Characteristics of Long-Term Care Registered Apprenticeship Programs: Implications for Evaluation Design. Appendix B. Site Summaries

09/13/2011

Development Services Incorporated

Program Sponsor: Development Services Incorporated  
Apprenticeship Occupation:   Direct Support Specialist (DSS)
Location Visited: Columbus, Indiana
Date of Visit: December 8-9, 2010

Overview of Site: Development Services Incorporated is a private, not-for-profit firm that provides direct support services 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 company’s 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 the U.S. Department of Labor (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 DOL’s 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. 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.11 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.

Program Design: Developmental Services began researching training program options for it staff in an effort to reduce medical error rates in 2004. A cost-effective way to reduce error rates was the primary motivation for adopting the LTC RAP. Recruitment and retention for Developmental Services had always been robust for Developmental Services because of the broad awareness of the quality of their training. Training through the community college was quickly ruled out as too expensive, although the company did consider using the training offered by the College of Direct Support, a regional provider of such training. Developmental Services leadership ultimately determined that the LTC RAP was both cost-effective and easily integrated into its existing training activities, which relied heavily on a combination of related technical instruction and on-the-job training (OJT). To initiate the LTC RAP, Developmental Services first contacted DOL’s Office of Apprenticeship (OA), which directed them to Indiana’s OA. The goal of the LTC RAP was to provide low-cost training that would reduce error and risk in client care.

The DSS registered apprenticeship program occupation has 15 core competencies, which are taught through a combination of related technical instruction and OJT. Many of the competencies, such as community living skills and participant empowerment, revolve around the unique circumstances implicit in the regular social contact maintained with clients by apprentices in this occupation. Unlike many long-term care occupations, DSSs interact socially with their clients for extended periods of time. Other competencies emphasize “soft skills” such as communication and client advocacy. More technical competencies include documentation and assessment skills. A trainer at Developmental Services emphasized that documentation skills were critical for the success of apprentices, since multiple staff work with the same client and need to stay apprised of incidents and drug administration. Another core competency is crisis prevention and intervention. Since clients can react unpredictably in stressful situations, apprentices spend time in both formal training and OJT learning strategies for diffusing difficult interactions with clients.12

Developmental Services places a high value on job candidates who have soft skills and the capability to manage stress that is inherent to direct support provision. Many applicants are not fully aware of the challenges associated with the work, and instead can view it as a “baby sitting job.” Developmental Services is therefore interested in applicants with prior direct support experience who are interested because they have the desire and aptitude for the rigorous training provided by the registered apprenticeship program. Developmental Services receives approximately 100 applications a month and extend offers to 25-30 applicants. Applicants almost always accept the job offer. Developmental Services staff indicated that they rarely turn away qualified applicants because Developmental Services usually has open positions to fill. The company advertises in newspapers, on-line, and at job fairs, and is always looking for new venues to seek out more qualified applicants. Applicants often come to Developmental Services with cardiopulmonary resuscitation (CPR) and other certification, but the company is selective in recognizing these certifications, preferring to re-teach its own curriculum during related technical instruction. Currently, only CPR training from the Red Cross and the American Heart Association are accepted; applicants without this certification are required to go through CPR training at Developmental Services.

Apprentices at Developmental Services are primarily White (96%) and female (83%), but range widely in age (the average age for a Developmental Services apprentice is 39; 25% are under 27 years old, while 25% are 51 years old or older). Most are not highly educated, but do have a high school diploma (95% of apprentices has a high school diploma as their highest degree). However, many apprentices have worked as a DSS or were employed in long-term care, and join the company with considerable experience. Developmental Services also employs many students as part-time employees and “floaters.” The 20-30 floaters move among group homes and Developmental Services facilities as they are needed to fill vacancies. Floaters have higher wages, fewer hours, more flexible schedules, and fewer benefits, making the position more attractive to students. Most apprentices have earnings that qualify them for the earned income tax credit. Apprentice-to-client ratios vary depending on the severity of the clients’ developmental disabilities.

For the OJT component at Developmental Services, apprentices must demonstrate a wide range of competencies in each work setting. However, apprentices are generally not aware that they are fulfilling specific core competency requirements for the LTC RAP. They understand what they are expected to know, but they do not always understand the structure of the registered apprenticeship model. The supervisors of apprentices, on the other hand, are knowledgeable in the core competency requirements. They confirm with the human resources department that an apprentice has dedicated the requisite hours to each of the core competencies and has mastered them. OJT occurs in the context of performing ongoing job responsibilities. The corecompetencies all come up regularly in the group homes and workshops, and supervisors constantly provide instruction and guidance. Developmental Services supervisors and the trainer providing clinical instruction suggested that work-based learning also occurs through regular team meetings and interactions with nurses on staff.

Related technical instruction starts with a set of basic training courses that are required before apprentices provide services for clients. This basic training includes medical orientation, training in two core medical competencies, CPR, and agency orientation, and can take as little as 10 days, depending on how quickly apprentices work through the on-line instructional material and how successful they are in passing assessments. After the basic training period, additional training is provided on non-violent conflict intervention, additional reviews of medical competencies, and related technical instruction for the 15 core competencies listed above. All tests related to medical core competencies are re-taken annually, and this often involves additional training. Developmental Services requires 3,000 hours dedicated to learning and practicing core competencies. Of the 3,000 hours, 216 are spent in related technical instruction. Most of the training is provided by either a human resources staff member responsible for overall operation of the apprenticeship program, or the medical trainer.

Developmental Services employs approximately 30 supervisors who work with apprentices. All Developmental Services supervisors have completed the Developmental Services LTC RAP. These supervisors meet with staff in group homes on a monthly basis to discuss clients. In addition to the monthly group meetings, the supervisors monitor staff as they do their work on a more regular basis. Each group home also has a nurse responsible for its clients. The nurse supervises apprentice administration of drugs, and is available for medical emergencies or to answer any questions that the apprentice may have. Consultation with the nurse is required before a client’s medical regimen can be adjusted. Nurses report to the human resources department on apprentice performance and mastery of the core competencies. Peer-to-peer support occurs on a daily basis, since multiple apprentices work together in the same group home. Peer-to-peer engagement also occurs at monthly group meetings, when a wider circle of apprentices working in the same group home have an opportunity to discuss challenges with each other.

The only scheduled wage progression occurs when the basic training is completed. All apprentices start at $7.25 an hour. After basic training, wages are increased depending on experience. Apprentices with no experience typically see their wages increase to $8.50, or by $1.25 per hour from the training wage. After basic training is completed, no subsequent bonuses or wage increases associated with the completion of the remaining related technical instruction and OJT are offered. However, as of 2007, apprentices who complete the LTC RAP are certified as direct support providers in Indiana. Before then, certified direct support providers had to receive training through the College of Direct Support or Ivy Tech Community College. However, some apprentices expressed skepticism about how many employers would recognize the apprenticeship credential, since they are accustomed to the better established Ivy Tech and College of Direct Support credentials.

Program Resources: All training at Developmental Services is conducted during work hours, although apprentices going through basic training are paid a lower wage than apprentices who have completed this basic training.13 Many of the competency tests can be completed on-line. Thus, if apprentices are renewing their competencies, they are not required to do this during work hours. There are no substantial equipment costs for the LTC RAP. The curriculum and tests for the medical orientation training were developed by Developmental Services, but other curriculum for related technical instruction was developed by Indiana University. Since the State of Indiana recognized persons completing a LTC RAP as certified direct support providers in 2007, there have been no additional licensing costs associated with the program at Developmental Services. Indeed, a major impetus for the LTC RAP at Developmental Services was to avoid the high licensing costs at the College of Direct Support.

Apprentices do not bear the cost of tuition, textbook, or school expenses but they are expected to travel to Columbus for initial related technical instruction. All instruction is conducted during work hours, although apprentices have the option of being tested on-line outside of work hours if it is more convenient for them. Apprentices assisting more self-sufficient clients who do not live in group homes bear the transportation costs of going from their homes to and client appointments and errands.

Developmental Services relies on United Way and other donors and grants to cover expenses in excess of reimbursements provided by Medicaid. Developmental Services also confers with seven other direct support providers in the Southern Indiana Provider Network (SIPN), which acts as a trade association and discusses employment and training issues. They do not receive resources from SIPN but they discuss best practices and promote the LTC RAP model.

Program Outcomes to Date: About 700 apprentices are currently enrolled in the LTC RAP at Developmental Services. As of December 2009, 34% of Developmental Services’ apprentices had completed the program, 30% were registered but had not yet completed the program, and 36% had dropped out.14 Developmental Services’ employee turnover rate was 49% in 2009, with 59% of the total turnover occurring within the first year of the apprentice’s time at Developmental Services. Some separations involve apprentices who have been certified but who had left Developmental Services employment. However, Developmental Services staff reported that most of the separations arise quite early in the training period, usually within a few months after being hired.

Developmental Services has an outcome measurement system that is largely based on client feedback and satisfaction. This measurement system is a way of providing a quantitative work goal. Most direct support providers in Indiana have a similar client-based outcome measurement system, although comparing client outcomes can be challenging because of the variety of client conditions. Indiana University assists Developmental Services in collecting these data. While the client data collected are not strictly an attempt to measure return on investment for the LTC RAP, Developmental Services does consider the LTC RAP as a cost minimization strategy.

Perceived Benefits and Challenges of the Program: Developmental Services staff reported that the primary benefit from the LTC RAP is its role as a risk management tool to reduce the risk of serious medical errors. Well-trained staff make fewer mistakes, which in the direct support industry can be costly. Apprentices at Developmental Services share the view that they receive much better training at Developmental Services as compared to less comprehensive training in non-apprenticeship programs offered by other employers and training organizations. The added training is a primary attraction of working at Developmental Services for the apprentices, who take pride in their skills. The apprentices also noted that the frequent peer interaction and peer learning is more fulfilling than their experience at other agencies, where the management is more hierarchical and less feedback is offered. One shortcoming of registered apprenticeships noted by many of the staff is that few other agencies recognize registered apprenticeship certification, and local community colleges do not accept certification for academic credit.

Sustainability: Developmental Services is not concerned about recruiting individuals to enter its LTC RAP. While staff aresomewhat concerned about the quality of many of the applicants, they are not concerned about program sustainability. The major challenge to sustainability cited by the staff was the cuts made to Medicaid reimbursement in Indiana as a result of the recession, as well as the persistent problem of covering costs that are not reimbursed by the state through grants and donations.

Evaluation Potential: The scale of the Developmental Services LTC RAP may meet the criteria for conducting several of the evaluation designs under consideration. Since Developmental Services requires all applicants to go through the LTC RAP, and since it never receives qualified applications in excess of their needs, a random assignment of the apprenticeship model within Developmental Services would be challenging, and would require substantial changes to its selection policies. A more promising evaluation strategy may incorporate other direct support providers in the SIPN group. These providers have expressed an interest in the apprenticeship model.

Home Care Associates

Program Sponsor: Home Care Associates
Apprenticeship Occupation:   Home Health Aide (HHA)
Location Visited: Philadelphia, Pennsylvania  
Date of Visit: January 20, 2011

Overview of Site: 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 DOL’s LTC RAP through its affiliate, Cooperative Home Care Associates, and worked with PHI (formerly known as the Paraprofessional Healthcare Institute) to develop its own LTC RAP. After consulting with the state apprenticeship agency (SAA) 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.

There are currently approximately 200 aides at Home Care Associates, of which 25 have completed the apprenticeship program.15 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 HHA’s 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 $9.70.16 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.

Program Design: The Home Care Associates LTC RAP for HHAs grew out of its established training program. The company provides basic training to all new employees. HHAs who show promise for greater responsibility such as mentoring and supervisory roles are recommended by senior staff to participate in Home Care Associates’ enhanced training. In this training component, HHAs further develop their leadership skills in home health care and learn specialized skills. It is from this enhancing training that the LTC RAP design has emerged and the competencies for HHAs were developed.

The HHA LTC RAP occupation has nine core competencies, which are taught at Home Care Associates through a combination of related technical instruction and OJT. Since HHAs are expected to provide companionship for clients, several of the competencies revolve around understanding this role including the first competency in “The Role of the Home Health Aide,” as well as “Client Rights and Confidentiality,” “Understanding the Needs of Various Client Groups,” and “Communication and Problem Solving Skills.” Instruction in communication is especially important for HHAs, who often function as an intermediary between clients and health care professionals. Other competencies are more task-oriented, including personal care skills and health-related tasks. Since HHAs are tasked with monitoring clients who may become progressively less capable of living independently, aides require skills in basic household maintenance. The core competencies that fall in this category include in-home nutritional support, infection control, and safety.

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. Enhanced training includes additional instruction in case management, peer-mentoring, best practices, and communication. Thus, apprentices not only have a higher level of training in the core competencies taught to all aides, they also develop leadership and mentoring skills. Other enhanced training includes working with clients with physical disabilities, hospice care, and mental illness.

Registered apprenticeship for the HHA occupation is unique in that aides do much of their work alone in private households. This makes OJT challenging to supervise and record as a part of the apprenticeship program. Home Care Associates has addressed this issue by emphasizing the role of more experienced aides as mentors to newer aides. Mentor aides, who receive related technical instruction on mentoring within the apprenticeship program, ensure that learning on-the-job and supervision for the program occur. Mentors are not continuously present with aides but they interact with them regularly to monitor the competencies they are achieving. OJT occurs in the context of performing ongoing job responsibilities and interactions with mentors at the Home Care Associates headquarters. Instances for apprentices to demonstrate the core competencies all arise regularly in the clients’ homes.

Apprentices at Home Care Associates are primarily African-American (85%) and female (92%). The average age for a Home Care Associates apprentice is 43. While data are only collected by DOL on registered apprentices at Home Care Associates, HHA apprentices had similar demographic characteristics to all Home Care Associates aides. Education levels for the apprentices are low. Only 42% of apprentices even have a high school degree, with only an additional 12% holding general equivalency degrees (GEDs). The remaining 46% of apprentices are high school dropouts. Some aides come to Home Care Associates with prior work experience as HHAs.

Program Resources: Home Care Associates has two grants to help fund training. The Philadelphia Workforce Development Corporation awarded the company an Industry Specific Partnership Initiative training grant that funds basic training for aides receiving Temporary Assistance for Needy Families. The Industry Specific Partnership Initiative grant is a sector-specific grant intending to target high-growth industries. HHAs had the fourth highest projected employment growth rate from 2006 to 2016 of the 181 occupations identified by the Commonwealth of Pennsylvania as “high priority occupations” for industry partnerships. A grant from the Patricia Kind Family Foundation and the Pew Charitable Trusts funded the enhanced and specialty training beyond the basic training, which apprentices and not all HHAs participate in.

Training for nurses in home health care is also occasionally provided by the 1199 Service Employees International Union (SEIU) Training Fund (the national health workers’ union). Although Home Care Associates works with the union, its workers are not unionized because they are worker-owners. Home Care Associates’ closest partners are other members of the PHI network, who introduced the company to new training and corporate models.

Medicare and Medicaid reimbursement rates for home health care vary by county in Pennsylvania. The reimbursement rate for Philadelphia is lower than less urban counties but the costs of care and the levels of sickness are higher in the city. Wages for the aides are also higher in Philadelphia because the city’s high cost of living. These factors put a major fiscal pressures on Home Care Associates, which necessitates outside funding such as grants for the apprenticeship training. Home Care Associates is working with its state association to lobbying on these issues with the state legislature.

Recruitment Process: To be eligible to participate in Home Care Associates’ LTC RAP, aides had to have at least 6 months of experience at Home Care Associates, including the completion of the basic training courses. This instructional time and the time on-the-job over the course of the 6 months of employment are counted towards apprenticeship completion because aides are learning required competencies during this early training period.

In addition to completing their basic training and a tenure requirement, aides are also required to have recommendations from their scheduling supervisors and the Chief Operating Officer at Home Care Associates to become an apprentice. In recruiting apprentices, priority is given to aides who have successfully completed enhanced training courses. Apprenticeship at Home Care Associates is therefore an augmentation or enrichment of a broader instructional regimen already in place. It also offers program completers a credential that demonstrates their expertise in this field.

Aides are recruited through a variety of venues, although most find out about Home Care Associates through word-of-mouth. The company has a good reputation among the areas HHAs because it offers full-time work and company dividends. Aides, and especially apprentices, are an integral part of recruiting other HHAs for Home Care Associates because they believe in the value of the program.

Program Outcomes to Date: As of December 2009, 65% of Home Care Associates’ apprentices had completed the program, 31% were registered but had not yet completed the program, and 4% had dropped out of the program.17 The turnover rate for all aides recorded by Home Care Associates was 57% in 2010. The turnover rate for apprentices is much lower than other employees.18 Sixty-six percent of aides employed at Home Care Associates have been working there for more than 1 year. The average tenure of an aide is 39 months. Turnover has declined somewhat with the recession, according to Home Care Associate staff. The apprenticeship program is currently not operating but apprentices who completed the program see a wage increase and become mentors within the company to other aides.

Home Care Associates has been recognized for its training program on several occasions. They have been awarded the Governor’s Achievement Award, the American Society on Aging's Best Practice Award, the Better Business Bureau's Best Health Service Award and the Philadelphia County Assistance Office's Employer Recognition Award. The Home Care Associates training model was specifically cited as a reason for the company’s recognition.

Perceived Benefits and Challenges of the Program: The primary benefit of the LTC RAP from the perspective of both apprenticeship completers and administrators at Home Care Associates is the pride that it provides for aides. Aides that complete the apprenticeship have significant stature within Home Care Associates as mentors to others. Their completion of the program entitles them to regular pay increases and bonuses, which is an important incentive in an occupation, which is often perceived as being the bottom of the nursing career ladder. Apprentices receive a badge indicating their completion of the program, which they take great pride in. Apprenticeship completers interviewed also noted that Home Care Associates’ apprenticeship program helped them to market the company to clients because of the rigorous training of their aides and to recruit new aides.

One of the challenges to Home Care Associates’ LTC RAP has been earning recognition for certification outside the organization. While apprentices are well respected within Home Care Associates, and aides feel as if Home Care Associates has a good reputation in the wider HHA community, completion of a registered apprenticeship is not always received as the mark of expertise or professionalism outside the company. Senior staff at Home Care Associates noted that they sometimes have difficulty conveying the meaning of the credential to aides, clients, and others in the industry. While this has been a challenge, Home Care Associates was able to work with the Commonwealth of Pennsylvania to develop licensing requirements for HHAs based on the training and skills the company requires. They hope that this state recognition will make apprenticeship more valuable to other employers and expand its in Pennsylvania. However, without increases in Medicaid reimbursement or other outside resources for the program, expansion of the training approach would not seem likely, according to Home Care Associates staff.

Sustainability: Demand for home health services has declined during the recession, and schedulers have faced some challenges guaranteeing full-time employment for current aides. However, Home Care Associates staff does not foresee any long-term problems with the sustainability of their work or the offering of basic training to new hires. However, the apprenticeship program, which includes the enhanced and specialty training, is too expensive for them to sustain currently. Senior staff hope to initiate the LTC RAP again but this will be dependent on the availability of outside resources and demand for home health services. The two major components of the cost of the registered apprenticeship program are the regular raises and bonuses for apprentices and the cost of the related technical instruction for which Home Care Associates needs additional resources. The basic related technical instruction for an apprentice costs between $8,000-$10,000.

Evaluation Potential: Evaluation of Home Care Associates’ LTC RAP may be challenging because of the criteria used to select apprentices and the current lack of scale appropriate for impact or non-experimental analyses. Apprentices are not randomly selected. Home Care Associates chooses the most qualified and promising aides to be apprentices. Non-apprentice HHAs at Home Care Associates also go through most of the basic training that is counted towards the apprentices’ related technical instruction. If non-apprentice aides are used as a comparison group, their training could substantially contaminate the impact estimate. Since apprentices are not randomly selected from among the HHAs at Home Care Associates, any comparison between apprentices and non-apprentice aides will overstate the impact of apprenticeship training. With appropriate financial assistance, Home Care Associates could conceivably develop a demonstration program that offers a complete apprenticeship experience to all of its HHAs. These aides could then be compared to a comparison group in another home health services provider that does not provide a comparable training program.

Evangelical Lutheran Good Samaritan Society

Program Sponsor: Evangelical Lutheran Good Samaritan Society
Apprenticeship Occupation:   Certified Nursing Assistant (CNA)
Location Visited: Conference Call with National Staff; Boise and Idaho Falls Nursing Facilities  
Date of Visit: November 30, 2010 for call;
January 11-12, 2011 for Idaho visit

Overview of Site: 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 metropolitan 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 Samaritan’s 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 publicize the 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 that were visited, approximately 32 apprentices are currently registered, the most of any of the 25 sites.

Good Samaritan’s 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 to 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.

Program Description: The LTC RAP includes five competencies: (1) advanced CNA, (2) mentor, (3) restorative, (4) dementia, and (5) medication administration. The related technical instruction component is a structured curriculum contained in workbooks with accompanying DVDs. The rationale for the DVDs was to provide training that was available at every site, uniform in nature, and not dependent upon the availability of the instructors. Both Idaho sites rely on these materials, with CNAs completing each instructional workbook and competency either over approximately one-quarter (Idaho Falls) or 1 year (Boise). CNAs study on their own or form study groups. Most study at home. Local sites offer selected competency trainings based on facility skill needs. For example, in the two Idaho sites visited, neither site used the medication administration competency training.

Related technical instruction is completed without pay, almost always completed outside of working hours. Apprentices receive pay increases at completion of each competency ($0.25 per hour in Boise, and $0.50 per hour in Idaho Falls) with apprentices receiving interim credentials for doing so. Completion of each workbook requires that supervisors (licensed practical nurses or registered nurses (RNs)) certify that apprentices can perform the required set of skills on the associated checklist, which is different for each competency. The restorative specialty also requires passing a test to successfully demonstrate proficiency.

OJT varies in length as it is based on a CNA’s prior knowledge and current abilities. For example, if a CNA has a prior background in caregiving, he or she may need far fewer hours of OJT to demonstrate proficiency than those with no experience in caregiving. Apprentices must demonstrate skills contained in checklists and the workbooks. Mentors work with apprentices and sign off on their checklists as they successfully demonstrate skill proficiency. Good Samaritan staff indicated that mentors can and should teach others. Less experienced CNAs feel safer often when they are working with their peers rather than supervisors, and it is easier for them to ask questions. Mentors will talk with supervisors if there are performance issues that they cannot address. There is no set length of time for completing the OJT component in the Idaho sites, although Idaho Falls staff could feasibly complete the entire apprenticeship of 3-4 competencies in 1 year, while Boise staff could take 3-4 years to complete the program.

The national registered apprenticeship program requirements for gaining approval for a LTC RAP requires completion of an application form containing a section on the number of hours to be spent in the apprenticeship. National Campus staff understood from DOL’s OA that total apprenticeship hours had to be approximately 1 year in duration. To meet this requirement, Good Samaritan national staff gave each component a length of time so when all related technical instruction and OJT hours were combined, the various components added up to 1 year. However, National Good Samaritan staff noted that they had reviewed data indicating that less than a year was needed to gain the required skills. National Good Samaritan staff suggested that if a sponsor is running a competency-based program, one should not have to meet any requirement for OJT hours.

Program Resources: Both Idaho sites have a human resources staff member who administers the LTC RAP as part of their job responsibilities. The Idaho Falls site also has one additional staff person involved in scheduling and supervision of clinical issues. There is no onsite instructor for either site as the instructor from its headquarters presents course material on the DVDs. Each site actively encourages mentors who have completed the mentor competency to mentor and support to other CNAs both in and outside of the LTC RAP. Both Idaho sites had at least a dozen mentors each. Supervisors (nurses or care managers) seem to be involved only to review the checklists of care giving issues at the end of each instructional workbook.

In recent years, no partners have contributed to program development or implementation nationally or at either site, although Good Samaritan had received at program inception an initial Council for Adult and Experiential Learning grant sponsored using DOL funding to help establish the program. However, Good Samaritan staff developed the materials themselves. Initially, they received some limited consulting from PHI who provided some guidance and shared some materials that they were allowed to reference. No workforce-related or training partnerships were used locally in the Idaho sites. The Boise DOL office had at one point attempted to work with the facility but did not maintain the effort after the DOL staff member changed jobs. One of the reasons for the lower level of involvement from the Boise DOL office is that Good Samaritan is a national LTC RAP, and therefore does not have direct contacts with all the DOL offices or SAAs in the company’s locations.

Recruitment Process: At the Idaho sites, management selects CNAs to participate based on a variety of criteria. More objective criteria include length of employment, work attendance history, and one’s rated functional proficiency in performing client care activities. However, personal characteristics that are not easily measured such as interpersonal skills, overall attitude, work ethic, and motivated are used to select apprentices. In one Idaho site, several staff responded that they would know a good apprenticeship candidate almost immediately after the new employee was hired, largely based on personal characteristics. In addition, participation in the apprenticeship program is voluntary.

Program Outcomes to Date: In the national registered apprenticeship data, approximately 387 apprentices have been registered since 2005, although additional apprentices were registered before the inception of the national reporting system. In the Boise site, 46 were enrolled since 2005. Twenty-six apprentices had not completed the entire apprenticeship either because they were no longer employed by the facility (20) or still employed but not actively participating (six). In the Idaho Falls site, approximately 15 CNAs were registered in the program, with 12 still actively participating.

In the two Idaho sites, not all apprentices intend to complete the entire apprenticeship, largely as a result of how the program is implemented. In Boise, apprentices start and complete the mentor competency over the first year, and then take other competencies (advanced, restorative, and dementia) as interested but not more than one each year because the facility cannot afford more than one pay increase per year. It also takes time to learn and implement the skills taught and provides apprentices something to look forward to over time by building more specialized skills and experience within the company. In Idaho Falls, apprentices usually start with the advanced CNA competency training and subsequently take the mentor competency training. Then, unless there is a job opening on the rehabilitation or dementia units, an apprentice may not take the rehabilitation or dementia competency trainings.

Perceived Benefits and Challenges of the Program: According to the company’s management staff and staff at both Idaho sites, the primary benefit is improving the quality of care provided by CNAs. They reported that the program’s positive spillover effect extends to all CNAs, even those who are never apprentices, via the mentoring process. Both Idaho facilities actively encourage mentors to work with other CNAs on staff to improve caregiving skills because such feedback is almost always better received from peers as opposed to management. The Idaho Falls site has experienced no deficiency citations on CNA issues in state surveys over the last two years, which staff think is largely due to the role of mentors working across all CNAs. Staff suggested that it is possible that there is a positive effect on CNA tenure as only 4% of active or recently completed apprentices left employment in 2010 compared to 49% turnover for all Good Samaritan CNAs. The LTC RAP also serves as an implicit marketing tool for high school and vocational technical school students. These students must satisfy their clinical requirements at the facility for their beginner CNA certification and are able to observe the assistance and positive atmosphere provided by apprentices through their mentoring activities and may want to become employees after certification. Apprentices cited various benefits in roughly the following order: sense of empowerment/pride in their work, the enjoyment of mentoring others, the pay increase, and the desire to be always learning.

With low reimbursement rates and margins in the long-term care industry, it is very difficult to incentivize programs financially through higher wages. Staff reported that when finances are tough, facilities can lose focus, and education is the first thing to be cut. National staff emphasized that the need for better caregivers has not gone away, and that facilities should invest in staff development to achieve better quality of care.

At both Idaho facilities, apprentices receive certificates when completing each competency training as well as the DOL certificate of completion of the apprenticeship. National staff noted that some facilities have awards ceremonies or recognize CNAs in other ways at apprenticeship completion. However, the Idaho sites’ facility staff reported that the certificates do not hold much meaning to apprentices currently. The certificate is not seen as a universal document as staff in other Idaho facilities do not recognize it. These managers suggested that the apprenticeship program needs to be recognized by other facilities to increase its value to apprentices who receive the certificates. When hiring, other employers only look at years of service when determining pay and do not ask how much training one has received.

Sustainability: National staff indicated that enrollment in the LTC RAPs is stagnating nationally as the program is in only 25 sites after 7 years of implementation. Sometimes a site discontinues the program when the local champion in facility management leaves the organization. In addition, the lack of funds for wage increases potentially removes higher wages as an incentive. Budget constraints at the Boise facility also led to the decision not to pay apprentices for taking related technical instruction as was originally planned. Idaho Falls has never paid for related technical instruction time. Medicaid reimbursement for nursing home care is not increasing, so facilities face leaner budgets over time. Competing demands within facilities also poses problems in new facilities adopting the program. In the two Idaho sites, continued enrollment does not seem to be a problem because new employees are always being hired, providing opportunities for selecting apprentices. Both Idaho facilities have strong champions on staff, who considerthe improvements in quality of care and staff attitudes direct benefits of the program.

Evaluation Potential: The number of apprentices at any one time, both nationally and at any one site, is low for purposes of a rigorous evaluation of outcomes using statistical techniques. Individual facilities are limited by patient bed size in terms of the number of apprentices they could generate. Unless the national staff can encourage other facilities to participate, Good Samaritan could not provide enough apprentices for a national evaluation using multivariate statistical analyses because the analyses would lack sufficient sample sizes of apprentices within the organization.

Selection bias is also an issue for evaluating Good Samaritan in that it is not clear how apprentices are selected. Unless detailed discrete, uniform criteria are used to select apprentices across sites, one could not know whether apprentices differed on unobservable characteristics. The risk of selection bias appears high as management at both Idaho sites effectively select the best CNAs on personal attributes to become apprentices so they provide appropriate role models for non-apprentices.

The varied implementation of the program across sites presents another evaluation challenge in that while the materials are consistent across sites, facilities customize the order of presentation to meet immediate facility needs, and offer the specialty trainings either if desired (Boise) or needed by the facility (Idaho Falls). Both Idaho facilities thought the mentor competency was the most important because of the potential for improving quality of care via peer feedback. Both facilities purposefully encourage apprentices to influence care delivered by non-apprentices, making selection of a within-facility comparison group problematic. Other Good Samaritan facilities without apprenticeship programs could potentially serve as a control group.

Air Force Villages, Inc.

Program Sponsor: Air Force Villages, Inc.
Apprenticeship Occupation:   Health Support Specialist (HSS)  
Location Visited: San Antonio, Texas
Date of Visit: January 25-26, 2011

Overview of Site: 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 skilled nursing facility (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 Alzheimer’s 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 military’s 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 HSSsand 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.

Program Description: The apprenticeship program was originally introduced to Air Force Villages by San Antonio DOL OA staff. When the program was implemented, the first related technical instruction classes were provided by North Central Kansas Technical College (NCKTC) on-line through its modular on-line program for HSS. Twelve CNAs participated in the original apprenticeship training and received college credit for it. Subsequent related technical instruction for the remaining cohorts wereconducted internally, with no college credits given. Instructors are recruited from facility management with in-house expertise. They also modified and tailored the NCKTC curriculum to the needs of the organization. Air Force Villages used materials from several organizations involved in the culture change movement, including the Pioneer Network, Action PACT, and PHI.

The “class” curriculum lasting 232 hours consists of eight modules: medical terminology (two modules with 45 hours); dementia care (16 hours); restorative care (30 hours); activity assistance (30 hours); environmental services (40 hours); person-centered care (16 hours); and soft skills (15 hours). Each module within the class has a folder, resources, and written materials. Program staff are particularly proud of developing the soft skills module which includes communication, mentoring, anger management, coping strategies, how to take care of themselves emotionally, how to prevent absenteeism, how to properly resign, and many other skills employees need to learn to be a responsible worker. Such skills are often lacking among newly hired employees. Staff reported that it had not been difficult to accommodate language and cultural differences in their instruction.

Each module is taught onsite by management over several weeks in two-hour classroom lectures on Tuesdays and Wednesdays prior to or after CNA apprentice shifts. For example, the director of environmental services will teach the environmental module, the safety director will teach Occupational Safety and Health Administration requirements, and the director of food services will teach dietary requirements. Each instructor designs his or her own class materials and assigns homework, quizzes, and tests, depending on the class content. Air Force Villages used the DOL LTC RAP materials to determine how many hours to devote to the mastery of competencies within the program but developed all the training curricula without relying on the DOL work process schedules. Instructors collect feedback from participants and modify coursework as needed. For example, a sequence of courses was changed after apprentices requested it. Apprentices can do some related technical instruction and OJT activities for a particular competency concurrently. For example, they can participate in OJT for one module and attend the next class at the same time. The organization is strict about class attendance; if apprentices miss more than two classes in one module, they are not allowed to complete the class. However, they may be eligible to participate in future offerings of the class.

There are no costs for apprentices to participate in the LTC RAP. At Air Force Villages, CNAs start at $9.09 per hour. Participating CNAs are unpaid for the program’s related instruction, but receive up to an 8% wage increase after completion of the 7-9 month class, or a bonus up to 8% of current salary if they were already topped out in their pay grade. There is a formula based on tenure that program managers use to choose between wage increases or bonuses. The OJT portion for the entire apprenticeship consists of 3,000 hours. RNs, licensed vocational nurses, and/or CNA mentors supervise OJT and ensure that apprentices practice all the skills they learned. Instructors have developed a form that is used for each student to document their OJT.

A graduation ceremony is conducted at the end of the class. Apprentices invite families, friends, and the facility’s residents who are important to them. Each apprentice receives a DOL certificate and a new badge for HSS. Apprenticeship completers no longer receive college credit hours for program participation; however, the certificate of completion is considered a nationally recognized certification. CNAs who have completed the apprenticeship can also become mentors. However, the mentoring is not official and mentors are not formally designated. There is no mentoring module for the LTC RAP at this time but there is a desire to formulate one.

Future plans for the program include the following: (1) participation of all new CNA hires; and (2) development of a career ladder for two levels of HSS with training curriculum for these levels and respective wage increases associated with these steps. Topics considered for these future modules include understanding the budget of the organization and financial statements, role of mentors, conducting an independent project, and grief and dying.

Program Resources: The organization is led by a capable administrator who inspires care and concern for both residents and employees. She espouses a vision of culture change made explicit in the new model of care. In effect, this administrator serves as an effective champion for the LTC RAP and has effectively led the rest of the management team in fulfilling that vision.

In spite of the name of the organization, managers and staff do not necessarily have military backgrounds and come more from mainstream health care. Managers willingly participate as instructors and develop class materials. This involves roughly a 6-12 two-hour sessions for each module taught. The ongoing costs for the program are primarily printing and the instructors’ use of their time to teach classes. There is administrative support necessary to enroll students into DOL’s RAPIDS database and document grades and attendance.

Local DOL staff introduced the registered apprenticeship program to Air Force Villages human resources staff in 2009. The first cohort was provided instruction through on-line courses using an existing curriculum of the NCKTC. Initial DOL grants for CNAs to attend that first class were not renewed because there were no more grants for this type of on-line related technical instruction at the college. The administrator has unsuccessfully sought to obtain funding to offset the costs for operating the related technical instruction.

Recruitment Process: Only certified CNAs are eligible to participate in the LTC RAP. CNAs must be employed in the facility for at least 3-6 months before applying to the registered apprenticeship program so that management can first assess whether they are a good fit. Staff evaluate whether the applicants have enough passion for the job, are conscientious workers, and have a good work attendance record. Some employees quickly see that they are not a good fit for the nature of work involved for the HSS position. Staff noted that if you start to lose people from the program, it affects the morale for the remaining participants. Eventually, all CNAs will be selected for the class, but CNAs will still have to prove themselves as responsible, caring workers prior to participation.

Program Outcomes to Date: Approximately 40 apprentices have been enrolled at the time of the site visit. Almost all apprentices have completed the apprenticeship, with language being an issue for one CNA, and class attendance issues with another half dozen CNAs. The program is in its third cohort with about 12 enrollees who are scheduled to complete it in summer 2011. Management now perceives the class as an essential part of its staff development program.

According to LTC RAP managers, the completion rates are high. Program managers could think of only one person who dropped out because of moving to another job. One of the reasons that completion rates are high is that management provides a lot of support and work with apprentices to help them complete the program. As the most common problem is child care, on occasion, they will allow apprentices to bring their children to class.

Anecdotally, Air Force Villages managers observe that their monthly turnover rate is lower since the program’s inception but the measure would require refinement for use in a future evaluation. No data on quality of care have been developed. The administrator suggested that the best outcome measures for understanding whether the facility is providing good quality of care would be patient and staff satisfaction measures. They quantify quality by measuring feedback from residents and staff by conducting staff and resident/satisfaction surveys every other year. They also collect data on falls, infection rates and are now engaging in a new study called Interact II to measure and reduce re-hospitalization rates.

Air Force Villages collects data on tenure, turnover, and wage increases, although it has not sought to evaluate it to understand how the LTC RAP contributes to these outcomes. Turnover calculations exclude temporary employees. Their turnover rates are calculated separately for each facility. Monthly turnover rates range between zero and about 10% of CNA staff, with the average monthly turnover rate between 1% and 5%. Staff suggested that some of the organization’s lower turnover rate may be attributable to the bad economy as there are fewer job openings in the industry.

Perceived Benefits and Challenges of the Program: The perceived main benefits of the program are higher quality of care for residents and building relationships among staff. The goal is to train CNAs so they can provide all services needed so that residents can build bonds with caregivers and CNAs can spend more time with residents. Apprentices expressed high satisfaction with the new model of care in that it increases their perceived value of their role. Many apprentices interviewed spoke of being empowered and respected for their care contributions. The LTC RAP’s biggest challenge is financial stability. Management is assessing the need to partner with DOL given the lack of ongoing financial support. It would appear that Air Force Villages can operate the class less frequently once all current CNAs are trained. An additional challenge comes from CNAs sometimes being resistant to doing all tasks in addition to personal care activities. They may be worried about time constraints and feeling overwhelmed with its new model of care.

Evaluation Potential: The site does not appear to provide enough apprentices for a future experimental or quasi-experimental evaluation. Some data such as tenure and wages exist that potentially could be used for a future evaluation. However, the organization does not routinely compare wages and other outcomes between LTC RAP participants and non-participants.

Agape Senior

Program Sponsor: Agape Senior
Apprenticeship Occupation:   Certified Nursing Assistant (CNA)
Location Visited: West Columbia (corporate headquarters, assisted living, assisted living dementia unit, and SNFs) and Conway (assisted living, including a dementia care assisted living unit, and SNF), South Carolina;
Phone calls with Northeastern Technical College and South Carolina Workforce Investment Board
Date of Visit: August 3-4, 2011 for South Carolina visit;  
August 8, 2011 for calls

Overview of Site: 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.

Agape’s 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 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.19 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. Agape’s 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’s OA. 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 Agape’s facilities because all related technical instruction is conducted simultaneously over a distance learning platform. The primary intended outcomes of the RAP 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.

Program Description: Aside from the basic CNA certification (identified as “level one,” which currently all apprentices have had upon entering the LTC RAP), the program has three competencies that apprentices must demonstrate mastery of: (1) geriatric, (2) mentor, and (3) palliative care. The first two competencies are part of the Advanced CNA (“level two”) portion of the LTC RAP. The third palliative care competency is optional for apprentices but all apprentices to date have completed the competency. While there is no distinct module for mentorship training, the curriculum adopted by Agape incorporates mentorship training in all other modules.

Related technical instruction is conducted uniformly across all Agape sites through the use of distance learning technology. Most instruction is conducted in person at either the West Columbia or the Conway facility, but apprentices at all facilities participate in class over a two-way video feed. Classes are held every Thursday, from 3:00 to 6:00 p.m., and are conducted on the apprentices’ own time. Different instructors are used for each module, and all instructors are senior staff members at Agape, with the exception of the courses on dementia, which utilize an outside instructor. Instructors produce their own course curriculum and material to hand out to apprentices. Classes typically include some lecturing, a substantial amount of hands-on activities, and a quiz. Notes are provided to the apprentices, and most apprentices maintain their notes together for future reference. One apprentice from an earlier cohort suggested that she still refers back to her course notes on-the-job, even after graduating. The apprentices said that while they do not receive homework, they all studied the material on their own time at home. They noted that it would be hard to get certified if they did not study on their own time.

Course content for the related technical instruction was designed to deepen the CNAs’ understanding of the material they learned in basic CNA training, with a special emphasis on geriatrics and palliative care. Apprentices are trained in a variety of interpersonal and communication skills, including coursework on the HIPAA protections, active listening, assertive communication with patients, and customer service. After these initial sessions, apprentices learn more medically substantive material, including the psychosocial aspects of aging, body mechanics, cancer, the stages of dying, and post-mortem care. Subsequent classes cover the changes that occur in a variety of body systems during the aging process, including the dermatological, respiratory, cardiovascular, and renal systems. At the end of the related technical instruction, apprentices spend several weeks learning about dementia, specifically how to communicate with those experiencing dementia.

Related technical instruction is completed on apprentices’ own time and without pay. Apprentices receive pay increases of “a quarter every quarter.” Thus, for every quarter of the class completed (somewhat less than a calendar quarter), each apprentice gets a $0.25 per hour raise in pay, from a starting wage of $9.00 to $11.00, depending on prior experience. Those who complete the entire related technical instruction therefore receive a $1 per hour raise. No interim credentials are earned, but at the end of the LTC RAP, apprentices receive a certificate of completion. If they pass a state examination, they become certified palliative care providers.

In addition to quizzes taken in class and the state palliative care certification test, supervisors of apprentices confirm that apprentices can practice their skills on-the-job. A competency checklist was developed with the related technical instruction, and this checklist is used by senior staff to monitor apprentices on-the-job. OJT is facilitated by many of the instructors for the Agape LTC RAP, who are also supervisors who work with the CNAs on a regular basis (except apprentices providing hospice care in client homes). In addition to the LTC RAP competency checklist, ongoing monitoring of all CNAs (both apprentices and non-apprentices) is conducted through compliance rounds, as well as annual clinical skills checks. Standard check-off sheets are used for both apprentice and non-apprentice CNAs for compliance rounds, so their performance can theoretically be compared in future evaluation efforts. Both the related technical instruction and the OJT components are typically completed in 1 year.

Program Resources: Ten percent of the Agape Chief Human Capital Officer’s time is dedicated to the LTC RAP, as well as 60% of his assistant’s time. A third person spends a small amount of time entering data into the national registered apprenticeship reporting system, RAPIDS. In addition to this dedicated staff, many senior staff volunteertheir time to plan curriculum for and teach related technical instruction. OJT is provided by supervisory staff that monitor and mentor all CNAs as a normal part of their job but specially tailor their oversight with apprentices to the LTC RAP competencies. The checklist used to monitor apprentices (as opposed to regular Agape employees) was developed at the same time as the curriculum and reflects each competency trainingreceived in the classroom. Agape Senior has also purchased three distance learning units and an $80,000 “bridge” unit for the distance learning system. These were used in combination with the three distance learning units received from Northeastern Technical College to deliver related technical instruction. The college paid for these units using a grant from Apprenticeship Carolina.

Agape Senior has internally covered its training costs for the third cohort of apprentices. In the first cohort, training was funded by a workforce investment board training grant to Northeastern Technical College, and in the second cohort, by a South Carolina Department of Employment and Workforce grant (which was funded by federal stimulus money). These resources for training were helpful for initiating the LTC RAP but Agape staff anticipate that they can continue training without outside financial support. Currently, financial resources for apprentice wage increases is provided by a one-time apprenticeship tax credit from the state worth $1,000 per apprentice. Agape continues to pursue grants to support its educational efforts, including a U.S. Department of Agricultural Rural Utilities Service grant to purchase additional distance learning equipment to expand the LTC RAP to rural Agape locations. Grant-seeking by Agape is facilitated by its unique corporate structure; while most of the long-term care provider companies owned by Agape Senior are for-profit, it also owns not-for-profit companies and a foundation that are free to apply for grants. Agape maintains close partnerships with South Carolina’s technical college system and with the workforce investment system but does not rely on partnerships with unions or trade associations.

Recruitment Process: Apprentices are recruited from incumbent Agape employees with basic CNA certification, although the program registered with DOL can be completed by those who are not certified (certified apprentices are simply credited with the hours associated with basic CNA competencies). For each of the three cohorts, the LTC RAP has been advertised on a bulletin board but most have been recruited through supervisors. Agape supervisors assess and rank their employees so that each is placed in either thetop (20%), middle (70%), or bottom (10%) of the staff. Apprentices are typically selected from the top 20% group, although some are drawn from the middle 70% group. While some of these assessments are subjective, Agape attempts to be rigorous in its differentiation of employees and is currently using assessment software called Wingspan. The LTC RAP is advertised to CNAs as an advanced training program that will make them better caregivers. Few of the apprentices were told about the associated wage increase initially, and only found out about it after starting the program. Apprentices from earlier cohorts play an important role in the recruitment process. Other CNAs are encouraged to participate by previous graduates, and these graduates set a standard in the quality of their caregiving that all employees are expected to follow.

Program Outcomes to Date: According to the national registered apprenticeship data, 59 apprentices have registered since the program began in 2009, although additional apprentices entering the program in 2011 have not been entered into the RAPIDS system. RAPIDS reports that apprentices were distributed across four Agape facilities but two additional sites have been added to the program during the third cohort in 2011. Although Agape staff recalled that 18 apprentices were registered in the first cohort, RAPIDS data indicate 20 registered. Both sources agree that 16 apprentices completed the program. RAPIDS data suggest that 39 apprentices were registered in the second cohort, and Agape staff indicated that 21 graduated (again, Agape staff recollection of initial enrollment is 35, diverging somewhat from RAPIDS records). Retention of apprentices is high; 93% of apprenticeship completers in the first cohort were still employed with Agape the following year. The retention rate for the larger second cohort of apprentices will be calculated in the fall of 2011, but it is expected to be 100%. Anecdotally, the quality of apprentices is thought to have improved tremendously. Quality improvements can be tracked empirically using supervisor checklists and data from Wingspan rankings and clinical rounds, although this comparison has not been made yet. Agape staff suggested that their recent good survey results (no citations for quality of care issues) can be attributed to better trained CNAs who have undergone the LTC RAP training. Wage data are not tracked by apprenticeship status but are available for all employees.

Perceived Benefits and Challenges of the Program: Most of Agape’s staff agreed that the primary benefit of the LTC RAP is to improve the skill level, and therefore the quality of care, of the CNAs. Agape has a strong educational mission and the LTC RAP is considered to be an integral part of its strategy for developing a skilled workforce. The LTC RAP has been a useful vehicle for promoting knowledge of specific topics that are considered important by Agape executives, such as the proper practices to care for patients with dementia. Staff also suggested that the apprenticeship has reduced turnover and given workers a new sense of pride in their work. Supervisors make it clear to all of their CNAs that they consider apprentices to be exemplary workers. Management suggested that because the apprentices were their best CNAs, it was likely that they would have received a raise anyway, so they are happy to pay for a wage progression that is tied to additional investment in the workers’ human capital. Most apprentices share management’s enthusiasm for the higher skill levels imparted by the LTC RAP. For Agape apprentices, the pay increase is highly valued but of secondary importance. They deeply appreciate the sense of pride they get from being recognized for their achievements. Apprentices felt that their certification would be recognized by other employers, especially since the palliative care test that they took was a statewide certification test. Nevertheless, few apprentices sought jobs elsewhere. Finally, both management and apprentices noted how much patients’ families appreciated the additional care and expertise furnished by apprentices relative to non-apprentices. The primary challenge associated with the program has been the cost of the wage progression, although this cost is not prohibitive for Agape. Staff indicated that a great deal of confidence in his instructors and in the operation of the distance learning equipment.

Sustainability: Agape staff believed the LTC RAP is not only sustainable but that it will expand over the next several years. South Carolina’s tax credit for apprenticeship programs is viewed as an additional incentive that has helped to win the support of Agape executives, but even this benefit is not considered to be essential to the sustainability of the program. The company’s executives and the LTC RAP instructors are committed to the program and in the third cohort (which is the largest class yet) the program is being operated successfully without any outside support except for the state tax credit. For many long-term care providers, reimbursement that is perceived to be inadequate threatens the sustainability of LTC RAPs. However, Agape has been profitable enough to feed several million dollars’ worth of profits back into indigent care and charitable contributions to local colleges through the Agape Foundation. The staff felt that additional apprenticeship promotional materials from DOL would help them to expand their apprenticeship.

Evaluation Potential: Agape’s registered apprenticeship program population is small but sufficient for rigorous evaluation, particularly if cohorts are pooled across time and the size of the registered apprenticeship program continues to increase. While there are many Agape facilities, their concentration in South Carolina, the predominance of a few particularly large facilities, and the continuity in management and approach to caregiving across sites should help in the evaluation process.

Selection bias in the recruitment of apprentices at Agape poses problems for evaluation. While the selection process is somewhat subjective, it is clear that the highest quality apprentices are chosen for the program, and there may also be a certain degree of self-selection. Certain employee assessment techniques, such as the ranking of employees, could be very helpful in modeling the apprentice selection process and therefore eliminating the selection bias from any evaluation. Another obstacle related to selection processes is that any comparison group selected from among Agape employees may benefit from spillovers of the apprenticeship. Apprentices regularly share what they learn with other CNAs and provide an example to follow. Such spillover into a comparison group could distort the estimated impact of the program.

In addition to employment records kept by Agape (which could be verified by researchers using unemployment insurance wage records), the company keeps employee quality records that could be used in an evaluation. All CNAs, including apprentices and non-apprentices, are ranked according to job performance. Each CNA is also monitored during regular compliance rounds.

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