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5 The Direct-Care Workforce
Pages 199-240

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From page 199...
... While not all direct-care workers care for older patients, they work primarily in settings important in the care of older adults, such as nursing homes, assisted living facilities, and home-care settings. According to the Bureau of Labor Statistics (BLS)
From page 200...
... . Direct-care workers are more likely to live in poverty, to lack health insurance, and to rely on food stamps than other workers (GAO, 2001b)
From page 201...
... . Nurse aides are employed primarily in nursing homes but also work in other institutional settings, such as hospitals and assisted living facilities.
From page 202...
... Both nurse aides and home health aides provide a degree of clinical services (e.g., wound care) and work under the supervision of a registered nurse (RN)
From page 203...
... are typically personal- and home-care aides rather than home health or nurse aides. There is little to no federal regulation regarding the training or staffing requirements for assisted-living facilities; instead, each state regulates workers in these settings.
From page 204...
... Although there are a number of state and federal requirements for the education and training of nurse aides, home health aides, and personal- and home-care aides, these requirements are minimal (Table 5-4)
From page 205...
... Where possible, direct-care education and training issues that are particularly relevant to the older patient population are highlighted. TABLE 5-4  Education and Training Requirements for Direct-Care Occupations Nurse Aides, Orderlies, Personal- and and Attendants Home Health Aides Home-Care Aides Federal requirements of Per federal rules, if employer Dependent on state, with 75 hours of training (for receives Medicare/Medicaid some requiring no formal nurse aides)
From page 206...
... . Nurse aides working in Medicare- or Medicaid-certified nursing homes or home health agencies are required to successfully complete the following: • At least 75 hours of state-approved training by, or under the general supervision of, an RN with at least 2 years of experience in nursing and at least 1 year of experience in a long-term care environment (or in home health care for training of home health aides)
From page 207...
... Home Health Aides Home health aides must meet federal requirements only if their employer receives Medicare or Medicaid reimbursement. Specifically, home health aides in such institutions must pass a competency test that covers 12 subject areas (Box 5-2)
From page 208...
... , including effective communication and problem-solving. While no federal requirements exist for personal-care attendants who work outside a nursing home or home health agency, states may conduct checks on the background, training, supervision, age, health, and literacy of these service providers if they receive Medicaid reimbursements (OIG, 2006)
From page 209...
... A study of direct-care workers in Pennsylvania estimated annual recurring training costs due to turnover to be almost $24 million for nursing homes and almost $5 million for home health and home-care agencies (Leon et al., 2001)
From page 210...
... As can be seen in Table 5-6, female directcare workers are considerably less likely to have health insurance coverage than are female workers in general. This situation can vary dramatically by occupation and region, however.
From page 211...
... For example, approximately threefourths of nurse aides in nursing homes and home health settings have no pension benefits (GAO, 2001b)
From page 212...
... In 1996 the IOM recommended that all personnel who provide direct care (especially in nursing homes) should receive annual training in lifting and transferring patients.
From page 213...
... In nursing homes, nurse aides often have to manage heavy patient loads, which not only increases the burden placed on them but can also decrease the quality of care that they provide (Schnelle et al., 2004)
From page 214...
... may lead to improvements in the quality of patient care. For example, allowing nurse aides to have greater responsibility in care decisions is associated with higher social-engagement scores among patients, and lower rates of turnover and higher rates of retention have been associated with lower incidence of pressure ulcers (Barry et al., 2005)
From page 215...
... . Moreover, 58 percent of ombudsmen identified inadequate training as a major impediment to quality care in nursing homes, and CNAs rank inadequate training among the top three problems that they face (Hawes, 2002)
From page 216...
... . In fact, in residential settings such as assisted-living facilities, the level of staff training is a key factor in determining whether residents will need to be relocated to nursing homes as their needs become more acute (Maas and Buckwalter, 2006)
From page 217...
... Another area where training is inadequate is in palliative care; workers in both nursing homes and home-care settings are typically not well trained in the care of patients at the end of life (Ersek et al., 2006; Ferrell et al., 1998)
From page 218...
... Federal requirements for the minimum training of certified nursing assistants (CNAs) and home health aides should be raised to at least 120 hours and should include demonstration of competence in the care of older adults as a criterion for certification.
From page 219...
... THE DIRECT-CARE WORKFORCE 219 TABLE 5-7  Nurse Aide Training Requirements (by State) , 2007 Minimum Training Hours/ Hours State (Minimum Clinical Hours)
From page 220...
... . In seeking to find ways to increase wages for direct care workers in this environment, several mechanisms have been employed, including: setting a minimum service rate percentage that must to be passed through to direct-care labor costs; creating rate enhancements for providers that compensate their workers at a higher level; establishing automatic cost-of-living-adjustments to be passed through to direct-care labor costs; and establishing procurement and contracting standards that specify
From page 221...
... . According to a 2005 study, nine states had developed or were in the process of developing programs that would address the lack of health insurance among health care workers (Harmuth and Dyson, 2005)
From page 222...
... . Improving the Work Environment Besides pay and benefits, a number of other factors may increase job satisfaction among direct-care workers, such as participation in decisions related to care planning and workplace improvement, the availability of career advancement opportunities, and high-quality supervision.
From page 223...
... . Efforts to increase the involvement of direct-care workers in decision-making have also been linked to increased overall job satisfaction and, ultimately, decreased turnover.
From page 224...
... . PHI  Under its grant, PHI developed the Home Health Aide Registered Apprenticeship at five sites to help home health aides gain basic skills and develop skills for specialty areas, such as hospice and palliative care, geriatrics, dementia, and peer mentoring (DOL, 2008c)
From page 225...
... Similarly, having home health aides assume responsibility for medication administration from RNs could help decrease the need for RN visits to homes. If direct-care workers are to assume these increased responsibilities, they may in turn need to delegate certain of their own tasks.
From page 226...
... In its first year the program led to a 62 percent decrease in worker injuries at the nursing home, and, thanks to the improved safety, between 2000 and 2005 the nursing home reduced its workers' compensation insurance premiums by over $800,000. The nursing home's administrator commented that "a highly efficient and highly skilled workforce makes fewer mistakes, reduces exposure to liability, and keeps insurance premiums low" (OSHA, 2007)
From page 227...
... Men As described previously, the population of direct-care workers is overwhelmingly female (Montgomery et al., 2005; Smith and Baughman, 2007)
From page 228...
... . Additionally, more than half of employers for nursing homes and home health agencies said that older workers were more likely to be loyal employees and have desirable skills and less likely to leave the position.
From page 229...
... . Examples of Efforts to Improve Recruitment and Retention While some efforts to improve the recruitment and retention of directcare workers focus on a single strategy, other programs and organizations have developed a mixture of policy- and provider-based interventions.
From page 230...
... Under this initiative, the ETA is investing more than $46 million to address health care workforce shortages, particularly among long-term care workers (DOL, 2007)
From page 231...
... Later, in 2006, the National Direct Service Workforce Resource Center was created by CMS, and it continues to address the recruitment and retention challenges of direct-care workers by providing information, resources, and assistance to all relevant stakeholders (e.g., policy makers, researchers, employers, workers, and patients) involved in the provision of quality care to older adults at the state and local levels (CMS, 2008a)
From page 232...
... CONCLUSION Because direct-care workers provide the bulk of paid direct-care services for older patients in nursing homes and other settings, it is vitally important that the capacity of this segment of the workforce be enhanced in both size and ability to meet the health care needs of older Americans. However, the recruitment and retention of sufficient numbers of these workers is challenging due to serious financial disincentives and job dissatisfaction as well as high rates of turnover and severe shortages of available workers.
From page 233...
... Direct-care workers typically receive low wages and have limited access to other benefits, including health insurance. Economic incentives should be bolstered to improve the desirability of these jobs.
From page 234...
... 2007. Job satisfaction of nurse aides in nursing homes: Intent to leave and turnover.
From page 235...
... 2006. Evaluation of a train-the-trainer program to enhance hospice and palliative care in nursing homes.
From page 236...
... 2002. Health insurance access survey of direct care workers in nursing homes and home-based care agencies in Boston, New Bedford/ Fall River.
From page 237...
... 1996. Nursing staff in hospitals and nursing homes: Is it ad equate?
From page 238...
... 1998. Proposed mini mum staffing standards for nursing homes.
From page 239...
... 2006. Subsidizing health insurance coverage for the home care workforce in two Wiscon sin counties: An analysis of options.
From page 240...
... 2004. Self-managed work teams in nursing homes: Implementing and empowering nurse aide teams.


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