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The Future of the Long-Term Care Workforce: It


Poorly Trained Paraprofessional Workforce Consequences: Diminished Quality of Care Paraprofessional Demographics Average Wages for Nursing Staff: ... – PowerPoint PPT presentation

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Title: The Future of the Long-Term Care Workforce: It

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
  • Chapel Hill, NC
  • December 7, 2000

GSA-DC-2000 1
  • 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

GSA-DC-2000 2
LTC Workforce Concerns
  • Need for a qualified, prepared professional and
    paraprofessional workforce
  • Concerns throughout the provider continuum
    (physicians, nurses, administrators, therapists,
  • 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?

GSA-DC-2000 3
Who Are the Frontline Workers?
  • Nursing assistants, home care aides, personal
    care workers form centerpiece of formal LTC
  • Care is intimate, personal and physically and
    emotionally challenging
  • Eyes and ears of the care system high touch

GSA-DC-2000 4
Who Are the Frontline Workers?
  • Typical worker is middle-aged, single mother with
    low level of education living at or just above
  • Large proportion of African - American, Asian or
    Hispanic workers, particularly in urban centers

GSA-DC-2000 5
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

GSA-DC-2000 6
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

GSA-DC-2000 7
Paraprofessional Demographics
GSA-DC-2000 8
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.
GSA-DC-2000 9
Wages of Long-term Care Paraprofessionals 1996
Source U.S. Bureau of Labor Statistics, 1997.
1996 National occupational employment and wage
GSA-DC-2000 10
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.
GSA-DC-2000 11
Lost-worktime Injuries per 10,000 Workers 1994
Source U.S. Bureau of Labor Statistics, 1997.
Injuries to caregivers working in patients
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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

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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
  • Tellis-Nayack and Tellis - Nayack (1988) -
    skilled people managers differentiating factors
    in 8 exemplary homes

GSA-DC-2000 19
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

GSA-DC-2000 20
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

GSA-DC-2000 21
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

GSA-DC-2000 22
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
  • Turnover rates not affected by greater NA
    involvement in resident assessments

GSA-DC-2000 23
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

GSA-DC-2000 24
  • In aggregate, interventions reduced turn over
    rates by 11 to 44
  • Financial rewards more important to worker
  • 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

GSA-DC-2000 25
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

GSA-DC-2000 26
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

GSA-DC-2000 27
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)

GSA-DC-2000 28
Examples of Frontline Worker Organizations
  • Direct Care Alliance - NY
  • National Network of Career Nursing Assistants -
  • Iowa Caregivers Association
  • Home Care Association of New York State
  • SEIU organizing workers in multiple states (e.g.,
    NY, CA, OR, WA)

GSA-DC-2000 29
Provider Initiatives
  • Special training programs
  • Career ladders and other advancement incentives
  • Financial incentives (increased wages, health
    benefits, sick leave, bonuses, DCAP, child care,
  • Culture change initiatives
  • Award/recognition programs

GSA-DC-2000 30
State Efforts to Recruit and Retain Frontline LTC
  • Study by North Carolina Division of Facilities
  • 46 states responded between May - June 1999
  • California, Wisconsin, Ohio, and Vermont did not
    respond (info on California and Wisconsin
    obtained by phone)

GSA-DC-2000 31
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
  • 30 states have taken action 3 are considering
  • Major activity is wage increase pass through

GSA-DC-2000 32
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
  • 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)

GSA-DC-2000 33
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,
  • Expanding use of volunteers (Americorp, student
    volunteers, older adults)

GSA-DC-2000 34
Stakeholder Roles
  • Federal
  • State/local
  • Provider
  • Consumer
  • Unions
  • Educational Institutions
  • Religious and other volunteer organizations
  • Families
  • Individual clients

GSA-DC-2000 35
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

GSA-DC-2000 36
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

GSA-DC-2000 37
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
  • Impact of state initiatives Do they really work?
    What do they cost?

GSA-DC-2000 38
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

GSA-DC-2000 39
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