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Building a High-Quality Long-term Care Paraprofessional Workforce

Transforming the Workplace


Terry L. Morrison, Director, Texas Wellspring Quality Improvement Project, Austin, TX.

Donna L. Hamby, M.S.N., R.N., N.P., Clinical Consultant, Texas Wellspring Quality Improvement Project, and Nurse Practitioner, Baylor Senior Health Network, Dallas, TX.

Judith B. Clinco, R.N., President, Direct Caregiver Association, Tucson, AZ.

In response to the critical need for qualified, trained, direct caregivers, new models of caring for the frail and elderly are emerging that transform the organizational culture of long-term care (LTC) settings.

The Texas Wellspring Quality Improvement Project began in April 1999, with four organizations:

  • The Texas Association of Homes and Services for the Aging (TAHSA).
  • Texas Health Care Association.
  • Wellspring Innovative Solutions, Inc.
  • The Texas Department of Human Services (DHS).

The project is an attempt to replicate the Wellspring model that originated in Wisconsin.

The Wellspring program is based on a continuous quality improvement model, utilizing:

  • Current best practices.
  • Data-driven decisionmaking.
  • Staff empowerment.

Developed by Wellspring Innovative Solutions, Inc., in Wisconsin, the program was formed in 1994 to improve quality and cut costs by implementing best practices. The original Wellspring group included 11 non-profit LTC facilities.

The Texas DHS involvement in the project stems from several efforts, including:

  • Evaluating service outcomes to determine need improvements.
  • Improving the quality of contracted nursing home services by developing client-specific outcomes to evaluate provider performance.
  • Working collaboratively with stakeholders to pilot new and innovative quality improvement strategies to better serve DHS clients.

DHS funding for the project came from recovered nursing home payments and legislation authorizing quality improvement projects with matching funds from participants.

The Wellspring model includes a nurse practitioner teaching seven clinical modules based on quality indicators to care resource teams. The care resource teams develop a module implementation plan that is reviewed by senior management, train facility staff, collect data, and evaluate implementation.

Morrison believes that the Texas Wellspring project is creating a paradigm shift among nursing home managers, workers, and patients. The model also involves:

  • Empowering staff.
  • Rethinking job descriptions, duties, and administrative roles.
  • Allowing more time for "care" in caregiving.

Though the project is still in its early stages, the model is showing a positive trend in its Quality Reporting System scores, which are based on HCFA quality indicators, survey scores, and investigations.

Another emerging model is the Caregiver Resource Center in Tucson, Arizona. Established in August 2000 as part of the Direct Caregiver Association, the Caregiver Resource Center addresses the needs of the general public, LTC providers, and direct caregivers. The Center is a collaboration primarily by LTC providers that reorganized their common problems with worker recruitment, retention, and limited training capacity. Sources of funding for the Caregiver Resource Center include:

  • Membership contributions.
  • Private and corporate donations.
  • State and local government.
  • Foundations and grants.

The Center provides:

  • Unbiased information and care options.
  • Workshops and seminars.
  • Support groups.
  • Resource materials for the general public.

For LTC providers, the Center provides:

  • Access to qualified direct caregivers.
  • Monthly in-service education for direct caregivers.
  • Seminars and workshops on best practices.

For direct caregivers, the Center also offers:

  • Comprehensive training.
  • Job placement.
  • Career counseling.
  • Ongoing support services.

The Caregiver Resource Center model has broad implications for strengthening the LTC paraprofessional workforce and improving the LTC system overall. Though the Center and similar organizations are operated as for-profit or not-for-profit entities, there is great potential for these organizations to partner with State and local governments to achieve a number of important objectives:

  • Ensuring that recipients receive the care and services they pay for.
  • Minimizing the possibility of abuse or exploitation.
  • Minimizing premature institutionalization.
  • Standardizing job titles and descriptions.
  • Increasing and standardizing training requirements.
  • Establishing certified training programs for formal and informal caregivers.


Greason N. Working to avert a caregiver crisis. Tuscon Citizen 2001 Jan; 22.

Morrison TL. Wellspring Program. Texas Journal on Aging 2000 Spr.

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