Strengthening the Direct Care Workforce
for Long-Term Services and Supports
Suggested Approaches From a National Panel of Experts
DCWs: Turnover among DCWs was seen by panelists as detrimental to the continuity and quality of care for recipients. Panelists were clear that the development and implementation of standard approaches for tracking DCW turnover and retention rates by AAAs and employers in the Aging Network are necessary to determine the actual extent of turnover and to identify the workplace and management practices associated with lower turnover rates. These practices should be publicized and disseminated throughout the Aging Network for replication purposes. Further, provider organizations could be incentivized to implement workforce improvement practices, using OAA and/or Medicaid funding, and include measures of workforce improvement (e.g., decreased turnover, increased number of job advancements, fewer unfilled positions) in their reports to AoA.
Regarding the role of education and training programs for DCWs in fostering quality care, the panelists again underscored a focus on desired outcomes for care recipients which directly link to core job competencies that are instilled through enhanced training programs. These core competencies should be broadened to include training to achieve quality of life outcomes for care receivers, such as sustained independent living, empowerment, choice and control over their care arrangements, and engagement in the management of chronic conditions.
Several panelists pointed to the potential role of the Aging Network in achieving better health care outcomes for care recipients. Specifically, they called for demonstration and evaluation research initiatives that address the Network's role in preventing unnecessary hospitalizations and emergency room use (i.e., improved service system outcomes) through partnerships and collaborative programs linking AAAs with primary care physician practices and hospital systems.
The issue of the variable quality of home care provider organizations was raised in discussing care outcomes, along with the suggestion to implement a voluntary system of accountability related to service reliability, consistency in workers, worker training requirements, and consumer satisfaction. High-performing provider organizations should be recognized for their successful efforts and consumers and family caregivers made aware of those with records of high performance. Another suggestion was to involve the AAAs in evaluating how DCWs can influence client outcomes. In addition, AAAs could influence provider organizations to raise the standards for delivering effective care by rewarding providers that achieve desired outcomes for DCWs (e.g., job retention, job satisfaction) and for consumers (e.g., increased length of stay in HBCS settings, reduced hospital and nursing home (re)admissions among waiver participants, fewer emergency department visits). In addition, AAA and ADRC staff could benefit from training and support that promotes their understanding of and preparation for undertaking legal and liability issues as they develop and maintain registries of providers that meet quality outcome criteria.
Family Caregivers: Regarding outcomes for family caregivers, several panelists recommended the implementation of a standardized caregiver assessment process and its application throughout the Aging Network to ensure that the service and support needs of caregivers are addressed. Other panelists expressed divergent opinions and cautioned that the content and administration of caregiver assessments could have adverse effects on caregivers and on the quality of care and outcomes for elders. There were also concerns that assessment of family caregivers would have a negative impact on supply, could lead to accusations of elder abuse, and should not be linked with training. One panelist pointed out that in the United Kingdom , caregiver assessment is a right under the Carers (Equal Opportunites) Act of 2004, but many eligible caregivers are unaware of that fact and few have availed themselves of it. Similarly, panelists cautioned against trying to be prescriptive with family caregivers because they make their own decisions about what type of help they want and when to seek help.
Other panelists asserted that caregiver assessment would help to ensure service quality and appropriate training of family members. Proponents of this approach recommended that assessment of family caregivers could occur at the time care recipients are discharged from the hospital to determine the caregiver's ability to manage new or expanded care tasks related to the care recipient's post-hospital care. As a critical agent in a family member's care, the caregiver's capacity at time of discharge has a direct bearing on the relative's successful transition back to and continued functioning in the home setting.
Approaches to Improve Outcomes for DCWs and Family Caregivers
6.1 Support demonstrations and evaluations of specialized DCW training programs that enable them to assist older adults' in managing chronic conditions and determine the impact on clients' health outcomes.
6.2 Have AAAs raise the standards for the workforce by rewarding providers that achieve desired outcomes for DCWs and consumers (e.g., increased length of stay in HCBS settings, reduced nursing home admissions among waiver participants, fewer emergency department visits, and reduced readmissions to hospitals).
6.3 Provide training and support to AAA and ADRC staff that promote their understanding of and preparation for undertaking legal and liability issues as they develop and maintain registries of providers that meet quality outcome criteria.
6.4 Incentivize provider organizations to implement workforce improvement practices, using OAA and/or Medicaid funding, and include measures of workforce improvement (e.g., decreased turnover, increased number of job advancements, fewer unfilled positions) in their reports to AoA.
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