All sponsors bear the cost of or raise funds to support the related technical instruction component of the program, including wages for staff conducting training, curricula, and class materials (Table 7). One cost that is handled differently across the five LTC RAPs is the payment of apprentices time during training. Two of the LTC RAPs (Developmental Services and Home Care Associates) allow apprentices to complete related technical instruction during work hours, while Good Samaritan, Air Force Villages, and Agape do not. Good Samaritan provides apprentices with curricula and instructional DVDs, but requires them to complete their training off the clock. Air Force Villages and Agape offer 2-hour and 3-hour related technical instruction sessions, respectively, although it is conducted during non-work hours at the facility. Staff at Developmental Services or Home Care Associates, which arelocated in states with occupational certification requirements, indicated that apprentices pay for the fees associated with state certifications.
Completing training during work hours can be an advantage for apprentices as workers who seek training outside of their employer may need to forgo wages they could have earned while in training. All sites pay apprentices wages during their OJT. Both Developmental Services and Home Care Associates apprentices are paid for their time during related technical instruction. However, apprentices at Good Samaritan, Air Force Villages and Agape must complete related technical instruction on their own time. None of the apprentices pay for the training materials.
The most serious budget constraint facing the LTC RAPs is low reimbursement rates for long-term care services. Sponsors that accept Medicaid and Medicare (Developmental Services, Good Samaritan, Home Care Associates, and Agape) often have to raise private funds to cover costs of the LTC RAPs. Providers are explicitly restricted from charging Medicaid clients a supplemental fee. Air Force Villages does not accept Medicaid from clients but receives reimbursement from Medicare, private insurance, and out-of-pocket payments by residents. Reducing training costs was the key outcome for Developmental Services in selecting the registered apprenticeship model over other options such as the local community college, which they found to be more expensive. However, the concern is that low reimbursement rates may prevent long-term care providers from investing in more rigorous training when it is not government mandated, including investment in registered apprenticeship. For example, Home Care Associates has discontinued its program due to its cost, which is estimated to be between $8,000 and $10,000 for an apprentice.10 Staff at Home Care Associates noted that Medicaid reimbursement rates in Philadelphia are lower than most other localities in the state, despite the fact that the cost of living is higher in the city. As a result, the LTC RAP relied on contracts and grants to operate the full apprenticeship program.
The LTC RAPs visited have also been affected by the recent recession. Home Care Associates staff suggested that the home health industry is especially hard hit because families have an incentive to reduce costs by providing informal care for elderly family members rather than paying for home health services. Many states have responded to reduced tax revenue by cutting Medicaid reimbursement rates, further exacerbating sponsors fiscal challenges in operating their LTC RAPs. The sponsors that rely primarily on Medicaid referrals for its clients have felt these cuts and this may challenge the sustainability of their LTC RAP.
It should be noted that few data on specific costs for operating the LTC RAPs are available for this study. While staff were specific on the what the potential costs were for operating the LTC RAP (e.g., related technical instruction, equipment, transportation, management, wage increases), it was difficult to link amounts to each of these costs either because the sites did not want to share proprietary information or did not track costs across time or separately from other training activities. It was especially challenging for sponsors to know what costs could be attributed to the program or to the apprentice. In turn, this made it difficult to quantify the monetary benefits to the apprenticeship programs in each site retrospectively, especially in measuring the marginal benefits of increased productivity or quality of care, without a more in-depth study.