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Building a High-Quality Long-term Care Paraprofessional Workforce

Workshop Brief for State and Local Policymakers

This workshop was designed for State and local policymakers in the legislative and executive branches of government who are interested in strengthening the long-term care paraprofessional workforce and improving quality of care and patient safety. The workshop was held in Dallas, Texas, February 7-9, 2001.

About the Workshop Sponsor.



At the completion of this workshop, participants were expected to be better able to:

  • Recognize the scope and nature of problems related to the shortage of paraprofessional health care workers in long-term care (LTC) settings.
  • Discuss specific working conditions and job-design factors commonly found in LTC settings that may hinder efforts to attract workers.
  • Describe new models for delivering LTC services that emphasize professional development and training for paraprofessional workers.
  • Understand the factors affecting the quality of care and patient safety in LTC settings such as nursing homes.
  • Explain the importance of informal caregivers as part of the LTC workforce.
  • Describe State efforts to increase compensation for paraprofessional health care workers.
  • Provide examples of broad State strategies to strengthen the paraprofessional health care workforce.

Session Summaries

Scope of the Problem

Numerous factors contribute to the current shortage of direct care workers in LTC settings, and quick fixes to the problem are few. Issues related to the shortage of paraprofessional health care workers include the difficult working conditions, lack of career development opportunities, and pay levels that are no longer competitive. There are also supply and demand issues regarding lower wage workers who are willing to provide direct patient care and the high level of competition for these workers from other sectors.

Working Conditions

Meeting the needs of frail and elderly patients is often very physically and mentally demanding, whether in an institutional or home setting. Low job satisfaction among direct care workers contributes to recruitment and retention problems. Direct care workers have few opportunities to participate in professional growth activities such as continuing training or advancement. These issues drive higher turnover and impede retention of talented caregivers.

Transforming the Workplace

New models for nursing homes (such as Wellspring) are transforming the work environment and resulting in lower staff turnover and increased job satisfaction. The concept of a Caregiver Resource Center is being tested in Tucson, Arizona.

Quality & Safety

A report by the Institute of Medicine in 1996 found that there is a strong link between staffing in nursing facilities and the quality of patient care. Subsequent studies have found that staffing levels, working conditions, and worker satisfaction can all affect the quality of care and the safety of both patients and LTC workers.

Informal Caregivers

Family members and other "informal" caregivers (e.g., friends and neighbors) provide the majority of care to the elderly and chronically ill, often at great personal expense. As LTC workforce shortages increase with the aging of the baby-boom generation, informal caregivers will be under pressure to provide higher levels of care to friends and family members. State and local programs to support informal caregivers can help provide valuable assistance to these critical LTC providers.

Wages & Benefits

LTC paraprofessionals are among the lowest paid workers in the country. Increasing workforce shortages have placed pressure on health care organizations to increase wages and benefits for these workers, however, compensation remains very low, and many workers live below the Federal poverty level. Several States have implemented or are considering "wage pass-throughs" under Medicaid but find that full rate increases seldom end up in workers' paychecks.

State Strategies

Given the potential for staffing shortages to have an impact on the availability and quality of LTC services, at least 15 States have mandated data collection efforts or created task forces to address these issues. States and the private sector are attempting to overcome these challenges through many new initiatives, including demonstrations to encourage entry-level and ongoing training; development of career ladders; efforts to recognize and support the work of family and other informal caregivers; development of new models that increase recognition and support of workers by management; and public and private efforts to increase wages and benefits. States discussed include: Massachusetts, California, Vermont, and Minnesota.

AHRQ's User Liaison Program (ULP) disseminates health services research findings in easily understandable and usable formats through interactive workshops. Workshops and other support are planned to meet the needs of Federal, State, and local policymakers, and other health services research users, such as purchasers, administrators, and health plans.

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