To provide an understanding of the LTC RAPs selected for study, a short description of each program is provided. More detailed descriptions of the LTC RAPs are provided in Appendix B of this report.
Developmental Services, Inc.
Development Services Incorporated is a private, not-for-profit firm that provides direct support services to clients with developmental disabilities. Its mission is to aid its clients in having fulfilling lives and managing the administration of their basic medical care. Ultimately, Developmental Services plans to move clients towards self-sufficiency, consistent with a plan developed with the client and his or her case manager.
The company receives client referrals from Medicaid state case managers. Developmental Services serves approximately 1,700 clients in group home and independent living settings across 30 counties in southern Indiana. The companys headquarters is located in Columbus, Indiana, approximately 45 miles south of Indianapolis. Apprentice training is conducted at the Columbus facility, while client care occurs throughout the state. Since direct support is by its nature dispersed and not concentrated in a single facility, Developmental Services operations are spread throughout the southern Indiana region. Initially, Developmental Services monopolized direct support service provision in the region, although now it has many competitors. Developmental Services operates 14 program facilities and oversees a large number of group homes across the region.
Developmental Services operates a registered apprenticeship program for DSSs. DSSs are responsible for assisting clients with developmental disabilities with the administration of their medicine, domestic activities in group homes and independent living facilities, transportation, and engagement with the community. They are expected to prevent or intervene in crises that emerge, and assist clients in becoming more self-sufficient. In 2004, Developmental Services sought the highest quality and lowest cost training program available, eventually deciding on registered apprenticeship. The apprenticeship program was formalized and registered with DOL in 2005. Developmental Services based the design of its LTC RAP on a training program it had operated since it was founded in 1975, for which all newly hired DSSs become apprentices. There are currently 700 apprentices at Developmental Services. In 2007, as a result of DOLs decision to increase the hours required for DSS apprenticeships, Developmental Services increased its core competency requirement to 216 hours of related technical instruction and 3,000 total hours, the majority of which is OJT. Initially, Developmental Services had time requirements of 144 hours of related technical instruction and 2,000 total hours.
Since 2007, Developmental Services apprentices who complete their requirements are certified as direct support providers by the State of Indiana. There is no associated promotion or earnings increase for apprentices upon completion of the program, but Developmental Services is interested in implementing a wage increase upon completion.5 Developmental Services cannot charge patients for direct support services; they must accept established Medicaid reimbursements as compensation. Therefore, tightened Medicaid reimbursements from the state have limited the ability of Developmental Services to raise wages for any staff upon completion of the apprenticeship program. While promotion and wage progression are not currently offered at Developmental Services through the apprenticeship program, it is expected to increase retention of apprentices who appreciate a professional and skilled work environment.
Home Care Associates
Home Care Associates is a worker-owned company founded in 1993 and provides home health services to clients in the Philadelphia area. HHAs, trained by Home Care Associates, offer care to clients in their homes to assist them in living independently.
Home Care Associates began its LTC RAP for HHAs in 2006. The company was introduced to the registered apprenticeship model through its affiliate, Cooperative Home Care Associates, and worked with PHI (formerly known as the Paraprofessional Healthcare Institute) to develop its own program. After consulting with the OA representative, Home Care Associates developed core competencies for their HHA position based on its current training program to meet the requirements of the LTC RAP.
HHAs at Home Care Associates provide both heartwork services and home health services. Heartwork services include basic companionship and assistance for clients who are able to live independently, but require companionship or care to live comfortably in their own homes. These services include light housekeeping, meal preparation, running errands, and communicating with and accompanying clients to health care providers. Home health services include assistance with basic medical care, including taking temperature, pulse, and blood pressure, changing non-sterile bandages, assistance with rehabilitative care, and assistance with administration of medicines. The program requires 2,025 total hours of OJT and related technical instruction to master the HHA core competencies. A total of 230 hours of related technical instruction in core competencies is required of apprentices, including 150 hours in basic training, 40 hours in enhanced basic training, and 40 hours of other enhanced training. Aides shadow mentors when they receive basic training. While all aides employed at Home Care Associates participate in basic training, only apprentices go on to take enhanced training.
There are currently approximately 200 aides at Home Care Associates, of which 25 have completed the apprenticeship program.6 Over the course of its history, Home Care Associates has trained and placed over 1,000 aides. The base wage for aides is $8.50 and all employees are guaranteed full-time employment. An HHAs base wage is increased by $0.20 upon the completion of the enhanced training and every specialty competency, which raises his or her hourly wage to at least $9.70.7 While the registered apprenticeship HHA guidelines require completion of two specialties, Home Care Associates requires that its apprentices complete all possible specialties, which are geriatrics, disabilities, mental illness, hospice and palliative care, dementia, and peer-mentoring. After completion of the entire apprenticeship program, aides also receive a $200 bonus, receive an official badge with their apprenticeship credential, and become a mentor for other HHAs. Costs associated with the wage increases have prevented Home Care Associates from continuing the LTC RAP.
Evangelical Lutheran Good Samaritan Society
Evangelical Lutheran Good Samaritan Society, or Good Samaritan, is the largest not-for-profit nursing home chain in the United States with 230 locations, mainly in rural areas. Its central headquarters is located in Sioux Falls, South Dakota. Its average facility size is under 100 beds but it also has some very large campuses in metro areas. The types of facilities range from single-site nursing facilities to sites that provide several types of care including skilled and long-term nursing care, assisted living, and care in independents homes located in neighborhoods.
Good Samaritans LTC RAP for advanced CNAs was started in 2003. The initial rationale to adopt the apprenticeship model for training was the need for better quality of care. National staff fielded a survey that identified a need for advanced CNA training above and beyond 75-hour federal requirement. The national staff routinely publicizethe program in employee newsletters, fliers, articles, and other promotional material as well as on its web site. LTC RAPs are only offered at 25 of the 186 facilities, with each facility operating its LTC RAPs independently. Nationally, 147 apprentices are currently active. Across the two nursing homes visited in Boise and Idaho Falls, Idaho, approximately 32 apprentices are currently registered, the most of any of the 25 sites.
Good Samaritans philosophy is more of a bottom-up approach to building the LTC RAP at its facilities with its national leadership staff serving primarily as a resource for local campuses that want to develop an apprenticeship program. This approach requires that local leadership staff initiate and manage the LTC RAPs and work with human resources and clinical staff to offer the program to selected employees. Even though the Good Samaritan national leadership has developed an infrastructure for the LTC RAPs, local campuses can lack commitment in terms of management time and employee incentives to incorporate the program into their institutions. Turnover among local leadership who championed the program is another problem.
The apprentice must complete the advanced CNA training, mentoring, and one specialty competency with approximately 180 hours of related technical instruction and between 1,500 and 2,500 hours of OJT. Some local sites appear to customize how the program is implemented and how long it takes to complete the apprenticeship. The primary intended outcomes of the LTC RAP are to improve the quality of care, empower CNAs, and improve retention by providing a career lattice to encourage staff development and promotion. The program also produces CNA mentors who are extensively used for training new hires.
Air Force Villages, Inc.
Air Force Villages is a not-for-profit retirement community located on two campuses in San Antonio, Texas. Its clientele includes a large number of retired military personnel. Each campus has large independent living complexes made up of apartment-type and standalone housing units. In addition, both campuses have SNF units. The main campus is certified for 104 SNF beds and 20 new assisted living facility beds coming on line in 2011, with approximately 75 of the SNF beds currently occupied. The second campus is certified for total occupancy of 650 including the 64-bed assisted living, secured Alzheimers disease unit and 35 non-dementia assisted living facility beds. The organization is undergoing a major expansion, building a new neighborhood-like complex to be known as the The Mission with household-type arrangements. Once the expansion is complete, the existing facilities will also be restructured into household-type arrangements.
The organization does not take Medicaid patients because reimbursement is too low for the quality of care it wishes to provide. Consequently, Air Force Villages takes private pay residents for whom staff provide a full continuum of care, some short-term Medicare-reimbursed skilled rehabilitation patients for which the facilities are increasing the number over time. Many residents also have coverage as retired members of the military through the militarys CHAMPUS insurance benefit.
Air Force Villages began its apprenticeship program in 2009 in response to its planned expansion as a means of training CNAs in its skilled nursing units in a new model of care to enact culture change. Current CNAs receive advanced training as HSSs and serve as universal workers, conducting all required tasks (e.g., resident care, housekeeping, cooking, laundry) for a small group of residents residing in one household building. In this new model of care, 2-3 HSSs serve 13-14 skilled nursing residents in a small house-like building. The new model of care could also be applied to residents in existing traditional buildings (e.g., long hallways of rooms), which are also being reorganized into neighborhoods.
Approximately 40 apprentices have been trained in three cohorts of approximately 12-15 CNAs each. The apprenticeship is 3,232 hours in length (232 hours of related technical instruction, and 3,000 hours of OJT). Although the intended purpose of the classes is to train CNAs as universal workers, other outcomes include higher wages, longer tenure, and most importantly, higher quality, person-centered care for residents needing skilled nursing care. After existing CNAs are trained, new employees will also be trained as HSSs.
Agape Senior is the umbrella corporation for a mix of 38 for-profit and not-for-profit companies that provide coordinated and interrelated long-term care services in a variety of facilities across South Carolina. Founded in 1999 in West Columbia, Agape was the first long-term care provider to sponsor a registered apprenticeship program in South Carolina. Corporate headquarters is located in West Columbia, South Carolina, and facilities exist in Conway, Laurens, Rock Hill, and other sites throughout the state. Across all its facilities, Agape has approximately 800 beds and has been able to maintain high occupancy rates in both assisted living and SNF settings.
Agapes LTC RAP was started in 2009 and offers advanced CNA and palliative care competencies. The LTC RAP is overseen by the Chief Human Capital Office, which orchestrates all educational efforts at the company. The advanced CNA apprenticeship is one of four apprenticeship programs operated at Agape (the others are not associated with direct care occupations and include dietitians and management), and is only one facet of a broader educational mission at the company. Agape executives are dedicated to building an educated workforce and only hire senior staff that can serve as instructors in these educational efforts. These educational initiatives for CNAs, along with other opportunities for more senior staff, are all components of Agape University, the educational arm of the company. In addition to the four apprenticeships, the company has partnered with Goodwill Industries and Midlands Technical College to provide basic CNA training for employees who are not already certified. Agape continues to build relationships with technical colleges in the region to strengthen these educational efforts and provide of instruction for the LTC RAP.
Agape is currently working with its third cohort of apprentices. The first cohort, who was trained in 2009, began with 18 apprentices.8 Sixteen of the apprentices became certified at the end of 2009. The second cohort, trained in 2010, expanded to 35 participants with 21 successful graduates. Agapes third cohort of 59 apprentices began its program in 2011, with 52 still enrolled as of August 2011. With a total of 1,400 employees and a strong teaching staff, the company expects enrollment in the apprenticeship to continue to grow.
An apprentice in the LTC RAP has to participate in 265.5 hours of related technical instruction and 2,000 hours of OJT to complete the basic CNA, advanced CNA, and palliative care certifications registered with DOL. As the LTC RAP only accepts employees who are already certified as CNAs with the basic CNA training, apprentices only have to complete 143.5 hours of related technical instruction (103.5 hours for advanced CNA, and 40 hours for palliative care) and 1,700 hours of OJT. The palliative care competency is certified by the National Palliative Care test. The operation of the LTC RAP is uniform across Agapes facilities because all related technical instruction is conducted simultaneously over a distance learning platform. The primary intended outcomes of the registered apprentice program are to improve the education of the Agape workforce and improve the quality of care. Two additional benefits regularly noted by Agape staff were that the LTC RAP reduces CNA turnover and helps to differentiate and reward high-quality CNAs.