Workforce Shortages in Long-Term Care: Addressing Cost, Quality, and Access

1. The Impact of Workforce Shortages on Cost, Quality and Access: How Should We Respond?Robyn I. Stone, Dr. P.H., Executive Director Institutefor the Futureof Aging Services State Long Term Care Programs: Balancing Cost, Quality and Access AHRQ Indianapolis, IN May 7, 2002 Institute for the Future of Aging Services

2. Current Problem • Severe labor shortage with geographic variation • High turnover rates • High vacancy rates • Intra and inter-sectoral movement • Long time to fill positions • 42 states report significant recruitment and retention problems

3. 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

4. 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

5. Workplace Level Framework • Organize arrangements • goals • administrative policies • reward systems • Social factors • management style • employee interactions • individual personalities

6. Workplace Level Framework • Physical settings/environment • Technology • job design • training • clinical tools • information systems

7. 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.

8. 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

9. State LTC Workforce Initiatives*

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

11. How do Wage Pass Through’s Work? • Designate specific percentage or dollar amount per hour or patient day for wages/benefits • Structured as mandatory or intended use • Provider flexibility varies (i.e. wages only, wages/benefits and/or other uses) • Typically Medicaid but may include other funding streams

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

13. 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

14. Broadening the Pool of Potential 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

15. 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

16. 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

17. Massachusetts Case Study • Coalition of Organizations to Reform Elder Care • Direct Care Workers’ Initiatives • Extended Care Career Ladder Initiative ($10 million state-funded demo in 29 nursing homes) • Direct Care Workers Training Scholarship Fund • Dedicated Wage Pass Through for CNA’s in Medicaid funded nursing homes

18. California Case Study • Interdepartmental and industry workgroup on improving CNA working conditions • Statewide CNA survey • Aging with Dignity Initiative to improve CNA and IHSS worker wages • Caregiver training initiative ($25 million from Work Investment Act and Welfare to Work Grants) • Employment development department “Ladders” program • County-level public authorities (provider registries, training and employer of record)

19. North Carolina Case Study • NC DHHS and UNC Partnership Pilot linking financial and other incentives to training and retention • Civil penalty fine monies • Supports training and financial incentive efforts • Creates Geriatric Nurse Aide II category • 7 training modules developed by North Carolina Division of Facility Services (NCDFS) available on CD ROM • NC Nurse Aide Registry mailing CHIP program info to all new CNA’s • $500,000 appropriation to develop and evaluate on-site internet CNA training; partnership with community college system

20. 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