L ong- T erm C are: W orkforce I ssues for S tates in a C hanging S ociety

1. Long-Term Care: Workforce IssuesforStatesin aChangingSociety Robyn I. Stone Dr.P.H. NASHP 15TH Annual Health Policy Conference Philadelphia, PA Institute for the Future of Aging Services

2. 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”

3. 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

4. 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 1980’s

5. 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)

6. 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

7. 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

8. 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

9. 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

10. 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

11. 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.

12. 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

13. State LTCWorkforce Initiatives*

14. Initiative Career Ladder/Training Health Insurance Task Forces/Commissions No. of States 20 14 25 State LTCWorkforce Initiatives*continued 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

15. CNA to LPN Training Medication Aide MN, MT, NV ME, NC, NJ, OR, WI Major Career Ladder Initiatives

16. Skill upgrade training Others: Voluntary CNA program Collaboration with community college to create a career ladder MA, VA, WI DE MI Major Career Ladder Initiativescontinued

17. 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 Other Key Initiatives (since 2000)

18. 4)Case-mix reimbursement 5)Higher wage rate/wage pass through 6)Increased minimum training requirements IA AK, ME, MA, MN, MO, MT, NJ, ND, PA, RI, VT, WA, WI ME, WI, WA Other Key Initiatives (since 2000)continued

19. Broadening thePool ofPotential 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

20. Training • Increase minimum hours for NA’s • 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 NA’s under RN • Web-based training, training scholarships

21. 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

22. Conclusion • It’s 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