Evaluation Design Options for the Long-Term Care Registered Apprenticeship Program. 1. Introduction


The United States faces a critical need for high-quality long-term care workers. The demand for long-term care services is projected to roughly double between 2000 and 2030 as the population ages (Johnson, Toomey, and Wiener, 2007). The U.S. Department of Labor (DOL) projects that home health aides (HHAs) and home care personal care assistants will be among the fastest growing occupations between 2008 and 2018 (DOL, 2011 ).

Long-term care workers include certified nursing assistants (CNAs), who work in nursing homes; HHAs, who work for home health agencies; health support specialists (HSSs), who work in residential care facilities, and direct support specialists (DSSs), who work in group homes or facilities for persons with intellectual disabilities. These direct care workers assist people with disabilities with daily activities such as bathing, eating, shopping, and housecleaning as in various types of group residential settings as well as in private dwellings.

Low wages, few fringe benefits, minimal levels of training, and the lack of a career ladder contribute to chronic workforce shortages (Stone and Wiener, 2001 ). Residential care providers and nursing homes report high turnover rates ranging from 40%-70% (National Center for Assisted Living, 2010; American Health Care Association, 2010).Low compensation and few options for advancement result in weak incentives for workers to enter or remain in the long-term care field (Khatutsky, Wiener, Anderson, and Squillace, 2011 ). Employers are also often dependent on tight Medicaid reimbursement rates, further constraining them from raising wages to attract new workers.

For some direct care workers, federal and state regulations require some minimal training. A federal standard of at least 75 hours of training applies for CNAs in skilled nursing facilities and HHAs in home health agencies. There are no federal (or sometimes even state) training requirements for personal assistant service workers, personal care attendants, aides in assisted living facilities, or direct care workers serving people with intellectual disabilities. To help improve recruitment and retention of direct care workers and to improve the quality of care, the Institute of Medicine (2008) recommended increased training requirements and career development for all direct care workers to address the workforce shortage and to improve the quality of care in long-term care settings.

Apprenticeship is a well-established strategy for training workers by combining classroom and experiential learning, and placing workers into careers that offer the opportunity for advancement. Best known for training occupations like plumbers and electricians, the apprenticeship model is now being applied to long-term care occupations. By improving the skills of direct care workers, higher wages can be justified by the greater productivity of workers. By restructuring employment in the long-term care industry, apprenticeship can provide a path for career advancement. Long-Term Care Registered Apprenticeship Programs (LTC RAP) is an initiative to expand the apprenticeship concept to long-term care workers. DOL’s Committee on Apprenticeship is committed to expanding apprenticeship into emerging industries, including the long-term care sector. DOL also has a goal of expanding employment options for women and the LTC RAP is one vehicle to achieve that goal.

Apprenticeships in long-term care are more common in other countries. In the United Kingdom, health and social care apprenticeships, such as health care assistants, are increasingly common. For example, Barchester Health Care, a large British company operating 200 nursing care homes with over 10,000 residents, uses apprenticeships extensively for long-term care workers (Mansfield-Loynes, 2011) and reports that apprenticeships reduce worker turnover significantly (personal communication, Terry Tucker, Director of Learning and Development, BarchesterHealthcare, July 28, 2011). Long-term care apprenticeships also exist in Australia and Germany. The fact that these types of apprenticeships are under way in a number of countries suggests that apprenticeship training for long-term care workers is feasible.

This report is the final deliverable of a joint project sponsored by the Office of the Assistant Secretary for Planning and Evaluation (ASPE), U.S. Department of Health and Human Services (HHS) and DOL to assess the feasibility of conducting a rigorous evaluation of the LTC RAP. This analysis evaluates possible research designs to evaluate the LTC RAP administered by DOL. Section 2 provides background on the LTC RAP. Section 3 discusses the key research questions that should be addressed by an evaluation of the LTC RAP. Section 4 discusses some characteristics of the program that are particularly important in considering evaluation research designs. Section 5 discusses a wide range of possible research designs, briefly assessing their advantages and disadvantages. Section 6 describes in detail four complementary research designs that could be used to evaluate the LTC RAP. Section 7 concludes with an analysis of the main evaluation designs to evaluate the LTC RAP. This report builds on two previous papers on the LTC RAP conducted by RTI International and the Urban Institute under this contract -- one paper analyzes administrative data on the LTC RAP, which is maintained by the DOL (Anderson et al., 2010) and the other paper reports on site visits to five LTC RAPs (Kuehn et al., 2011).

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