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Expanding Long-term Care Choices for the Elderly

Recruiting & Retaining Workers


Robyn Stone, Dr.P.H., Executive Director, Institute for Policy Research, American Association of Housing and Services for the Aging, Washington, DC.

Patrick Flood, Commissioner, Vermont Department of Aging and Disabilities, Waterbury, VT.

Dr. Stone noted that paraprofessional long-term care (LTC) workforce shortages are of prime concern to State legislatures and urged using this crisis to develop the LTC system for the future. She asserted that many of the problems are related to society's negative attitudes toward LTC; a heavy focus on lawsuits, surveys, and regulations is driving workers away and keeping others from entering the field.

Frontline workers, such as nursing assistants, home care aides, and personal care workers, are the centerpiece of an LTC system. They provide care that is intimate, personal, and physically and emotionally challenging. They are the "eyes and ears" of the care system. The typical worker is a middle-aged, single mother with a low education level, living at or just above the poverty level. Large proportions are black, Asian, or Hispanic. Hourly wages are quite low, even for those at the top of their professions.

Inadequate staffing levels diminish quality of care at a time when more complex care is often required. Factors leading to this include fiscal cutbacks, increased demand, and labor shortages. Some organizations attempt to deal with this through temporary workers or single tasking (e.g., "feeders"); Dr. Stone noted that these solutions make no sense from a policy standpoint.

The paraprofessional workforce is often poorly trained and inadequately supervised. Core competencies, for example, interpersonal communication, clinically informed problem solving, and critical thinking, are missed. There are no incentives for ongoing training. These factors lead to a labor supply that is less qualified.

The consequences of inadequate staffing levels and poor training are:

  • Diminished quality of care.
  • High turnover.
  • Poor job quality.
  • Abuse and neglect.
  • Higher rates of injury to staff and clients.

Success in recruiting and retaining workers depends on a variety of interactive factors at different levels:

  • Demographics and economics.
  • Health and LTC policy, including reimbursement and regulatory/quality assurance issues.
  • Labor policy.
  • Immigration policies, especially in such states as New York, California, and Texas. (Dr. Stone noted that this has many unintended consequences for States, and that the potential for exploitation of the workers is extremely high.)
  • Workplace-level factors, such as organizing arrangements (goals, administrative policies, reward systems); social factors (management style, employee interactions, individual personalities); physical settings/environment; and technology (job design, training, clinical tools, and information systems).

There has been a paucity of research on frontline workers. Existing research has shown the following:

  • Local economic conditions have the strongest effect on turnover rates.
  • For-profit organizations report the highest turnover rates.
  • Homes in which nurses accept nursing assistants' advice or discuss care plans with them report significantly lower turnover rates.
  • Homes in which nursing assistants are involved in care-planning meetings reported much lower turnover rates.
  • The most important predictor of job satisfaction and nursing assistant turnover was a management style that allowed worker autonomy.
  • Less turnover occurs among nursing assistants (in nursing facilities [NFs]) who learned how to effectively juggle responsibilities and were given autonomy.
  • Workers need to feel personally responsible for work and receive feedback from supervisors.
  • Turnover rates are not affected by increases in aide training.
  • Turnover rates are not affected by greater nursing assistant involvement in resident assessments.

In one 18-month study on home care workers in five cities, the Ford Foundation subsidized the costs of salary increases, improved benefits, guaranteed service hours, and increased training and support. Although these improvements significantly reduced turnover rates, once the demonstration project was over, the publicly funded agencies reverted to their former practices.

Dr. Stone noted that this shows the need to get organizations invested and to build around that investment. For example, the WellSpring project in Wisconsin requires each participating assisted living provider to invest $2,000 per month to a pool; the pool is used to pay a geriatric nurse practitioner to manage and sustain the program. Dr. Stone also urged policymakers to seek to develop partnerships with foundations in order to leverage funds and to work with all stakeholders—Federal, State, local, providers, consumers, unions, educational institutions, religious and other volunteer organizations, and families—to develop innovations.

A study on State efforts to recruit and retain frontline workers found that 42 States consider aide recruitment/retention to be a major workforce issue, and 30 States have already taken action. The major activity is wage increase "pass-throughs," approved and implemented by 16 States using one of two methods:

  • Ten States use a set dollar amount for workers per hour or patient day.
  • Six States use a percentage of the increased reimbursement rate.

There is variation among State pass-through efforts. Nine States target home care aides only; four target NF aides only; three target both. Although the majority of States intend increases to be distributed equally across aides, some allow providers to determine which frontline staff will get the increase and what percentage is used for wages as opposed to benefits. No empirical evaluation has been done on the effect of these pass-throughs.

Other major State trends include:

  • Enhancement incentives (e.g., client satisfaction, level of provider accreditation).
  • Transportation reimbursement.
  • Nurse aide career ladders.
  • Nurse aide training levels.
  • Former welfare recipient training.
  • Expanding use of volunteers (Americorp, student volunteers, older adults).
  • State workgroups/task forces.

To deal with its workforce issues, Vermont began to shift the balance between NFs and community-based services in 1996. The State has developed a waiver program (Act 160) in which consumer- or surrogate-driven services are delivered within the home. This program:

  • Fosters consumer control.
  • Is cost-effective, with low administrative costs.
  • Provides high-quality care.
  • Helps ease staffing issues.
  • Supports both the individual and the family.

Eligibility criteria mandate that the consumer/surrogate must:

  • Have sufficient cognitive ability to direct care.
  • Have the ability to communicate orally, in writing, or with an assistive device.
  • Be able to recruit, hire, train, and supervise a worker.
  • Be able to manage time sheets and forms.

Case managers are employed by either the Area Agency on Aging or the home health agency serving the area. They determine eligibility, are responsible for ensuring that the worker is adequately trained, and are accountable for service quality. Case management is very intensive when a consumer/surrogate decides to join the program. The average caseload is between 10 and 20 clients.

Safeguards built into the program include:

  • Verification by the case manager that the consumer/surrogate is able and willing.
  • Review and approval by the regional waiver team.
  • Inability to hire from the State's abuse registry, determined when the State screens each proposed worker.
  • Examination of State criminal records.
  • Prohibition against employment of the spouse, parent of a dependent child, or the surrogate. (Note: The caregiver can live with the consumer, as long as he/she is not also the surrogate or spouse; this is viewed as adult foster care.)
  • Requirement for the case manager to see the consumer at least every 60 days.
  • As almost all consumers in this program receive some services from a home health agency, staff from that agency can also monitor his/her condition and circumstance.

The program is designed to be very consumer-friendly. The State uses a payroll agent to:

  • Process initial paperwork.
  • Process time sheets.
  • Pay withholding.
  • Maintain tax records.
  • Provide W-2s.

In the unit rate, the State pays for: salary, Federal and State taxes, unemployment, workers' compensation, and administrative fees. Workers are paid an average of $8.50 per hour, $1.00 more than home health agency staff. Patrick Flood explained the desire to put pressure on home health agencies to increase their staffs' salaries. Combined with an administrative fee, the unit rate equals $9.75/hour.

As the program has grown, so have estimated cost savings. In the $14 million program, the State estimates savings of more than $2 million in fiscal year 2000. Mr. Flood stated that savings are expected to increase.

The State's satisfaction survey among program participants found that:

  • Two-thirds were very satisfied, and one-third was satisfied. Mr. Flood noted that no one submitted negative comments.
  • The things people liked best about the program were: having reliable help (42 percent), control over hiring (31 percent), and knowing the personal care attendant (19 percent).
  • Seventy-one percent of participants found managing their caregivers easy; 19 percent found it very easy; 5 percent found it difficult.
  • Reasons for choosing to participate in the program included: lack of/inadequate home health staff (21 percent), control over who is hired (21 percent), higher personal care attendant wages (17 percent), recommended by case manager (17 percent), and already had a caregiver (13 percent).


Stone RI. Frontline workers in long-term care: challenges and opportunities for grantmakers. Washington (DC): Institute for Future of Aging Services; 2000 Apr.

Current as of September 2000

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Internet Citation:

Expanding Long-term Care Choices for the Elderly. Workshop Brief, September 11-13, 2000, User Liaison Program. Agency for Healthcare Research and Quality, Rockville, MD.

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