The goals of the LTC RAP are to increase the skills and productivity of the workers, raise quality of care, prolong job tenure and reduce turnover, and improve job satisfaction and employee wages. The sponsors interviewed for this study saw these advantages as reasons to operate their LTC RAP. However, other findings in this report present a challenging picture for apprenticeship, or any other advanced training for that matter, in the long-term care industry. A central problem in this field is the inability of employers to achieve sufficient cost savings or extract sufficient revenue increases from gains in productivity and quality of care that might result from a more highly skilled workforce. Part of the problem revolves around the difficulty to this point of documenting cost savings or productivity gains.
Another problem is a third-party reimbursement system that does not provide higher payments to higher quality providers. These problems limit the ability of employers to pay significant wage increases for progressing through and completing an apprenticeship. Other challenges, such as limited knowledge of the approach and limited recognition of credentials, reflect the fact that LTC RAPs are still in their early stages in the industry. If LTC RAPs were to expand broadly, more employers and workers may begin to recognize the credentials of those completing apprenticeships as reflecting genuinely high professional skills. A key question is whether sufficient outside support or employer interest will generate an expansion of LTC RAPs. A rigorous evaluation of LTC RAPs may affect the outcome. Were an evaluation to show significant net benefits for employers, for quality of care, or for workers, the LTC RAP approach potentially could attract significant support as one way of dealing with the well-recognized and long-term problems of building a well-qualified long-term care workforce.
The registered apprenticeship model is intended to be self-sustaining because the sponsor uses its training budget for the LTC RAP in place of the training approach they would use otherwise. Usually, new long-term care workers receive only minimal basic training (75 hours in the nursing home and home health care occupations) before they begin work. In four of the five sites visited, the LTC RAP provides training that lasts much longer than is typical, far exceeding the usual minimal requirements. As such, apprenticeship does indeed generate more training, but presumably at additional costs to employer sponsors.
In order for the LTC RAPs to be sustained and spread more widely, the benefits of the LTC RAP need to outweigh the costs. Apprenticeship training is intended to increase the skills and productivity of the workers, the quality of care, prolong job tenure, and reduce turnover. How well the program does so is still uncertain. Sponsors typically receive no government or other outside resources for the development and operation of their LTC RAPs, and therefore must dedicate significant internal resources for continuing the LTC RAPs. Medicaid reimbursement, the primary payer in long-term care, is relatively low compared to other payers and does not recognize the need for or existence of direct care workers with training beyond the minimum level. For the sponsors, higher skills therefore may come at significant non-reimbursable costs unless the skills that workers learn result in greater productivity, which is hard to accomplish or prove in a service industry such as long-term care.
While these challenges do exist, expanding the number of these programs in the long-term care setting may offer an innovative approach to addressing the workforce shortage. From January 2005 to December 2009, there were 3,744 individuals who began LTC RAPs in 121 unique programs (Anderson, et al., forthcoming). While this number is small compared to the universe of registered apprenticeship programs, some ground has been gained through efforts by the OA to promote LTC RAPs in the industry. In addition, as part of the landmark ACA of 2010, Congress authorized funds for the Health Professions Opportunity Grants program, which supports the development of health care occupational training programs, including long-term care, for welfare recipients and other low-income individuals. It is required that these programs partner with SAAs to develop registered apprenticeship opportunities for serving participants and engaging health care employers. If evaluated, these combined efforts at expanding LTC RAPs may offer some evidence of their effectiveness and document ways for addressing the challenges. Thus, policymakers potentially could consider registered apprenticeship as a partial means to address the long-term care workforce shortage and the need for better skills, but the need to understand and address the challenges to its success are formidable.