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PHCAST: Final Evaluation Underscores Urgency of Building out Comprehensive, Competency-based Training for Direct Care Workers

July 14, 2016

By Anne Montgomery and Daniel Wilson

Too often, personal and home care aides are the least noticed part of the direct-care workforce, for these reasons: first, wages are typically low and employment benefits are sparse. Second, few states have established high-quality training programs that provide a solid skills baseline for this essential work–and there are no standards at the national level. The lack of national requirements creates another barrier as well–no federal Medicaid funds are available to support state-based training for this workforce.

Yet change is afoot on both fronts. The Department of Labor’s revised Fair Labor Standards Act (FLSA) final regulations, which now include personal and home care aides in requirements governing minimum wage and overtime, has survived multiple legal challenges. The FLSA wage protections stand to boost income for personal and home care aides, even as the Affordable Care Act’s expansions of private health insurance and Medicaid are improving the ability of millions of workers to gain access to health care coverage. On the training front, an initiative embedded in the Affordable Care Act known as the Personal and Home Care Aide State Training Demonstration Program (PHCAST), has the potential to provide the personal and home care aide workforce with a solid foothold in establishing professional training standards–initially at the state level, and perhaps over time, at a national level.


The inspiration for PHCAST was the Institute of Medicine’s 2008 “Retooling the Workforce for an Aging America Act.” That seminal report called for reframing the challenge of preparing the eldercare workforce–broadly defined as licensed health care professionals, direct-care workers, and family caregivers–to focus on ramping up training and infusing geriatric competencies across the full range of practitioners, including direct-care workers.

Six states participated in PHCAST: California, Iowa, Maine, Massachusetts, Michigan and North Carolina, with grants of about $2 million each over three years. The statute required PHCAST grantees in six states to develop and/or augment and scale personal and home care aide training programs based on ten core competencies, as follows: role of the aide; consumer rights, ethics and confidentiality; communication; personal care skills; health care support; nutritional support; infection control; safety and emergency training; consumer needs/specific support; and self-care. States developed training programs that varied in length from 50 to 120 hours, and trained both new and incumbent workers.


In 2012, an interim report of the PHCAST demonstration was released by the Health Resources and Services Administration (HRSA). It laid out significant detail on each state’s programs and what they aimed to accomplish. A final report has just been released, and while it only briefly describes high-level findings, they provide reason for optimism:

  • Attrition rates in the PHCAST demonstration among personal and home care aides who were trained were far lower than normal, ranging from 1 to 12 percent, as compared to usual training programs, which experience attrition rates ranging from 40 to 60 percent; 
  • Trainees reported extremely high levels of satisfaction with the core competencies training, ranging from 92 to 100 percent; 
  • Curricula were developed with collaborative involvement and input from a range of workforce organizations, state agencies and private sector entities; this was also true for program administration and testing and credentialing of trainees; 
  • Demonstration programs centered on collaborations between public educational institutions and private workforce training organizations, which piloted training programs in community colleges, high schools, direct-care worker agencies and in-service training programs and through distance learning. Most also partnered with professional associations representing personal and home care aides; 
  • Struggling with a paucity of well-qualified instructors at the beginning of their programs, states initially built their programs around faculty who were already training certified nursing assistants and home health aides, adapting the curricula to the different needs of personal and home care aides. Over time, the training programs generated a new cadre of trainers who through train-the-trainer classes and webinars learned critical adult learner-centered teaching skills; 
  • Advisory teams fostered collaboration among community colleges and educators, consumers, state government agencies, community organizations and home care provider agencies; 
  • By the end of the demonstration, several state participants planned to expand their training within local community college systems; 
  • Three of the six PHCAST states supplemented entry-level training with specialty training focused on different populations needing long-term care, in order to expand career opportunities for personal and home care aides; 
  • Some states developed comprehensive websites for personal and home care aide training, including online curricula and handouts, and systems allowing trainers to track and monitor trainees’ progress and to answer questions about content, though they also found that trainees needed technical support to successfully complete training provided in this format; 
  • States also found that many trainees needed ancillary supports to complete training successfully and enter the workforce, such as child care, transportation, mentoring, as well as stipends and scholarships and meals during day long training sessions.


Why are these findings important? Stepping back, we know that the home and community-based workforce, now at about 2 million, must grow by roughly a million during the next decade in order to meet growing demand from our aging population. And that’s just the beginning. To have any hope of meeting the needs of aging Boomers over the next three decades, we must harness the work done in the $15 million, 3-year PHCAST demonstration and take it forward. That requires taking a close look at the details of how states embedded the statutory core competencies into comprehensive training programs.

We need to know, for example, more about how participating states wove PHCAST’s comprehensive training for personal and home care aides into a variety of educational programs and how they approached (or plan to approach) the question of credentialing personal and home care aides. How was the training used to build career opportunities for aides who would like to specialize in the care of vulnerable elders and individuals with disabilities?

Lessons from PHCAST can tell us a lot: for example, Michigan adapted the PHI’s personal care services curriculum, along with three additional in-service trainings in dementia, home skills, and prevention of adult abuse and neglect. North Carolina’s PHCAST training targeted unemployed workers, and developed three levels of training–basic, intermediate and advanced–as well as advanced training in home care, geriatric care, and medication aide specialties. Maine’s curricula and a credentialing system was designed to prepare direct-care workers to be able to choose to be personal support specialists, direct support professionals, and mental health rehabilitation technicians.

The final evaluation suggests that a major benefit of PHCAST is that it can show us not only how to implement quality pre-service training but also how to develop career paths that will provide greater professional opportunities for these workers. The demonstration was a key investment in skills-building in long-term supports and services, which is fundamental to the success of our evolving care system. As the population of older adults in the U.S. rises dramatically, a robust, highly trained direct-care workforce will become an even more essential part of the health care economy. PHCAST shows how the interpersonal skills, techniques, and knowledge needed by frontline workers can be taught, replicated, and moved into mainstream programs.

The Bottom Line

So here’s the bottom line: We need to analyze and broadcast the key findings and best practices of PHCAST–the curricula, the methods of teaching skills needed to care for frail elders, individuals living with dementia, those with mental health challenges, and people aging with lifelong disabilities – along with methods for capturing the impact of comprehensive training on recruitment, retention, tenure and job satisfaction among aides.

We should also harvest PHCAST to identify ways of measuring the competence and reliability of aides, including feedback from beneficiaries/consumers on their experience and satisfaction. PHCAST makes it clear that quality pre-service training can make a difference – and should be required to strengthen the direct-care workforce and the quality of long-term services and supports.

Daniel Wilson is PHI’s director of federal affairs and is headquartered in Washington D.C.

Anne Montgomery is Deputy Director at Altarum Institute’s Center for Elder Care and Advanced Illness where she oversees a portfolio of work primarily aimed at helping to establish policy frameworks for delivery of services spanning medical and long-term services and supports.

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