon and Smyer (1994) - middle management
  culture change essential to improvements in NA
  job design
• Bowers and Becker (1992) - less turnover among
  NAs who learned how to effectively juggle
  responsibilities and were given autonomy

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Banaszak-Holl and Himes NA Turn over Study

• 254 facilities in 10 - state metropolitan areas
• Average turnover rate was 32 in 6 months
• Variables intrinsic and extrinsic rewards, job
  design, facility characteristics, local economy

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Study Findings

• Local economic conditions had strongest effect on
  turnover rates
• For-profits reported higher turnover rates
• Homes in which nurses accepted NAs advice or
  discussed care plans with them reported 1/3 lower
  turn over rates

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Study Findings

• Homes in which NAs were involved in care planning
  meetings reported 50 lower turnover rates
• Turnover rates not affected by increases in aide
  training
• Turnover rates not affected by greater NA
  involvement in resident assessments

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Feldman et al. (1990) Home Care Worker Study

• 18 - month Ford Foundation grant
• Case - control study of worker satisfaction and
  turnover among 1,289 workers in 5 cities
• Interventions included salary increases, improved
  benefits, guaranteed service hours, increased
  training and support
• Foundation subsidized costs of worklife
  improvements

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Findings

• In aggregate, interventions reduced turn over
  rates by 11 to 44
• Financial rewards more important to worker
  satisfaction
• Need for workers to feel personally responsible
  for work and to receive feedback from supervisors
  were more important
• After demo, publicly funded agencies reverted to
  former practices

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Examples of Major Research Initiatives

• UCSF Center for Health Professions - Allied
  Health Workforce Innovations for the 21st
  Century. (Funded by California Endowment and
  California Healthcare Foundation)
• Institute for the Future of Aging Services -
  Wellspring Nursing Home Alliance Evaluation in
  Wisconsin (Funded by Commonwealth Fund

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Examples of Major Research Initiatives

• Wisconsin Alzheimer's Institute, University of
  Wisconsin- Workforce Education Training and
  Assistance Program for Wisconsin Assisted Living
  Workers (Funded by Hartford Retirement research
  and Bader Foundations)
• Philadelphia Geriatric Center - Study of LTC
  Workforce Crisis in Pennsylvania (Funded by the
  Council on LTC for the State of Pennsylvania,
  Department on Aging and Department of Welfare)
• Center for Health Workforce Studies, SUNY Albany
  - Study of Nursing Home Administrator Training
  and Turnover in New York State (Funded by Samuels
  Foundation)

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Foundation Involvement

• Commonwealth Fund
• Retirement Research Foundation
• Hartford Foundation
• California Healthcare Foundation
• United Hospital Fund (NY)
• Bader Foundation (WI)
• Kate B. Reynolds Charitable Trust (NC)

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Examples of Frontline Worker Organizations

• Direct Care Alliance - NY
• National Network of Career Nursing Assistants -
  OH
• Iowa Caregivers Association
• Home Care Association of New York State
• SEIU organizing workers in multiple states (e.g.,
  NY, CA, OR, WA)

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Provider Initiatives

• Special training programs
• Career ladders and other advancement incentives
• Financial incentives (increased wages, health
  benefits, sick leave, bonuses, DCAP, child care,
  transportation)
• Culture change initiatives
• Award/recognition programs

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State Efforts to Recruit and Retain Frontline LTC
Workforce

• Study by North Carolina Division of Facilities
  Services
• 46 states responded between May - June 1999
• California, Wisconsin, Ohio, and Vermont did not
  respond (info on California and Wisconsin
  obtained by phone)

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Major State Trends

• 42 states said aide recruitment/retention is a
  major workforce issue
• State with lowest unemployment rate (Minnesota,
  2.1) and highest (West Virginia, 6.8)
  identified recruitment and retention as a major
  concern
• 30 states have taken action 3 are considering
• Major activity is wage increase pass through

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Wage and Benefit Pass Throughs

• 16 states have approved/implemented some form
• Two methods
• 10 states implement pass throughs based on a set
  dollar amount for workers per hour or patient day
  (range from .50 to 2.14 per hour and 4.93 per
  day)
• 6 states establish pass throughs as a percentage
  of the increased reimbursement rate (80 of
  Minnesota 40 rate increase earmarked for worker
  wages and benefits Illinois requires 73 of all
  rate increases)

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Other Major State Trends

• Enhancement incentives
• Transportation reimbursement
• Nurse Aide Career Ladders
• Nurse aide training levels (MS, DE, ME)
• Former Welfare recipient training (NJ, NM, FL,
  AR)
• Expanding use of volunteers (Americorp, student
  volunteers, older adults)

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Stakeholder Roles

• Federal
• State/local
• Provider
• Consumer
• Unions
• Educational Institutions
• Religious and other volunteer organizations
• Families
• Individual clients

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Federal Activity Focused on Frontline Long-Term
Care Workforce

• DOL Skills Development Conference
• OSHA Injury Reduction Among Workers Conference
• HRSA trends study
• AHRQ user liaison meeting on LTC workforce with
  state officials
• ASPE/RWJ technical expert panel meetings on
  future of frontline LTC workers

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Future Research Imperatives

• Frontline worker profile across care settings
  special emphasis on diversity, geographic
  distribution, unionized
• Magnitude of shortage crisis differentiating
  local factors how temporary?
• Factors influencing worker satisfaction and
  recruitment/retention

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Future Research Imperatives

• Role of training elements of successful training
• Relationship between worker satisfaction and
  retention and quality of care/life
• How successful are best practices? How to
  measure success how sustainable and how
  replicable
• Impact of state initiatives Do they really work?
  What do they cost?

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Future Research Imperatives

• Future demand for frontline workers potential
  sources of workers barriers and limitations
• Domestic and global variation in worker
  shortages lessons learned from other countries

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