A Descriptive Analysis of the U.S. Department of Labor's Long-Term Care Registered Apprenticeship Programs. 1. Introduction

07/01/2010

The United States faces a critical current and future need for long-term care workers to meet the demands of the aging population. Indeed, the U.S. Department of Labor (DOL) projects that home care personal care assistants and home health aides (HHAs) will be among the fastest growing occupations in coming years (Bureau of Labor Statistics, 2009). Currently, low wages, few fringe benefits, minimal levels of training, and the lack of a career ladder contribute to a chronic workforce shortage. The Institute of Medicine (2008) recently recommended increased training requirements and career development for all direct care workers in order to address this workforce shortage.

Registered apprenticeship is a longstanding approach used in some occupations to provide in-depth training and develop careers. Apprenticeship uses a combination of work-based and formal learning to ensure workers master a specified set of occupational competencies. The National Apprenticeship Act (NAA) of 1937, established the foundation for developing and expanding the nation’s skilled workforce through registered apprenticeship programs and produces standards for safeguarding the welfare of apprentices. Often referred to as the Fitzgerald Act, the NAA created a comprehensive system of partnerships among business, labor, education, and government that has shaped skill training through registered apprenticeship for succeeding generations of American workers.

Upon completing an apprenticeship, apprentices receive a nationally recognized DOL Office of Apprenticeship (OA) or State Apprenticeship Agency (SAA) certificate of completion recognized by employers and often by state licensing boards. Only an apprenticeship program registered with the OA or a SAA and meeting the minimum requirements for standards of apprenticeship established in 29 CFR 29.5, can receive certification and be recognized across the country.

Registered apprenticeship offers several potential advantages for both long-term care workers and employers. Workers earn salaries while they are learning on the job in the context of actual long-term care settings. Registered apprenticeships may also offer workers incremental pay increases as they earn interim credentials toward recognized steps on a career ladder often by progressing from introductory jobs to acquiring specialized competencies. (http://phinational.org/training/resources/apprenticeships/).

Employers generally gain confidence that trained apprentices have mastered a well-specified set of occupational competencies. A competency-based approach to apprenticeship ensures that learning focuses on practical skills and allows workers to gain credit for skills learned through previous experience. Training occurs at the place of employment and often at a nearby community college, other learning center or on-line. Peer-mentors in some organizations may offer additional support in attaining required skills. An apprenticeship can also help workers gain non-academic skills such as teamwork, communication, and problem-solving.

Long-Term Care Registered Apprenticeship Programs (LTC RAPs), administered by the DOL’s OA and developed by employers, employer associations and labor-management organizations, provide formal training and work experience for direct care workers in long-term care settings. The goal of LTC RAPs is to significantly improve worker skill development, job mobility within long-term care settings, organizational productivity, and quality of care. Developing improved job opportunities linked to higher compensation and a career ladder is an important strategy for reducing the long-term care workforce shortage and possibly improving quality of care (Institute of Medicine, 2008). Since the program’s inception in 2003, over 100 long-term care employers have offered LTC RAPs employment and training to almost 4,000 apprentices (RTI International/Urban Institute analysis of program data, 2010).

Registered apprenticeship programs are primarily funded directly by employers with some assistance with start-up funding from government (including DOL) or private organization (e.g., foundation) grants. The organizational sponsors of apprenticeship programs register their programs with federal and state government agencies. Sponsors provide on-the-job training (OJT) and academic instruction to apprentices according to their licensing requirements. For example, Certified Nursing Assistants (CNAs) must have a minimum of 75 hours of state-approved training to meet federal requirements, with typical certification courses covering anatomy and physiology, nutrition, body mechanics, infection control, and client rights (OA, DOL Employment and Training Administration [ETA], 2010). A number of additional employers, agencies, and associations have expressed interest in the LTC RAPs model (Office of the Assistant Secretary for Planning and Evaluation [ASPE], 2009).

LTC RAPs include all of the required components of registered apprenticeship. First, OJT occurs at a worker’s place of employment. Second, related instruction may take place onsite or at technical or community colleges. Related instruction may occur through various modes of instruction (e.g., in-person, web-based, correspondence course). Third, mentoring is often a feature of many apprenticeships, occurring sometimes through mentors who have completed apprenticeships themselves. Mentors provide on-the-job coaching and help apprentices identify and acquire competencies needed to perform their jobs successfully.

Registered apprenticeships are structured to develop increased job competency over time. Apprenticeships can be either competency-based, time-based, or a hybrid of the two, a decision made by sponsors who can shape OJT and curricula previously developed by the OA to suit employer needs. All three types of apprenticeship require apprentices to master a set of competencies, but the time-based approach additionally mandates minimum hours of on-the-job and related instruction.

Current LTC RAPs offer apprenticeships in four major occupations: CNAs, Direct Support Specialists (DSSs), Health Support Specialists (HSSs), and HHAs. CNAs, O*NET-SOC Code 31-1012.00, work in free-standing or hospital-affiliated nursing homes caring for persons with clinical needs and/or needing assistance with eating, bathing, and similar activities. The CNA apprenticeship is competency-based and offers two models, one with interim credentials and one without. In the interim credentialed model, apprentices must complete entry-level and advanced level training, which is followed by one or more specialties such as dementia or restorative care (Exhibit 1). After completion of each level and each specialty, apprentices receive a Certificate of Training. Upon completion of Levels 1, 2 and any specialty from Level 3, apprentices receive a Certificate of Completion of Apprenticeship.

EXHIBIT 1. Certified Nursing Assistant Apprenticeship Model
Certified Nursing Assistant Apprenticeship Model
O*NET-SOC CODE: 31-1012.00
(Competency-based, interim credentials)
Level 1 - Entry Level (about 300 hours). Basic training that meets and/or exceeds requirements by federal and state laws. Certificate of Training/Interim Credential & Incremental Wage Increase. Level 2 - Advanced (about 1,000 hours). Certificate of Training/Interim Credential & Incremental Wage Increase. Level 3 - Specializations. Geriatrics, Dementia Care, Restorative, Mentor. Certificate of Training awarded for each level & Incremental Wage Increase. Completion of Levels 1, 2, and any specialization. Certificate of Completion of Apprenticeship.

DSSs, O*NET-SOC Code 21-1093.00, provide care most often in group homes for persons with intellectual and developmental disabilities needing monitoring and assistance in daily activities. The DSS apprenticeship currently is a competency-based model with no interim credentials offered, although two organizations, American Network of Community Options and Resources (ANCOR) and the National Association of Direct Support Professionals (NADSP), are developing models offering interim credentials (Exhibit 2). Apprentices who successfully complete all the components of the program receive a Certificate of Completion of Apprenticeship.

EXHIBIT 2. Direct Support Specialist Apprenticeship Model
Direct Support Specialist Apprenticeship Model
O*NET-SOC CODE: 21-1093.00
(Competency-based, no interim credentials)
(American Network of Community Options and Resources (ANCOR) and the National Association of Direct Support Professionals (NADSP) are developing a model with interim credentials)
On-the-Job Learning (leads to Certificate of Completion of Apprenticeship): Introduction to the Direct Support Role and Orientation to the Work Environment. Contemporary Best Practices in Community Support (customized for unique support environment/special population). Advocacy, Supporting Empowerment and Recognition, Prevention and Reporting of Abuse, Neglect and Exploitation. Wellness Issues (Customized to Work Setting or Special Population). Communication. Teaching and Supporting Others. Crisis Management.

HSSs, O*NET-SOC Code 31-1011.00, work in assisted living facilities and retirement homes providing care for mostly elderly persons needing monitoring and assistance with daily tasks. Assisted living facilities usually do not provide the highly skilled clinical care that is usually provided in nursing homes, thus staff certification requirements for these two settings differ. The HSS apprenticeship currently is a hybrid model (time-based and competency-based) with no interim credentials, although a large national employer has recently developed a model with interim credentials but had not yet registered apprentices using it (Exhibit 3). Apprentices who successfully complete all components of the program receive a Certificate of Completion of Apprenticeship.

EXHIBIT 3. Health Support Specialist Apprenticeship Model
Health Support Specialist Apprenticeship Model
O*NET-SOC CODE: 31-1011.00
(Hybrid model -- combination of Competency and Time-based, no interim credentials)
  (Comfort Keepers, a large national employer, developed a model with interim credentials)  
On-the-Job Learning (leads to Certificate of Completion of Apprenticeship): Compentency Training: Certified Nurse Aide (500-1000 hours); Activity Director (250-500 hours); Dining Services (540-1080 hours); Environmental Services (510-1020 hours); Home Health Aide (250-500 hours); Rehabilitative Aide (200-400 hours); Certified Medication Aide (750-1500 hours).

HHAs, O*NET-SOC Code 31-1011.00, work in home health and hospice agencies providing services to people living in the community having clinical needs and/or needing assistance with eating, bathing, and similar activities. The HHA model is a competency-based apprenticeship offering interim credentials or Certificates of Training when apprentices complete various levels of training within the occupation (Exhibit 4). The apprenticeship begins with entry-level (Level 1) training, of which at least 16 hours of classroom training must be completed before beginning the supervised practical training component. Apprentices receive a Certificate of Training upon completion. To receive the Certificate of Completion of Apprenticeship, apprentices need to complete Level 1 and then any two specialties.

EXHIBIT 4. Home Health Aide Apprenticeship Model
Home Health Aide Apprenticeship Model
O*NET-SOC CODE: 31-1011.00
(Competency-based, interim credentials)
Level 1 - Entry Level (on-the-job learning: 675-700 hours; related instruction: 150 hours): Training exceeds federal requirements of 75 hours with at least 16 hours of supervised practical training. Certificate of Training/Interim Credential & Incremental Wage Increase. Specializations: Hospice & Palliative Care; Geriatrics; Disabilities; Mental Illness; Dementia; Peer Mentor. Certificate of Training/Interim Credential awarded for each level & Incremental Wage Increase. Completion of Level 1 and any two specialiations leads to Certificate of Completion of Apprenticeship.

Specialty training differs across the three occupations that have such training. CNAs can specialize in dementia care, geriatric care, restorative care, or mentoring. HHAs can specialize in care for people with disabilities, palliative care for patients receiving hospice, care for people with mental illness, dementia care, geriatric care, or mentoring. HSSs can receive specialty training in dining services, environmental services, or as an activity director, certified medication aide, certified nurse’s aide, HHA, or rehabilitative aide. Following completion of each type of specialty training, apprentices also receive a Certificate of Training.

Generally, competency-based apprenticeship programs emphasize skill mastery without requiring a specified time commitment to training, although OJT ranges from 3-5 months for each level of training with varying hourly ranges of related instruction. In contrast, time-based apprenticeships mandate occupational competencies apprentices must learn for certification within a fixed amount of time at the end of which participants receive a certificate. Time-based apprenticeships generally provide an extended period of entry-level training lasting a minimum of 2,000 hours, with at least 144 hours of related instruction.

Although the number of LTC RAPs is currently small compared to the number of apprenticeship programs in other industries with a deep history with the apprenticeship model, expanding the number of these programs in the long-term care setting offers an innovative approach to addressing the workforce shortage. To assess the potential for the apprenticeship model to improve worker competencies, employer productivity, and quality of care delivered, ASPE in the U.S. Department of Health and Human Services and the DOL’s OA and the Office of the Assistant Secretary for Policy have contracted with RTI International, and its subcontractor, the Urban Institute, to develop evaluation design options that could be used to assess LTC RAPs. The tasks involved in developing options for evaluation design include analyzing existing administrative data on LTC RAPs, conducting site visits of selected apprenticeship work sites, and using the information obtained to develop the potential evaluation designs for consideration by ASPE and DOL.

This report provides an overview of LTC RAPs based on existing administrative data from DOL. The purpose of this initial review is to support the design of a potential future evaluation of the effects of LTC RAPs on apprentices and the program sponsors that administer or operate them. The report summarizes findings from both apprentice and program-level analyses on how employment and training characteristics vary across different types of apprentices and apprenticeship programs. The report also provides a context for selecting program site visits where more intensive process/implementation analyses will take place and enrich our understanding of the actual operations of LTC RAPs.

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