Pathway to the Future: How Workforce Development and Quality Jobs Can Promote Quality Care Conference Package. Home Care: Does a Better Workforce = Better Care?

05/01/2004

A.E. Benjamin, Ph.D.
University of California, Los Angeles

THE BROAD CHALLENGE(S)

  • Expanding demand.
  • Worker shortages.
  • Worker turnover.
  • Worker quality.
  • Policy indifference.
  • Hidden nature of home care work.

HOME HEALTH CARE

  • Stronger arguments, growing data.
  • Outcomes data (OASIS, etc.).
  • Structure, process (causal links?).

PERSONAL ASSISTANCE SERVICES

  • Passionate arguments, little data.
  • Defining outcomes
    • Improvement vs. maintenance vs. slowing decline.
  • Measuring outcomes.
  • Specifying causal chains
    • The worker connection.

NEW DEVELOPMENTS -- NEW CHALLENGES

  • Client/consumer as employer.
  • Cash/discretionary spending.
  • Family and friends as workers.
  • Public authorities as C-W link.

ASPE STUDY IN CALIFORNIA

  • 1994-98.
  • Service outcomes.
  • Clients (1,095) and workers (618) in IHSS.
  • Two home care models:
    • Agency-based.
    • Consumer-directed.

SETTING: IN-HOME SUPPORTIVE SERVICES PROGRAMS (IHSS)

  • Medicaid state plan PAS.
  • 200,000+ recipients.
  • Up to 283 hours/month.
  • Consumer-directed and agency models.

CASH & COUNSELING DEMONSTRATION AND EVALUATION

  • 1996-2003.
  • Cash (flexible monthly allowance).
  • Counseling (supportive services).
  • C. flexibility to hire and purchase.
  • Setting: Medicaid in Arkansas, Florida, New Jersey.
  • Design: Randomized assignment to cash vs. usual Medicaid PAS.

WHAT DO CONSUMERS (CLIENTS) REPORT?

  • UCLA
    • More satisfaction.
    • Better quality of life.
    • No differences: Unmet needs, safety concerns.
    • More client empowerment.
    • Less worker turnover.
    • Fewer language problems.
  • Cash & Counseling
    • Very good worker performance.
    • Capable and reliable.
    • Less disrespectful.
    • Less worker theft.
    • Fewer unmet needs.
    • Fewer indicators of low-quality care.
    • More QOL satisfaction.

POSSIBLE EXPLANATIONS OF BETTER OUTCOMES

  • Matching.
  • Familiarity.
  • Responsiveness.
  • Interpersonal relationships.
  • Targeted, informal training.

FUNCTIONS OF PUBLIC AUTHORITIES IN CALIFORNIA

  • Bargaining agent.
  • Training resource.
  • Registry.
  • Background screening.
  • Quality of care monitoring.

PUBLIC AUTHORITIES AND QUALITY OF CARE?

  • Documenting quality issues.
  • Enhancing C-W matching.
  • Improving C-specific trainign.
  • Addressing interpersonal problems.
  • Marketing to improve responsiveness.

CONCLUSIONS

  • Workforce and service quality are related.
  • Relationships are complex.
  • Expanding choice may be key to enhancing quality.
  • Stronger ties between PAs and WIBs may be productive.
Who are the Workers?
UCLA Cash & Counseling (Arkansas)
Middle-aged women Most females age 40-64
Same race/ethnicity Same race
Family (50%) and friends (25%) Family and friends (90%)
Half: previous care Most: previous care
1/3 live with consumer 1/4 live with consumer

 

What Do Workers Do?
UCLA Cash & Counseling
Serve one consumer Serve one consumer
More unpaid hours More unpaid hours
More flexible scheduling More non-business
Perform wider range of tasks
  • Health
Variety of tasks
  • More health care tasks

 

Wages, Benefits, Working Conditions
UCLA Cash & Counseling
Lower wages Lower wages
Almost no benefits Almost no benefits
Little formal training Little formal training
No professional supervision No professional supervision
Half have another job Typically part time

 

How Do Workers Assess their Work Lives?
UCLA Cash & Counseling
-- More satisfied with...
Well-prepared Job preparation
Well-informed about C’s conditions Information about C’s condition
Satisfied with supervision Feedback on performance
Able to get needed information Compensation
  Working conditions

 

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