Your browser doesn't support JavaScript. Please upgrade to a modern browser or enable JavaScript in your existing browser.
Skip Navigation U.S. Department of Health and Human Services
Agency for Healthcare Research Quality
Archive print banner

This information is for reference purposes only. It was current when produced and may now be outdated. Archive material is no longer maintained, and some links may not work. Persons with disabilities having difficulty accessing this information should contact us at: Let us know the nature of the problem, the Web address of what you want, and your contact information.

Please go to for current information.

Building a High-Quality Long-term Care Paraprofessional Workforce

State Strategies


The Honorable Mark C. Montigny, Chairman, Senate Ways and Means Committee, Massachusetts State Senate, Boston, MA.

David Illig, Ph.D., Special Advisor, Office of Planning and Evaluation, California Health and Human Services Agency, Sacramento, CA.

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

LaRhae Knatterud, Director, Division of Aging, Minnesota Department of Health and Human Services, St. Paul, MN.

States are experimenting with a variety of ways to strengthen the paraprofessional workforce. Given the array of problems contributing to the current worker shortage, several States have developed comprehensive strategies that include:

  • Raising wages.
  • Recruitment initiatives.
  • Training initiatives.
  • Career ladders.

These States have demonstrated the need to pursue a range of initiatives and the importance of working across agencies such as Medicaid, welfare-to-work programs, and labor departments.


Chronic understaffing of certified nursing assistants (CNAs) and recruitment and retention difficulties are among the nursing home quality of care issues in Massachusetts. In response to these concerns, Senator Mark Montigny developed, in fiscal year 2001, legislation called "The Massachusetts Senate Nursing Home Quality Initiative," which addressed nursing home staffing issues in the Senate budget. The development of a coalition was key to this legislation. The coalition includes representatives from the nursing home industry and management, union and non-union CNAs, and advocacy groups.

Components of Massachusetts' Nursing Home Quality Initiative include the following appropriations:

  • Wage pass-throughs for CNAs ($35 million).
  • Career ladder grant program to nursing homes ($5 million).
  • Funding for CNA training, adult education, and job support for current and former welfare recipients ($1.1 million).
  • Scholarship program for CNAs ($1 million).

Initiatives that were originally included in the legislation but were subsequently vetoed include:

  • Statewide advisory board on quality of care in nursing homes.
  • Survey of health insurance for health care workers.
  • Consumer satisfaction survey for nursing home residents and their families.

Plans for this legislative session include:

  • Continuing the wage pass-through.
  • Addressing other health care workforce shortage and training issues.
  • Continuing to push for components of the initiative that were vetoed.


California initiatives include efforts to improve the knowledge of the paraprofessional market and address the needs of the paraprofessional workforce. Several of these initiatives have been implemented in the past 3 years, including:

  • Long-term Care Integration Pilot Program: Stemmed from 1996 legislation that established demonstration projects to integrate long-term care (LTC) and community-based care for the elderly and adults with disabilities in order to create a continuum of service options, align positive incentives, and end cost-shifting.
  • Long-term Care Council: Comprised of directors from departments related to some aspect of LTC. The council is charged with creating goals, objectives, and strategies for improving coordination of LTC services and community-based programs and services across departments.
  • CNA Workgroup: Interdepartmental and industry workgroup whose purpose is to identify options for improving work conditions and training for CNAs.
  • Aging with Dignity Initiative: Part of the 2000 Budget Act to help:
    • Seniors and disabled adults live more independently.
    • Improve the quality of care in nursing homes.
    • Improve the caregiver workforce.
    This initiative includes the following elements:
    • Workforce improvements include increased wages by means of wage pass-throughs and increases in the minimum wage.
    • A caregiver training initiative was also enacted, providing $25 million from the Federal Workforce Investment Act and Federal Welfare-to-Work grants for funding regional collaboratives to develop innovative ways to recruit, train, and retain LTC paraprofessionals. A separately funded evaluation includes a comprehensive market analysis to provide better information about practical career ladders for paraprofessionals, worker job movement, and forces affecting demand and supply of workers.
    • An outside actuarial study of MediCal reimbursement rates for LTC facilities is being conducted to determine the adequacy of these rates.

California also has an In-Home Supportive Services (IHSS) program. IHSS began in 1959 with State funding to provide support, such as personal care and general cleaning, to those who would otherwise be in LTC facilities. The program became consumer-directed in the early 1970s. Most IHSS clients directly hire their service provider who can be a friend, relative, parent, or child.


Vermont also has addressed the paraprofessional workforce issue. The State's 2.6-percent unemployment rate has created a tight competitive market in which LTC facilities are competing for workers in other service industries such as fast food. Vermont has needed to shift the balance of public expenditures for LTC, which have increased from 12 percent of community-based services to 22 percent since 1996.

Vermont's strategies to address the paraprofessional workforce shortage include:

  • Wage pass-throughs and wage increases.
  • Consumer-directed services that are cost-effective and more flexible.
  • Congregate housing services.
  • Changes in the culture of care, such as improving the quality of the environment, training and career opportunities, and direct care worker empowerment.
  • Establishing a task force and study that surveyed consumers, caregivers, and providers about work motivation and satisfaction, retention strategies, important benefits, and reasons for choosing a paraprofessional career. Survey results showed wages and benefits, training and career opportunities, and respect and empowerment as the most significant factors.


In response to growing LTC issues in Minnesota, an LTC task force was established in May 2000. The task force consisted of 12 legislators and the commissioners of the Departments of Health, Human Services, and the Housing Finance Agency. The goals of the task force were to:

  • Develop a common understanding of the needs and issues in LTC.
  • Reach agreement on best strategies.
  • Recommend proposals for the 2001 legislative session.

Minnesota's severe shortage of LTC workers is a result of:

  • Low unemployment rates.
  • Low wages.
  • Fewer young workers.
  • The perceived unattractiveness of the job.

The task force found that the LTC needs and preferences of Minnesota's consumers were changing and that the LTC system no longer met the preferences of older people. More than 25,000 direct care workers are required to meet the current demand for LTC services in Minnesota. This number is expected to increase to more than 45,000 by 2006.

Minnesota's strategies for developing a stable LTC workforce include:

  • Providing competitive wages and benefits.
  • Optimizing labor resources through the use of technology.
  • Cultivating creative recruitment of direct care workers, such as intergenerational programs and recognition awards.
  • Making training more responsive to the needs of LTC workers.
  • Preparing LTC workers to meet the changing needs of their customers.
  • Providing support for family caregivers.
  • Making available more consumer-directed care options.
  • Improving the ability of people to meet their own needs.


State of Minnesota Long-term Care Task Force 2000. Reshaping long-term care in Minnesota. Final report. St. Paul (MN). 2001 Jan.

Previous Section Previous Section       Contents                        

Internet Citation:

Building a High-Quality Long-term Care Paraprofessional Workforce. Workshop Brief, February 7-9, 2001. User Liaison Program. Agency for Healthcare Research and Quality, Rockville, MD.

The information on this page is archived and provided for reference purposes only.

AHRQ Advancing Excellence in Health Care