State-Based Initiatives to Improve the Recruitment and Retention of the Paraprofessional Long-Term Care Workforce

U.S. Department of Health and Human Services

State-Based Initiatives to Improve the Recruitment and Retention of the Paraprofessional Long-Term Care Workforce

Institute for the Future of Aging Services

Paraprofessional Healthcare Institute

June 3, 2003

PDF Version: http://aspe.hhs.gov/daltcp/reports/2003/pltcwf.pdf (42 PDF pages)

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This report was prepared under contract #HHS-100-01-0025 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and the Association of Homes and Services for the Aged. For additional information about this subject, you can visit the DALTCP home page at http://aspe.hhs.gov/_/office_specific/daltcp.cfm or contact the office at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, S.W., Washington, D.C. 20201. The e-mail address is: webmaster.DALTCP@hhs.gov. The Project Officer was Andreas Frank.

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TABLE OF CONTENTS

I. INTRODUCTION

II. BACKGROUND

III. LESSONS FROM THE FIVE STATE CASE STUDIES

IV. CONCLUSIONS AND NEXT STEPS

STATE REPORTS

CALIFORNIA

MASSACHUSETTS

NORTH CAROLINA

PENNSYLVANIA

WISCONSIN

NOTES

LIST OF TABLES

TABLE 1. Key Contacts

TABLE 2. AHCA Annualized Turnover and Vacancy Rates

TABLE 3. AARP Actual and Predicted Population Characteristics

TABLE 4. AARP Actual and Predicted Population Characteristics

TABLE 5. AARP Predicted Population Growth

TABLE 6. Unemployment Rates

TABLE 7. Median Hourly Wages for Home Health Aides and Nursing Assistants

TABLE 8. Reports Available by State

I. Introduction

In 2001, the Institute for the Future of Aging Services (IFAS) was awarded a contract by the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services to launch a national initiative designed to improve recruitment and retention of direct care workers in the long-term care field.

As part of this initiative, IFAS and the Paraprofessional Healthcare Institute (PHI), have identified a range of workforce improvement initiatives at the state and sub-state level to reduce high vacancy and turnover rates among direct care workers and improve the quality of their jobs. This report summarizes the experiences of five states that have pursued several strategies to address this issue to inform policy makers, long-term care providers, organized labor and other worker groups and consumers across the country grappling with serious shortages of direct care workers.¹

While previous studies have surveyed state public policy initiatives to address direct care workforce recruitment and retention issues², this report reviews in greater depth state policies and provider practice initiatives in five states -- California, Wisconsin, North Carolina, Massachusetts and Pennsylvania.

These states were chosen for several reasons. First, they have adopted several strategies to strengthen the direct care workforce issue, including wage and benefit enhancements, training and career ladder initiatives, efforts to foster culture change in nursing facilities to improve worker satisfaction and performance; and studies that document the problem. Second, the workforce improvement initiatives in these states include policy and provider practice changes in nursing homes and in home and community-based care settings. Third, the five states vary with respect to the long-term care populations they serve, the characteristics of their direct care workforce, the nature of their long-term care delivery systems, and their economic and political environments.

While activities in these states have results that can be shared, their impact has not been systematically evaluated. Rather than representing models, they show how states can strengthen the long-term care workforce by addressing many of the factors that contribute to high vacancy and turnover rates among frontline staff.

II. Background

The paraprofessional long-term care workforce -- nurse aides, home health and home care aides, personal care workers, and personal care attendants -- forms the centerpiece of the formal long-term care system. Approximately 2 million paraprofessional or "direct care" workers provide hands-on care, supervision and emotional support to many more millions of elderly and younger people with chronic illness and disabilities. As federal and state policymakers focus more attention on quality outcomes in health and long-term care, the need for a prepared, committed and sustainable long-term care workforce has become a greater and greater priority.

At the same time, long-term care providers and state agencies responsible for long-term care are reporting unprecedented vacancies and turnover among direct care workers. National data show annual turnover rates ranging from about 45 percent to over 100 percent for nursing homes. In a 2002 national survey, 37 states reported that nurse aide recruitment and retention were major issues in their states.³ Even in the face of the recent economic slowdown and rising rates of unemployment, the vast majority of states continue to report significant difficulty in recruiting and retaining qualified direct care workers.

There are many factors that may contribute to high vacancy and turnover rates among direct care workers:

• Wages are generally low. In 2001, the median hourly wage was $8.46 for Home Health Aides and $9.27 for Nursing Aides, Orderlies, and Attendants according to the U.S. Bureau of Labor Statistics.⁴

• Benefits are typically poor. Of particular concern to many workers is the lack of health insurance.

• The public image of direct care workers is often negative, (e.g., an inadequately trained woman with few skills, receiving low pay for unpleasant work, and with little hope for advancement.)

• Workers themselves, according to multiple research studies, do not feel valued or respected by their employers and supervisors.⁵

• The work is hard, and made more so by staff vacancies, while the patient population to be cared for is increasingly sick and more disabled. Job preparation and continuing education and training frequently fail to prepare workers for these challenges.

The shortage of direct care workers is likely to worsen over time as demand for long-term care services increases. The 21st century will experience an unprecedented increase in the size of the elderly population as a result of the aging of the baby boomers. At the same time, the number of women aged 25-44 who have traditionally provided paid long-term care is growing substantially smaller. The result of these demographic shifts is an emerging "care gap" that, if left unanswered, could severely restrict the ability of providers to deliver adequate long-term care, particularly in home- and community-based care settings where reliance on paraprofessional workers is greatest.

III. Lessons from the Five State Case Studies

In each of the five states examined in this report, state agencies, provider groups, workers, consumers and others have moved aggressively to respond to direct care worker shortages in the long-term care industry. Despite nearly a decade or more of experience, however, most of their activities have not been systematically evaluated.⁶ In addition, information is missing on which of the many initiatives implemented are most effective in reducing high vacancy and turnover rates among direct care workers and improving the quality of their jobs.

In spite of limited evaluative information, the states in this report offer a number of lessons. First, they underscore the importance of data on the scope and nature of the problem from a variety of perspectives and over time. Three of the five have collected systematic data on the characteristics of the direct care workforce, and the reasons for workers keeping or leaving their jobs and what can improve job quality. Such data helps to develop targeted solutions and keep workforce problems in the long-term care industry on the agenda of policymakers, providers and consumers.

Second, these states also demonstrate that both policy and practice changes are necessary to achieve change. Policy changes can lead and reinforce the changes in provider organizations needed to improve recruitment and retention, while initiatives by providers can demonstrate the effectiveness of new ways of valuing direct care workers in the field.

Third, these states suggest that to achieve long-term changes in policy and practice, statewide workforce improvement efforts require collaboration among the key stakeholders in long-term care -- providers, workers, consumer groups, and public agencies responsible for long-term care policies and regulation. Broad-based coalitions appear to increase the chances for achieving policy and practice changes. In addition, stakeholders in these states have begun to recognize that the plight of low-wage workers in long-term care is influenced by the circumstances of low-wage workers in other sectors. As a result several states have brought the workforce development and adult education sectors to the table to work alongside the agencies responsible for long-term care policy and financing.

These five states also suggest areas for improvement in the next wave of initiatives to improve the paraprofessional workforce. For example, while the activities in the five states cover a range of interventions and collaboration is an element in some of them, many are carried out in piecemeal fashion. Stakeholders working in nursing facilities and home environments do not necessarily know of each others' efforts. Those who are primarily concerned about wage and benefit enhancements may not be aware of training and curriculum revision initiatives. Even when several state agencies are working on the issue, they tend to work independent of each other. Developing an effective long-term strategy to address the paraprofessional workforce challenge will require that all policy and practice changes reinforce one another, and all public and private stakeholders are working on a coherent, shared agenda.

The five states examined in this report also demonstrate that much of the funding for long-term care workforce solutions now comes from discretionary sources. This raises questions about the sustainability of frontline worker strategies during economic downturns, which are contributing to budget deficits in most states at present. Indeed, several direct care worker initiatives in the five states, including those that appear to be effective or hold great promise, are now in jeopardy due to funding cutbacks. Thus, it may be that until each of these initiatives are integrated into ongoing budgets or built into reimbursement incentives for higher quality of care, such initiatives will be difficult to sustain. Innovative strategies in the private sector need to be developed and incorporated into funding resources for direct care worker initiatives as well.

IV. Conclusions and Next Steps

To make best use of resources in the current economic climate, states and providers need reliable information about what works to improve recruitment and retention of direct care workers in the long-term care field. These five states serve as good examples of the range of initiatives that public and private sector stakeholders, working together, can accomplish to improve the recruitment and retention of long-term care paraprofessionals. Their experiences, however, remain examples rather than "best practice" until the effectiveness of state and provider workforce initiatives can be measured and compared more accurately.

Some new national resources will help to fill the information gap. The Department of Health and Human Services, Office of Assistant Secretary for Planning and Evaluation has contracted with the Institute for the Future of Aging Services to develop a direct care workforce measurement "toolkit". The measures in it will allow valid comparisons among different workforce initiatives, based on widely accepted measures of employee turnover, job satisfaction, resident perceptions of worker competence, and worker empowerment. A draft of the toolkit will be available in the fall of 2003 and a report on its use will be completed in the fall of 2004.

In addition, two new national demonstration programs will soon be launched to test the effectiveness of innovative frontline workforce initiatives. The Administration's New Freedom Initiative includes funding over the next several years for state and community demonstration programs to recruit and retain direct service workers. In addition, the Better Jobs Better Care Program, funded by The Robert Wood Johnson Foundation and The Atlantic Philanthropies, will support research and demonstration programs around the country that by 2005 will begin to produce findings on effective public policies and workplace strategies.

CALIFORNIA

A. Population and Workforce Characteristics

Because of its large immigrant population, California is a relatively youthful state compared to the United States as a whole. However, the state's future demographics will be dramatically different. Today, 11 percent of Californians are age 65 and older. Over the next 20 years, California will experience an 80-percent increase in the number of older adults, a rate of increase that is larger than all but four other states.⁷ The future older adult population will be the most diverse in the nation.

There are approximately 125,000 direct care workers employed in California as nurse aides, orderlies, personal care workers and home care aides⁸ and approximately 200,000 more employed through the state's In-Home Supportive Services Program (IHSS). Turnover among nurse aides in nursing homes is about 54 percent and vacancy rates are nearly 7 percent.⁹ High vacancy and turnover is occurring in spite of a state trend toward higher rates of unemployment (6.3 percent).¹⁰ The commitment of certified nurse aides (CNAs) to remain in the field once they are trained is tenuous. Within three years of becoming certified as a nurse aide, about 50 percent of CNAs fail to renew their certification.¹¹

Low wages are often blamed for the imbalance of direct care workers in California. To examine this claim, the California Employment Development Department (EDD) engaged the University of California at Los Angeles (UCLA) School of Public Policy and Social Research to conduct a labor market study to compare the wages, benefits and job stability of entry-level workers in nursing and personal care facilities, hospitals, home health agencies, individual and family social services and residential care homes. The study found that in terms of wages, benefits, opportunities for advancement and risk of injury, caregiver occupations fare less well than competing occupations. In particular, the hourly wage for nursing aides was about 10 percent lower than the prevailing wage for competing occupations in the same area.¹²

B. Characteristics of the Long-Term Care Services System

California's long-term care service delivery system has several distinct features. Medicaid spending on home care is almost entirely allocated through the In-Home Supportive Services (IHSS) program, which also receives state and county funding. Under this model, the state allows consumers to hire, train, and terminate their direct care worker (an independent, often self-employed worker) who provides assistance and support in the consumer's home.¹³ Unlike certified nursing assistants, IHSS workers are not required to receive training from the state as a condition of employment.

California's long-term care delivery system includes a higher proportion of residential care beds per 1,000 people aged 65 than almost any other state and a lower proportion of licensed nursing facility beds.¹⁴ While the state's Medicaid spending on nursing homes has decreased and its home and community-based care spending has increased, the state expended close to $3 billion dollars for nursing home care in FY 2002, more than twice as much as it invested through Medicaid in the IHSS program.¹⁵

C. Policy and Practice Initiatives to Improve the Workforce

California has taken significant steps to respond to long-term care workforce issues. Consumer groups, providers, and organized labor have worked collaboratively with public agencies, academic centers and private foundations to implement a broad range of policy and practice initiatives in response to the shortage of direct care workers in both nursing home and home and community-based care settings.

State Policy Initiatives

Public Authorities. In 1992, through the active intervention of consumers and organized labor, California began to establish county-based public authorities to assist independent providers and consumers participating in the state's In-Home Supportive Services Program (IHSS). These authorities were responsible for setting up "registries" to help IHSS clients identify and hire workers and to help potential workers find jobs. Most significantly, they were to act as the "employer of record" for workers by providing them with a mechanism to bargain for improved wages and benefits. Prior to 1992, IHSS workers were neither employees of the State of California, nor employees of the county, and could not organize to bargain for better wages and benefits. Between 1993 and 1999, seven California counties established public authorities. By 1999 all counties were required to create such an authority. The state provides start up funds and, since 1996; state matching funds have been made available through the state's Medicaid program (Medi-Cal) to cover administrative expenses. As a result of aggressive advocacy by a variety of consumer and worker groups working in concert with the public authorities and county officials, the wages of IHSS workers have increased from about $4.25 per hour in 1992 to up to $10.50 per hour including an additional 60 cents an hour for benefits.

Long-Term Care Council. The California Long-Term Care Council was established in 2000 to coordinate long-term care planning and policy development across state aging agencies and to improve service access and quality. Members of the Council include the directors of the Departments of Aging, Developmental Services, Health Services, Mental Health, Rehabilitation, Social Services, Veterans Affairs, the Office of Statewide Health Planning and Development, and the Departments of Alcohol and Drug Programs, Housing and Community Development and Transportation. The Council has been charged with coordinating the development of the state's Olmstead plan and preparing a strategic plan for addressing the needs of the state's aging population. The strategic plan will address the infrastructure that will be needed to respond to the rapid growth of the state's older adults including recruiting and maintaining a quality workforce.

Aging with Dignity Initiative. In response to the advocacy of consumer groups and organized labor, the California legislature made nearly $500 million available to fund the Aging with Dignity Initiative. This initiative is targeted on expanding in-home and community-based care options for older adults and individuals with disabilities, improving the quality of nursing home care and increasing the size of the long-term care workforce. Workforce related achievements have included establishing higher minimum staffing ratios in nursing homes and funding salary and benefit increases for certified nursing assistants and IHSS workers. Altogether $54 million was made available in 1999 and $200 million in 2000 to increase wages and benefits for the state's direct care workers.

Wage Pass-Through. Under the state's Medicaid program -- MediCal -- two wage pass-through initiatives have been funded, in 1999 and 2000, to increase the wages of nursing home workers. A wage pass-through is a one-time wage adjustment intended to make direct care workers wages more competitive. In 2001, $10 million was also set aside for nursing homes who serve a high proportion of MediCal recipients, to be passed on as a bonus to exemplary direct care staff.¹⁶ After concerns were raised about the extent to which the first wage pass-through actually reached workers in the form of higher wages, the Department of Health Services began to conduct reviews of facilities to ensure that the wage pass-through actually went to the employees for whom it was intended.¹⁷

Caregiver Training Initiative (CTI). Also in conjunction with the Aging with Dignity Initiative, the California Department of Social Services, and the State Aging Agency launched the Caregiver Training Initiative (CTI) with $25 million of federal Workforce Investment Act (WIA) and Welfare-to-Work funds. CTI funds were allocated to regional collaboratives to develop innovative ways to recruit, train and retain CNAs in nursing homes and the IHSS program. For example, the Private Industry Council of San Francisco received a $1.3 million grant through CTI to work with county welfare agencies, workforce investment boards, public authorities, organized labor, employers, community colleges and school districts to increase enrollment in IHSS training programs, to provide training in basic skills and English as a Second Language and to improve career opportunities for IHSS providers through the development of career ladders. The Northern Rural Training and Employment Consortium, made up of five workforce investment boards, received over $2.6 million to fund the Northern California Employment Network Health Caregiver Training Program. The purpose of this project is to develop a continuum of health care education opportunities in the target areas, from CNAs to LVNs and RNs. The project works with community colleges, regional occupational programs and private industry to train an estimated 350 welfare-to-work recipients, other low-income individuals, dislocated homemakers and youth who have aged out of the state's foster care or caregiving occupations.¹⁸

Caregiver Training Initiative (CTI) Expansion. In 2002, the Caregiver Training Initiative was expanded through a new $10.5 million grant to increase the number of frontline workers in California's health care workforce by up to 2,000 individuals. These funds have been used to boost the number of training sites for prospective CNAs by using existing health care facilities as well as to provide recruitment, job readiness and job placement assistance to nurse aide trainees. Candidates are hired as nurse aides; receive 16 hours of workplace orientation, followed by a 160-hour state-required training curriculum, a 10-hour preparation program for the state certification exam, and additional hands-on training. The new nurse aides are then offered continuing employment at higher wages than other entry-level CNAs, whether with the employer that provided the training, with other long-term care employers in the community, or in other health care professions.

Selected Recruitment and Retention Practice Initiatives

Allied and Auxiliary Health Care Workforce Project. This project, funded by the California Endowment and the California Health Care foundation, provided grants to develop model programs and resources to address problems in the state's allied and auxiliary health care workforce. Twenty-two organizations received funding in 2001 including several grantees that used this funding to address frontline workforce issues. The California Association of Homes and Services for the Aging (CAHSA) obtained funding to conduct a survey of their membership and to hold focus groups to examine the magnitude of recruitment and retention problems among the non-profit residential providers they serve and to identify the strategies that seemed most effective in ameliorating these problems. The In-Home Supportive Services Consortium in San Francisco used their grant funds to develop a care mentoring program to improve on-site support of new home care workers and to implement a case management strategy to arrange for and coordinate services that might help IHSS workers to stay in the field (e.g., English language training, assistance with affordable housing, transportation and child care). Moonpark College/Ventura County Community College obtained a grant to increase the number of qualified Latinos and high school graduates who enroll in Morepark College's entry level CNA program; and Santa Barbara City College in collaboration with the South Coast Regional Health Occupation Center developed a comprehensive, collaborative, region-wide approach to nurse aide recruitment and retention, drawing on the results of a survey that had been conducted of the characteristics of CNAs who stay on the job for more than three years.¹⁹

Health Careers Training Program. The Office of Statewide Health Planning and Development (OSHPD) implemented a Health Careers Training Program to develop local partnerships for training various health care workers, including nurse aides, LVNs, RNs, and others. As a part of this program, OSHPD developed a Senior Nursing Assistant Career Ladder project to provide career mobility for experienced nurse aides while assisting probationary or lesser-experienced aides. The senior nursing assistants lead, monitor, mentor, and train other direct care workers in the delivery of direct patient care.

The Employment Training Panel (ETP). The Employment Training Panel is a joint business-labor supported state agency within the Employment Development Department established to retrain workers. It is funded through a small tax on the unemployment insurance paid by for-profit employers in the state. ETP has committed $15 million to build job ladders designed to advance entry-level workers. The program assists employers to establish training programs for lower paid workers to move up the career ladder and workers to move to higher paying positions. Agencies and facilities, which employ paraprofessional health care workers, such as CNAs, who must receive training and/or renew their certification, are eligible for receiving funding support under the ETP.

Home Care Workers Training Center. The Home Care Workers Training Centers were created by organized labor in California to enhance the skills, knowledge and professional growth of IHSS workers. The center in Los Angeles County is using a grant from the California Endowment to provide IHSS workers with hands-on training including CPR, First Aid, Nutrition/Food Preparation, and Alzheimer's care. The center also provides IHSS workers with one-on-one career counseling to explore opportunities for advancing to higher-level jobs in the health care industry. To date, over 600 independent providers have graduated from the training center.²⁰

Regional Health Occupations Resource Centers (RHORC). Nine RHORCS, located in each region of the state, encourage area-wide collaboration among community colleges and health care employers to address the needs of California's health care industry. The centers work with the health care industry to assess current and future employment and training needs, develop curricula, and share information on health occupations. They make use of exemplary workers to define the duties and skills needed to successfully perform a job. In 2001, the South Coast RHORC was funded by the California Endowment and the California Health Care Foundation to establish a Nurse Assistant Recruitment and Retention Project in collaboration with the Center for the Health Professions at the University of California, San Francisco. As part of the project, two region-wide surveys were conducted: the Long Term Veteran CNA Survey and the Housing and Child Care Survey. Both surveys provided information on-the-job concerns of nurse aides and the skills and attitudes they believed were needed to succeed. A conference and workshop were then sponsored by the RHORC so that nurses, administrators and aides could meet together to discuss survey findings, identify barriers to successful workforce recruitment and retention and develop strategies for eliminating these barriers. The Sun Coast RHORC has also developed a Mentor Training Program to enhance the skills of nurse aides who exhibit leadership qualities. The first CNA Mentor Training Program was initiated in February 2002.

California Training and Education Providers (CTEP). The California Training & Education Providers is a component of the San Diego Workforce Partnership, an organization established to coordinate a comprehensive workforce development system. CTEP oversees the development and maintenance of data bases to connect people with jobs, including direct care workers in the long-term care field. The project also arranges training courses for a variety of occupations including individuals who wish to become home health aides, LVNs and nursing assistants/aides.

Homecare Empowerment, Research and Organizing (HERO). HERO is an organization run by home care workers in California and their supporters to raise awareness of the important contributions these workers make to their community, to advocate for better wages and benefits, and to develop tools and supports identified by workers as important to their work life.

MASSACHUSETTS

A. Population and Workforce Characteristics

Older adults (65 years of age and up) make up 14 percent of the population in Massachusetts and the state is ranked 11^th among all states in terms of the proportion of its population that is elderly. Over the next 20 years the number of older adults in the state is expected to increase by about 40 percent.²¹

During the economic boom in the 1990's, Massachusetts experienced a severely tight labor market with a statewide unemployment rate near 2.4 percent.²² The state's unemployment rate continues to be below the national average at 5.3 percent.²³ Massachusetts has a significant immigrant population that contributes to the direct-care workforce, yet also has a very high cost of living, one of the highest in country.

Long-term care providers in the state employ about 55,000 direct care workers. Nursing home providers reported a 54 percent turnover rate and a 7 percent vacancy rate in CNA positions in 2002.²⁴ Staff turnover rates in home care agencies are about 40-60 percent. In-home providers reported increased difficulty in hiring staff, and consumers reported lack of access to in-home services because agencies did not have enough workers to meet client requests.²⁵ The mean hourly wage for home health aides is $10.52 and $11.36 for nurses' aides, orderlies and attendants in Massachusetts in 2001.²⁶

B. Characteristics of the Long-Term Care Services System

For many years, Massachusetts has had a well-developed aging network, made up largely of Aging Services Access Points (ASAPs) operating under the aegis of the state Executive Office of Elder Affairs. They provide supportive services to older adults. Nevertheless, a substantial proportion of the state's Medicaid long-term care funding is expended on institutional services. Massachusetts nursing homes are currently facing a severe financial crisis, brought on in part by the heavy reliance of these facilities on Medicaid payments, lower than average participation by private pay clients and difficulties in attracting qualified direct care workers.²⁷

C. Selected Policy and Practice Workforce Improvement Initiatives

The state's long-term care stakeholders have a long history of working together. As a result, Massachusetts has had success in bringing together key stakeholders to address direct-care worker shortages, and securing the attention of state policy makers in forging specific changes in public policies.

State Policy Initiatives

Nursing Home Quality Initiative. In response to the advocacy of organized collaborations of consumer groups, workers and providers, the state legislature funded a Nursing Home Quality Initiative in 2001 to address direct care worker shortages in the long-term care system. The Nursing Home Quality initiative resulted in three workforce improvement interventions:

• Wage Pass-through. A dedicated, $ 35 million "wage pass-through" was funded in 2001 to increase the wages of Certified Nursing Assistants (CNAs) working in Medicaid-funded nursing homes. Overall wages for nurse aides increased by 8.7 percent. Wage levels have been maintained at the FY 2001 level through continuation funding in subsequent budget years.

• Direct Care Workers Scholarship Training Program. A scholarship training program was also established and has awarded over 3000 scholarships to aspiring direct care workers in both nursing home and home and community-based care settings. Scholarships paid for training and testing costs for students. A small amount has been used for tutoring and English as a Second Language Training for trainees who lacked proficiency in English.

• Extended Career Ladder Initiative (ECCLI). The Extended Career Ladder Initiative was funded by the state to provide workplace education for direct care workers in the long-term care system. It is operated by the Commonwealth Corporation (CommCorp), a quasi-public agency charged with managing workforce development initiatives for low-wage workers. The goal of ECCLI is to improve the quality of long-term care and staff retention through workplace skills training and opportunities for advancement. To achieve its goals, ECCLI funds educational partnerships of long term care employers with the education community and workforce development agencies. Since 2000, about $14 million has been allocated to support programs for skill development of direct care workers, job advancement through career ladders and improvements in caregiving and workplace practices. In some settings, programs have focused on pre-certification training such as "English as a Second Language" training and literacy classes that enable workers to prepare for jobs as certified nursing assistants or home health aides. Other providers have used these resources to create mentoring programs, which give experienced workers a career step up while providing new workers with assistance as they acclimated to the job. Still other programs offered workers opportunities to specialize in clinical areas like rehabilitation care or Alzheimer's care. One round of grants were awarded to clusters of nursing homes to work together to implement in-depth culture change activities. Over 200 workers have received training through this program. According to an evaluation of the program it has had a positive impact on reducing vacancies, turnover, and the use of temporary workers by improving morale and skills.²⁸

Other Wage Enhancements. In addition to the wage pass-through implemented as part of the Nursing Home Quality initiative, the legislature sought to institute a provider bed tax, $50 million of which was to be dedicated to increasing wages, benefits, and hours for direct-care staff in nursing homes or on activities that demonstrably improve the facility's recruitment and retention of nursing staff. This initiative was not introduced in time for a vote and due to the current fiscal climate, may not be pursued. It would provide a substantial opportunity for increases in staffing levels, raises in workers' wages, and expansion of their health insurance benefits. It would also provide employers with resources for enhanced training and improvements in workplace practices to increase retention.

Commission on the Future of Long-Term Care. The legislature established a commission to conduct a two year study and make policy recommendations regarding the direction of long-term care in the Commonwealth. If convened, it is charged with examining the status, needs and adequacy of the long-term care workforce as part of its mandate.

Governors Health Care Task Force. This task force examined the financial and quality crisis confronting Massachusetts' health and long-term care providers. A draft report was recently issued which recommended that the state continue to fund the career ladder and wage pass-through programs currently in place as a way to address direct care worker shortages.

Health Insurance Study. The Massachusetts Division of Medical Assistance, under a federal grant from the U.S. Health Research and Services Administration, developed recommendations on ways to expand health insurance coverage within the Commonwealth. It found that the state had a special responsibility for certain health and human services workers, including direct care workers in long-term care. Building on this, the Division of Health Care Financing and Policy received funding from the Robert Wood Johnson Foundation to analyze various options for providing such coverage.

Selected Recruitment and Retention Practice Initiatives

Coalition of Organizations to Reform Eldercare (CORE). This multi-stakeholder coalition of consumers, providers, social workers, and labor unions -- staffed by Greater Boston Legal Services -- is focused primarily on the shortage of staff in the state's nursing homes. CORE has developed a grassroots network of family members who have actively advocated for legislative and budget initiatives to increase nursing home staffing, to improve compensation and to expand training opportunities. CORE was a major actor in the state's nursing home quality initiative, which secured the "wage pass- through" for nursing assistants, the career ladder program for entry-level nursing home workers, and the scholarship fund for CNA training.

Direct Care Workers' Initiative (DCWI). This is a coalition of providers, consumers and organized labor working on policy and practice initiatives to strengthen the paraprofessional workforce in both nursing home and home and community-based care settings. The DCWI is staffed by the Paraprofessional Healthcare Institute (PHI). DCWI has initiated a new, multi-year health insurance project to develop a framework and principles for a public policy proposal to expand health insurance coverage for direct care workers; and to organize broad-based campaigning to gain public approval of the proposal. Health Care for All has completed a study for DCWI, identifying workers' health insurance status and needs. The study documented that 25% of long-term care workers and that many others are overwhelmed by their share of premium costs.²⁹ PHI and Health Care for All are currently engaged in discussion with employers, workers, and consumers about how to shape a policy proposal to expand access.

NORTH CAROLINA

A. Population and Workforce Characteristics

North Carolina's elderly population is growing much faster than that of other states, both because of the aging of the baby boomers and a large influx of retirees. Today, about 12 percent of the population is age 65 and older. Over the next 20 years, the number of older people will almost double.³⁰ Unlike many other states, almost half of North Carolina's older adults live in rural areas³¹ making it especially challenging to recruit adequate numbers of direct care workers and provide needed services. North Carolina also has a much larger proportion of black elders than the majority of other states.³²

In 2002, the state's long-term care providers, including nursing homes, residential care and home health, and home care providers, employed approximately 62,890 direct care workers. Vacancy rates for certified nursing assistants in nursing homes were about 8 percent in 2002.³³ The mean hourly wage for home health workers in 2001 was $8.18 and $8.84 for nurse aides, orderlies, and personal care workers.³⁴

B. Characteristics of the Long-Term Care System

North Carolina's long-term care expenditures are heavily weighted toward nursing homes. About 77 percent of Medicaid long-term care funding goes to support nursing facilities. The state's long-term care system also includes a much higher than average number of board and care homes (known as adult care homes). Medicaid per capita expenditures for long-term care is also much lower than most other states.³⁵

C. Policy and Practice Workforce Initiatives to Improve the Workforce

In 1999, North Carolina's Division of Facility Services conducted a unique and revealing study of the state's long-term care direct care work force. Staff from the Division analyzed the number of individuals certified to work as nursing assistants in the state versus the number on North Carolinas' nurse aide registry. The study found that over 83,000 people, almost as many individuals as were certified (over 96,000), were not employed in the long-term care industry as those who were currently active.³⁶ The study also found that most individuals who were actively working as nursing assistants received income from more than one job, and 73 percent received some income from outside the health care sector.³⁷ Since that time, state officials have assumed a national leadership role in surveying all states to identify policy and practice initiatives that have been developed in response to direct care worker recruitment and retention issues and disseminating the results.

State Policy Initiatives

North Carolina Department of Health and Human Services. The North Carolina Department of Health and Human Services has been very active in addressing direct care worker shortages in the state. The Division of Facility Services has worked collaboratively with an array of agencies to develop a unique database, which matches nurse aide registry data with Department of Labor employment data. The database allows the state to track turnover rates and vacancies across nursing facilities, adult care home and home care agencies. It also permits the state to track individuals who leave the long-term care field to see where they are employed and the wages they earn in comparison to those who remain active as direct care workers. An insert to the annual license renewal application is now sent to all licensed long-term care providers in the state so that turnover and vacancy rates can be analyzed on an annual basis.³⁸

In 2001 the North Carolina General Assembly appropriated $500,000 to the Department to develop, implement and evaluate on-site Internet training and other innovative training programs to improve recruitment and reduce turnover of nurse aides in nursing facilities. The community colleges system was charged with working with nursing home providers on this effort. As a result of this funding:

• A nurse management and supervisory training program for RN's was developed to help them to more effectively work with their nurse aide staff.

• A mentoring program was developed to help more experienced nurse aides help new hires.

• A public education campaign was initiated. Public service announcements have been developed for TV as well as brochures and postcards to support the campaign.³⁹

North Carolina Institute of Medicine Report on Long-Term Care. The North Carolina Institute of Medicine's Task Force on Long-Term Care has issued a report on the current and likely future issues facing the states older adults and people with disabilities in need of long-term care services. The task force examined the shortages of direct care workers facing long-term care consumers and providers. To address these shortages, the task force recommended that the legislature increase funding for Medicaid in-home and adult care home personal care and nursing home reimbursement rates to enhance wages and benefits for direct care workers. They further recommended that providers be monitored to insure that increased funding was used for this purpose. In addition to wage enhancements, the task force recommended that the legislature appropriate funds for workforce development including continuing education and career ladder programs, and that the state explore ways to provide health insurance to long-term care workers.⁴⁰

Real Choice Grant. In 2001, the state received a $1.6 million "Real Choice" grant from the Center for Medicare and Medicaid Services. The state is using these funds to improve recruitment and retention of direct care workers. Grant activities include developing a career ladder for direct care workers, implementing a public education and awareness effort to promote worker recruitment and retention entitled "Challenging Careers, Compassionate Hearts", and designing a consumer-directed care model.⁴¹ The grant has also been used to help establish a statewide association for direct care workers, named, the "Direct Care Workers Association of North Carolina." The goal of the association is to improve the quality of long-term care by promoting the interests of direct care workers through education, professional development and public education.

Selected Recruitment and Retention Practice Initiatives

Win-A-Step. The goal of the Win-A-Step Program (Workforce Improvement for Nursing Assistants: Supporting Training, Education, & Payment for Upgrading Performance) is to assess recruitment and retention problems in the state and improve direct care workers job quality and reduce vacancies and high turnover. The project is jointly conducted by the North Carolina Department of Health and Human Services and the Institute on Aging at the University of North Carolina under a grant from the Kate B. Reynolds Charitable Trust.⁴² Under the program, employers agree to pay a bonus or wage increase to workers who stay in their facility for at least five months, and who have successfully completed training courses in a number of content areas. Workers are also given a stipend for each completed course. Training curricula are developed in response to skill gaps identified by nursing assistants and staff development coordinators in participating nursing homes. Participants in the training program attended educational courses held within their own facilities and conducted by the facility or agency staff. Over 400 workers received training under Win-A-Step and over 80 employers participated. Evaluators of the program found that participants were half as likely as control group members to leave the facility in which they worked during the study period. In addition, 70 percent of participants reported that Win-A-Step increased their chances of remaining an employee of their facility/agency in the future, and over 75 percent reported improved job satisfaction.⁴³

The North Carolina Health Care Facilities Association (NCHCFA). NCHCFA, the trade association representing almost all of the state's licensed nursing homes, in collaboration with the North Carolina Community College System, has developed and implemented several statewide initiatives to improve recruitment and retention of direct care workers including:

• Safe Hands. A program developed to promote public awareness and mentoring, as well as career advancement for nurse's aides. A CD-ROM was created to educate people about the role of the nurse aide as well as career opportunities that are available in the states nursing homes.

• Fabulous Fifty. An event held each year by the association to publicly recognize fifty outstanding nurse aides in the state.⁴⁴

NCHCFA is also addressing the lack of affordable health insurance among nursing home workers. The association recently identified an affordable group health insurance plan, originally developed for workers in a particular fast food chain. It plans to market the plan through its member facilities in the near future. Three benefit coverage options will be available -- two include some prescription drug coverage, and all three include a $10,000 life insurance benefit. Each benefit option can be extended to both full and part time workers.⁴⁵

PENNSYLVANIA

A. Population and Workforce Characteristics

Pennsylvania is one of the most rapidly aging states in the nation. Older adults age 65 and above make up 16 percent of the state's population. Over the next 20 years their numbers are expected to increase by about 25 percent.⁴⁶ At the same time, the market for direct care workers in long-term care remains very tight. Pennsylvania long-term care providers employ about 94,000 individuals: nursing homes employ about 42,000, personal care facilities 27,000 and home and community-based service providers about 25,000. The overwhelming majority of these individuals are direct care staff.⁴⁷ Nursing homes in the state report vacancy rates for certified nursing assistants of about 10 percent and annual turnover rates in nursing homes of about 50 percent.⁴⁸ The mean hourly wage for direct care workers in Pennsylvania in 2000 was $ 9.52 for nursing aides, orderlies and personal care attendants.⁴⁹ Based on estimates by the Department of Labor and Industry, the number of nursing assistants is expected to grow about 22 percent between 1998 and 2008, while state projections of need will require a growth rate of about 86 percent. Employers throughout many parts of Pennsylvania report pervasive shortages of certified nursing assistants locally.

B. Characteristics of the Long-Term Care Services System

Pennsylvania's public long-term care resources are heavily invested in nursing homes. Despite allocating state lottery and tobacco settlement funds to expand home and community-based services, the state has the second highest total and per capita nursing home expenditures in the country. In 2001, the state implemented a new "Bridge" program largely funded by tobacco settlement funds for people who need home and community-based long-term care services and are not eligible for Medicaid.⁵⁰

C. Policy and Practice Initiatives to Improve the Workforce

Pennsylvania's public agencies, particularly the Pennsylvania Intra-Governmental Council on Long-term care, have taken the lead in investigating the state's long-term care workforce shortages. Two coalitions of committed providers, workers, consumers and others have also come together to promote a high quality direct care workforce.

State Policy Initiatives

The Pennsylvania Intra-Governmental Council on Long-Term Care. The Pennsylvania Intra-Governmental Council on Long-term care was established in the mid 1980's to assess the State's long-term care system and recommend new directions. It is made up of administrative officials, legislators, providers, advocates and consumers.

• Workforce Issues Work Group. In 2001, the Council created the Workforce Issues Work Group to examine recruitment and retention problems in the state, and to solicit alternative solutions based on empirical and quantifiable information. The work group commissioned three studies. The first study surveyed a representative sample of 900 long term-care providers to collect information on recruitment and retention problems and the strategies they employed for dealing with them. A second study involved focus groups with 167 frontline workers to find out their perceptions of why recruitment and retention was such a pervasive problem. The third study was a follow-up to the initial focus group study. Three reports have been published based on these studies: "Pennsylvania's Frontline Workers in Long-term care: the Provider Organization Perspective,"⁵¹ "In Their Own Words: Pennsylvania's Frontline Workers in Long-term Care, and "In Their Own Words, Part II: Pennsylvania's Frontline Workers in Long-term Care."⁵² The studies found that low wages and benefits were only one factor contributing to the workforce crisis and that the extent to which workers were recognized and respected, appropriately prepared and trained and involved in care decisions were equally important in determining whether workers stayed in or left their jobs.

Direct Care Workforce Initiative (DCWI). In 2001, the state legislature created the Direct Care Workforce Initiative to which provided $ 3.4 million in funding to Area Agencies on Aging to develop projects that addressed the shortage of direct care workers in home and community-based care settings. The majority of grant funds were used to provide direct benefits to workers including making sign-on and longevity bonuses available to workers, subsidizing childcare and transportation, helping with the purchase of uniforms, and granting other direct benefits. Funding has also been used to train direct care workers and supervisors, organize best practice seminars, and offer life skills training, mentoring assistance and basic skills training at local vocational schools and community colleges. The funds were also used to implement a statewide education campaign to improve the image of direct care workers. The workforce initiative has now been extended for two additional years and has received $3.4 million in additional funding. The state has also encouraged nursing facilities and counties to increase their collaboration in solving recruitment and retention problems by making an additional $1.5 million available in 2002 to fund relevant projects.⁵³

Selected Recruitment and Retention Practice Initiatives

Pennsylvania Culture Change Coalition (DCCC). This statewide coalition of advocates, workers and union representatives, providers, nurses, researchers, and state agency officials has come together to promote improvements in policies, practices and research across the spectrum of long-term care services and settings. One member of the coalition, the Presbyterian Home of Moshannon Valley, has developed a new model of resident centered care entitled the Kaleidoscope Initiative to improve the quality of direct care workers' jobs and the quality of patient care. Kaleidoscope includes a shared management style, career paths for direct care workers, extensive orientation and continual mentoring, career ladders, flexible scheduling so that workers can negotiate their working hours, and the use of teams to involve workers in decision making.⁵⁴

Critical Jobs Training Grants (CJTG). This state initiative combined $24 million in funds from the Departments of Aging, Welfare, Community and Economic Development, Labor and Education to fund training and education for high-demand jobs, including frontline workers jobs in long-term care. The Institute for Caregiver Education received a grant under this program to restructure the work environments in eight of the states' nursing homes, building off the principals of the Pioneer Network.⁵⁵ Nurse aides and managers are provided training through the grant to support workplace redesign.

The Southwestern Pennsylvania Partnerships on Aging (SWPPA). SWPPA is a regional initiative in 10 counties that brings together over 400 individuals and organizations including older adults, caregivers, non profit and for profit aging, long-term care and health care providers, business and community organizations, government agencies and academic institutions to improve the well being and quality of life of older adults through policy and program changes. In 2001, SWPPA completed a survey of direct care workers to identify why some workers stayed in their jobs for long periods and others left. Subsequently they have initiated a workforce development and culture change project "Healthy Elders…Healthy Jobs 2005" to address workforce retention in southwestern Pennsylvania nursing homes by implementing changes based on Pioneer network principals.⁵⁶ The project identifies "culture change champions" in each participating facility, from each level of the facilities staff, and analyzes the facilities operations and values to see what modifications need to be made in the workplace culture. SWPPA has also developed an Aging Caregiver Training Curriculum for entry-level direct care staff and have partnered with local colleges and universities to develop applied research efforts around pain management and the conditioning of frail elders.

Lancaster County Workforce Investment Board (WIB). The Lancaster WIB, the agency responsible for deciding how federal Workforce Investment Act funds are spent, received a grant from CJTC to develop a media campaign to increase the supply of workers in the health care industry. The media campaign averages 30 messages weekly during high profile time slots to market careers in health care to workers in other fields and to those who want to advance their careers. As part of the campaign, potential workers who are interested in long-term care jobs are connected directly to nursing home employers seeking staff. The Lancaster WIB has also developed a program to train frontline supervisors working in long-term care settings that helps senior managers to support supervisors as they learn new management skills.

The Delaware County Workforce Investment Board. The Delaware County Workforce Investment Board has funded the Certified Nursing Assistant Training Pilot Project to improve vacancy and turnover among entry-level long-term care workers. It provides a 90-hour training curriculum that includes life skills training, literacy and documentation skills and case management to job applicants. Agreements have secured with area providers to hire graduates. The project targets low income youth age 18-21.

Department of Labor and Industry Apprentice Program. The Department of Labor and Industry, the Pennsylvania Department of Public Welfare, and the Pennsylvania Workforce Improvement Network have developed an apprenticeship program for entry-level workers using $15 million in Temporary Assistance for Needy Families (TANF) funds. If implemented, the program would target direct care workers and help them to gain the skills necessary to deliver care in various long-term care settings.

WISCONSIN

A. Population and Workforce Characteristics

Wisconsin is ranked 23^rd among all states in terms of the proportion of its residents age 65 and older. Older adults make up 13 percent of the state's population and their numbers are expected to increase by 48 percent between 2000 and 2020.⁵⁷ Wisconsin employs approximately 51,000 direct care workers in nursing home and home and community-based settings. Vacancy rates for nurse aides in Wisconsin nursing homes were about 7 percent in 2002 and turnover rates were about 55 percent.⁵⁸ Wisconsin's unemployment rate is less than the national average at 5.3 percent.⁵⁹

B. Characteristics of the Long-Term Care Services System

Wisconsin has long been considered a leader among the states in the delivery of home and community-based services for older adults and people with serious long-term disabilities. For many years, the Community Options Program (COP), was the state's signature long-term care program, providing a wide range of home and community-based services, including assessment and care management. The State is now developing a "next generation" endeavor, the Family Care Program, to integrate all long-term care services at the county level. The program, which has been tried in nine counties on an experimental basis, pools federal and state funds to create an individualized long-term care benefit program for eligible persons. In spite of its commitment to home and community-based services, Wisconsin continues to spend about two-thirds of its Medicaid long-term care funding on nursing homes.

C. Policy and Practice Initiatives to Improve the Workforce

Wisconsin policy makers, program officials and long-term care providers, particularly Area Agencies on Aging and nursing facilities, have taken a variety of actions to address the shortage of health care workers in the state, including those who work in long-term care settings.

State Policy Initiatives

The leadership around long-term care workforce issues has come primarily from Wisconsin public agencies, particularly many of the Area Agencies on Aging, and selected nursing home providers who are experimenting with the implementation of significant workplace reforms to improve the quality of care and the quality of the direct care worker's job.

Year of the Long-Term Care Worker. Wisconsin's Governor highlighted the importance of the state's paraprofessional long-term care workforce by proclaiming "The Year of the Long-Term Care Worker" from May 1999 to May 2000. A task force was established specifically to address the high vacancy and turnover rates facing the long-term care provider community. Also in response to the Governor's proclamation, the Community Options Program conducted a survey of COP worker shortages and the Wisconsin Caregiver Association (WCGA) was founded to provide education and advocacy for nurse aides, orderlies, personal care workers, attendants, home health and hospital aides and respite workers.

Health Care Worker Shortage Committee. The Governor's Health Care Workforce Shortage Committee was established in 2001 to bring partners in the health care industry, labor, education, and government together to develop innovative solutions to address health care worker shortages in Wisconsin, including the difficulties facing long term-care providers in recruiting and retaining direct care workers. The Secretary of the Department of Workforce Development and the President of the Wisconsin Technical College System are the co-chairs. Priority was given to four areas: retention and recruitment, education, redesign of work, and investment and resources. The final report of the Committee has been issued. The recommendations are sweeping and affect every aspect of the state's health care system. Of particular relevance to the long-term care sector, the report recommends increased state funding for training, particularly to help recruit low income, academically disadvantaged and underrepresented minority populations, creating incentives to providers to offer education and training programs, implementing flexible learning options for trainees including long-distance learning, establishing apprenticeships and evening and weekend training programs, developing regional partnerships between health care employers, labor and educational institutions to support health care workforce development, providing career counseling and life long learning experiences; launching a statewide health care worker recruitment effort; developing mentor programs to assist minority and English as a Second Language students; charging each school district to provide access to health occupation education programs for entry level jobs such as nursing assistant, and improving the workplace culture so that workers feel valued by developing mentoring and recognition programs, career ladders, improving safety and security and developing collaborative work models.

Medicaid Wage Enhancements. The Wisconsin legislature funded a Medicaid wage pass-through that provided a 5-percent increase for nurse aides in nursing facilities in 1999. However, there is no evaluation of its impact on improving recruitment and retention of direct care staff. Also in response to worker shortages, the state increased the hourly rate paid for personal care (hands-on care provided to individuals in their own homes to help them with daily living activities) from $12/hr. to $15.50/hr.

Selected Recruitment and Retention Practice Initiatives

Community Links Workforce Project. To stimulate the development of practical approaches for addressing the high vacancy and turnover rates among the state's long-term care workers, the Bureau of Aging and Long-Term Care Resources implemented the Community Links Workforce Project with $600,000 of COP and COP-Waiver funds. All counties received relatively small grants to engage in a range of grass roots efforts to strengthen or expand the workforce serving COP participants. Counties used these funds to work with consumers, providers and workers to develop a wide range of activities to improve workforce recruitment and retention. For example, Waushara County received a Community Links grant to explore the feasibility of forming a home care cooperative. As a result, Cooperative Care was established with a start-up loan from a local bank. The organization is owned and operated by 75 caregivers who pay a modest membership fee to join. In the year since its inception, Cooperative Care has added 12 new worker/members, attracted private pay clients from surrounding counties, and negotiated and secured a contract with the Waushara County Community-Based Long-Term Care Program.

Several counties have used Community Links grants to develop new financial and motivational incentives such as pay increases for current employees, bonuses for working on Sundays and holidays, referral fees for employees who find new workers and sign on bonuses. Counties have also used their grants to recognize the valuable contributions of direct care workers. One county gives an extra vacation day for every 200 hours worked. Other workers are rewarded for their efforts by being given a share of their employer's profits. Benefits such as paid time off, health insurance and help with childcare are also offered.

Another Community Links project used its grant to recruit former welfare recipients, paying for their school, books, childcare and transportation plus a stipend. When hired, these new workers also receive one-on-one mentoring from an experienced worker for six months. In another project, people required by the courts to do some community service can volunteer to provide people with disabilities home care assistance. People with developmental disabilities have also been recruited, often coming to work with a job coach who helps them with basic skills. In some counties, nursing homes, community-based residential facilities, home health agencies and other community programs are working together to recruit, cross-train and support and share their workers. Grants have also been used to help the clients of independent providers. For example, new employment agencies have been set up to help clients of independent providers with payroll and tax-withholding and with worker training.

Even with modest funding, many of these initiatives have spawned similar activities across the state.

Wisconsin Long-Term Care Workforce Alliance. The Wisconsin Long-Term Care Workforce Alliance is a coalition of organizations working together to improve long-term care quality of care by promoting collaborative partnerships to enhance recruitment and retention of frontline workers in nursing home and home and community-based settings. Coalition members include representatives from the Wisconsin Department of Health and Family Services, the nursing home and assisted living membership organizations, Area Agencies on Aging, organizations that advocate for the elderly and younger people with disabilities, the Wisconsin Caregivers Association and the Eastern Wisconsin Area Health Education Center. In 2001, the alliance focused on the development of a statewide campaign to improve the image of long-term care workers, building on a successful campaign conducted by Kenosha County's Community Links Project.

Wisconsin Association of Homes and Services for the Aging (WAHSA). The Wisconsin Association of Homes and Services for the Aging has been instrumental in launching a new campaign, "Making Life Better One Person at a Time" to help attract more people into the long-term care profession. The association developed a series of sample brochures, media alerts, posters, and other materials that are distributed monthly to individual members to help them create better community awareness of the importance of the long-term care worker and to help recruit new workers. Activities include scheduling luncheon meetings with local media, outreach to middle and high schools, the distribution of posters and brochures promoting long-term care careers, and the development of a Careers Website. WAHSA is also working on a comprehensive user's guide for sponsoring a Long-Term Care Careers Camp designed to introduce youth in grades 5-12 to the various long-term car professions. This product is being developed jointly be the Association and the Southwest Georgia Area Health Education Center.

Wellspring. Wellspring Innovative Solutions Inc. is a confederation of 11 freestanding, not-for-profit nursing homes in eastern Wisconsin, known as the Wellspring Alliance. It was founded in 1994 and became fully operational in 1998. Wellspring's goals are to make the nursing home a better place to live by improving the clinical care provided, and to create a better work environment by giving employees the skills they need to do their jobs, giving them a voice in how their work should be performed and enabling them to work as a team toward common goals. The Wellspring model includes clinical consultation and education coordinated by a clinical nurse specialist hired by the Alliance, a shared program of staff training based on best clinical practices, the sharing of comparative data on resident outcomes, and a structure of multidisciplinary care resource teams who are empowered to develop and implement interventions that they believe will improve the care of residents. An evaluation funded by the Commonwealth Fund found that Wellspring successfully and intentionally meshes clinical and culture change together to meet its goals. Positive outcomes included evidence that rates of turnover were lower and increased more slowly than in comparable Wisconsin nursing homes within the same time period; Wellspring facilities improved their performance on the federal survey to a greater extent than their peers; staff were more vigilant than their peers in other nursing homes in assessing problems and took a more proactive approach to resident care; and no additional increases in net resources were required for implementation. Observational evidence and interview results indicate a better quality of life for residents, a better quality of work life for staff and an improved quality of interaction between residents and staff.

Career Training Alliance. The Career Training Alliance for state and federally certified nurse aides began in 1997 as a coalition of health care providers and community-based agencies with the YWCA of Madison, Wisconsin as the lead agency. The program's mission is to empower, through education and employment, unskilled, unemployed and under-employed people to become nurse aides to address the needs of the local health and long-term care community and to help them build a career. The program requires an eight-month commitment from students to complete the two-month training, to secure employment upon course completion and to remain with the employer for at least six continuous months. Case management help is available to all new graduates to plan work schedule arrangements and help problem-solve. A free loaner car may be available for the first six months on the job to help stabilize transportation and financial needs. Before students begin their three weeks of clinical experience, a mentoring instructor visits each of the nursing home or home health agency sites to directly train the experienced aides who will be mentoring the students. Since 1997, the program has enrolled 118 students, has graduated 96 and has seen 64 graduates continue to work in long-term care or hospital settings. In addition, 13 percent of the graduates are enrolled in nursing continuing education.

Worker Education, Training and Assistance (WETA). The Wisconsin Alzheimer's Institute of the University of Wisconsin Medical School developed the Worker Education, Training and Assistance project to educate and retain direct care workers while providing opportunities for increased salaries, improved benefits, employee recognition, career advancement and insight into how to improve the work environment. The program involves 145 staff from 40 community based residential facilities and two home health agencies. Each worker signs an agreement to attend WETA education and training sessions while staying in their current job for the duration of the program. In return, employers agree to pay WETA tuition fees, with some providing employee salary increases of up to 8 percent. The program also includes a workplace coaching and mentoring element in which trained supervisors provide help to WETA participants in applying their newly learned skills. Evaluation of the program is being conducted by the Center for Health Policy and Program Evaluation at the University of Wisconsin-Madison.

Center for Delivery Systems Development. The Center for Delivery Systems Development at the University of Wisconsin has received a planning grant from the Helen Bader Foundation to promote the recruitment and retention of direct care workers in home and community-based care settings. The project will apply national research findings on recruitment and retention strategies to one or two Family Care Management Organizations (CMO) and their related provider networks. Each site will develop linkages with its local technical college and other training providers to add to the existing curricula for personal care and certified nursing assistants, using a curriculum developed at the University of Wisconsin-Madison. The tasks will include the formation of a local recruitment and retention workgroup of CMO and provider network staff to identify critical areas of need and types of workers required; the development of a customized array of incentives for providers and workers to encourage training and retention; and an evaluation to assess the feasibility of setting up a local registry of direct care workers. The project team will work with staff from the Wisconsin Bureau of Quality Assurance and the Department of Regulation and Licensing to identify barriers to the universal worker concept. The project will include an impact evaluation.

Wisconsin Caregivers Association: The Wisconsin Caregivers Association (WCGA) was founded to provide education and advocacy for nurse aides, orderlies, personal care workers, attendants, home health and hospice aides and respite workers. Leadership for the development of WCGA is provided by a group of volunteers from other associations, nursing homes, residential care facilities, home care agencies, organizations for aging services and educational institutions. The organization produces a quarterly newsletter, has held one annual meeting and has drafted a manual on grassroots organizing for use in developing local coalitions of caregivers and their allies.

NOTES

1. For a more in-depth review of specific recruitment and retention practices, readers may turn to the Provider Practice Profiles database sponsored by IFAS and PHI, http://www.directcareclearinghouse.org/practices/index.jsp.

2. Paraprofessional Healthcare Institute and the North Carolina Department of Health and Human Services' Office of Long Term Care. Results of the 2002 National Survey of State Initiatives on the Long-Term Care Direct Care Workforce, June 2002, http://www.directcareclearinghouse.org/download/2002_Nat_Survey_State_Initiatives.pdf.

3. Paraprofessional Healthcare Institute and North Carolina Department of Health and Human Services' Office of Long Term Care. Results of the 2002 National Survey of State Initiatives on the Long-Term Care Direct Care Workforce, May 2002, http://facility-services.state.nc.us.nc2003nsurvey.pdf.

4. US Bureau of Labor Statistics. 2001, http://www.bls.gov/oes/2001/oessrcst.htm.

5. Robyn I. Stone and Joshua M. Wiener. Who Will Care for Us? Addressing the Long-term Care Workforce Crisis, The Urban Institute and The American Association of Homes and Services for the Aging, October 2001, pp. 22-24. [http://aspe.hhs.gov/daltcp/reports/ltcwf.htm]

6. For a review of recent related research on this topic, see Recent Insights about Frontline Long-Term Care Workers: A Research Synthesis 2000-2002, Institute for the Future of Aging Services, currently being prepared under a contract with DHHS/ASPE.

7. AARP, Public Policy Institute. Across the States 2002: Profiles of Long-Term Care Systems, 2002, http://research.aarp.org/health/d17794_2002_ats.pdf.

8. US Bureau of Labor Statistics. 2002, http://www.bls.gov.

9. American Health Care Association. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, February 12, 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf.

10. US Bureau of Labor Statistics. February 2003, http://www.bls.gov.

11. Paul M. Ong, Jordan Rickles, Ruth Matthias, and A.E. (Ted) Benjamin. California Caregivers: Final Labor Market Analysis, an analysis for the California Employment Development Department UCLA School of Public Policy and Social Research, September 15, 2002, http://www.calmis.ca.gov/SpecialReports/CTI-Final-2003.pdf.

12. Ibid.

13. Currently, 96 percent of California's IHSS caseload receives services through the independent provider model and only 4 percent utilize workers who are directed by an IHSS-contracted agency (Heinritz-Canterbury, 2002).

14. Charlene Harrington, James H. Swan, Valerie Wellin, Wendy Clemena, and Helen M. Carrillo. 1998 State Data Book on Long Term Care Program and Market Characteristics, November 1999, http://cms.hhs.gov/medicaid/services/98sdbltc.pdf.

15. Barbara Coleman, Wendy Fox-Grage, and Donna Folkemer. State Long Term Care: Recent Developments and Policy Directions, Appendix A: State Summaries, July 2002, http://aspe.hhs.gov/daltcp/reports/stateltc.htm.

16. Ibid.

17. State Wage Pass-Through Legislation: An Analysis, April 2003, http://www.paraprofessional.org/publications/WorkforceStrategies1.pdf.

18. Employment Development Department, Employment and Training special projects, Caregiver Training initiative list of awards.

19. Patricia Franks, Susan A. Chapman, Monique Nowicki, Arnab Mukherjca. Trends, Issues, and Projections of Supply and Demand for Nursing Aides and Home Health Care Aides: CA Fieldwork, the Center for the Health Professions, University of California, San Francisco, March 2002, http://futurehealth.ucsf.edu/pdf_files/CNA-HHA%20-LTC%20FINAL.pdf.

20. SEIU Local 434B. May 4, 2003, http://www.seiu434b.org/training_center/training_center.cfm.

21. AARP, Public Policy Institute. Across the States 2000: Profiles of Long-Term Care Systems, 2002, http://research.aarp.org/health/d17794_2002_ats.pdf.

22. Massachusetts Division of Employment and Training. Unemployment rates down from one year ago in most area; Annual average rates also show decline, Press Release 3/1/2000.

23. US Bureau of Labor Statistics. February 2003, http://www.bls.gov.

24. American Health Care Association. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, February 12, 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf.

25. Barbara Frankand Steven Dawson. Health Care Workforce Issues in Massachusetts, the Massachusetts Health Policy Forum, June 2000.

26. US Bureau of Labor Statistics. 2001, http://www.bls.gov/oes/2001/oessrcst.htm.

27. Massachusetts Health Care Task Force Final Report, 2002, http://www.state.ma.us/healthcare/pages/pdf/final.pdf.

28. Susan Eaton. Extended Care Career Ladder Initiative Working Paper, 2002, Kennedy School of Government.

29. Marcia Hams, et al. Health insurance access survey of direct-care workers in nursing homes and home-based care agencies in Boston, New Bedford/Fall River, including surveys of employees and of employers, Direct Care Workers Initiative and Paraprofessional Healthcare Institute, Spring 2002.

30. AARP, Public Policy Institute. Across the States 2000: Profiles of Long-Term Care Systems, 2002, http://research.aarp.org/health/d17794_2002_ats.pdf.

31. University of North Carolina's Institute on Aging. 2001, http://www.aging.unc.edu/infocenter/data/.html.

32. North Carolina Division of Facility Services. Comparing State Efforts to Address the Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers, September 1999, http://www.directcareclearinghouse.org/dowload/NC%201.pdf.

33. American Health Care Association. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, February 12, 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf.

34. US Bureau of Labor Statistics. April 2003, http://www.bls.gov.

35. Charlene C. Harrington, et al. 1998 State Data Book on Long Term Care Program and Market Characteristics, November 1999.

36. North Carolina Division of Facility Services. Comparing State Efforts to Address the Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers, September 1999, http://www.directcareclearinghouse.org/dowload/NC%201.pdf.

37. Thomas Konrad, and Jennifer Craft Morgan. Workforce Improvement for Nursing Assistants: Supporting Training, Education, & Payment for Upgrading Performance (WIN A STEP UP), 2002, http://www.aging.unc.edu/research/winastepup/about.html.

38. Paraprofessional Healthcare Institute and North Carolina Department of Health and Human Services' Office of Long Term Care. Results of the 2002 National Survey of State Initiatives On the Long-Term Care Direct Care Workforce, June 2002, http://facility-services.state.nc.us.nc2003nsurvey.pdf.

39. North Carolina Division of Facility Services. Results of a Follow-Up Survey to States on Wage Supplements for Medicaid and Other Public Funding to Address Aide Recruitment and Retention in Long-Term Care Settings, September 2001, http://www.directcareclearinghouse.org/download/careerna.pdf.

40. North Carolina Institute of Medicine Task Force on Long-Term Care. A Long-Term Care Plan for North Carolina: Final Report, January 2001, http://www.nciom.org/ltcfinal.pdf.

41. North Carolina Department of Health and Human Services (NC DHHS). Grant to help boost caregivers' retention, career options, January 9, 2002, http://www.dhhs.state.nc.us/pressrel/1-9-02.htm.

42. Thomas Konrad & JenniferCraft Morgan. Workforce Improvement for Nursing Assistants: Supporting Training, Education, and Payment for Upgrading Performance: Executive Summary, 2002, http://www.aging.unc.edu/research/winastepup/execsummary.pdf.

43. Susan Harmuth. Telephone conversation, October 14, 2002.

44. Ibid.

45. Paraprofessional Healthcare Institute and North Carolina Department of Health and Human Services' Office of Long Term Care. Results of the 2002 National Survey of State Initiatives On the Long-Term Care Direct Care Workforce, June 2002, http://facility-services.state.nc.us.nc2003nsurvey.pdf.

46. AARP, Public Policy Institute. Across the States 2002: Profiles of Long-Term Care Systems, 2002, http://research.aarp.org/health/d17794_2002_ats.pdf.

47. Joel Leon, et al. Pennsylvania's Frontline Workers in Long Term Care: the Provider Organization Perspective, the Polisher Research Institute, February 2001, http://www.pgc.org/PRI/projects/PA_LTC_workforce/PA_LTC_workforce_report.pdf.

48. American Health Care Association. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, February 12, 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf.

49. US Bureau of Labor Statistics. 2001, http://www.bls.gov/oes/2001/oessrcst.htm.

50. Barbara Coleman, Wendy Fox-Grage, and Donna Folkemer. State Long Term Care: Recent Developments and Policy Directions, July 2002, http://www.ncsl.org/programs/health/forum/ltc/ltcmain.htm.

51. Joel Leon, et al. Pennsylvania's Frontline Workers in Long Term Care: the Provider Organization Perspective, the Polisher Research Institute, February 2001, http://www.pgc.org/PRI/projects/PA_LTC_workforce/PA_LTC_workforce_report.pdf.

52. In Their Own Words: Pennsylvania's Frontline -- Workers in Long Term Care, February 2001, http://www.workforce21.net/report_care.pdf.

53. Dale Laninga. Telephone conversation, August 15, 2002.

54. National Clearinghouse on the Direct Care Workforce. Practice Profile Data Base, 2003, http://www.directcareclearinghouse.org/practices/index.jsp.

55. The Pioneer Network. http://www.pioneernetwork.org.

56. Ibid.

57. AARP, Public Policy Institute. Across the States 2002: Profiles of Long-Term Care Systems, 2002, http://research.aarp.org/health/d17794_2002_ats.pdf.

58. American Health Care Association. Results of the 2002 AHCA Survey of Nursing Staff Vacancy and Turnover in Nursing Homes, February 12, 2003, http://www.ahca.org/research/rpt_vts2002_final.pdf.

59. US Bureau of Labor Statistics. February 2003, http://www.bls.gov.

TABLE 1. Key Contacts
State	Name	Organization	Contact Info
California	Ted Benjamin	In-Home Supportive Services (IHSS) Program	tedbenj@ucla.edu
	Ruth Matthias	UCLA School of Public Policy and Social Research, Allied and Auxiliary Health Care Workforce Project	Matthias@ucla.edu
	Jeanne West	Sun Coast Regional Health Occupations Resource Center, CNA Recruitment/Retention Project	jw@jeannewest.com
	Brenda Kelly	CTEP	916-262-2189
Massachusetts	Senator Mark Montigny	Nursing Home Quality Initiative	MMontign@senate.state.ma.us
	Carol Kopolka	Commonwealth Corporation, Extended Career Ladders Initiative	ckopolka@commcorp.org
	Wynn Gerhard	Greater Boston Legal Services, Coalition of Organizations to Reform Eldercare	wgerhard@gbls.org
	Barbara Frank	Paraprofessional Healthcare Institute, Direct Care Workers Initiative (DCWI)	Bfrank1020@aol.com
North Carolina	Susan Harmuth	North Carolina Division of Facility Services, Department of Health and Human Services	Susan.Harmuth@ncmail.net
	Thomas Konrad	Sheps Center for Health Services Research, University of North Carolina at Chapel Hill	Bob_konrad@unc.edu
		Win-A-Step Project	Leigh_anne_roystr@unc.edu
Pennsylvania	Dale Laninga	Pennsylvania Intra-Governmental Council on Long-Term Care, Direct Care Workforce Initiative	dlaniga@state.pa.us
	Carol Williams	Pennsylvania Culture Change Coalition	carol_williams@auditorgen.state.pa.us
	Mary Ann Kelly	Southwestern Pennsylvania Partnership on Aging	swppa@nb.net
Wisconsin	Judith Zitske	Community Links Workforce Project	zitskjb@dhfs.state.wi.us
	Mary Ann Kehoe	Wellspring Innovative Services, Inc.	mak@goodshepherdservices.org
	Bob Kellerman	Wisconsin Long Term Care Workforce Alliance	kellermanb@mailbag.com
	John Sauer	Wisconsin Association of Homes and Services for the Aging, Inc.	Jsauer@wahsa.org

TABLE 2. AHCA Annualized Turnover and Vacancy Rates(Ending June 30, 2002)
State	CNA Turnover Rate (%)	CNA Vacancy Rate (%)
California	54.1	7.5
Massachusetts	51.3	7.6
North Carolina	83.8	7.8
Pennsylvania	50.7	9.8
Wisconsin	51.3	7.6
Average for 5 States	58.2	8.1

TABLE 3. AARP Actual and Predicted Population Characteristics
State	Year	Ages 65-74  (% of Total State Population)	Ages 75-84  (% of Total State Population)	Ages 85 and Up  (% of Total State Population)
California	2000	5.6	3.8	1.3
	2020	8.8	4.1	1.6
Massachusetts	2000	6.7	5.0	1.8
	2020	10.2	4.7	2.0
North Carolina	2000	6.6	4.1	1.3
	2020	9.2	4.9	2.0
Pennsylvania	2000	7.9	5.8	1.9
	2020	10.4	4.9	2.1
Wisconsin	2000	6.6	4.7	1.8
	2020	10.9	5.3	2.3

TABLE 4. AARP Actual and Predicted Population Characteristics(Average of Five States)
Year	Ages 65-74  (% of Total State Population)	Ages 75-84  (% of Total State Population)	Ages 85 and Up  (% of Total State Population)
2000	6.7	4.7	1.6
2020	9.9	4.8	2.0

TABLE 5. AARP Predicted Population Growth
State	Population Growth Ages 65 and Up (%)
California	80
Massachusetts	40
North Carolina	56
Pennsylvania	25
Wisconsin	48

TABLE 6. Unemployment Rates(February 2003)
State	Unemployment Rates (%)
California	6.6
Massachusetts	5.3
North Carolina	5.8
Pennsylvania	6.2
Wisconsin	5.3
NOTE: The U.S. national unemployment rate in April 2003 was 6.0%.

TABLE 7. Median Hourly Wages for Home Health Aides and Nursing Assistants(2001)
State	Home Health Aide Median  Wage Per Hour ($)	Nursing Assistant Median  Wage Per Hour ($)
California	8.74	9.78
Massachusetts	10.35	11.13
North Carolina	8.06	8.64
Pennsylvania	8.81	9.82
Wisconsin	8.90	9.85
Average for 5 States	8.97	9.84

TABLE 8. Reports Available by State
State	Report(s)
California	Heinritz-Canterbury, J. (2002) Collaborating to Improve In-Home Supportive Services: Stakeholder Perspectives on Implementing California's Public Authorities. Report prepared by the Paraprofessional Healthcare Institute.
	The Quest for Caregivers: Helping Seniors Age with Dignity. (March 2001) Report prepared by the California Employment Development Department.
	The Hidden Health Care Workforce: Recognizing, Understanding, and Improving the Allied and Auxiliary Workforce. (July 1999) Report prepared by California Twenty-First Century Workforce Project.
Massachusetts	Eaton, S. (September 2001) Extended Care Career Ladder Initiative (ECCLI) Round II: Baseline Evaluation Report. Commonwealth Corporation.
	Frank, B. & Dawson, S. (June 2000) Health Care Workforce Issues in Massachusetts. The Massachusetts Health Policy Forum.
	Hams, M., et al. (Spring 2002) Health insurance access survey of direct-care workers in nursing homes and home-based care agencies in Boston, New Bedford/Fall River, including surveys of employees and of employers. Direct Care Workers Initiative and Paraprofessional Healthcare Institute.
	Massachusetts Division of Employment and Training. (2000) Unemployment rates down from one year ago in most area; Annual average rates also show decline. Press release 3/1/2000.
	Massachusetts Extended Care Federation. (October 2001) 2001 Employment Trends in Massachusetts Nursing Facilities. Massachusetts Extended Care Federation. [Published annually. Also available for previous years.]
North Carolina	Harmuth, S. (2002) The direct care workforce crisis in long-term care. North Carolina Medical Journal. March/April 2002. 63(2).
	Harmuth, S. (2002) Results of the 2002 National Survey of State Initiatives on the Long-Term Care Direct Workforce. Report published by the Paraprofessional Healthcare Institute and the North Carolina Department of Health and Human Services.
	Konrad T.R. & Morgan, J.C. (2002) Workforce Improvement for Nursing Assistants: Supporting Training, Education, and Payment for Upgrading Performance (WIN A STEP UP): Executive Summary. [http://www.aging.unc.edu/research/winastepup/execsummary.pdf]
	North Carolina Department of Health and Human Services. (January 9, 2002) Grant to help boost caregivers' retention, career options. [http://www.dhhs.state.nc.us/pressrel/1-9-02.htm]
	North Carolina Division of Facility Services. (September 2001) Results of a Follow-Up Survey to States on Career Ladder and Other Initiatives to Address Aide Recruitment and Retention in Long-Term Care Settings.
	North Carolina Division of Facility Services. (September 2000) Results of a Follow-Up Survey to States on Wage Supplements for Medicaid and Other Public Funding to Address Aide Recruitment and Retention in Long-Term Care Settings.
	North Carolina Division of Facility Services. (September 1999) Comparing State Efforts to Address the Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers.
	North Carolina Institute of Medicine. (January 2001) Long-Term Care Plan for North Carolina: Final Report. Submitted by the North Carolina Institute of Medicine Task Force on Long-Term Care to the North Carolina Department of Health and Human Services.
	Souza, C. & Welsh, P.G. (2002) The crisis in long-term care: Finding and retaining our direct care workers. North Carolina Medical Journal. March/April 2002. 63(2).
	University of North Carolina Institute on Aging. (1999 and 2002) Institute on an Aging Society [http://www.aging.unc.edu/infocenter/data/.html]
	Workforce Improvement for Nursing Assistants: Supporting Training, Education, & Payment for Upgrading Performance. (2002) [http://www.aging.unc.edu/research/winastepup/index.html]
Pennsylvania	Eaton, S.C. (April 1997) Pennsylvania's Nursing Homes: Promoting Quality Care and Quality Jobs. Report from the Keystone Research Center.
	Leon, J., Marainen, J., & Marcotte, J. (2001) Pennsylvania's Frontline Workers in Long-term care: the Provider Organization Perspective, the Polisher Research Institute, Philadelphia Corporation on Aging.
	Pennsylvania Association of Non-Profit Homes for the Aged. (1996) Long-Term Care Statistics and Information: Demographics on the Aging Population Long-Term Care Nursing Facilities Personal Care Homes Housing.
	Pennsylvania Intra-Governmental Council on Long-term care and the Polisher Research Institute. (February 2001) In Their Own Words: Pennsylvania's Frontline -- Workers in Long-term care.
	Pennsylvania Intra-Governmental Council on Long-term care and the Polisher Research Institute. (October 2002) In Their Own Words, Part II: Pennsylvania's Frontline -- Workers in Long-term care.
	Southwestern Pennsylvania Partnership for Aging. (January 2001) Direct Care Workers In Long-Term Care An Emerging Crisis.
Wisconsin	Community Links Program (Judy Zitske's presentation at the American Society on Aging annual meeting April 2001, New Orleans LA)
	Dresser, L., Lange, D., & Sirkus, Al. (March 1999) Improving retention of frontline caregivers in Dane county.
	WI LTC Workforce Alliance. WI LTC Worker Image Campaign.
	Wisconsin Association of Homes and Services for the Aging (WAHSA). (2001-2002) Image campaign.

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NATIONAL INITIATIVE TO IMPROVE THE RECRUITMENT AND RETENTION OF THE PARAPROFESSIONAL WORKFORCE IN LONG-TERM CARE REPORTS AVAILABLE

Measuring Long-Term Care Work: A Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes

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Pathway to the Future: How Workforce Development and Quality Jobs Can Promote Quality Care Conference Package

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Pathway to the Future: How Workforce Development and Quality Jobs Can Promote Quality Care--Symposium Summary

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Recent Findings on Frontline Long-Term Care Workers: A Research Synthesis 1999-2003

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State Wage Pass-Through Legislation: An Analysis

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State-Based Initiatives to Improve the Recruitment and Retention of the Paraprofessional Long-Term Care Workforce

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