The United States lacks a formal training system for long-term care occupations with and few government standards that regulate the qualifications of long-term care workers. However, there is an unprecedented need for skilled long-term care workers with the passage of the Patient Protection and Affordable Care Act (ACA) and the growing health care needs of the aging Baby Boom generation. To address this issue, the U.S. Department of Labor (DOL) has expanded the use of registered apprenticeship, a training approach that combines classroom instruction and work-based learning, to long-term care occupations. This section introduces the use of the registered apprenticeship model for long-term care training and the potential for evaluating the approach.
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1.1. The Long-Term Care Industry and Registered Apprenticeship
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Improving the skills of the long-term care workforce is often proposed as a strategy to improve the quality of care in long-term care settings (Institute of Medicine, 2008). Long-term care workers include certified nursing assistants (CNAs) in nursing homes, home health aides (HHAs) working for home health agencies, health support specialists (HSSs) in residential care facilities, and direct support specialists (DSSs) in group homes or facilities for persons with intellectual disabilities. These workers assist people with disabilities with daily activities such as bathing, eating, shopping, and housecleaning in private dwellings as well as in various types of group residential care facilities and nursing homes.
With the aging of the population, the need for long-term care workers is increasing. The demand for long-term care services in the United States is projected to roughly double between 2000 and 2030 as the population ages (Johnson, Toomey, and Wiener, 2007). DOL projects that HHAs and home care personal care assistants will be among the fastest growing occupations between 2008 and 2018 (DOL, 2009).
Conversely, the United States faces current long-term care workforce challenges, which will grow larger in the future. Residential care providers and nursing homes already report high turnover rates ranging from 40%-70% (NCAL, 2010; American Health Care Association, 2007) and many vacancies. Low compensation and few options for advancement result in weak incentives for workers to enter or remain in the long-term care field (Khatutsky, Wiener, Anderson, and Squillace, 2011). Moreover, the low-skill levels of many workers in these occupations make it costly for employers to raise job quality through paid training. Employers are also often dependent on reimbursement rates set by state Medicaid programs, further constraining them from raising wages to attract new workers.
The long-term care system lacks a formal training and career development program that is applied across different states and long-term care settings. A federal standard of a minimum of 75 hours of training for CNAs in skilled nursing facilities (SNFs) and HHAs is required, but the content of this training greatly varies. There are no federal (or sometimes even state) training requirements for personal assistant service workers, personal care attendants, aides in assisted living facilities, or direct care workers serving people with developmental disabilities (Institute of Medicine, 2008). One solution to improving the skills of these workers is to use low-cost strategies so that employers can justify higher wages with the promise of a more productive workforce. Another solution is to restructure employment in the long-term care industry so that entry-level work affords the opportunity of career advancement and wage progression.
Apprenticeship, which addresses both of these solutions, is a well-established strategy to train workers by combining classroom and experiential learning and placing workers into careers that offer the opportunity for advancement and wage progression. The apprenticeship model is distinguished by its integration of instruction and work. Apprentices learn occupational competencies in formal classroom settings and while working at a job that directly applies and reinforces those competencies. Structuring training in this way provides apprentices with an income and assurance that the skills they obtain are in demand by employers. In addition, the work-based learning offered by on-the-job training (OJT) helps workers to understand how their classroom instruction is relevant to their work. Evidence suggests that the returns to apprenticeship training exceed the returns to community college instruction (Hollenbeck, 2008).
An essential component of apprenticeship is clear wage and career progression. Wage increases are often tied to the completion of certain occupational competencies, either in their classroom instruction, OJT, or both. Regardless of the specific structure of the wage progression, under all circumstances apprentices who complete their program should continue to work for the employer at a higher wage than when they started the apprenticeship. This advancement opportunity, which is tied to the mastery of competencies, provides an incentive for the apprentices to acquire skills demanded by employers.
Apprenticeships in the United States are sponsored by private employers, jointly by an employer or group of employers and a union, and by the military. They are highly decentralized in terms of decisions by apprenticeship sponsors regarding curriculum and program structure. Most programs operate within the Registered Apprenticeship system, which is supervised by DOLs Office of Apprenticeship (OA), and state apprenticeship agencies (SAAs). The OA certifies program completion, protects the safety and welfare of apprentices, provides guidance and technical assistance to program sponsors, monitors program equal opportunity plans to prevent discrimination against women and minorities, and promotes the expansion of the use of apprenticeship by employers. The OA works with SAAs and its own regional staff to reach out to potential sponsors on the registered apprenticeship model and how they could implement it for training their employees.
In 2001, the OA1 launched its Advancing Apprenticeship Initiative (AAI), which emphasized the expansion of apprenticeship programs in industries were currently growing and did not have a history of using the apprenticeship model. At the time, these high-growth industries included health care, especially in long-term care occupations. This strategy was based on recommendations by a 2001 General Accounting Office report, Registered Apprenticeships: Labor Could Do More to Expand to Other Occupations. The report recommended that the registered apprenticeship model was highly successful in construction and manufacturing industries and should be replicated and expanded into other industries to develop a skilled workforce.
To address the call for expanding registered apprenticeship to the long-term care industry, the OA developed a strategy to reach out to the long-term care industry. Since then, some industry providers have used the registered apprenticeship model to develop a skilled long-term care workforce to help lower a variety of costs, including those associated with retraining costs resulting from high turnover and medical error. More advanced skills earned by apprentices may also provide employers the opportunity to create a natural career ladder that may entice job applicants interested in upward mobility and improve the lives of long-term care workers overall. Moreover, registered apprenticeships involve a wage progression within the program, as occupational competency trainings (short components where a specific job skill or task is mastered) are successively completed. This wage progression, along with the distinction of participating and completing the apprenticeship, introduces the possibility for career advancement as it may improve the skills of the long-term care workforce.
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1.2. Evaluating Long-Term Care Registered Apprenticeship
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To assess whether the registered apprenticeship model is an effective approach for training long-term care workers, the U.S. Department of Health and Human Services (HHS) and the DOL have funded a study to better understand LTC RAP characteristics to inform possible design options for future evaluations of LTC RAPs. To develop evaluations, HHS and DOL need to understand: how LTC RAPs are structured and implemented, the perspectives of sponsors, apprentices, and partners: and the successes and challenges of operating LTC RAPs. This report examines the characteristics of five LTC RAPs for providing such information to assess potential evaluation design options for evaluating LTC RAPs.
To guide the data collection and analysis conducted, the study addresses the following research questions:
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What are the goals of the LTC RAP?
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What are the apprenticeship sponsors work settings and characteristics, and how might these influence the outcomes of the registered apprenticeship?
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What core competency trainings are offered by sponsors?
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Are apprentices paid to attend training or is it accomplished outside of work hours?
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What participation incentives are offered? How is the LTC RAPs wage progression or career ladder structured?
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What are the major recruitment sources for the LTC RAP? How are apprentices selected? What recruitment challenges do these programs face?
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What are the demographic and educational characteristics of apprentices?
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What resources are available to the LTC RAP? How many staff are dedicated to the program? Does the sponsor have relationships with partners that provide resources?
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What are the perceived outcomes of the LTC RAP, and what outcomes does the sponsor currently measure?
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What are the factors that contribute to a programs sustainability and replicability?
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What are the implications of the LTC RAPs for the feasibility of evaluating them in the future?
To best answer these questions, information for the analysis is primarily drawn from visits to five LTC RAPs. Each of these sites has a registered apprenticeship program for at least one of the following long-term care occupations:
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DSSs, who work in group homes or other facilities to assist clients with developmental disabilities.
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CNAs, who work in nursing homes and SNFs.
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HHAs, who work for agencies that provide long-term care services to clients in their homes.
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HSSs, who work in residential care facilities.
After providing an overview of each of the selected sites, this report provides a cross-site analysis of apprentice recruitment and characteristics, the features of the LTC RAPs, the resources necessary to operate the programs including any partnerships, such as with educational entities, the potential impacts of the programs, and the sustainability and replicability of these programs. The report concludes with a discussion of the implications for evaluation of the LTC RAP model. Data collected through the site visits was supplemented by data from the Registered Apprenticeship Partners Information Data System (RAPIDS). The findings from this report will inform the development of the feasible evaluation designs that could be implemented to study the effects of the LTC RAPs. A final report will assess and present these evaluation design options.
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1.3. Methodology
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The site selection process used four criteria to identify a dozen potential sites to visit. To best inform the most rigorous potential evaluation design options, the size of the program served as the primary site selection criterion, with the sites having the largest numbers of apprentices entering programs making the initial selection list. To obtain diversity in the LTC RAPs selected, secondary criteria included the region of the country, occupation (DSS, CNA, HHA, and HSS), and type of apprenticeship model (time-based or competency-based).
It was originally planned for the study team to visit six LTC RAPs for this study. However, the study team experienced difficulty obtaining commitment to participate from some sites originally recommended for several reasons. Two sites were in the process of ending their LTC RAPs because the program was too expensive to continue running. One site had delayed full implementation of its LTC RAP because of spending cuts. Based on the site selection process and the agreement of sites to participate in the study, the five sites selected are:
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Developmental Services, Inc. -- a not-for-profit, private direct support services provider to persons with developmental disabilities in southern Indiana, which has sponsored its LTC RAP since 2004.
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Evangelical Lutheran Good Samaritan Society (Good Samaritan) -- a not-for-profit, private, national nursing home chain headquartered in Sioux Falls, South Dakota, which has sponsored its LTC RAP since 2003.2
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Home Care Associates -- a not-for-profit, worker-owned home health care provider in Philadelphia, Pennsylvania, which has sponsored its LTC RAP since 2006.3
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Air Force Villages, Inc. -- a not-for-profit, private retirement community in San Antonio, Texas, which has sponsored its LTC RAP since 2009.
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Agape Senior -- a faith-based, for-profit umbrella corporation which owns 38 for-profit and not-for-profit companies providing long-term care services in a variety of facilities across South Carolina, which has sponsored its LTC RAP since 2009.
In late 2010 and 2011, the study team sent two-person teams to conduct 2-3 day site visits to each LTC RAP. To systematically examine the five LTC RAPs, semi-structured interviews were held, most often in-person, with staff from apprenticeship sponsors, apprentices, and partners. Questions were designed to elicit information on the implementation and evaluation potential of the programs for the development of evaluation design options for this project (the interview guide is provided in Appendix C).
While staff at the sponsoring organizations were readily available for interviews, accessing apprentices and partners was more challenging. Apprentices, for the most part, were not centrally located because of the varied settings in which they work and train so it was challenging to interview a robust sample of apprentices. The study team also had to rely on sponsor staff to recruit apprentices for interviews so it is possible that only apprentices with more positive experiences were recruited. Representatives from the community college system and the workforce investment system that acted as resources to the LTC RAPs were contacted separately to be interviewed, typically by phone. These partners were usually not highly involved with the implementation of the LTC RAPs, either because they were seen as a competing source of training (in the case of community colleges in many of the states), or because they were seen as a separate DOL program (in the case of the workforce investment system). Perspectives from the workforce investment system are largely absent from this report because it was rarely involved in the operation of the LTC RAPs and was not considered a key partner by the sites.4
After the site visits, the researchers developed five-page summaries of the interviews using any background documents provided by the sites and notes from the site visit interviews. These summaries were sent to the administrators of the LTC RAPs for review to ensure that all information was accurate and to clarify any questions that arose as the reviews were written. These summaries are provided in Appendix B. Cross-site analysis was conducted on the various program design and implementation elements including apprentice recruitment and characteristics, the features of the LTC RAPs, program resources, partnerships, perceived program impacts, and program sustainability and replicability. The next section of this report provides an overview of the five LTC RAPs and compares overall characteristics of the sponsors and the programs.
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