Strengthening the Direct Care Workforce
for Long-Term Services and Supports
Suggested Approaches From a National Panel of Experts
Panelists discussed the importance of a variety of methods to improve both the supply and retention of DCWs.
With respect to increasing the supply of DCWs, panelists recommended drawing upon immigrant populations, displaced workers over 55 years old whose jobs were lost in the current recession, and persons with developmental disabilities who could be trained as DCWs. Separately, it was widely acknowledged that the wages and benefits paid for direct-care work are a deterrent to recruitment and retention efforts. For example, home care work is among the fastest-growing occupations in the nation; however, home care workers earn on average less than ten dollars an hour ( Dawson , 2010). One panelist noted that DCWs frequently are not paid minimum wage. Under the Fair Labor Standards Act, those working in the home, even if employed by third parties, are designated as “companions to the elderly and infirm” and are excluded from these protections (PHI, 2010). The latest Department of Labor semiannual regulatory agenda indicates that there are plans to review the companionship exemption. This is especially important in light of a recent investigation into violations of employment and labor laws in America 's cities, which showed that home care workers were frequent victims of overtime violations, off-the-clock violations, and meal break violations (Bernhardt et al., 2009). Consequently, a number of panelists suggested advocating for the enforcement of existing employment and labor laws to ensure protection for these workers.
State workforce registries, generally regarded as effective systems for collecting, organizing, and disseminating information on the available pool of DCWs, were mentioned by several panelists. According to CMS's National Direct Service Workforce Resource Center , 23 states have worker registry websites that match persons needing direct support or personal assistance at home or in the community with caregivers looking for work. These computerized registries have the capability to match home care workers' qualifications with consumers' needs, generate lists of potential workers for consumers to interview, and provide access to training for both consumers and workers. It was also suggested that the Aging and Disability Resource Centers (ADRCs), in cooperation with State Units on Aging (SUAs) and Area Agencies on Aging (AAAs), could house statewide registries because they serve as information portals for consumers. This would require federal agencies to provide funding for information technology to create a user-friendly, easily accessible system. Private agencies could also partner to create a database of available DCWs.
Chief among the incentives discussed for retaining DCWs were: a) adequate wages, b) benefits, c) career advancement opportunities and career pathways, d) effective supervision and leadership, e) mentorship programs including peer-to-peer mentoring, and f) recognition of the intrinsic benefits of the job such as compassionate care, which are critical components of this type of work. Panelists discussed several challenges to implementing increases in pay and benefits. For example, federal agencies such as AoA are likely to find it difficult to try to promote changes at the state and local levels and in the private market. Another barrier to increasing DCW wages related to the prevalence of small- and mid-size home care agencies and their flat organizational structure that limited opportunities to implement career ladders and consequently improve compensation. Another panelist mentioned the possibility of working with unions in order to improve compensation packages. Increases in pay and benefits packages would, in turn, help attract and retain workers, thereby increasing the supply of DCWs.
With respect to increasing worker benefits, particularly health insurance, panelists suggested that smaller agencies could pool together to buy into a larger government or private health care plan. Health care reform and the prospect of health insurance availability for those without it now may also have an impact on this issue. Currently, many low-paid home health aides do not want to work more hours for fear of losing their Medicaid benefits.
One panelist mentioned an intervention study in Ohio where career ladder opportunities were created for nurse assistants in nursing homes so that they could become Dementia Care Specialists (Noelker & Ejaz, 2001). However, when the nurse assistants completed the course, they received a change in title but not a wage increase.
Another suggested avenue to pursue for better retention is improved supervision of DCWs. There is, in fact, a substantial body of research on the importance of good supervision for retention of DCWs (Noelker, Ejaz, Menne, & Bagaka's, 2009). Thus, several panelists referred to the need for improved management training programs for providers of long-term-care services and supports. One panelist suggested that standards should be developed for the Aging Network related to creating supportive work environments and effective worker retention practices. Moreover, these same standards should be used as performance standards for provider organizations under contract with Area Agencies on Aging.
Approaches to Increase the Supply and Retention of DCWs
1.1 Collaborate with the Department of Labor to extend Fair Labor Standards Act laws to home care workers, and explore funding implications of requiring provider organizations to offer living wage salaries and benefits to DCWs.
1.2 Provide incentives and technical assistance to the states that currently do not have worker registries to develop and implement them, possibly through grants to ADRCs, SUAs and AAAs, so that persons needing direct support are matched with caregivers seeking work.
1.3 Through ADRC grants, support the establishment of linkages between ADRCs and existing worker registries in states that have them.
1.4 In collaboration with CMS, launch a pubic service campaign that would elevate the public's image of DCWs and the importance of their role in the nation's health care workforce.
1.5 Collaborate with boards of nursing and other associations to promote the use of existing training protocols, and implement and test supervisory training programs for nurses in long-term care focused on team leadership skills, person-centered care, empowerment, and mentoring and coaching DCWs.
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