Improving Quality and Availability
of Direct-Care Workers
a report prepared by Maine’s Work Group for Community-Based Living
Maine, like nearly every other state in the country, faces a serious and growing shortage of direct-care staff to meet the needs of persons with disabilities in both community-based and institutional settings. To reduce the shortage of direct-care staff for community-based services, we recommend that the State should:
Direct care workers are employed under many job titles: nurses aides, home health aides, home care aides, personal care aides, in-home service support workers, homemakers, behavioral specialists, mental health rehabilitation technicians, independent living skills specialists, crisis program workers, qualified mental health professionals, and educational technicians, among others. These staff provide basic and essential services and supports across the full range of disabilities including mental illness, developmental disabilities, physical disabilities, dementia, and the need for assistance with basic activities of daily living. These are the paid caregivers, who, along with unpaid relatives and friends, make it possible for many persons with disabilities to live at home or in other community settings, instead of in an institution.
Many direct-care staff find their work personally rewarding. However, direct-care work can often be physically strenuous, including turning, lifting, or physically supporting consumers. The work can also be emotionally challenging, and some of the tasks can be unpleasant.
Direct care staff are a fundamental key to the basic quality of life for the consumers they serve. The shortage or availability of direct-care staff is a key variable in the quality of care.
The Need — Not Just Numbers, But Turnover and Quality
Direct care work is a fast-growing field. Agencies and programs need
to keep creating more direct-care jobs to keep up with the growing need for
services. A recent survey of Medicaid agencies and State Units on Aging found
that 42 of the 50 states already consider hiring and keeping direct-care aides
to be a "major issue" (footnote 1). While
the hiring and retention of direct-care staff is considered a serious problem
in Maine, the state agencies that are responsible for services for persons with
disabilities, for the most part, do not collect data on the number of direct-care staff, the number of vacancies, staff turnover rates, or the average number
of days it takes to hire replacements for workers who leave the job.
In part, because our population is aging, demand for additional direct-care staff is growing quickly. The U.S. Department of Labor has found that "personal care and home health aides" is the seventh-fastest growing occupation in the nation. (footnote 2) They predict the number of new direct-care jobs will increase by an average of 5% every year between now and 2008.
However, the need to fill new jobs is not even half the problem. Most newly hired direct-care aides leave their jobs within the first year. Although there is no commonly accepted standard for measuring turnover, the annual turnover rates for all direct-care aides across the country are reported to vary from 21% to over 100%. A recent survey of 23 Maine mental health services agencies found the annual turnover rate for 2,000 FTE (full-time equivalency) direct-care staff positions averaged 29%. (footnote 3) That means that for every newly created direct-care job that programs need to fill, these same programs need to hire 4 to 20 or more persons to replace the workers who left. That means higher job advertising and hiring costs, higher training costs for agencies, and more stress and extra work for the direct-care workers who stay on the job. It also means lower quality of care for consumers who are cared for by a string of inexperienced strangers who don't stay long enough to learn the consumer's preferences and needs. New aides who are unfamiliar with a consumer’s disability, personality, and normal day-to-day condition may fail to recognize changes that would otherwise signal a need for serious attention. There is no single cause to the high turnover problem, and no single answer.
Several states across the country, including Pennsylvania, Ohio, Maryland, California and North Carolina have conducted one-time or on-going bi-annual surveys to measure healthcare and/or direct-care workforce supply and demand. The surveys collect data on the number of persons in various direct-care jobs, age of employees, number of students in training, numbers of vacant positions, vacancy rates across type of job and region, and average number of days to fill vacant positions. As an early step, we recommend that Maine conduct a similar survey of direct-care staff and employers across the full range of types of disability. The Legislature is considering a resolve, L.D. 1498, "to Require the Collection of Health Care Practitioner Workforce Data," by surveying licensed or registered health care staff as a condition of licensure or renewal. While the bill is primarily aimed at medical providers, it could be broadened to cover a wider array of direct-care staff. The survey would collect information on each provider's age, specialty, work setting, education, and activity status. It would also be useful to ask about the likelihood of remaining in the profession and reasons for staying or leaving.
The Legislature is also considering resolve L.D. 1346, "to Establish a Commission to Study the Health Care Workforce Shortage." While this bill is also focussed on nursing and other primarily medical professions, it too could be broadened to encompass direct-care staff for persons with disabilities. If created, this Commission could be charged with responsibility to conduct the kinds of surveys of health care staff and employers described above.
Members of the Work Group know from their own and from other’s personal experience that many of the people who currently do get hired to perform direct-care services lack the appropriate training, skills, trustworthiness, career dedication, and attitude to do the job properly, and that the situation won't change until the job itself is fundamentally redefined to become a more respected occupation.
Build Respect for the Profession
The problems of chronic high turnover and the challenge of filling
new positions won’t be solved until the job itself is defined and respected
as a professional occupation commensurate with teaching, social work, or nursing.
Enhancing the status of the direct-care profession will be a process, which
could involve some of the following approaches:
Improve Recruitment and Training
A 1997 survey of Maine nursing homes and boarding homes found that
79% of new Certified Nursing Assistants (CNAs) left within the first year. (footnote
4) Many newly hired aides leave before their training and orientation
are completed. Some people leave agencies shortly after being hired because
the work is not what they expected, or because the job interview process was
not structured to screen out persons whose work habits, abilities or attitudes
were unsuited for the job. Agencies that address these problems by putting more
thought and effort into the hiring and training process can achieve reduced
turnover rates, reduced overall training costs, and better quality of care and
support. Improving recruitment and training requires a plan, which could include:
Improve Wages and Benefits
Direct care jobs typically pay low wages and offer few, if any, benefits.
As Robyn Stone, a leading long term care researcher, wrote last year, "Paraprofessionals
are among the worst paid workers in the service sector." (footnote
5) Nationwide, most community-based direct-care staff work part-time
(footnote 6) due to a variety of factors, including
unreimbursed travel time, difficulty with childcare due to awkward work schedules,
and lack of motivation due to uncompetitive pay relative to the demands of the
job. In 1998, home health aides in Maine were paid a median hourly wage of $7.88,
while personal and home care aides were paid $7.34. (footnote
7) Even assuming a 40-hour workweek, both groups still earned less
than the 1998 Federal Poverty Level for a family of four (footnote
8), and less than two-thirds of the average annual salary for all Maine
workers.
According to a study of the federal Current Population Surveys for 1987-89, fewer than half (43%) of all home care aides across the U.S. received health insurance benefits at work. (footnote 9) More recent research suggests the proportion of home care staff earning health benefits may be below one-third. (footnote 10) Nationwide, in the late 1980's, only a quarter of all home care staff in America earned retirement benefits. (footnote 11) Direct care staff usually have to provide their own transportation to-and-from consumer's homes or community-based care sites, and the costs of that transportation are often unreimbursed. In short, most direct-care workers can often find other less challenging entry-level jobs at better wages and benefits, especially in the current climate of very low unemployment. (footnote 12) Employers of direct-care staff should be encouraged to improve wages and benefits as one method to reduce turnover and attract new employees to the field. We should also explore whether the creation of a statewide or regional direct-care staff association could lead to lower group rates for health insurance and other benefits. Since 1997, Rhode Island has allowed certified child care workers who serve children in state-funded programs to buy-in to the state's Medicaid managed care health insurance coverage at state-subsidized rates. The State could explore that option for extending health care benefits to direct-care staff in Maine.
Consumer-Directed Care Options
Consumer-directed care programs provide vouchers or cash grants to
consumers who then use the money to recruit, hire, train, and direct their own
staff, or to purchase other supports. Consumer-directed options expand the size
of the available work force because consumers often hire relatives, neighbors
and friends who would normally not enter the direct-care field. Therefore, some
of the direct-care staff shortage could be reduced by making consumer-directed
care options available to consumers across all types of disability.
There are many existing examples of consumer-directed care programs across
the country and in Maine, especially for persons with physical disabilities,
long term care needs, and developmental disabilities. Consumers with serious
cognitive impairments can often participate by way of a family member or friend
with power-of-attorney to make necessary decisions on their behalf.
Consumers who participate in these programs appreciate a greater degree of control
over their own lives and the opportunity to be served by people they know and
trust instead of having an agency send strangers into their homes. Among a sample
of 139 of Maine long term care consumers surveyed by phone in 2000, 93% of those
who had chosen a state-funded consumer directed care option were "very
satisfied" with their services, while only 56% of the consumers served
by traditional agency-based services within the Medicaid waiver programs for
the elderly and adults with disabitlies could say the same. (footnote
13)
There are important differences between consumer-directed care programs. Programs vary in their initial education and training requirements for consumer-participants. Some programs require the consumer to become the employer of record and to handle all the paperwork for payroll, withholding taxes and benefits. Some programs provide some or all of those services on every consumer's behalf, while others make those services optional at the consumer's choice. While consumer-directed care programs are thought to save states money, when compared to traditional agency-based services the full results of the first rigorous evaluation of consumer-directed care, the three-state Cash and Counseling program, will not be available until 2003. However, most states usually set the size of the month cash or voucher grants to a fixed percentage of the sum that would have been available for a consumer's care through a traditional agency. While consumer satisfaction with these programs is very high, there is a concern that the direct-care staff often earn a lower wage and are far less likely to receive benefits than the direct-care employees of traditional agencies.
Next Steps
Although beyond the scope of Maine’s responsibilities under the
Olmstead decision, consideration should be given to developing support
of the profession from private corporate and charitable sources. Such support
would not only contribute toward continued growth and stability of the profession,
but also potentially reduce the demand upon state and federal funding, while
still meeting essential human needs.
Summary
The current provision of home and community-based services for persons
with disabilities is already hampered by a shortage of direct-care staff, and
these shortages are likely to get worse in the absence of direct efforts to
reverse current trends. We recommend that the State should:
Footnotes: