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.