Pathway to the Future: How Workforce Development and Quality Jobs Can Promote Quality Care Conference Package. Workforce Improvement Initiatives to Improve Workforce Retention: What is the Evidence Base?

05/01/2004

Lauren Harris-Kojetin, Ph.D., M.A.
Institute for the Future of Aging Services

PRESENTATION OVERVIEW

  • IFAS
  • Why evaluate?
  • What has been evaluated recently?
  • What works and should be invested in?
  • What additional investments are needed to promote long-term care (LTC) direct care workforce improvements that are evidence-based?

INSTITUTE FOR THE FUTURE OF AGING SERVICES (IFAS)

  • Independent policy research center within the American Association of Homes and Services for the Aging (AAHSA).
  • Conduct research...
    • to improve the quality of aging services
    • to support a quality, stable LTC workforce
    • through partnerships with AAHSA members and other organizations.
  • Disseminate findings and evidence-based practice models to AAHSA members and others.

WHY EVALUATE?

  • Need to know what works and what does not:
    • Where should limited resources go?
    • Do they really work?
    • Which works best?
    • Was there a change in outcomes of interest?
    • Did the change in outcomes occur because of the initiative or because of something else?
    • How sustainable and replicable are practices?

RECENT INSIGHTS ABOUT FRONTLINE LONG-TERM CARE WORKERS: A RESEARCH SYNTHESIS 1999-2003

  • Authors:
    • Lauren Harris-Kojetin, PhD
    • Debra Lipson, MHSA
    • Jean Fielding, MGS
    • Kristen Kiefer, MPP
    • Robyn I. Stone, DrPH
  • Funded by ASPE, DHHS

A NOTE ON TERMINOLOGY

  • Paraprofessional workers
  • Direct care workers
  • Frontline workers
    • Nurse aides or Nursing assistants
    • Personal care aides or assistants
    • Home health aides
    • Home care aides
    • Others who provide hands-on assistance with bathing, eating, dressing, and other activities of daily living for persons with disabilities (focus on elderly)

TYPES OF INITIATIVES EVALUATED 1999-2003

  • Alternative labor pools
  • Career ladders
  • Culture change
  • Enhanced staff-family communication
  • Multi-faceted initiatives
  • Peer mentoring
  • Self-managed work teams (SMWTs, in process)
  • Wage enhancement
  • Fifteen interventions reviewed in research synthesis
    • Two have not (yet) had outcome evaluation
    • Two did not measure actual turnover or retention
    • Eight showed non-significant, negative, or inconclusive results or did not use robust quasi-experimental design
    • Three showed significant positive results using a pre-post comparison group design with retention and/or turnover

WHAT INITIATIVES WORK?

  • Pre-post comparison group design
  • retention and/or turnover of direct care
  • Peer mentoring
    • Growing Strong Roots
  • Multi-faceted initiative
    • WIN A STEP UP -- education and payment incentive
  • Culture change
    • Wellspring -- quality improvement and organizational change process

GROWING STRONG ROOTS

  • Trained, experienced certified nursing assistants (CNAs) matched with new CNAs.
  • Training
    • 6-hour project coordinator orientation and manual
    • 6-hour mentor training, manual, and newsletter
    • guide to orienting mentors’ supervisors/gaining facility support
    • booster training
  • Mentoring active 8 weeks.
  • Salary increase for mentor.

GROWING STRONG ROOTS EVALUATION RESULTS

  • Pre-post comparison group design.
  • Twelve nursing homes (six treatment, six comparison) in New York state.
  • Data collected immediately prior to implementation and 3 months after implementation.
  • Statistically significant improvement in retention among those mentored
    • 18 point increase in average retention rate while increase not significant among comparison group.

WIN A STEP UP

  • Education and incentive program.
  • Ten modules on clinical skills, interpersonal skills, and communication.
  • Nurse aides (NAs) get $70 per completed module.
  • Facilities must agree to commit staff time and give either retention bonus ($75) or wage increase (>$0.25/hour) 3 months after completion of modules.
  • NAs who complete >7 modules and stay at facility >3 months after training get matching $75 bonus from WIN A STEP UP.

WIN A STEP UP EVALUATION RESULTS

  • Pilot.
  • Pre-post comparison group design.
  • Four nursing homes, one home health agency, one adult care home in North Carolina.
  • Data collected immediately prior to implementation and several months after implementation.
  • Annual turnover rates significantly lower (15%) for NAs in the program compared to those in the matched comparison group (32%).
  • Program active in 37 North Carolina nursing homes as of April 2004, with plans to involve 55 nursing homes by July 2005.

WELLSPRING INNOVATIVE SOLUTIONS

  • Alliance super structure.
  • Clinical training modules.
  • Shared advanced practice nurse.
  • Nursing coordinator to link components at facility level.
  • Care resource teams.
  • Systematic collection and use of outcome data.
  • Non-hierarchical management philosophy.

WELLSPRING EVALUATION RESULTS -- RETENTION

  • Wellspring facilities fared better than other Wisconsin facilities on retention:
    • CNA’s: Wellspring retention increased by 6 percent, other homes decreased by 6 percent.

WELLSPRING EVALUATION RESULTS -- TURNOVER

  • Wellspring facilities fared better than other Wisconsin homes on turnover.
  • RN’s: Wellspring exhibited 6 percent lower turnover rates post implementation, while other homes saw a 7 percent increase.
  • LPN and CNA turnover rates increased for both Wellspring and other homes, but increase was smaller for Wellspring.

GAPS-STRENGTHEN EVIDENCE BASE

  • Evaluate existing models.
    • Distinguish relative role of different model elements in outcomes.
  • Develop and test new interventions.
  • Strengthen evaluation designs.
    • Measure longer-term effects.
    • Measure variation within facilities (units, shifts).
    • Measure actual behavioral outcomes.
    • Measure outcomes consistently.
    • Use of a comparison group.
  • Determine transferability of evidence-based models across settings.

GAPS-PROMOTE EVIDENCE BASE

  • Disseminate evidence-based practices for replication more broadly.
  • Provide technical assistance to providers to implement and sustain new models.
    • Give on-going feedback to providers.
  • Determine how to replicate effective interventions beyond the initial demonstration (inform technical assistance).
    • Assess extent to which replicated models are really being implemented.
  • Determine how to sustain interventions.
  • “Incentivize” the use of evidence-based models.

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