The five sites visited differ along the site selection criteria discussed -- program size, geographic region, occupational focus, and apprenticeship model (Table 1). Four of the sites are private, not-for-profit providers (Developmental Services, Good Samaritan, Home Care Associates, and Air Force Villages), while Agape is a for-profit provider. Home Care Associates is also a worker-owned firm, so its employees share in the organizations profits every year. The five sites provide a wide range of long-term care services.
Three of the five sites visited (Good Samaritan, Air Force Villages, and Agape) provide nursing care services to clients using CNAs. In all three sites, employees provide long-term care for clients at nursing homes and retirement communities maintained by the sponsor. Good Samaritan has a LTC RAP to train relatively new CNAs, while Air Force Villages is training its current CNA employees to become HSSs, using the registered apprenticeship model to provide more holistic care of medical and personal care needs for its residents. Agapes LTC RAP trains current employees certified as CNAs to become advanced CNAs, with expertise in palliative care.
In contrast, both Developmental Services and Home Care Associates provide services to clients at home and in group home settings. Developmental Services provides support to clients with developmental disabilities living in a network of group homes and independent living facilities. DSSs, who are trained during the first year of employment through the LTC RAP, help their clients progress toward self-sufficiency in accordance with a plan developed by the clients case manager. This includes supervising clients in workshops where they engage in paid work, assisting in money management, and administering medicine. In Philadelphia, Home Care Associates employs HHAs to provide services in the homes of elderly persons and other clients with cognitive deficits across the city, including clients with Alzheimers or dementia, mental illness, and developmental disabilities. The nature of the work of these aides varies with the needs of the client and can include assistance with medications and wound care, nutrition and meals, chores around the house, and errands. All HHAs receive basic training provided by Home Care Associates but only those who demonstrate excellence in their care skills and leadership qualities are selected for the LTC RAP. Employees completing apprenticeships then become designated mentors to less experienced HHAs.
Four of the LTC RAP sponsors (Developmental Services, Good Samaritan, Home Care Associates, and Agape) receive Medicaid reimbursement for services provided. Only Air Force Villages does not accept Medicaid reimbursement because leadership perceives the level of reimbursement to be too low to provide an adequate level of care. Staff from the remaining sites also indicated that Medicaid reimbursement rates are too low for services provided. Both Developmental Services and Home Care Associates staff cited these payment rates as an important constraint on their operations, and both organizations have sought supplemental funding. Agape staff did not feel as constrained by Medicaid reimbursement rates because they have been successful in attracting clients to the assisted living who can pay out-of-pocket or with long-term care insurance. Good Samaritan, Home Care Associates, Air Force Villages, and Agape accept Medicare reimbursement, which has higher reimbursement rates but has narrower service coverage. While these four sites all accept private paying patients, whose payments are higher than Medicaid reimbursements, Developmental Services opts to only serve Medicaid patients as a part of its mission.