News Archive

2007: June, May, March, January
2006: December, May, April
2004: October, August, May, April, February
2003: July
2002: January
2001: October, September, August

JUNE 2007

Clearinghouse Director Vera Salter Steps Down

June 19, 2007 - Vera Salter, PhD, Director of the National Clearinghouse on the Direct Care Workforce since its founding in 2000, left her full-time position at the end of May.

Salter built the Clearinghouse into the premier national information resource supporting the movement to improve the quality of long-term care through the creation of quality jobs for frontline workers. The Clearinghouse website currently receives as many as 40,000 visits per month.

President Steven Dawson of PHI, the parent organization of the Clearinghouse, praised Salter’s efforts: “The National Clearinghouse has become a trusted source of information and analysis for the full range of stakeholders across the field. Its library, state activities pages, best practice profiles, and worker voices provide a wealth of information to all those working to improve the quality of jobs for direct-care workers. Vera has been the driving force behind this excellent resource.”

“Vera has been a valued contributor to the PAS Center,” says Teresa Scherzer, PhD, MSW, of the Center for Personal Assistance Services at the University of California, San Francisco. “Her collaboration with the Center has contributed to the knowledge and dissemination of state- and community-based efforts to improving working conditions of personal care workers. Moreover, her warmth, humor, and positive spirit infuses her collegial relationships and makes her a valued colleague and friend.” The Clearinghouse contributes information to the PAS Center website.

Salter is now working as an empowerment coach and consultant. She will remain involved in the direct-care workforce movement as a member of the board of the Direct Care Alliance.

In the wake of Salter’s departure, PHI is reorganizing its communication department. PHI’s Director of Communications Karen Kahn will serve as the temporary director of the Clearinghouse until PHI hires an Online Communications Specialist to oversee an even more robust PHI web presence. PHI currently maintains three separate websites — www.directcareclearinghouse.org, www.coverageiscritical.org, and www.paraprofessional.org —all of which will soon be accessible through a single web portal. PHI will launch the new website, which will provide users with more advanced search and interactive capacities, in 2008.

Joe Angelelli Joins PHI: A Coalition-Builder, a Researcher, and a Passionate Long-Term Care Reformer

June 8, 2007 - Joe Angelelli, PhD, is joining the Paraprofessional Healthcare Institute (PHI) as its Pennsylvania State Director. Angelelli will assume his new position on July 2.

"We are thrilled that Joe will be joining PHI," says National Policy Director Steven Edelstein. "He is a passionate long-term care reformer who brings with him a great depth of knowledge and experience, both as a researcher and as a coalition-builder."

Angelelli comes to PHI from the Pioneer Network, where he had served as Director of Networking and Development since 2005. "Joe brought energy, passion and expertise not only to the Pioneer Network but to the entire culture change movement," said Bonnie Kantor, executive director of the Pioneer Network. "His new position is an exciting one, which will allow him to build on the work he did here."

Before joining the Pioneer Network, Angelelli was an assistant professor in the Community Health and Health Policy and Administration departments of Brown University and Pennsylvania State University. He has conducted research on health care issues in long-term care and other settings and written numerous articles for peer-reviewed journals about nursing homes and the culture of aging in the United States. He earned his PhD in gerontology and public policy at the University of Southern California.

"I know Joe will do an incredible job in bringing people of the commonwealth together to improve the quality of direct care jobs and quality of care for long-term care consumers," says Edelstein.

Montana Leads the Way in Covering Caregivers; Other States Also Explore Ways to Insure the Uninsured

June 6, 2007 - Montana has approved a new way of providing health care coverage for health care workers. As of January 2009, the state will increase its Medicaid payments to agencies that deliver in-home care so they can purchase health insurance for a significant number of their direct-care employees.

“We applaud Montana’s ground-breaking legislation,” says Carol Regan, director of PHI’s Health Care for Health Care Workers (HCHCW) initiative. “This is part of a growing national trend that will benefit everyone who needs long-term care services — and the family members who care for them.”

The direct-care workforce in long-term care (nursing assistants, home health aides, personal care attendants, etc.) is one of the fastest-growing in the American economy. Key to keeping up with increased demand is lowering the profession’s alarmingly high turnover rates, and studies show that health insurance helps keep workers in their jobs. Yet approximately two out of every five direct-care workers lack health care coverage.

The Montana effort, called Healthcare for Montanans Who Provide Healthcare, allows employers to offer health insurance to personal care attendants and private duty nurses. The state’s budget for the coming biennium includes an additional $2.6 million to raise payments to employers who participate in Medicaid in-home care. Federal matching funds will bring the total to about $5 million a year. To receive the extra money, employers must agree in writing to spend it on health insurance for their direct-care employees, which must meet a set of quality criteria established by the state. The plan is expect to cover 1,000 currently uninsured workers. The bill was signed into law on June 1.

A separate piece of legislation also passed this year. Senate Bill 206 requires Montana’s Medicaid agencies to look into funding insurance in a similar fashion for nursing homes, developmental disability community service agencies, and other long-term care organizations.

“To me what we are doing here is a great example of how private business and government can and should work closely together to get something done and make a positive difference in people’s lives,” says Bill Woody, president of Consumer Direct Personal Care and Nightingale Nursing. “I am thrilled that the Montana Legislature has recognized the dedication of our employees, the valuable work done by in-home caregivers and the critical role that the ability to offer affordable health insurance plays in enabling businesses such as ours to recruit, hire and retain qualified workers.” Woody’s in-home care agency developed the concept paper that gave birth to the Montana insurance initiative and spearheaded the effort to secure funding from the legislature.

“Montana has taken a significant step towards ensuring the availability of a high-quality long-term care workforce now and in the future,” Woody says. “At the same time, we will all clearly reap positive social and economic benefits because more of our fellow citizens have health insurance.” 

Woody, who also owns and operates in-home care agencies in Arizona, Alaska, Nevada, and New Mexico, believes other states should consider replicating or adapting Montana’s approach. “The issues that make this initiative important -- the emerging crisis in the long-term care workforce and general lack of affordable health insurance -- are not unique to us,” he says. “It seems to me we are all grappling with the same problems and challenges.  Why not learn from each other?”

HCHCW is already working with several other states and employers who are finding new ways to cover direct-care workers. For example:

“We’re excited about the progress being made in Montana and elsewhere,” says Regan. “We look forward to working with more states as they expand health coverage to the uninsured or restructure their long-term care systems.”

MAY 2007

PHI Helps Focus Attention on Pennsylvania Workers

May 24, 2007 - As part of its Health Care for Health Care Workers initiative in Pennsylvania, PHI is helping to shine a spotlight on the needs of the commonwealth’s direct-care workers.

On May 4, PHI held a briefing for Allegheny County legislators on how the Prescription for Pennsylvania, a new statewide legislative plan to reform health care, would benefit direct-care workers. That same day, the Pittsburgh Post-Gazette ran an editorial by Tracy Lawless, head of the Pennsylvania HCHCW initiative, about the need for affordable health insurance for direct-care workers. Lawless, who had spoken at a May 3 press conference in support of the proposed law, also did a radio interview on Metro Networks News after the hearing. Lawless also helped organize a May 23 rally in support of the bill.

PHI is part of a coalition of Pittsburgh-area groups, including Consumer Health Coalition and Mon Valley Unemployed Committee, who support the legislation. The coalition called the press conference to address the media covering the second day of hearings by the House Insurance Committee. They spoke about the need for affordable, quality health care for all Pennsylvanians.

The coalition also sent a letter to state legislators urging them to support the legislation. “The Prescription for Pennsylvania would reduce health care costs and, we believe, slow the growth in insurance premiums that continues to force more employers to drop coverage and swell the ranks of the uninsured,” the letter says.

The state’s new plan would subsidize workers who earn less than 300 percent of the federal poverty level, which would make most direct-care workers eligible for subsidies, since the average wage for a direct-care worker in Pennsylvania is $9 an hour. 

Speakers at PHI’s legislative briefing included a direct-care worker, a consumer, and a home care employer, who talked to legislators about challenges facing the direct-care workforce and the need for long-term care reform, including better health care coverage for caregivers. In attendance were local state elected officials, representatives from the Governor's office, and several state and federal legislative staff.

“With the nation's third-oldest population and the fastest-growing segment of people over 80, long-term care must be a top priority for the Commonwealth,” said Rep. Todd Eachus, Majority Policy Chairman and co-host of the event, in a PHI press release. “Quality care starts with direct-care workers, and lawmakers need to know the facts about what these professionals face every day.”

About 700 people attended the rally to promote health care coverage for low-wage workers, according to an article in the Pittsburgh Post-Gazette. The article quoted Lawless as saying that employers are reluctant to provide insurance because of the high cost, but paying for coverage could save money in the long run by cutting down on the cost of recruitment and training as retention rates improved.

In her op-ed, Rx for Pennsylvania: Health-care workers need health-care coverage,

Lawless wrote:  “What happens when direct-care workers lack health coverage? Many are forced to seek better-paying jobs with health benefits so they can care for themselves and their families. Who suffers? Pennsylvanians who need long-term care.”

MARCH 2007

Allison Wagner Named National Campaign Manager for PHI's Health Care for Health Care Workers Campaign

March 14, 2007 - Bronx, New York -Allison Wagner, an accomplished campaign coordinator with over 15 years of experience running grassroots advocacy campaigns, has been named the National Campaign Manager for PHI's Health Care for Health Care Workers (HCHCW) campaign. The campaign seeks to expand health coverage for direct-care workers in the United States.

Nationally, two out of five direct-care workers lack health coverage of any kind. The direct-care profession (nursing assistants, home health aides, personal care attendants, etc.) is one of the fastest-growing in the American economy, primarily because the number of Americans over 65 years old is expected to double between 2000 and 2030. During that same period, the number of people traditionally available to provide this care will increase by only 7 percent, creating the potential for a large "care gap." Additionally, low wages and few benefits force many direct-care workers to seek other ways to make a living. Studies show that health insurance is key to keeping workers in their jobs.

"Direct-care workers provide most of the hands-on care that our nation's elders and those living with disabilities depend upon each day," said Wagner. "The fact that so many of these workers lack health insurance compromises the long-term care system in a variety of ways, not the least of which is many workers are just one injury or illness away from financial ruin, and having to leave the workforce altogether."

In her new position, Wagner will be responsible for developing overall campaign strategy and assisting with the implementation of state-based campaigns. "While this is a national issue," Wagner said, "it is primarily a problem being addressed at the state and local level. By and large, the federal government has been focused elsewhere in recent years."

Before joining PHI, Wagner served as a coalition campaign manager for anti-tobacco advocacy campaigns, as a consultant to interest groups in the areas of voter mobilization and grassroots action, and as a candidate campaign manager. Most recently, she served as a consultant to issue and candidate campaigns, providing strategic planning services, research, and voter contact expertise. A graduate of Wake Forest University and a native of Maryland, she is based in the HCHCW national campaign office in Washington, D.C.

For more information about the Health Care for Health Care Workers campaign, visit www.coverageiscritical.org

To contact Allison Wagner, email: awagner@paraprofessional.org or call 718-928-2066.

JANUARY 2007

PHI to Assist in DOL Expansion of Nursing Home Apprenticeship Program

January 24, 2007 - PHI will provide technical support and training to a three-year program funded by the U.S. Department of Labor (DOL) to expand the Health Support Specialist (HSS) apprenticeship program developed by the Kansas Department of Commerce.

The DOL’s $1.6 million grant to North Central Kansas Technical College will fund the The Golden Horizons Career Works Nursing Home Apprenticeship Program, providing a career path for universal workers in nursing homes. The apprenticeship includes training in culture change.

Participating employers will be supported by a team that includes area Workforce Investment Boards and the PHI, which will work with the technical college and Golden Gate to include its peer mentoring curriculum and adult learner-centered training approaches in the HSS apprenticeship. The major employer participating in the program is Golden Gate National Senior Care, the nursing home chain formerly known as Beverly.

In the first year of the grant, Golden Gate will implement the apprenticeship in 24 facilities in Kansas and Missouri. In the second year, the program will be expanded to 37 additional sites, including 6 in Michigan.

The project is part of a new set of community-based job training grants awarded last month by the U.S. Department of Labor. In a press release announcing the grants, Assistant Secretary of Labor for Employment and Training Emily Stover DeRocco said they “recall the imperative that businesses and the workforce system team up with their region’s community colleges to ensure that workers are armed with the right skills to thrive in the 21st century economy.”

DECEMBER 2006

PHI Reports on Quality Care and the Direct-Care Workforce

December 19, 2006 - Four new policy reports from PHI offer in-depth reporting and analysis on issues of interest to state policy makers and Medicaid directors, consumer and worker advocated, long-term care providers, research, and other long-term care stakeholders.

Paying for Quality Care: State and Local Strategiesfor Improving Wages and Benefits for Personal Care Assistants

"Too little attention has been paid to the impact of low wages and benefits on the quality of care received by Medicaid personal care recipients," says Dorie Seavey, PhD, principal author of Paying for Quality Care. "As part of quality assurance, states and the federal government need to monitor and develop standards for the compensation received by direct-care workers."

Discussions of how to improve direct-care wages often are confined to wage pass-throughs, but Seavey and her PHI colleague and coauthor Vera Salter, PhD, identify seven strategies — including wage pass-through —that are being used to improve wages and/or benefits. Their report details pros and cons and provides local and state examples for each. It also documents the link between the quality of care and the adequacy and stability of the direct-care workforce and describes the haphazard method by which Medicaid state reimbursement rates —the principal driver of worker compensation levels —are set for home- and community-based services. The paper was commissioned and published by AARP's Public Policy Institute.

Bridging the Gaps: State and Local Strategies for Ensuring Backup Personal Care Services

Bridging the Gaps, also written by Seavey and Salter for AARP's Public Policy Institute, looks at what happens when a home care worker does not show up. "The problem of backup in home- and community-based services is tremendously important, and yet it's not talked about much because it's often hidden," says Seavey, a labor economist and national policy analyst for PHI. When reliable backup services are not available to people with disabilities, they face emotional distress, physical harm, and loss of independence or self-determination.

This report examines state and local initiatives to ensure effective backup services for Medicaid personal care services. Three complementary strategies are considered: improving state requirements for backup services; developing effective tracking and monitoring systems; and supporting the development of backup management systems and programs such as "call-off" notification systems, specialized backup agencies, worker pools, and worker registries.

Addressing New York City's Care Gap: Aligning Workforce Policy to Support Home- And Community-Based Care

Turning to one of the country's largest home care workforces, Addressing New York City's Care Gap points out that the direct-care workers who provide home- and community-based care to elders and people with disabilities in New York City account for one in seven of the city's low-wage workers. What's more, while the number of traditional caregivers is expected to shrink, the demand for these workers is expected to increase by 50 percent over the next ten years, making it one of the fastest-growing employment sectors in the city's economy.

Noting that public workforce investment systems often shy away from investing in these jobs because of low wages and other job quality issues, authors Seavey, Steven L. Dawson, and Carol Rodat make a compelling case for a concerted public workforce investment strategy. They argue that "the low quality of direct-care jobs is not an 'innate' characteristic of this work," but rather the very dimension that must be changed to keep up with future needs. Careful injection of workforce dollars, they add, can begin to address the need for more workers by improving job quality.

Prepared for the New York City Workforce Investment Board, the report identifies four key investment areas for upgrading the homecare profession and calls for collaboration between employers, unions, workforce development centers, and trainers to implement targeted initiatives.

Reimbursement Practices and Issues in Vermont's Long-Term Care Programs

Vermont is often looked to as the vanguard of state rebalancing efforts because of its emphasis on consumer choice of long-term care settings and access to care. Reimbursement Practices and Issues examines the challenges raised by the state's reimbursement and rate-setting practices in publicly funded long-term care services. The report was prepared by Seavey and PHI's Hollis Turnham for the Long-Term Care Workforce Policy committee of the Community of Vermont Elders (COVE), a Better Jobs Better Care grantee.

Reimbursement Practices and Issues describes how rates are set across the state's entire portfolio of long-term care settings and programs, clarifying what COVE Director Dolly Fleming calls "an extremely complex and confusing reimbursement system." That system, the authors conclude, does not support the programmatic or fiscal goals of the state's new Choices for Care Medicaid waiver program. Recommendations outline the ingredients of an improved reimbursement approach that would support quality care, sufficient provider capacity, and an adequate, well-trained and stable long-term care workforce. The report's framing of data and analysis should also prove useful to policymakers in other states who wish to examine their long-term care reimbursement systems.

*Abstracts of all four papers, with links to their full text, can be found at PHI's National Clearinghouse on the Direct Care Workforce at www.directcareclearinghouse.org.

MAY 2006

PHI’s Elements of a Quality Job Featured in Health Progress

May 5, 2006 - A recent issue of Health Progress, the magazine for managers of Catholic health care organizations, featured an article outlining the Paraprofessional Healthcare Institute’s Elements of a Quality Job.

The article notes that implementing these elements can, as the summary puts it, “make the difference between chronic turnover, on one hand, and employing a dedicated staff large enough to keep pace with the growing need for long-term care and services, on the other.”

Breaking the Turnover ran in the November-December issue of the magazine, whose theme was “Workplace Issues.” It describes each of the then-seven elements (PHI has since expanded them to include nine) and briefly discusses strategies for putting them into effect.

The article also includes a sidebar describing the “Four Ps,” PHI’s curriculum for teaching communication skills to direct-care workers.

Health Progress is published by the Catholic Health Association of the United States.

APRIL 2006

PHI’s Michigan Policy Director Joins State Advisory Commission

April 6, 2006 - PHI’s Michigan Policy Director, Hollis Turnham, has been appointed to the Michigan Long-Term Care Supports and Services Advisory Commission. The group is charged with helping Michigan improve its long-term care system in several ways, in part by improving the quality of direct-care jobs.

The commission was appointed to implement the recommendations of the Governor's Medicaid Long-Term Care Task Force. Turnham facilitated that task force’s workforce development work group, whose Recommendation No. 8 calls for the state to “Build and sustain a competent, highly valued, competitively compensated and knowledgeable long-term care work force.”

“The task force recommendations lay out the link between quality of care and the quality of training, leadership, and compensation associated with careers in long-term care,” says Turnham. “Now the commission is charged with helping the department actualize those recommendations and our expectations for high quality.”

Turnham is one of 14 appointees to the advisory commission. She and two others – a representative of SEIU Local 79 and a representative of the Michigan Association for Homes and Services to the Aging – were appointed to represent direct-care workers. One of the other appointees represents the general public, three represent providers of Medicaid-funded long-term care supports and services, and the other seven represent primary and secondary consumers of long-term care supports and services.

“It is important to ensure that our state’s long-term care services remain the highest quality,” said Governor Jennifer M. Granholm in a February 14 news release announcing the appointments. “This commission will play a critical role in implementing recommendations from the state’s Medicaid Long-Term Care Task Force and will serve as an effective and visible advocate for improving the quality of our long-term care system.”

The commission will assist the Office of Long-Term Care Supports and Services, which is the sole developer of long-term care policy within Michigan’s Department of Community Health.

OCTOBER 2004

Online Tool Calculates Cost, Benefits of Wage Increases

October, 15, 2004 - With Medicaid costs rising rapidly, state policymakers are understandably reluctant to increase wages for Medicaid-funded direct-care workers, even when those wages are too low to lift workers and the families they support out of poverty.This creates a dilemma not only for workers but for employers and policymakers, since low wages make it more difficult to attract enough qualified workers. Finding sufficient workers is especially challenging in the critical and growing arena of home- and community-based personal assistance services, where wages tend to be lower and full-time work harder to find than in nursing homes and other institutional settings. Furthermore, states are obligated under federal law to pay Medicaid-funded workers enough to maintain a stable workforce of sufficient size to meet the needs of Medicaid beneficiaries, as underscored in the recent Ball v. Biedess ruling (for details, go to http://www.directcareclearinghouse.org/news.jsp#az82004).

But the burden to states of raising wages is not quite as onerous as it might seem. Every dollar a state invests in wages is partially offset by savings in other areas, including increased matching federal Medicaid funds and higher personal income tax contributions by higher-earning workers.

A new online tool allows state policymakers and other long-term care stakeholders to estimate the real costs and benefits of increasing wages for Medicaid-funded personal assistance workers. Free of charge and easy to use, the Return on Investment calculator estimates the effect on a wide range of factors – including, staff turnover costs, retention rates, and the number of families who would be leaving poverty – of a proposed wage increase of any size. The tool works for all 50 states and the District of Columbia.

To access the calculator, which was created by the Paraprofessional Healthcare Institute with funding from the Centers of Medicaid and Medicare Services, go to:
http://www.directcareclearinghouse.org/roi/index.html

DCA Conference Unites and Inspires Worker Advocates

October 13, 2004 - In a striking display of the power and promise of the growing movement to improve job quality for direct-care workers, more than 130 long-term care workers, consumers, employers and advocates gathered in Washington, D.C. for the national conference of the Direct Care Alliance, which is staffed by PHI. For the rest of the story, click here.

AUGUST 2004

Judge Orders Arizona to Raise Home Care Pay Rates

August 20, 2004 - A federal district judge has ruled that Arizona must raise wages for attendant care workers and personal care workers in order to ensure that Medicaid beneficiaries receive the home- and community-based services they are entitled to. The Court’s decision in Ball v. Biedess follows four and a half years of litigation in a statewide class action lawsuit on behalf of a group of elderly and disabled Medicaid recipients. The suit was brought against the Arizona Health Care Cost Containment System (AHCCCS), which administers the state’s Medicaid programs, by lawyers from the Arizona Center for Disability Law, AARP Foundation Litigation, and DNA Peoples Legal Services....to read more click here

MAY 2004

Expert Opinion: Steven L. Dawson

May 14, 2004 -- With vacancy and turnover rates of direct-care workers still at crisis levels, adopting "employer of choice" strategies could help providers ease the problem, believes Steven L. Dawson, president of the Paraprofessional Healthcare Institute. "It's like a bucket with 12 holes in it: You can't fix just two, or six or even ten of the holes and still expect to retain a stable direct-care staff -- you have to pay attention to every aspect of the problem," he says in this snalfnews.com interview. Dawson is the author of numerous papers analyzing the direct-care labor crisis, including "Direct Care Health Workers: The Unnecessary Crisis in Long-Term Care," and "Long-Term Care Financing and the Long-Term Care Workforce Crisis: Causes and Solutions." To access these articles and a wide range of additional resources available from the National Clearinghouse on the Direct Care Workforce, click here.

First, what is the Paraprofessional Healthcare Institute (PHI)?

Our mission at PHI is twofold -- to improve the quality of the direct-care worker's front-line jobs, and in doing so improve the quality of care for long-term care consumers. We focus our work on re-designing systems around the relationship between the consumer and her caregiver -- we believe that only a respected and valued workforce will be able to provide quality care to residents. We do this work at both the practice level, consulting directly with provider agencies, and at the policy level.

Bring us up to date on the direct-care staffing crisis. How bad is it right now, and what are some of the contributing factors?

The staffing situation is slightly better than it was a couple years ago when the economy was at its hottest, but vacancy rates are still severe -- and among paraprofessionals, it worsens the lower down the job quality ladder you get. Nursing homes are having somewhat less trouble than before, in terms of CNA vacancy rates -- but only slightly. The American Health Care Association (AHCA) still reports turnover rates of CNAs above 70 percent, and vacancy rates above 8 percent. And home care and personal care providers, particularly where the jobs tend to be part time with no benefits, continue to have even greater difficulty in finding staff. Also, those geographic areas that have the highest immigration rates are doing better than those that don't have an influx of non-native born workers.

However, as the economy begins to heat up again and the employment rates begin to strengthen, I believe we're going to not just see high turnover rates, but return to the high vacancy rates that the industry experienced just a few short years ago -- and that's when the industry and the political policy makers will again begin to pay even more attention, when workers stop showing up. The system has been built around an assumption of fairly high turnover and churning of the workforce, and while that's a serious problem, everything becomes far more difficult when workers don't show up at all. So higher vacancy rates will trigger a more intense look at the direct-care workforce, and, assuming the economy continues to strengthen, I think we'll see those vacancy rates back up to 11 and 12 percent again within just the next year or two.

The problem will continue to deepen because of the demographic issues. Most people in the industry are aware of the increasing demands of higher prevalence of disabilities and an aging population will place on long-term care services, but what's less understood is that the traditional supply of long-term care workers has changed substantially. The long-term care system was built assuming an endless supply of women entering the workforce between the ages of 25 and 44, but since 2000 or so, that pool of workers has remained relatively unchanged -- it's not increasing the way it used to because now the smaller "Post Baby Boom" generation is entering the workforce. That means that as the economy heats up, a relatively fixed pool of women entering the job market will have more choices for employment -- as they did in the late 1990s -- and so long-term care providers will be forced to compete aggressively again in the labor market for their CNAs and home health aides.

Let's talk about turnover first. If so many CNAs feel the work they do is a special calling, why do so few stay?

It's like a bucket with 12 holes in it: You can't expect to fix just two, or six or even ten of the holes and still expect to retain a stable direct-care staff -- you have to pay attention to every aspect of the problem. There are a number of factors all along the employment chain -- from recruitment and selection through supervision and support -- and unless you attend to all of them, you still lose people. It starts with having good selection criteria, and includes obvious things like decent wages and benefits and how people are treated.

Unfortunately, I think we see too much "either/or" thinking in the industry. It's either "If we just pay people more that's all we need to do," or "If we just paid attention to people more, and trained them better, we wouldn't have to worry about wages and benefits." But it's not either/or, it's always both. It's one thing to be greeted in the morning and feel appreciated, but if you're still making $6.50 an hour, don't have health insurance and are worried about your kids being cared for by a neighbor, it's hard to do your best work. Similarly, if you're making $12 an hour, but you're treated like you are invisible, that's not enough to keep you in your job either.

Another reason for the high turnover of direct-care staff is the high turnover in administrative and professional staff. If you have constant churning at the higher level, you're certainly not going to have a stable environment or a positive culture in which direct-care workers are going to feel supported and stable. Finally, I think we have to also acknowledge that there is a broad, societal backdrop in our industry in terms of who is providing care to whom -- it's primarily low-income women providing care to low-income women -- and in addition, the direct-care workforce is disproportionately women of color. That's the norm of long-term care. It's just a reality that these are people whose work society has not traditionally acknowledged or fully valued -- they are too often invisible -- and at the same time they're working within an industry where the administration and professional staff are primarily white and middle class. It's a framework that needs to be acknowledged, because it's always there -- and is likely to become more true as our workforce in this country is drawn increasingly from non-native born workers.

You've talked and written about the importance of being an "employer of choice." How does that concept help fill some of those holes in the bucket?

It's a phrase we use to help employers understand that they are dealing within a labor market. They didn't have to worry about that back when they had an endless supply of women willing to work under pretty much any conditions that were offered. But as the labor market shifts, employers have to understand that they have to offer competitively attractive jobs. Just as they are trying to compete for consumers, just as they have to compete for finance capital, they also now have to compete for workers in order to have a successful business, and that really changes the power dynamic within the organization.

That means that as providers, we must make a longer term investment in staff resources, and that's a worthy investment only if we achieve a more stable workforce. If we're still constantly churning, there's no sense in investing up front. It's good business logic that if I become an employer who invests in the work force up front in training, support, higher wages ands benefits, the result will be a more stable, longer-term workforce -- and in return I won't have to pay the other costs of constantly paying top price for temporary workers, and constantly hiring, terminating and disciplining staff. In simple terms, it's a "high road" versus "low road" kind of strategy, and whether it's because of a lack of resources, the regulatory climate or other factors, long-term care has typically taken the low road of simply assuming high turnover, and managing the workforce accordingly.

Are you talking about the high road from a mission perspective as well? It sounds like doing the right thing for people is also good business.

Although more research is required to prove conclusively that better jobs do in fact create better care -- it's intuitive. PHI and other practitioners work on the belief that a more stable workforce gets to know their clients better, and at least has the opportunity to provide a higher quality of care. It still amazes me that some things that seem pretty obvious are often ignored in our industry -- for example, "consistent assignments" in which the CNA is assigned to the same unit or client as much as possible. If we know that CNAs are attracted to this work mostly because they value caring for their client, but we still structure the job so they can't form good relationships with clients, then it should not surprise us when they leave in frustration. So, consistent assignment is one of the very fundamental, and yet relatively simple and low-cost restructurings that can be done to recognize who your workforce is and why they show up for work each day.

Another example is that people in low-wage jobs typically, by definition, have relatively few financial assets, and therefore it's harder for them to deal with problems before they turn into crises. When a car breaks down, or there's child care difficulty, they just have fewer assets to fall back on, and that becomes an obstacle to getting to work or doing a good job while at work. Employers don't have to become a social service center and take on that level of responsibility, but they can certainly help their employees gain access to community-based resources, whether it's to address domestic violence at home, or transportation needs, housing, or child care. For instance, many of our direct-care workers are eligible for the federal Earned Income Tax Credit -- increasing income, in some cases, by several thousand dollars -- and employers could easily help organize support to help their employees apply for and receive that tax-related income.

Think of it almost like a "case management" approach to your direct-care staff. At Cooperative Home Care in New York -- which is an 800-worker, employee-owned home care agency affiliated with PHI -- we have several counselors who work with our employees on those types of issues. And they now have very effective relationships with all sorts of different community organizations that act as an additional safety net for staff as they deal with the realities of direct-care work.

Are there providers or organizations that are making significant progress with "employer of choice" type programs?

There are countless examples now, across the country. The Direct CareGiver Association, in Tucson, Arizona, is a consortium of providers who came together to recruit and train direct-care workers for a variety of home care, nursing home and hospice positions. The Loomis House, a skilled nursing facility in Holyoke, Massachusetts, participated in a state-funded career ladder initiative -- they cut their CNA turnover in half and saved more than $100,000 in staff recruitment, replacement and training costs over the past three years. And Ararat Nursing, in Mission Hills, California, has created a multi-level career path for their CNAs -- their system has even shown a link between their very comprehensive approach to staffing and improvements in resident outcomes -- of increased physical activity and decreases in use of antipsychotic drugs and sleeping pills. Your readers can learn details of these and more than fifty other examples by visiting the National Clearinghouse on the Direct Care Workforce, at www.directcareclearinghouse.org, and clicking on "practice profiles."

One broader example that is particularly exciting is within the "Better Jobs, Better Care" initiative, which is the national direct-care demonstration program funded by The Atlantic Philanthropies and the Robert Wood Johnson Foundation. One of the demonstration states is North Carolina, where they are creating a set of standards for how direct-care staff are supported, trained and supervised within long-term care facilities. Eventually, they hope employers will be rewarded for those behaviors in the State's reimbursement rates -- that's the type of system change that I think is very important. We know employers can't do this just on their own. There has to be change both at the practice level, in terms of day-to-day management and structure of the facilities, but also at the policy level, in financially rewarding "good behavior" that results in a high-quality, stable workforce.

What kinds of progress are you seeing at the policy level?

There's a lot happening at both the state and federal level. It is encouraging that both CMS [Centers for Medicare and Medicaid Services] and the Department of Labor [DOL] have begun to focus on this workforce in a way they never have before. HHS and the DOL are now talking to each other, which had not happened much before, and are in fact sponsoring a national symposium on the direct-care workforce in May. It's really the first time the two agencies have agreed that direct-care employment is an opportunity -- both to create decent jobs, and provide high-quality care.

At the state level, we continue to see both practice and policy initiatives across the country. This is where providers can more easily become involved in policy matters. In partnership with the North Carolina Department of Health and Human Services, PHI co-publishes each year a survey of those state activities -- in April we published the most recent survey, which also can be accessed at the National Clearinghouse website. I urge your readers to find out what is happening in their state, and then participate in the demonstration programs and task forces that are becoming active across the country.

But with so much focus on government initiatives to keep people out of nursing homes, will much attention be given to staffing in institutional settings?

It's just logical. You can't invest in a whole lot of staff training on how to ensure quality outcomes, and then go back six months and find that 50 percent of those staff members you trained aren't there anymore. Maintaining a stable staff is essential to having a strategy where quality is improved and measured over time, so I think it is through the "quality improvement" processes where you'll see increasing focus on facility-based staffing -- that is why I expect that the Quality Improvement Organizations (QIOs), with encouragement from CMS, will focus increasingly at the direct-care, paraprofessional staffing level.

From your observation, is the "employer of choice" concept resonating with providers?

Yes. The State of Maine, for example, is encouraging long-term care providers to adopt the "employer of choice" model, and is providing technical assistance to do just that. What I think is most interesting is that organizations like the Pioneer Network and others who have been working a long time on "culture change" initiatives are now taking an even stronger and more blended approach in terms of understanding that the consumer can't get what she needs, unless her caregiver is also receiving the support she needs.

Copyright snalfnews.com 2004. Reprinted by permission.

APRIL 2004

PHI Awarded $4 Million Grant

April 14, 2004 — The Paraprofessional Healthcare Institute (PHI) has been awarded a grant of up to $4 million over the next four years by The Atlantic Philanthropies. The board of trustees of The Atlantic Philanthropies voted to award the money, the largest single grant PHI has ever received, on March 8. “Direct-care workers are the face, hands, and voice of care and support for millions of our nation’s elderly and those living with disabilities,” says PHI President Steven L. Dawson. “We are very pleased that this generous grant by The Atlantic Philanthropies acknowledges the crucial link between quality care and quality jobs.”

The grant, which requires PHI to raise matching funds of at least $2.5 million over the next four years, will enable the organization to field a range of new “quality jobs/quality care” initiatives on behalf of direct-care workers across the country, expanding from the 10 states where it currently has a significant presence into 15 by 2007. It will support an expansion of PHI’s national policy work and the continued growth of its National Clearinghouse on the Direct Care Workforce, the nation’s primary source of policy and practice information about the direct-care workforce. And it will help PHI add managerial, administrative, and program staff, growing from 21 to approximately 33 staff over the next four years.“

Until PHI emerged as a champion for change, there was not a significant force addressing the needs and capacities of the workers who spend the most time with residents in long-term care settings,” says Laura Robbins, Program Officer for The Atlantic Philanthropies. “PHI’s work is critically important if our society is to provide quality care to older adults and others in need of chronic care.”

The Atlantic Philanthropies (www.atlanticphilanthropies.org) has four “program fields”—aging, disadvantaged children and youth, health of populations, and reconciliation and human rights. Atlantic also co-funds, with the Robert Wood Johnson Foundation, the national Better Jobs Better Care demonstration initiative, for which PHI serves as the national technical assistance office.

FEBRUARY 2004

Governors Hear Recommendations for Supporting the Direct-Care Workforce

Feb. 25, 2004 - Steven Dawson, president of the Paraprofessional Healthcare Institute, spoke at the National Governors Association’s winter meeting about improving working conditions in order to maintain a stable direct-care workforce.

On February 23, The NGA's Health and Human Services Committee hosted a session on expanding home care as an option for the elderly and those living with disabilities. The subject matter reflected the group’s ongoing interest in long-term care reform, which is driven by the burgeoning demand for long-term care and services and states’ desire to keep their Medicaid budgets under control.

Dawson urged the governors to increase funding for wages and benefits and coordinate resources scattered among aging, long-term care, and labor departments in order to better support employers’ efforts to recruit, train, and retain workers. “I realize these are difficult times and increases in compensation will be difficult,” he said. “However, in the long run, because this is a market dynamic, demand will place an upward pressure on wages and benefits.”

Dawson also called for states to create not only more, but better, home care jobs. “Currently,” he said, “the states are rewarding inefficiency — a system churning through workers at 50 and 60 percent or more turnover rates, creating lousy jobs and not wonderful care. Instead, as you build expanded home care programs, you have an opportunity to build not just a care system, but also a stable workforce — and that will in turn strengthn low-income communities.

”In this time of precious resources,” he concluded, states should “find the points of leverage that will solve two problems with the same dollar — providing the elderly and disabled decent care, and providing low-income women decent jobs.”

Rick Surpin, chair of PHI’s Board of Directors, named “Outstanding Social Entrepreneur,” by the Schwab Foundation

Feb. 25, 2004 - Founder of Cooperative Home Care Associates (CHCA), the Paraprofessional Healthcare Institute (PHI) and Independence Care System (ICS), Rick Surpin has been a leader in the effort to promote quality jobs for home health aides and other direct-care workers. That leadership was recognized when Surpin was named an "Outstanding Social Entrepreneur" for 2004 by the Schwab Foundation for Social Entrepreneurship. Through international and regional meetings and supporting its outstanding entreprenuers, the Schwab Foundation promotes addressing social problems through innovative services, products, and approaches that are nonideological, practical, and replicable.

Surpin founded CHCA in 1985 and served as the company’s president until he launched ICS in 2000. CHCA was the country’s first worker-owned home care agency, and now employs over 750 home health aides, 70 percent of whom own shares in the company. Independence Care System is a managed care agency that supports people living with severe disabilities; many ICS clients rely on home health aides from CHCA to support and assist them so they can live independently in the community. The synergy of these two enterprises, along with the nonprofit PHI, which promotes the quality jobs/quality care model across the nation, has catapulted Surpin’s vision into the forefront of today’s discussions about the future of caring for America’s elderly and disabled populations.

JULY 2003

Five Coalitions Awarded $7 Million to Strengthen the Long-Term Care Workforce

July 16, 2003 -- The Robert Wood Johnson Foundation (RWJF) and The Atlantic Philanthropies today announced the selection of five state-based coalitions to carry out demonstration projects under Better Jobs, Better Care, a program that was launched and is supported by both foundations. The goal of the program is to improve the recruitment and retention of quality direct care workers - nursing assistants, home health aides, and personal care attendants - who provide necessary care and support to elderly people with chronic diseases or disabilities.

To read the press release, click here (pdf).

New Database Offers Creative Ideas to Address the Workforce Crisis

A new initiative from the Paraprofessional Healthcare Institute (PHI) and the Institute for the Future of Aging Services (IFAS) is designed to help providers and other interested parties develop creative ideas to address the workforce crisis in long-term care. The Practice Profile Database, housed on PHI's National Clearinghouse on the Direct Care Workforce website, outlines programs designed to improve the recruitment, training, and retention of direct-care workers who care for the elderly and people living with physical and mental disabilities. Each profile includes a program description, links to additional information, and contact information for people who want to learn more. The project is part of two long-term care workforce initiatives funded by the U.S. Department of Health and Human Services (HHS). More information about the two HHS initiatives is included on the Clearinghouse website (www.directcareclearinghouse.org), which has been redesigned to include this new feature and to make it easier to access the site's other extensive resources. To access the profiles, go to www.directcareclearinghouse.org/practices.

PHI Culture Change Specialist Susan Misiorski Featured on Upcoming CMS Webcast

PHI consultant Susan Misiorski, who is also president of the Pioneer Network, appears on the CMS webcast Innovations in the Quality of Life - Pioneer Network Broadcast, September 27. Misiorski, Rose Marie Fagan, and other Pioneer board members and innovators provide a thorough explanation of the Pioneer Network, the concept of culture change in nursing homes, and their efforts to create long-term care settings in which people are proud to live and work. A clip from HeartWork, a video produced by the Paraprofessional Healthcare Institute, illuminates how direct-care workers feel about their role within long-term care.

To view the webcast from a satellite site or an individual computer, register at http://cms.internetstreaming.com. Videotapes will be available for purchase two weeks after each broadcast.

JANUARY 2002

PHI's Workforce Development Strategy Focus of Two Aspen Institute Reports

Two new publications from the Aspen Institute, Cooperative Home Care Associates: A Case Study of a Sectoral Employment Development Approach and Grow Faster Together or Grow Slowly Apart: How Will America Work in the 21st Century?, highlight the Paraprofessional Healthcare Institute's industry-based workforce development strategy. These papers are available at http://www.paraprofessional.org and http://aspeninst.org/dsg/2002report/fullreport.pdf, respectively.

Cooperative Home Care Associates (CHCA), published by Aspen's Economic Opportunities Program, focuses on the flagship company in PHI's Cooperative Healthcare Network. A worker-owned home care agency, CHCA employs close to 650 African-American and Latina women, the majority of whom have recently transitioned from public assistance. CHCA models an innovative employment strategy for the industry, investing significantly in training and advancement of aides to promote retention and quality care for consumers. As a result, CHCA has established a reputation as an excellent employer and a high-quality service provider, providing the agency with significant opportunities to grow and thrive in a difficult marketplace. Click here to download the case study.

The Aspen Institute's Domestic Strategy Group (DSG) recently released Grow Faster Together or Grow Slowly Apart: How Will America Work in the 21st Century? This paper identifies three major problems facing the American economy: a worker gap, a skills gap, and a wage gap. The DSG notes that for the past 20 years, businesses have relied on a growing native-born workforce that was rapidly increasing its level of education and skill. With this growth at a stand still, businesses will need new strategies to expand the skilled workforce. To support these changes, the report offers five public policy solutions:

  1. Make work pay.
  2. Build a more skilled workforce and foster upward mobility.
  3. Restore worker security while enhancing workforce flexibility.
  4. Provide a more supportive workplace for working families.
  5. Rethink immigration policy.

Grow Faster Together . . . describes the efforts of several business enterprises to promote new workforce development strategies and to reshape public policy to support those efforts, including Cooperative Home Care Associates and its partnership with the Paraprofessional Healthcare Institute. Read the full report at http://aspeninst.org/dsg/2002report/fullreport.pdf

PHI Staff Member profiled by McKnight's Long-Term Care News

McKnight's Long Term Care News profiles PHI's Senior Training Associate Sara Joffe in its January issue. The article focuses on Ms. Joffe's role in producing HeartWork, a unique theatre performance, in which six home care and nursing aides tell the stories of their lives.  To read McKnight's LTC profile on-line, go to www.mcknightsonline.com

OCTOBER 2001

Voices for Change: Direct-Care Workers Speak Out. Third Annual Paraprofessional Assembly

On October 25-27, 2001, 60 direct-care workers from the Cooperative Healthcare Network traveled from New York, Michigan, New Hampshire, Arkansas, and Pennsylvania to attend the third annual Paraprofessional Assembly. These workers were joined by about 40 others, including agency administrators, PHI staff members, researchers, and funders. To read more about and see photos from the event, click here.

Cooperative Home Care Associates Receives $1.4 Million Training Grant

On October 25, 2001, Governor George Pataki and Senate Majority Leader Joseph Bruno announced $80 million in grants to continue New York State's effort to improve recruitment, retention, and training of health care workers. The state awarded grants to hospitals, nursing homes, and home health agencies, including $1.4 million to Cooperative Home Care Associates (CHCA), a member of PHI's Cooperative Healthcare Network.

CHCA will use these funds to continue its enhanced training program, a four-week program that integrates communication and problem solving skills into the standard home care curriculum. CHCA, located in the South Bronx, employs over 600 home health aides, most of whom are Latina and African American women. A worker-owned licensed agency, CHCA contracts with the Visiting Nurse Service, the Dominican Sisters Family Health Service, and Independence Care System to provide home health services to the elderly and to adults living with disabilities.

"We believe that quality training is essential to quality care," says Michael Elsas, president of CHCA. "Our trainees receive an extra two-weeks of training, beyond that required by federal and state law. This allows them to develop the skills and the confidence they need to provide compassionate and competent care to our clients."

SEPTEMBER 2001

AFSCME's Cheating Dignity report brings new attention to wages of direct-care workers

Cheating Dignity:  The Direct-Care Wage Crisis in America is a new report from the American Federation of State, County and Municipal Employees (AFSCME). AFSCME commissioned the Paraprofessional Healthcare Institute to write the report, which compares the wages of caregivers to the wages of other workers providing services, such as car repair, dog training, and aerobics instruction. Each of these occupations pays considerably more, on average, than the $7.97 per hour earned by direct-care workers. 

These low wages are exacerbated by the often part-time nature of direct-care work. Thus, 18 percent of nursing home and home care workers-nearly one of every five-live below the federal poverty level. Moreover, these workers are more than twice as likely as other American workers to have no health insurance.

As Cheating Dignity points out, the poor wages and working conditions for direct-care workers have created a labor crisis that is the worst the industry has ever experienced.

But who is responsible for these poor wages? AFSCME argues, we all are. As taxpayers, we pay more than 60 percent of the cost of long-term care through Medicaid and Medicare-thus, we must demand that our tax dollars are used to improve the wages of caregivers who provide critical assistance to members of our community who are elderly, chronically ill, or living with disabilities. Our loved ones deserve quality care provided by compassionate caregivers who can choose this work because it pays sufficient wages to escape the traumas of constant poverty.

To view comments by PHI's President, Steven L. Dawson, presented at the AFSCME press conference announcing the report, go to: www.directcareclearinghouse.org.

To download a copy of Cheating Dignity, go to: http://www.afscme.org/pol-leg/cdtc.htm.


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