One of the greatest barriers to the sustainability of the LTC RAP is the high cost of training and incentives to participation such as wage increases. These high costs almost always were reported in interviews, but sponsors did not provide the study team with any detailed documentation. Employers by nature are propriety about their business operations and some sponsors may not have wanted to provide details on costs. Some sponsor staff noted that such costs were incurred as part of the sponsors management staff responsibilities and did not record the separate costs for design and implementation of the LTC RAP. Nor were costs for materials development presented. Only one site, Home Care Associates, calculated that the related technical instruction costs for one apprentice as between $8,000 and $10,000. This program appeared to be at the high end of costs because of various more expensive training components involved. Home Care Associates ultimately discontinued its LTC RAP precisely because of the challenge of these costs when its foundation support ended. For Home Care Associates as well as other home health care service sponsors, demand for long-term care services has declined during the recession as some families began providing care themselves. In addition, Medicaid budgets and reimbursement rates have been reduced as state tax revenue declined with the economy. Sponsors attempted to cover costs that could not be covered by normal revenues with grants and other philanthropic donations. Unfortunately, these funds have also been more difficult to obtain because of the recent recession.
The costs of developing sufficient training resources were also a barrier to sustainability. Good Samaritan and Air Force Villages management noted that they prepared much of their materials at considerable costs in management time. Air Force Villages stated that DOL could help sustain LTC RAPs by developing related technical instruction materials and resources so that sponsors could focus on recruitment activities and OJT. The only site that did not cite cost issues as a major barrier to sustainability, Agape, suggested that it expected to expand the size of the program. Agape staff acknowledged the costs in management time required to develop the curriculum, but considered them a one-time cost. Agape staff found the financial assistance provided by South Carolinas $1,000 per person apprenticeship tax credit particularly helpful, and suggested that other LTC RAPs would benefit from other states providing this level of support for apprenticeship.
Recruitment also has the potential to pose problems for sustainability. If qualified and interested applicants are not available, then apprenticeship programs cannot be sustained. However, this did not seem to be a major issue to the LTC RAPs visited. All five registered apprenticeship programs except for Developmental Services only offered apprenticeships to select employees and they thought their employee pool had a sufficient number of qualified individuals. Developmental Services staff reported that they were not worried about recruitment as a threat to its sustainability, although they did note that its applicant pool is not always well-qualified. They suggested that they never receive enough qualified applicants that they would turn anyone away. In a labor market with many low-skilled individuals looking for work, overall recruitment for the sites was not cited as a problem.
Another factor to program sustainability noted by some sites was the need for buy-in by the firms leadership. Developmental Services has dedicated all of its training resources to the LTC RAP and leadership in the organization has supported the use of the program for all employees. Some sites are still testing whether apprenticeship is the right training approach on a subset of their staff and sponsor leadership has not supported full implementation. For example, Good Samaritans program is voluntary for its facilities to offer and for employees to participate. Home Care Associates supports the program only for its top-performing HHAs and the program is offered only when resources are available.
One concern of apprentices -- the lack of a recognized and portable credential -- may hinder the sustainability of LTC RAPs. For example, staff and apprentices at Home Care Associates noted that while the apprentices are proud of earning their apprenticeship credential, they also find it challenging to communicate the meaning and the value of the credential with other individuals in their field. This is especially problematic as the site is working with its state industry association and the state to develop a licensing requirement for HHAs. However, the use of a community or technical college as a training provider may lend credibility to the apprenticeship credential. For Agape apprentices, they saw their apprenticeship credential as legitimate and recognizable because it was from the local technical college where they received related technical instruction.
The sites visited rarely reported partnerships with the workforce investment system, the educational system, or the long-term care industry, all of which often help sustain training programs. For example, staff seldom identified partnerships with One Stop Career Centers, community colleges, or long-term care industry groups. The lack of such partnerships may greatly hinder sustainability. For Developmental Services, the educational system was a competitor for providing training that the sponsor could conduct more cost-effectively in-house. Similarly, long-term care industry groups were not involved as partners other than providing some technical assistance early on in the program development. The impetus for developing such partnerships may need to come from the partnering organizations as opposed to the sponsors to be seen as valuable.
7.2. Replicability of the Registered Apprenticeship Model for Long-Term Care Occupational Training
Staff interviewed at the LTC RAPs wererelatively certain that other organizations could replicate the LTC RAP and suggested that the most significant obstacle to replication was that long-term care providers were not aware of the apprenticeship model as a training option. A staff person at Developmental Services introduced the organization to registered apprenticeship because she discovered how inexpensive the model was compared to other advanced training options. She thought that other direct support service firms would find Developmental Services registered apprenticeship model cost-effective. One condition that would make apprenticeship a potentially cost-effective training option if states would implement more stringent certification regulations and employers would need a more rigorous training program such as apprenticeship to meet these standards.
Home Care Associates staff saw its registered apprenticeship program as a success because it was built off its current training. The model Home Care Associates used was developed by PHI, in partnership with DOL and had already been tested and implemented in New York. Thus, the LTC RAP was a replication of previous efforts but modified to the needs of the sponsor.
The staff at Good Samaritan and Air Force Villages suggested that a successful program may be difficult to replicate without a champion. Administrators of the Developmental Services and Home Care Associates programs explicitly rejected this suggestion, arguing that anyone could successfully implement the model. However, the apprentices and staff at Developmental Services suggested that their local champion was integral to the performance of the program. Agape administrators and apprentices credited their local champion with the success of the LTC RAP and suggested that it would not have been implemented without his efforts.
Site staffs views on replicabilityalso seems to depend on a variety of local conditions, including the degree to which sites are dependent on Medicaid and Medicare reimbursement for revenue. Sites that were able to identify other funding sources in addition to Medicaid and Medicare did not cite as many financial constraints to their LTC RAP. However, it was not clear that low reimbursement rates were a primary obstacle to the success of these programs. Developmental Services staff reported feeling constrained by Medicaid reimbursement but operated a large and successful LTC RAP, while Home Care Associates had to end its LTC RAP because of these same financial constraints. Neither Agape and Air Force Villages were constrained by Medicaid reimbursement rates because both had additional revenue streams. Therefore, while Medicaid and Medicare reimbursement provided a budget constraint on many of the LTC RAPs, it did not appear to be a major factor in being able to replicate the program.
Another important determinant of replicabilitywas the nature of demand for long-term care services (demand for HHAs seems to be more volatile than demand for CNAs or DSSs). Several sponsor staff cited the recession and reduced demand for long-term care services as a reason for cutting costs. In the case of Home Care Associates, this contributed to the decision to end its LTC RAP for the time-being. The need for state certification and licenses was also a commonly cited constraint on replicability, insofar as staff were not as enthusiastic about the LTC RAP if they did not think their training would be recognized elsewhere. The sponsors that lobbied for state credential recognition and occupational standards, such as Developmental Services and Home Care Associates, had a great sense of pride in the credentials they were providing apprentices. Agape has all of its apprentices take a national palliative care certification test, so this credential is more widely accepted. While most sponsors suggested that broader acceptance of their credential was important, none seemed to be concerned that this would result in apprentices leaving their LTC RAP for other employment or changing careers. The lack of widespread use of registered apprenticeships as a training model also stymies efforts to create awareness about LTC RAPs. While sites already had operating LTC RAPs, some suggested that DOL and others could help to better promote LTC RAPs to other long-term care providers.
As noted earlier, few of these LTC RAPs had any contact with the workforce investment system. Those who did were primarily one-time grant recipients. After further inquiry, none of the sites suggested that lack of involvement with the workforce investment system was a barrier to replicability. With financial constraints as a continuing problem for LTC RAPs, grants for incumbent worker training through the workforce investment system may assist in successful program implementation.