Who WillCARE for

Us?Addressing the Long-TermCare Workforce Crisis

Robyn I. Stonewith Joshua M. Wiener

The UrbanInstitute

Copyright © October 2001. The Urban Institute and the American Association of Homes andServices for the Aging. All rights reserved. Except for short quotes, no part of this book may be repro-duced or utilized in any form or by any means, electronic or mechanical, including photocopying,recording, or by information storage or retrieval system, without written permission from the UrbanInstitute and the American Association of Homes and Services for the Aging.

The Urban Institute is a nonprofit, nonpartisan policy research and educational organization thatexamines the social, economic, and governance problems facing the nation. The American Associationof Homes and Services for the Aging represents 5,600 not-for-profit providers committed to advanc-ing a healthy, affordable, ethical long-term care system for America.

Financial support for this paper was provided by the Office of Disability, Aging, and Long-Term CarePolicy, Office of the Assistant Secretary for Planning and Evaluation, U.S. Department of Health andHuman Services, and by The Robert Wood Johnson Foundation. The views expressed in this paperare those of the authors and do not necessarily represent those of the Urban Institute, its trustees, orits funders; the American Association of Homes and Services for the Aging; the U.S. Department ofHealth and Human Services; or The Robert Wood Johnson Foundation.

I N T R O D U C T I O N 2

Executive Summary 3

The Long-Term Care Frontline Workforce 3

What Is the Problem? 3

Factors Affecting the Supply and Quality of Workers 4

Public and Private Efforts to Develop a Qualified, Stable Frontline Workforce 5

I N T R O D U C T I O N 8

Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis 9

The Long-Term Care Frontline Workforce 10

The Long-Term Care Worker Problem: Definition and Magnitude 12

Factors Affecting the Supply and Quality of Frontline Workers 16

Health and Long-Term Care Policy 18

Public and Private Efforts to Develop a Qualified, Stable Frontline Workforce 25

Developing Policy through a Research and Demonstration Agenda 33

References 35

A B O U T T H E A U T H O R S 39

Contents

The paraprofessional long-term care workforce—

nursing assistants, home health and home care aides, per-

sonal care workers, and personal care attendants—forms the

centerpiece of the formal long-term care system. These front-

line workers provide hands-on care, supervision, and emotional

support to millions of elderly and younger people with chronic ill-

ness and disabilities. Low wages and benefits, hard working condi-

tions, heavy workloads, and a job that has been stigmatized by society

make worker recruitment and retention difficult.

I N T R O D U C T I O N

Executive Summary

3

L ong-term care providers report unprecedented vacancies and turnover rates for para-professional workers. Increasingly, the media, federal, and state policymakers andthe industry itself are beginning to acknowledge the labor shortage crisis and its

potentially negative consequences for quality of care and quality of life. These shortagesare likely to worsen over time as demand increases. This paper, developed with supportfrom the Office of the Assistant Secretary for Planning and Evaluation in the U.S.Department of Health and Human Services and the Robert Wood Johnson Foundation,provides a broad overview of the long-term care frontline workforce issues.

The Long-Term Care Frontline Workforce

Most paid providers of long-term care are paraprofessional workers. After informal care-givers, these workers are the most essential component in helping older persons andyounger people with disabilities maintain some level of function and quality of life.According to recent U.S. Bureau of Labor Statistics (BLS) data, nursing assistants heldabout 750,000 jobs in nursing homes in 1998, while home health and personal care aidesheld about 746,000 jobs in that same year. Like informal caregivers, the overwhelmingmajority of frontline long-term care workers are women. About 55 percent of nursingassistants are white, 35 percent are black, and 10 percent are Hispanic. Most workers arerelatively disadvantaged economically and have low levels of educational attainment.While these paraprofessional workers are engaged in physically and emotionally demand-ing work, they are among the lowest paid in the service industry, making little more thanthe minimum wage. National data on the number of workers with health benefits is lack-ing, but state and local studies suggest the rate of uninsurance is high.

What Is the Problem?

The severe shortage of nursing assistants, home health and home care aides, and otherparaprofessional workers is the primary trend influencing the current wave of concernabout the long-term care workforce. National data on turnover rates show wide varia-tion, depending on the source of the data: One source suggests that turnover rates

average about 45 percent for nursing homes and about 10 percent for home health programs, while other dataplace average annual nursing home turnover at over 100 percent a year. High rates of staff vacancies andturnover have negative effects on providers, consumers,and workers: The cost to providers of replacing workersis high; quality of care may suffer; and workers in under-staffed environments may suffer higher rates of injury.

The future availability of frontline workers does notlook promising. There will be an unprecedented increasein the size of the elderly population as the “baby boom”generation ages. BLS estimates that, in response to thisrising demand, personal and home care assistance will bethe fourth-fastest growing occupation by 2006, with adramatic 84.7 percent growth rate expected. The num-ber of home health aides is expected to increase by 74.6 percent and that of nursing assistants by 25.4 per-cent. While these projections suggest that the demandfor workers will increase, the actual number of jobs maybe tempered by the rate of economic growth and theextent to which purchasers are willing or able to pay. Atthe same time, as baby boomers approach old age, thepool of middle-aged women who have traditionally pro-vided care will also be substantially smaller. Finally, withvery low population and labor force growth, even a “nor-mal” business cycle recession would likely yield only amodest increase in the number of unemployed whocould become part of a frontline worker pool.

Factors Affecting the Supply and Quality of Workers

The success of efforts to recruit, retain, and maintain along-term care workforce is dependent on a variety ofinterdependent factors. One important influence onindividuals’ decisions to enter and remain in the long-term care field is how society values the job. Frontlineworker jobs in long-term care are viewed by the publicas low-wage, unpleasant occupations that involve pri-marily maid services and care of incontinent, cognitivelyunaware old people. This image is exacerbated by mediareports that feature poor quality care by providers.

Conditions in the labor market are also importantinfluences on the decision to join the long-term careworkforce. Several studies have identified the strength ofthe local economy as a major predictor of turnover ratesin long-term care. A study conducted in North Carolinafound that fewer than half the individuals trained as

nursing assistants in that state over the last decade werecurrently certified to work in that occupation, with most“leavers” working at higher-wage jobs.

Health and long-term care policies also significantlyaffect workforce recruitment and retention. Medicareand Medicaid account for almost three-fifths of long-term care expenditures and therefore play a substantialrole in determining provider wages, benefits, and train-ing opportunities. Regulatory policy on long-term carefocuses primarily on protecting consumers, rather thanon responding to workers’ concerns. Regulation tends toemphasize entry training, with limited attention to con-tinued career growth or development. One major policyissue for workforce development is the extent to whichstates allow nursing assistants to perform certain taskscurrently performed by nurses (e.g., administering med-ications or providing wound care). Giving frontlineworkers added responsibility and autonomy may moti-vate them to remain in the job or encourage others toseek these positions. Program design features, such aswhether consumer-directed home care is provided, canalso affect the size of the labor force by making it easy orhard for relatives and friends to be paid for careprovided.

Labor policy plays an important role in determiningthe size of the pool of frontline long-term care workers.The federal government invests more than $8 billionannually to prepare primarily low-income and unem-ployed individuals for new and better jobs. Ironically,state and federal employment agencies indirectly preventthe long-term care industry from participating in train-ing support programs by requiring that program grad-uates secure wages that are higher than typical frontlineworker salaries. While these policies are designed to pro-tect trainees from being shunted into poverty-level jobs,they essentially preclude graduates from entering theparaprofessional long-term care labor force. The federalWork Investment Act of 2000 does not include the samerequirements, but the effects of the new law are unclear.

Federal welfare initiatives are particularly relevant tothe development of this workforce. The federal PersonalResponsibility and Work Opportunity ReconciliationAct of 1996 (PRWORA) created the Temporary Assis-tance for Needy Families (TANF) program, whichreplaced the cash welfare system with a new block grantprogram and provides flexibility to states in developingjob opportunities. Many states follow a “work first” strat-

4

WhoWill Care

for Us?

egy that discourages skill-based training; although suchpolicies are designed to get recipients into the workforce, they conflict with federal nursing home and homehealth aide training requirements.

Given the current labor shortage and gloomy projec-tions about the future pool of workers, many providershave expressed interest in immigration as a tool forexpanding the potential labor pool. But immigration oflow-wage workers would have to substantially increaseto keep pace with population aging and new long-termcare demands. Policymakers must recognize that havinglow-skilled immigrants fill entry-level jobs inthe long-term care industry wouldlikely mean a sharp cultural dis-continuity between the clientand the caregiver.

The confluence of theabove factors and individ-ual employer and em-ployee decisions areplayed out in the work-place. Organizationalarrangements, socialfactors, physical set-ting, and environmentand technology allaffect the successful de-velopment of the front-line workforce. A review ofthe literature reveals that littleempirical research on workplaceinterventions has been done. Mostof the research has been conducted innursing homes and tends to be descriptive,rather than analytical, describing various manage-ment/job redesign efforts, training activities, and finan-cial and nonmonetary reward programs. In the 1980s,several small, qualitative studies of nursing assistantsidentified the organization’s management style (e.g.,supervisors with “good people skills,” promotion ofworker autonomy) as the most important predictor ofhigher job satisfaction and lower turnover rates. A laterstudy examined factors determining nursing assistantturnover, and found that local economic conditions hadthe strongest effects on turnover rates. One of the latterstudy’s most important findings was that homes inwhich nurse supervisors accepted nursing assistants’

advice or simply discussed care plans with the aidesreported turnover rates that were one-third lower thanthose without these practices. Other studies have under-scored the importance of including nursing assistants incare planning and providing feedback to help assistantsunderstand the connection between interventions andresident outcomes.

Research on home care workers has been more diffi-cult to conduct because it must be carried out in indi-vidual homes. The most comprehensive study of homecare worker satisfaction and turnover, conducted over a

decade ago, assessed the impact of salaryincreases, improved benefits, guaran-

teed number of service hours, andincreased training and support

on worker retention. In theaggregate, the interventions

reduced turnover rates by11 to 44 percent. Thestudy found that whilefinancial rewards wereimportant to workersatisfaction, motiva-tion, and retention, jobqualities such as good

personal relationshipsbetween management

and workers and betweenthe worker and the client

were more important. Disap-pointingly, when research fund-

ing terminated, agencies reverted totheir former practices.

Public and Private Efforts to Develop a Qualified, Stable Frontline Workforce

As noted previously, recruiting and retaining frontlinelong-term care workers have become a priority for manystates. State initiatives have included the followingoptions:

� Establishing “wage pass-throughs,” in which a statedesignates some portion of a public long-term careprogram’s reimbursement increase to be used specifi-cally to increase wages and/or benefits for frontlineworkers.

5

WhoWill Care

for Us?

� Increasing worker fringe benefits, such as healthinsurance and payment for transportation time.

� Developing career ladders by establishing additionaljob levels in public programs, training requirements,or reimbursement decisions.

� Increasing and improving training requirements.� Developing new worker pools, including former wel-

fare recipients.� Establishing public authorities to pro-

vide independent workers andconsumers ways to addressissues about wages and bene-fits, job quality, and secu-rity.

Providers, too, areexperimenting with arange of interventions.The literature containsnumerous descriptionsof programs in nursinghome and home caresettings that haveattempted to addressrecruitment and reten-tion (although few suchprograms have beenevaluated). For example,the “Pioneer Homes”approach to changing nurs-ing home culture does notfocus specifically on recruitingand retaining workers, but it tries tolink the facility to the outside worldand create a community: Plants and ani-mals abound, children interact with residents,and workers are respected as an essential part of the careteam. Evaluations of this model have not been com-pleted.

The Wellspring model of quality improvement isanother approach to changing nursing home workplaceculture. Wellspring is a consortium of 11 freestandingnursing homes whose top management have made aphilosophical and financial commitment to a contin-uous quality improvement initiative. The three-prongedapproach includes intensive clinical training, periodic

analysis of outcomes data to monitor quality, and a man-agement change/job redesign effort, in which nursingassistants become essential members of care teams andare empowered to make certain decisions.

Cooperative Home Care Associates, a worker-ownedcompany located in New York, Boston, and Philadelphia,is staffed overwhelmingly by former welfare recipients.

After three months’ employment, a worker canpurchase shares in the company. Wages are

higher than the average for home careaides, and workers receive fringe

benefits as well as guaranteedhours. Workers are encouraged

to advance their careers andearn higher pay and status asassociate trainers or byassuming administrativepositions.

Many frontline long-term care workers havedeveloped their own ini-tiatives to improve theirstatus, compensation,and job opportunities.These include the IowaCaregivers Association,

the National Network ofCareer Nursing Assistants,

and the Direct Care Al-liance. Unions, particularly

the Service Employees Interna-tional Union (SEIU), have made

major inroads in organizing bothnursing home and home care workers

in selected states across the country.

Developing a Research and Demonstration Agenda

This broad overview of long-term care frontline workerissues has identified a number of knowledge and infor-mation gaps that need to be addressed to further thedevelopment of a qualified, sustainable workforce: Weneed a better understanding of the sources of the prob-lem, the effects of policy interventions, and which ele-ments in different approaches succeed and fail . We needan updated profile of the frontline workforce in all long-

6

WhoWill Care

for Us?

term care settings that describes their demographiccharacteristics, wages and benefits, geographic distribu-tion, levels of education, and health literacy. Policy-makers need to better understand the magnitude of thelong-term problem so that they are more motivated indeveloping this workforce, the barriers to doing so, andthe possible consequences of different policy interac-tions. Research is needed to assess state strategies’ effec-tiveness at ameliorating the short-term crisis, as well asto determine whether such strategies as wage pass-throughs could be replicated successfully. Finally, weneed to develop and test creative ways of developingnew pools of workers to meet the demand for servicesin the future.

Federal and state agencies and private foundationshave begun to invest in applied research that will helpprovide some solutions. The U.S. Department of Healthand Human Services’ Office of the Assistant Secretaryfor Planning and Evaluation (ASPE) is collaboratingwith the Robert Wood Johnson Foundation to developa research and demonstration agenda on this issue, andother private foundations and agencies of the federalgovernment are also supporting similar research efforts.

The future of the frontline long-term care worker is,in many ways, a barometer for the health of our agingcommunities. Stakeholders at the federal, state, and locallevels and in the public and private sectors must cometogether to find creative solutions to this problem.

7

WhoWill Care

for Us?

The paraprofessional long-term care workforce—

nursing assistants (NAs), home health and home care

aides, personal care workers, and personal care attendants—

forms the center of the formal long-term care system. These

frontline workers provide hands-on care, supervision, and emo-

tional support to millions of people with chronic illnesses and dis-

abilities, and work in a variety of settings, including nursing homes,

assisted living and other residential care settings, adult day care, and

private homes. The care they provide is intimate and personal. It is also

increasingly complex and frequently both physically and emotionally

challenging. Because of their ongoing, daily contact with the care

recipient and the relationships that often develop between the worker

and the client, these frontline workers are the “eyes and ears” of the

care system. In addition to helping with activities of daily living,

such as bathing, dressing, toileting, eating, and managing med-

ication, these workers provide the personal interaction that is

essential to quality of life and quality of care for chronically

disabled individuals.

I N T R O D U C T I O N

9

Who Will Care for Us?Addressing the Long-Term CareWorkforce Crisis

L ow wages and benefits, hard working conditions, heavy workloads, and the stigmaattached to long-term care jobs make recruitment and retention of workers difficult,even when unemployment rates are high. While concerns about this workforce have

varied over the past two decades (Crown et al. 1992; Bayer et al. 1993; Atchley 1996;and Wilner and Wyatt 1998), there is growing concern about the current and future sup-ply of long-term care paraprofessionals, in large part because of the very strong economy(Rimer 2000; Stone 2000). Indeed, many observers refer to the the current difficulty ofattracting workers as a crisis.

Estimates of turnover rates for NAs working in nursing homes range from 45 percentto 105 percent, depending on the source. Estimates of home care worker turnover arelower, although anecdotal evidence points to great variation across agencies and amongindependent providers (AHCA 1999; Burbridge 1993; MacAdam 1993; Crown et al.1995). As higher-paying jobs with better working conditions have opened up for womenwho have typically worked in nursing homes or home care, long-term care workers havebecome increasingly hard to find. With the national unemployment rate falling to 4.1 percent in May 2000 (BLS 2000), recruitment and retention problems are likely topersist. Finding qualified, committed NAs or home care aides has become a second-orderpriority, as many nursing homes, residential care providers, home care agencies,community-based care organizations, and families look for anyone available to providefrontline care.

Issues related to frontline long-term care workers have historically received little atten-tion from policymakers, researchers, and the general public. Recently, however, the mediahas begun to document the crisis status of this labor shortage, underscoring its potentialnegative effects on quality of care and quality of life. Policymakers at the federal and statelevels are also beginning to acknowledge this problem. Officials from 42 states respond-ing to a 1999 national survey on long-term care workforce issues identified recruitmentand retention of frontline workers as a major priority, and those from 30 states reportedengaging in a workforce initiative (NCDFS 1999).

Difficulty in recruiting nursing and home healthaides is likely to become worse as the number of peopleneeding long-term care increases relative to the numberof people between ages 20 and 64, who make up most of the workforce. Between 1998 and 2008, BLS estimates there will be 325,000 more nursing assis-tant and 433,000 more personal care and home healthaide jobs (BLS 2000), but there is little evidence thatthere will be enough people to fill them. Reflecting the growing emphasis on provision of long-term care at home or in alternative residential settings rather than institutions, total employment in nursing homesis projected to grow less quickly than in home and community-based settings. A sharp economicdownturn could end the current worker shortage, butthe long-run demographic imbalance between thedemand for and supply of workers will only worsen overtime.

This paper provides a broad overview of the issuesaffecting the long-term-care frontline workforce. Thefirst section provides a profile of the workers anddescribes the nature of their jobs across the continuumof long-term care settings. That section is followed by adiscussion of the urgency and magnitude of the prob-lem from both short- and long-term perspectives. Weunderscore the need to address the immediate crisisrelated to the shortage of workers, as well as the moresystemic problem of developing a qualified, committed,stable frontline workforce. The third section reviews thefactors influencing the supply and quality of frontlineworkers. At the macro level, these include how societyviews this occupation, the status of the economy, andpolicies affecting health and long-term care, labor,welfare and immigration. At the micro level, factorsaffecting the supply and quality of frontline workersinclude organizational arrangements, social factors,environmental characteristics, and technology. In thefourth section, we identify public and private sectorefforts to increase the supply of frontline workers and todevelop a qualified, sustainable workforce. The fifthsection outlines a research and demonstration agendathat will help inform the development of policies and programs to ensure the availability of a trained,committed, and caring pool of frontline workers in the21st century.

The Long-Term-Care Frontline Workforce

The Long-Term Care System

Long-term care encompasses the broad range of types ofhelp with daily activities that chronically disabled peopleneed for prolonged periods of time. These primarily low-tech services are designed to minimize, rehabilitate, orcompensate for loss of independent physical or mentalfunctioning, and include assistance with basic activitiesof daily living (ADLs) such as bathing, dressing, eating,or other personal care. Services may also help withinstrumental activities of daily living (IADLs), includinghousehold chores, such as meal preparation and clean-ing, and life management, such as shopping, medicationmanagement, and money management. The servicesinclude hands-on and stand-by or supervisory assistance.Long-term care also encompasses social and environ-mental needs and is therefore broader than the medicalmodel that dominates acute care (Stone 2000).

Long-term care is provided in a range of settings,depending on the recipient’s needs and preferences, theavailability of informal support, and the source of reim-bursement. Among the care silos that have been createdprimarily by reimbursement policy, the nursing home(or nursing facility, as it is referred to by Medicare andMedicaid) is the major institutional setting for long-term care. In 1996 there were 16,840 nursing homes in the United States, for a total of 1.8 million beds(Rhoades and Krauss 1999). Approximately 13 percentof these facilities had Alzheimer’s special care units,which accounted for 73,400 beds. An additional 28,500beds were located in distinct rehabilitation and/or sub-acute special care units.

“Home and community-based care” is a catchallphrase that refers to a wide variety of noninstitutionallong-term care settings, ranging from various types ofcongregate living arrangements to individuals’ ownhomes. The boundaries between institutional and non-institutional environments are far from clear. Manyassisted living and board and care facilities are largebuildings that strongly resemble nursing homes or hotelsin physical appearance and philosophy. Other residen-tial care sites are small and homey, offering privacy andchoice to residents. In contrast to nursing homes, whichare licensed and regulated by the federal governmentbecause they receive significant Medicare and Medicaid

10

WhoWill Care

for Us?

reimbursement, states and local jurisdictions are largelyresponsible for the licensing and regulation of residentialcare. Consequently, there is no consensus on the defini-tion of “residential care” or on the number of facilitiesnationwide. One recent national study of assisted livingreported that there were 11,472 facilities, with approx-imately 650,500 beds, in 1998 (Hawes et al. 1999). A1991 study estimated that there were 28,188 licensedboard and care homes, serving over 500,000 people(Clark et al. 1994). These data, however, underestimatethe total board and care population, as the number ofunlicensed facilities is unknown.

Other community-based settingsinclude adult day care, in whichdisabled elderly individualsreceive supervision, personalcare, social integration, andcompanionship in a groupsetting, usually duringthe workweek from nineto five. Most long-termcare users live at home,either in their ownhomes (with or withouta spouse), or in the homeof a close relative.

The long-term carepopulation is diverse interms of age and level of dis-ability. Of the estimated 12.8million Americans reporting long-term care needs in 1995, as measuredby the need for assistance with ADLs orIADLs, 57 percent were over the age of 65. Another 42 percent were younger adults, and 3 percent were chil-dren (National Academy on Aging 1997). Family andfriends (i.e., unpaid caregivers) are the major providersof long-term care. Nearly 75 percent of people ages 18to 64 receiving long-term care assistance in the commu-nity (i.e., outside of nursing homes) rely exclusively onunpaid caregivers; only 6 percent of the younger disabledrely exclusively on paid services. Another 138,000 per-sons ages 18 to 64 reside in nursing homes (Tilly et al.2000). Similarly, about 60 percent of the 3.9 millionelderly receiving long-term care in the community relyexclusively on unpaid caregivers, primarily spouses and

children; only 7 percent rely solely on paid services.About 1.4 million older persons reside in nursing homes.

Over the past decade, the nursing home populationhas become older and more severely disabled. In 1996,83 percent of the residents had three ADL limitations,compared to 72 percent in 1987 (Rhoades and Krauss1999). These residents are also more likely to be cogni-tively impaired (Spillman et al. 1997). Elderly personsreceiving long-term care in the community report lowerlevels of disability than those in nursing homes, with ap-proximately 17 percent reporting limitations in three or

more ADLs (Alecxih 1997).

Profile of Frontline Workers

Most paid providers of long-term care are parapro-fessional workers. Afterinformal caregivers, theseworkers are the key tohelping older personsand younger peoplewith disabilities main-tain some level of func-tion and quality of life.

According to recent BLSstatistics (2000), NAs held

about 750,000 jobs in nurs-ing homes in 1998, and home

health and personal care aidesheld about 746,000 jobs. This fig-

ure underestimates the total number ofhome care workers, since many aides are

hired privately and may not be included in official fed-eral statistics. According to a study of independent homecare workers in California, for example, the stateemploys more than 200,000 workers through its In-Home Supportive Services (IHSS) program, 72,000 inLos Angeles County alone (Cousineau 2000). In theirnational study of home care workers providing assistanceto the Medicare population, Leon and Franco (1998)found that 29 percent of the workers were self-employed.

As is true with informal caregivers, most frontlinelong-term care workers are women. According tonational data on this work force from 1987 through

11

WhoWill Care

for Us?

1989 (Crown 1994), an estimated 93 percent of NAsand home care workers were female. A 1995 survey ofhome care workers reported that 96 percent of thoseemployed by agencies—and 100 percent of the self-employed—were female (Leon and Franco 1998).Crown (1994) estimated that almost 7 out of 10 work-ers were white; 27 percent of the NAs and 29 percent ofhome care aides were black. More recent data from BLS(1999) indicate that 35 percent of NAs are black and 10 percent are Hispanic. There is also significant geo-graphic variation in the racial profile of frontline work-ers. A recent study of home care workers participating inCalifornia’s IHSS program found that 32 percent of theagency workers and 41 percent of the independentproviders (including paid family caregivers) were white(Benjamin et al. 2000). Forty-five percent of the agencyworkers and 30 percent of the independent providerswere Hispanic; comparable estimates for black workerswere 15 percent and 20 percent, respectively.

Most of these frontline workers are relatively dis-advantaged economically. According to data from thelate 1980s, they tend to have low levels of educationalattainment: Approximately 25 percent of NAs and 38 percent of the home care workers had not completedhigh school (Crown et al. 1994). Median earnings forNAs and home care aides in the late 1980s were $9,000and $5,200, respectively, and many current workers liveat or below the poverty level. Many are also jugglingwork and family responsibilities: 50 percent of the NAsand 33 percent of the home care workers, for example,have children under the age of 18.

While long-term care providers are engaged in workthat is physically and emotionally demanding, theiroccupation is among the lowest paid in the service indus-try. Paraprofessionals in nursing homes, home care, andother long-term care settings tend to make little morethan the minimum wage (BLS 2000). In 1998, medianhourly wages for NAs working in nursing and personalcare facilities were $7.50; for those working in residen-tial care, the rate was $7.20 per hour. The lowest 10 per-cent earned less than $5.87 and the highest 10 percentearned a little more than $11.33. The median hourlywage for home health aides in 1998 was $7.20; for per-sonal and home care aides, it was between $6.00 and$7.00, depending on the job category. The lowest 10 percent of these workers earned less than $5.73 perhour and the highest 10 percent earned a little more than

$10.51 per hour. In the study of California’s IHSS work-ers that Benjamin et al. (1998) conducted, the meanhourly wage for agency workers was $6.22; for client-directed, independent providers, it was $4.79.

Information on the proportion of workers nationallywith benefits such as health insurance and sick leave is notavailable. The most recent national profile of frontlineworkers, which used data from the late 1980s (Crown etal. 1995), indicated that 28.5 percent of NAs and 38.9 percent of home care workers had no health insur-ance coverage. Independent workers and those employedby small residential care providers or home care agencieswere less likely to receive this benefit. It is not clear, how-ever, whether this coverage applies only to full-time work-ers and how much the employer actually contributes. Ifthe employee’s share of the premium cost is too high,workers generally opt out of the benefit (Wilner andWyatt 1998). Cousineau (2000) found that 45 percent ofthe 72,000 independent home care workers hired throughthe IHSS program in Los Angeles are uninsured. Two-thirds work at least 25 percent time, and 10 percent workfull-time or more. One in three workers maintain one ormore jobs in addition to the IHSS position.

The Long-Term Care Worker Problem: Definition and Magnitude

The severe shortage of NAs, home health and home careaides, and other paraprofessional workers is the primarycause of concern about the long-term care workforce.Various media reports have underscored the inability ofnursing homes, residential care providers, home careagencies, community-based organizations, and individ-uals and their families to find workers. According torecent anecdotes (Rimer 2000), some frustrated pro-viders and families are willing to give up the search forquality employees as long as they can find people to fillthe positions. This crisis is not limited to the UnitedStates. It is a global problem, particularly in the Euro-pean Union and Japan, where the proportion of the pop-ulation that is elderly is much higher than in the UnitedStates (Christopherson 1997).

While this crisis has received significant attention overthe past six months, the phenomenon is not new. In fact,during the late 1980s, tight labor markets in many com-munities created significant worker shortages that cat-alyzed policy debate, state and provider initiatives, and

12

WhoWill Care

for Us?

several seminal research activities, including the devel-opment of the first national profile of the paraprofes-sional workforce (Crown 1994; Crown et al. 1995). Thistime, however, there is growing recognition that an eco-nomic downturn will not solve the problem. Demo-graphic, economic, and policy trends suggest thatwithout serious intervention, the inadequate supply offrontline workers will remain a problem that couldworsen over the next few decades.

The problem, however, is not simply one ofsupply. The more fundamental, long-termdilemma is how to develop a commit-ted, stable pool of frontline workerswho are willing, able, and preparedto provide quality care to peoplewith long-term care needs. Boththe short- and long-term prob-lems must be addressed if we are to design qualitysystems of care to meet theneeds of people with chronicdisabilities.

The Current Problem

Across the country, long-termcare providers are reportingparaprofessional labor vacanciesand high turnover rates. Nursinghomes, assisted-living and otherresidential care providers, homehealth agencies, community-basedhome care and adult day care programs,and individuals and their families all reportsignificant difficulties in recruiting and retainingfrontline workers. Nationally, data on turnover ratesshow wide variation. One source suggests that turnoverrates average about 45 percent for nursing homes andabout 10 percent for home health care programs(Hoechst Marion Roussel 1996). Feldman (1994), citingMarion Merrell Dow data, reports that turnover amonghome care workers for private agencies is 12 percent,while turnover among those working for public agenciesis much higher. Other data place average annual nursinghome turnover at 105 percent (Wilner and Wyatt 1998).

Officials from 42 state Medicaid or aging officesresponding to a North Carolina Division of Facility Ser-

vices’ 1999 survey reported significant recruitment andretention problems among their paraprofessional work-force. A more recent survey of all long-term careproviders in Pennsylvania found that nearly 70 percentof providers reported significant problems with eitherrecruitment or retention; 35 percent reported that theproblems were extreme (Leon et al. 2001). Californianursing homes reported an overall employee turnoverrate of 67.8 percent, with the annual NA turnover rate

estimated to be even higher (Ruzek et al. 1999).A 1999 survey of New York nursing homes

and home health agencies, conductedby the New York Association of

Homes and Services for the Aging,found that the average NA

turnover rate between 1997 and1998 was 42 percent for theentire state: 21 percent for theNew York City/Long Islandarea, and 56 percent for therest of the state. Straker andAtchley (1999) found NAturnover rates ranging from88 percent to 137 percent inOhio nursing homes, withhome health aide turnoverrates ranging from 40 percent

to 76 percent. In addition, theauthors observed that nursing

homes—particularly those thatsaw turnover as a serious problem—

were very likely to underestimate theirturnover rates. Annual NA turnover rates

in North Carolina reportedly exceed 100 percent; the comparable estimate in adult

care homes is over 140 percent (NCDFS 1999). Fur-thermore, the number of inactive NAs in North Car-olina’s nurse aide registry is greater than the number ofactive NAs, suggesting that these individuals are notseeking jobs in the long-term care sector. A FloridaDepartment of Elder Affairs report to the state legisla-ture noted that only 53 percent of trained NAs wereworking in health-related fields one year after certifica-tion (cited in Bucher 2000).

Worker shortages, however, vary across and withinstates, as well as between providers. Massachusetts’s nurs-ing home administrators reported an 11 percent vacancy

13

WhoWill Care

for Us?

rate in frontline worker positions in 1999 (MHPF2000). The Home Care Association of New York Statealso acknowledges a major worker shortage, noting thatit takes providers at least two to three months to fill aidepositions (Home Care Association of New York State,Inc. 2000). Leon et al. (2001) found that only 8 percentof responding long-term care providers in Pennsylvaniaidentified the problem as severe. This estimate wassignificantly higher for privately owned nursing homes(12 percent) and home health agencies (18 percent).Although the job vacancy rate for all frontline work-ers in Pennsylvania was 11 percent, the rates were highest among certified home health agencies (15 per-cent), licensed noncertified home health agencies (14 percent), and privately owned nursing homes (13 percent). Across the state, 13 percent of providersreported vacancy rates exceeding 20 percent. But whileall types of nursing homes had chronic levels of jobvacancies, only 6 percent of government facilities hadhigh job vacancy rates, compared with over 19 percentof the privately owned nursing homes reporting vacancyrates of greater than 20 percent. A disproportionate per-centage of home health and home care agencies had highvacancy rates, with more than 25 percent of the certifiedhome health providers and 27 percent of licensed, non-certified agencies reporting rates greater than 20 percent.

High rates of staff vacancies and turnover have neg-ative effects on the major stakeholders within the long-term care system: providers, consumers (individuals andtheir families), and workers (PHI 2000). Labor shortagesand high turnover also affect federal and state policy-makers, who are responsible for ensuring that the pro-grams they either fund or directly operate are providingquality care.

Turnover is expensive for health care providers. Sev-eral studies suggest that staff turnover and vacancycosts—for recruitment, training, increased managementexpenses, and lost productivity—ranges from worker toworker. The turnover cost of a nursing home NA hasbeen estimated at four times the employee’s monthlysalary, translating into a replacement cost of $3,840(Pillemer 1996). Zahrt (1992) documented the costs ofreplacing home care workers, including the costs ofrecruiting, orienting, and training the new employee andthe costs related to terminating the worker beingreplaced (e.g., exit interview, administrative functions,separation pay, unemployment taxes): The total cost

associated with each turnover was $3,362. In addition tothe financial costs of the initial hire, there are costs asso-ciated with lost productivity during the time it takes forthe recently hired worker to complete the learning curve(Atchley 1996). Furthermore, this estimate does notinclude the costs of the attrition that occurs between ini-tial hires, training, and retention. White (1994), forexample, found that out of 351 potential home careworker recruits who completed a scheduled interview,216 were actually accepted into the training program,133 actually started classes, 106 graduated, and only 46were still with the agency six months after they wereplaced.

Across all Pennsylvania providers, the estimated totalannual (recurring) cost of training due to turnover in2000 was at least $35 million (Leon et al. 2001). Nurs-ing homes’ training costs accounted for $23.9 million,and home health/home care agencies’ costs accountedfor $4.8 million. The regions encompassing large met-ropolitan areas accounted for 75 percent of the costs. Inaddition to the recurring turnover costs, one-time statetraining costs for filling currently open jobs were esti-mated at $13.5 million.

Labor shortages and high turnover rates may also havenegative consequences for consumers. While there is lit-tle empirical evidence to establish causal links, anecdotesand qualitative studies suggest that problems withattracting and retaining frontline workers may translateinto poorer quality and/or unsafe care, major disruptionsin the continuity of care, and reduced access to care(Wunderlich et al. 1996). Because of the important rolethat workers play in meeting the most basic needs oflong-term care users and the close personal relationshipsthat are frequently established between aides and carerecipients, the reduced availability and frequent churn-ing of such personnel may ultimately affect clients’ phys-ical and mental functioning. Several studies haveobserved that inadequate staffing levels, an inevitablebyproduct of worker shortages, are associated withpoorer nutrition (Kayser-Jones and Schell 1997) andpreventable hospitalizations (Kramer et al. 2000) amongnursing home residents. A reduced pool of workers alsoplaces more pressure on family caregivers, who arealready providing the bulk of care to disabled individu-als in the United States.

Nursing assistants, home care aides, and other work-ers who enter and remain in these jobs may also suffer

14

WhoWill Care

for Us?

from the effects of labor shortages and high turnover.Workers who are providing care in understaffed envi-ronments may experience higher levels of stress and frus-tration, which may lead to poorer quality of care.Workers in nursing homes may be responsible for thecare of too many residents, leaving them unable to ded-icate adequate time to individuals. In home care, shortstaffing may limit aides’ personal interaction with theirclients.

Short staffing may also result in increased rates ofinjury and accidents, although there have been no stud-ies documenting such a direct relationship.These workers are already employed inone of the most hazardous occupa-tions in the service industry(Wise 1996): The injury inci-dence rate per 100 full-timeNAs was 16 percent in1996; the comparable ratefor home health careaides was 9 percent(SEIU 1997). Some re-searchers have speculatedthat overworked andfrustrated staff may alsobe more likely to physi-cally or emotionally abusenursing home residents orhome care clients (PHI 2001)or become the victims of abusefrom underserved care recipients.

Finally, high turnover and increasedvacancies may leave new workers withfewer mentors for on-the-job learning and peersupport (PHI 2001). Overworked supervisors, further-more, have less time to train and support frontline work-ers. In focus groups with nurse supervisors employed by several nonprofit nursing homes in Kansas, Long and Long (1998) found that understaffing was a major contributor to nurses’ decisions to leave thefacility.

The Long-Term Outlook

During the 21st century, there will be an unprecedentedincrease in the size of the U.S. elderly population as thebaby boom generation ages. While most elderly people

are not disabled, the likelihood of their needing long-term care increases with age. The number of people age85 and over—those most likely to need long-termcare—is projected to increase fivefold in the next 40 years: Estimates range from 8.3 million to 20.9 mil-lion in 2040, depending on assumptions about fertility,mortality, and immigration patterns (Stone 2000).Recent analyses of national and international data indi-cate a decline in disability rates among the elderly overthe past decade (Manton et al. 1997; Christopherson1997; Waidmann and Manton 1998), but that trend is

probably not sufficient to counteract the sig-nificant increase in the size of the elderly

population over the next 40 years.Using various mortality and dis-

ability scenarios, Kunkel andApplebaum (1992) esti-mated that by the year2020, the number ofolder Americans needinglong-term care will bebetween 14.8 and 22.6million people.

Assuming reasonablerates of economic growth,

baby boomers are likely tohave higher real incomes

during their retirement yearsthan today’s retirees (Man-

chester 1997). Those facinglong-term care decisions may be

more willing and able to purchase for-mal services than to rely solely on informal

care. This trend, coupled with the aging of the pop-ulation, will contribute to an increased demand for for-mal long-term care services over the next 30 years.

The future availability of informal caregivers is lesspredictable. The ratio of the population in the averagecaregiving range (ages 50 to 64) to the population age 85and older is projected to decrease, from 11 to 1 in 1990to 4 to 1 in 2050 (RWJF 1996). But this estimate doesnot include the large number of elderly spouses, partic-ularly wives, and the increasing number of adult childrenwho may be available to care for their parents. The par-ents of the baby boom generation have a larger averagepool of family members than did the Depression-erageneration. During the next 50 years, however, older

15

WhoWill Care

for Us?

people’s average number of adult children is expected tofall. A large proportion of working-age women will be inthe labor force, and more will be juggling parenting andelder care responsibilities. A recent survey of private geri-atric care managers (Stone 2001) suggests that the num-ber of people purchasing care for relatives who do notlive nearby is growing, which could place more demandson the formal long-term care system.

According to BLS (1998), personal and home careassistance is projected to be the fourth-fastest growingoccupation. The number of home health aides isexpected to increase by 74.6 percent between 1996 and2006; the comparable estimate for the nursing homeaide occupation is 25.4 percent.

A variety of factors, however, may offset the long-term demand for and supply of paraprofessional work-ers (Wilner and Wyatt 1998). The actual number ofavailable jobs may be tempered by both the rate of eco-nomic growth and the effective demand—that is, theextent to which purchasers are willing or able to pay(Crown et al. 1992). Some analysts (Bishop 1998) sug-gest that the dramatic slowdown in the growth of allhealth care costs in the 1990s, attributed to marketforces and the pressures of managed care, will reduce thenumber of health care jobs available, particularly interms of unskilled jobs. For example, recent home healthcare policy changes, including reductions in Medicarepayments, may diminish the future growth rate.

In the aggregate, the trends described above suggest thatthe demand for NAs, home care aides and other direct careworkers will increase. There is, however, serious concernabout the availability of these workers. By 2010, as babyboomers approach old age and begin to require assistance,the pool of middle-aged women available to provide low-skilled basic services will be substantially smaller than it istoday (Feldman 1997). The pool of “traditional” care-givers—women between the ages of 25 and 54—is pre-dicted to increase by only 7 percent during the next 30years. More importantly, the pool of potential entry-levelworkers—women age 25 to 44 in the civilian workforce—is projected to decline by 1.4 percent during the next sixyears (PHI 2000). The baby boom workforce has passedthrough this age range, and the rate of increased partici-pation of women in the workforce is slowing considerably.

The educational level among minority women—those most likely to enter the paraprofessional work-force—is also improving dramatically. While the educa-

tional status of both white and black women improvedbetween 1990 and 1998, the increase was most strikingfor the latter group. The proportion of black women age25 or over with a high school education increased from51.3 percent to 76.7 percent over that period; the pro-portion with four or more years of college increased from8.1 percent to 15.4 percent (U.S. Bureau of the Census1998). These more-educated women may be less willingto work in the same low-wage, low-benefit jobs as thosewho preceded them (Burbridge 1993).

The official unemployment rate in the United States isat a historic low, and a dramatic increase in unemploy-ment in the near future seems unlikely. With very lowpopulation and labor force growth, even a “normal” busi-ness cycle recession will likely yield only a modest increasein the number of unemployed (Judy 2000). Therefore, theunemployed do not offer a large untapped pool of poten-tial frontline workers. While individuals moving fromwelfare to work represent another potential source oflabor, a substantial proportion of these individuals havealready been absorbed into the economy (MHPF 2000).Those who remain on public assistance may have multi-ple physical, mental, and lifestyle barriers to employment,particularly with respect to the type of caring yet demand-ing work required of NAs and home care aides. Manypolicymakers and providers in the United States, as well asin Western Europe and Japan, view immigrants as apotential pool of workers. But, as will be discussed in thenext section of this paper, reliance on a major new influxof immigrants to solve the labor shortage may have sig-nificant negative consequences for our society.

The long-term outlook for the paraprofessional labormarket is not promising, even without considering the more fundamental issue of developing a qualified,committed workforce. The lack of a well-trained, well-qualified workforce for long-term care—professionaland paraprofessional—is an even graver problem thanfinancing and delivery problems (Stone 2000). There arefew financial or cultural incentives for workers to obtaintraining or to pursue careers in the care of people withchronic illness and disabilities.

Factors Affecting the Supply and Quality of Frontline Workers

The successful recruitment, retention, and maintenanceof a committed, prepared long-term care workforce are

16

WhoWill Care

for Us?

dependent on a variety of factors that intervene at dif-ferent levels. At the highest level, the value society placeson direct care work interacts with economics and publicpolicies—including health and long-term care re-imbursement, regulation and program design, labor and welfare training, and workforce development andimmigration—to influence the supply and quality ofparaprofessional workers. At the workplace level, orga-nizational arrangements, social factors, the physical set-ting and environment, and technology all influenceemployers’ ability to attract and retain workers. Policy-makers and providers need to consider the interactionsof the factors described below, including the counter-vailing effects of certain initiatives, in enhancing orimpeding the development of a qualified, sustainablefrontline workforce.

The Value of Frontline Caregiving

One important influence on individuals’ decisions toenter and remain in the long-term care field is how soci-ety views and values the job. Although there has beenprogress in reducing ageism, many still believe thatgrowing old is an inevitable evil leading to decrepitudeand death—an idea the mass media often reinforces.This negative image is matched by the ubiquitous fear oflong-term care. “I’d rather die than be in a nursinghome,” and, “I will never be a burden on my children,”are the mantras of some middle-aged adults, many ofwhom are already engaged in some level of caregiving fortheir parents. Frontline jobs in nursing homes, assistedliving, and home care are viewed by the public as low-wage, unpleasant occupations that involve primarilymaid services and “butt-wiping” of incontinent, cogni-tively unaware elderly people.

This image is exacerbated by reports in the massmedia that feature very negative stories about living andworking conditions in long-term care facilities and aboutwidespread fraud and abuse in home care. While qualityconcerns are certainly warranted, the current climate isintolerant of mishaps or bad results (Kapp 1997). AsKane (2000) noted, “We are at risk of turning the greatbulk of well-intended, hard-working long-term careproviders into a depressed and beleaguered group, whoare too fearful of missteps to exercise creativity or evencommon sense in their daily work.”

The adversarial relationship between consumers andregulators on the one hand, and providers on the other,has significantly tarnished the long-term care industry’simage, ultimately affecting the reputation of the front-line worker. The strict regulatory approach championedby several leaders on Capitol Hill, undertaken by the Health Care Financing Administration (HCFA), andembraced by many consumer advocates may haveunintended negative consequences for the paraprofes-sional workforce. Anecdotes informally reported to us byworkers at a consortium of Wisconsin facilities reputedto provide quality care suggest that these aides aredepressed and demoralized by aggressive survey inspec-tion and enforcement activities and by the way themedia portrays their jobs and work environment. InFlorida, the recent rash of litigation against nursinghomes is not only causing liability insurers to pull out ofthe market, it is also discouraging potential employeesfrom applying for jobs in the industry (Bucher 2000).

Status of the Economy

Several policymakers and researchers, when discussingthe current shortage of NAs, home care aides, and otherdirect care workers, have argued, “It’s just the economy,stupid!” They perceive this crisis as a short-term problemthat will be ameliorated by an economic downturn.While the problem is more entrenched and complicated,there is no doubt that the status of the local economy isa major determinant of the supply and stability of thefrontline workforce. Several studies (Crown et al. 1995;Feldman et al. 1990; Banaszak-Holl and Hines 1996)have identified the strength of the local economy as amajor predictor of turnover rates in nursing homes andhome care. Experience in several local markets duringthe early and late 1980s demonstrated that the ability toattract and retain frontline workers ebbed and flowedwith economic cycles (Feldman 1997).

Recruitment, retention, and turnover are related toconditions in both the long-term care labor market andthe overall labor market (Atchley 1996; Burbridge1993). When the general labor market is tight, there aremore jobs for qualified people, who are likely to find bet-ter opportunities outside long-term care. Likewise, whenthe long-term care labor market is expanding, competi-tion for new staff intensifies among providers, recruitingmay become less selective, and retaining existing staff

17

WhoWill Care

for Us?

becomes more difficult. More attention is paid to hiringworkers than to searching for individuals who have therequisite personalities and/or skills for the job.

Policymakers and providers have expressed keen inter-est in understanding the extent to which there is intra-sec-toral movement (from one nursing home to another orfrom one setting to another) versus movement out of thelong-term care or health sector altogether. Informal dis-cussions with providers suggest that many workers quit totake a job with another facility or agency, supporting thenotion that providers are “stealing from one another.”Feldman (1994) has observed that as hospitals de-empha-size inpatient hospital care, they are beginning to offersubacute care and various forms of community-basedcare. Nursing homes have increasingly specialized in reha-bilitation and subacute care and have branched out intohome care. As a result, the nursing home and home careindustries are converging and are beginning to competefor people in the same labor pool, contributing to theshortage of frontline workers.

Konrad (1999) examined the extent to which trainedNAs in North Carolina are currently employed in thelong-term care sector, identified other concurrent or sub-sequent jobs these individuals hold, and determined theannual earnings of active versus inactive NAs. The studyfound that less than half of the 180,000 North Car-olinians trained to work as NAs during the last decadeare currently certified to work in this occupation. Evenamong those who are certified, many apparently workonly part-time as NAs, supplementing their income withearnings from unrelated jobs in low-wage industries.Most of the individuals who are no longer certified asNAs have left the long-term care field and appear to havemore stable jobs at higher wages in other industries.

Health and Long-Term Care Policy

Health and long-term care policies at the federal andstate levels significantly affect the recruitment and reten-tion of the frontline workforce, influencing employerand employee decisions through reimbursement, regula-tion, and program design.

Reimbursement Policy

Medicare and Medicaid, the major sources of publicfunding for health care, account for most long-term care

expenditures (Stone 2000). In 1995, approximately$106.5 billion was spent on long-term care, with publicresources accounting for 57.4 percent of the amount.The largest part of public funds, 37.8 percent, camefrom Medicaid (21.1 percent federal and 16.7 percentstate). Medicare paid 17.8 percent of the $106.5 billion,and other federal and state programs supplied lesseramounts (e.g., Veterans Affairs, Older Americans Act,Social Service Block Grant, state general assistance).

Medicare provides coverage for short, post-acute staysin skilled nursing facilities and for home health servicesto community-dwelling beneficiaries who need skillednursing, particularly following a hospitalization. Medi-caid, the federal/state health care program for the poor, provides coverage for more traditional, chronic,and nonmedical services in nursing homes and institu-tions for people with mental retardation. Using waiversand state plan options, Medicaid also covers home andpersonal care for people who meet the low-incomerequirements.

Because these programs are major sources of long-term care funding, reimbursement policy plays a sub-stantial role in determining workers’ wages, benefits, andtraining opportunities. Nationally, Medicaid financescare for about two-thirds of all nursing home residents.At the extremes, Medicaid covers just over 50 percent ofresidents in three states, while in four states the programfinances over 80 percent (Manard and Feder 1998).These third-party payers influence the price of labor bydetermining the amount of money public agencies andprivate insurers are willing to pay (PHI 2000). Whileproviders have some flexibility in setting wages andbenefits, that flexibility is limited by this third-partypayer constraint (Atchley 1996). If payment rates fail tokeep up with the true cost of providing services, organi-zations have less flexibility to offer competitive wagesand benefits.

For years, states have tried to control Medicaid nurs-ing home and home care expenditures by placing limitson reimbursement (HCIA-Sachs and Arthur AndersenLLP 2000). Many home health providers relied onMedicare to make up for Medicaid shortfalls. RecentMedicare cuts, however, have significantly curtailed thispractice. Specifically, the Balanced Budget Act of 1997(BBA) reduced payments to home health agencies byrequiring that reimbursement limits be held to a below-inflation rate of growth. The federal government has

18

WhoWill Care

for Us?

placed similar limits on Medicare reimbursement fornursing home care, which dropped by 12.5 percent in1999.

There are few empirical data to support or refute theargument that reimbursement rates are too low to allowproviders to pay adequate wages and benefits to directcare workers. Consumer advocates argue that reim-bursement would be adequate to pay frontline staff if thedollars were not being spent on high salaries for man-agers and on corporate overhead. Frank and Dawson(2000) make the case that within Massachusetts’s highlycompetitive labor market, the third-party payerdynamic has played a significant role in keep-ing wages and benefits artificially low,below the levels necessary to attractand retain quality staff.

One source of reimbursementthat has not received muchattention but that influencesrecruitment and retention ofworkers is the State Supple-mental Payment (SSP) tothe federal SupplementSecurity Income (SSI) ben-efit. SSI is a cash benefitprogram for low-incomeelderly or disabled individu-als; states have the option ofsupplementing this benefit.Most low-income individualsliving in residential care settings,particularly board and care homes,rely on their SSI benefits to cover roomand board. A number of states also use SSPfunds to augment SSI payments to facilities.Several residential care providers have indicated thatbecause the SSP reimbursement is so low, they are notable to offer the wages necessary to attract direct careworkers in the current labor market.

Regulatory Policy

Regulatory policy in the long-term care area focuses pri-marily on protecting the consumer, and pays little atten-tion to the needs or concerns of frontline workers.Although regulations do address the need for training,they do not fully address the range of educational and

on-going support activities that paraprofessionals needin order to assume increasingly complicated and com-plex responsibilities.

At the federal level, major nursing home reform wasintroduced with the passage of the Omnibus BudgetReconciliation Act of 1987 (OBRA), which officiallyacknowledged the importance of NAs by mandatingthat they complete 75 hours of prescribed training. Thislegislation, however, focused only on entry training, andpaid little attention to the necessity for continued careergrowth or development of competencies other than to

require 12 hours of in-service training per year. Statesalso require that NAs be trained, but the

number of hours and the specificrequirements vary widely.

The federal government hasenacted guidelines for home

health aides whose employersreceive reimbursement fromMedicare. Federal lawrequires home health aidesto pass a competency testcovering 12 areas, and alsosuggests at least 75 hours ofclassroom and practicaltraining supervised by a reg-istered nurse. Training and

testing programs may beoffered by the employing

agency, but they must meet thestandards set by the Health Care

Financing Administration (HCFA).Training programs vary depending on

state regulations. Home care and personalcare workers employed by agencies that are reim-

bursed by Medicaid or other state programs may also besubject to certain training requirements, but this prac-tice varies by state and local community.

One major issue for the development of the residen-tial care frontline workforce is the degree to which statesare willing to modify their nurse practice regulations toallow aides to perform certain tasks, such as administer-ing medication, caring for wounds, and changingcatheters (Kane 1997). A number of states, includingOregon, Kansas, Texas, Minnesota, New Jersey, andNew York, have enacted nurse delegation provisions, butthe latitude and interpretation of the provisions vary

19

WhoWill Care

for Us?

tremendously. This issue is important because it gets tothe heart of the debate about autonomy for workers aswell as consumers. The assisted living philosophy assertsthat residents should live in a homelike environment andshould be able to make choices about their care, includ-ing decisions that may put them “at risk.” Workers, too,should be allowed to make decisions about the care pro-vided. Opponents of nurse delegation, particularly stateboards of nursing, argue that aides do not have the skills(and cannot be trained) to engage in such activities asmedication management, and that patient safety wouldbe jeopardized if workers were allowed more responsi-bility and autonomy. Proponents, meanwhile, argue thatwith the appropriate training and proper supports, nursedelegation would provide more intrinsic rewards forworkers, perhaps expanding the pool of individualsattracted to these jobs.

Program Design

Medicare-covered skilled nursing and home health careand Medicaid-covered nursing-home care are entitle-ments with little room for innovation. States, however,have much more discretion in developing home- andcommunity-based service programs financed throughMedicaid waivers, the personal care state plan option, orstate-only funds. Many states have developed consumer-directed programs that allow beneficiaries to hire and firetheir workers. At least 35 states allow family members tobe paid as home or personal care providers. The flexibil-ity in these programs may have helped expand thosestates’ potential pool of workers. Researchers studyingthe IHSS program in California, for example, found thatone-fifth of the paid family providers were new to care-giving; that is, they did not provide informal carebefore participating in the IHSS program (Benjamin et al. 2000). This finding suggests that some familymembers not predisposed to informal caregiving mightjoin the pool of formal care workers under certaincircumstances.

Labor Policy

Federal and state labor policies have an important role toplay in the expansion of the pool of frontline long-termcare workers. The federal government invests more than$8 billion annually to prepare primarily low-income andunemployed individuals for new and better jobs (PHI

2000). Ironically, state and federal employment agenciesindirectly prevent the long-term care industry from par-ticipating in training support programs by requiring thatparticipants graduating from those programs securewages that are higher than typical frontline workersalaries. While they are designed to prevent trainees frombeing shunted into poverty-level jobs, these policiesessentially preclude graduates from entering the para-professional long-term care labor force.

The federal Work Investment Act (WIA), whichreplaced the Job Training Partnership Act in July 2000,establishes a flexible state framework for a national work-force preparation and employment system designed tomeet the needs of employers, incumbent workers, and jobseekers. States wishing to continue receiving job trainingfunds were required to submit final plans for federalapproval by October 2000. WIA offers opportunities forexperimentation with training initiatives in the long-termcare field. Funds can be used to create transitional jobs tohelp low-income adults become employable through“paid work experience” and on-the-job training. The pro-gram is so new, however, that its implications for thedevelopment of a frontline workforce remain to be seen.

The Occupational Safety and Health Administration(OSHA) is the federal agency responsible for overseeingand monitoring the workplace for activities that mayharm workers’ physical or mental well-being. As notedpreviously, frontline long-term care work is a potentiallyhazardous occupation, and OSHA has historicallyfocused most of its attention on identifying and apply-ing negative sanctions to employers in violation ofcertain regulations. In 1992, however, OSHA beganexperimenting with a new approach that replaces inspec-tions, enforcement tactics, and bureaucratic relation-ships with a partnership with employers to preventworkplace accidents and injuries (Wise 1996).

As of the summer of 1996, 12 such programs hadbeen approved or were being implemented. To beapproved by OSHA, state programs had to (1) use datasuch as workers’ compensation claims or OSHA logs; (2) provide employers the choice of a partnershipapproach through the establishment of a comprehensivesafety and health program; (3) include an enforcementcomponent; (4) show a measurable impact in reducingillness, injury, and death in the affected workplaces; and(5) include outreach activities and consultation withlabor, management, and other interested parties duringthe development of individual programs.

20

WhoWill Care

for Us?

Welfare Policy

Three federal welfare initiatives are particularly relevantto the development of this workforce. The TemporaryAssistance for Needy Families (TANF) program, createdby the federal Personal Responsibility and Work Oppor-tunity Reconciliation Act of 1996 (PRWORA), replacedthe cash welfare system with a new block grant program.States now have considerable authority to determinehow the block grant funds are used to aid the poor.TANF gives states flexibility in developing job oppor-tunities at the state and county levels, including thecreation of public job creation programs and the optionof offering wage subsidies in lieu of direct cash grants towelfare recipients.

Although PRWORA was designed to increase workopportunities for welfare recipients, some provisions inthe legislation may undermine that goal. Many states fol-low a “work first” strategy that sees placement in a job—any job—as preferable to entry-level, skill-based training(PHI 2000). States adhering to this philosophy encour-age former welfare recipients to secure jobs as quickly aspossible. Ironically for the long-term care profession,however, PRWORA conflicts with federal nursing homeand home health aide requirements for skill-based train-ing, making it harder for former welfare recipients tojoin the pool of qualified frontline workers. Accordingto PHI (2000), policymakers have recently begun to rec-ognize the problems with the work-first philosophy, andnew state regulations may encourage skill-based training.

Recognizing the need to develop employmentprospects for TANF participants, who face a five-yearlifetime limit on benefits, the 1997 BBA authorized theU.S. Department of Labor to create a $3 billion Welfare-to-Work grant program for states and local communi-ties. These grants help long-term welfare recipients andcertain low-income noncustodial parents in high-poverty areas get jobs and succeed in the workforce. Jobcreation through public- or private-sector employmentwage subsidies is permitted under the Welfare-to-Workprogram. Selected experiences with the Welfare-to-Workprogram are highlighted in the sections on state andprovider efforts. It is important to note, however, thatthe success rate with this population has varied widely.Many former welfare recipients are not predisposed tojoin the long-term care workforce and lack the basicwork skills to assume the responsibilities of a caregiver.

Without proper training, ongoing mentoring, and ade-quate supports (e.g., subsidized child care), this programcould be setting individuals up for failure.

Immigration Policy

Given the current labor shortage and gloomy projectionsabout the future pool of workers, many providers haveexpressed interest in using immigrants to expand thepotential labor pool. Countries such as Japan, Italy andGermany that are far “grayer” than the United States havealready begun to pursue an aggressive immigration strat-egy: For example, Italy recruits from Peru, and Japan hasbegun to encourage immigration from the Philippines.

Immigration currently accounts for 40 percent of thelabor force growth in the United States (SEIU 1997).Forty percent of immigrants are in two occupationalgroups: operator/laborer/fabricator and service worker(Fix and Passel 1994). Almost two-thirds of immigrantscome to the United States for family unification, and arenot seeking high-skilled employment opportunities.They comprise a current and future labor pool for low-skilled jobs, including the paraprofessional long-termcare workforce (Stone 2000). Consequently, policies tolimit the entry of low-skilled immigrants, particularly by limiting family-based immigration, may diminish the future labor pool of NAs and home care workers(Camarota 1998).

Recent immigration initiatives have been designed toexpand the pool of skilled workers, particularly in thehigh-tech industry. In the health and long-term care sec-tor, rules have been loosened to address the severe nurs-ing shortage in hospitals and, to a lesser extent, nursinghomes. Little attention, however, has been paid to theparaprofessional workforce.

Rogers and Raymer (2001) assessed immigration’spossible “population-rejuvenating” effects in the UnitedStates and found little evidence of it, given past, recent,and current levels of inflows. Their analysis of the datafrom 1950 to 1990 indicates that although immigra-tion’s impact has contributed to higher worker-to-elderlyratios, the amount of immigration over the past decadeshas been insufficient to counteract the much strongerimpact of population aging. While the dependency ratiois not a proxy for the frontline worker-to-elderly ratio,these findings do suggest that immigration policy wouldhave to be designed to allow a large influx of low-skilled

21

WhoWill Care

for Us?

immigrants if it were to address the demand for long-term care workers.

An immigration policy strategy for ameliorating theworker shortage has some appeal during our currentperiod of economic prosperity. But it is important to rec-ognize that immigrants reduce the employment oppor-tunities of low-skilled workers in areas where the localeconomy is weak (Fix and Passel 1994). This negativeeffect, furthermore, tends to fall disproportionately onpeople of color, many of whom are employed as front-line workers (Wilner and Wyatt 1998). Finally, policy-makers must also recognize that some low-skilledimmigrants who fill entry-level positions in low-wageoccupations in nursing homes, assisted living, or homecare may need various forms of public assistance, partic-ular if the economy weakens.

Workplace Level

While societal values, demographics, economics, andpublic policies influence how the workforce develops,the workplace is where the interactions between thesefactors and individual employer and employee decisionsare played out. The four workplace dimensions—organizational arrangements, social factors, physical set-ting, and environment and technology—are all key tothe successful development of the frontline workforce.

Organizational arrangements include the goals andstrategies of the provider organization, the formal struc-ture and administrative policies, and the reward systems.Rewards include wages and benefits, bonus and non-monetary recognition programs, and career development/promotion opportunities.

Social factors include organizational philosophy andvalues, management style, interactions with employers,the behavior and attitudes of other employees andresidents/clients, and individual personality attributes,life histories, and lifestyles.

The physical setting/environment includes the work-place’s character (e.g., whether it is homelike or institu-tional); physical design, which may enhance or impedethe worker’s ability to provide care; and the extent towhich the setting is ergonomically healthy.

Technology encompasses a wide range of factors,including job and role design, training programs, theavailability of assistive devices and adaptive technology

to facilitate care, the availability of clinical protocols andother care tools, and the role of information technologyin enhancing the work life of NAs, home care aides, andother frontline workers.

A review of the literature reveals a paucity of empiri-cal research related to workplace interventions (Stone2001). Most of the research has been descriptive ratherthan evaluative, identifying various management/jobredesign efforts, training activities, and financial andnonmonetary reward programs. Much of the “best prac-tice” work has been anecdotal, summarizing the attri-butes of innovations (reported by either the providers ortheir peers) with little critical analysis. Furthermore,studies tend to focus on specific settings, with fewattempts to compare workers’ situations across the con-tinuum of long-term care. The majority of studies havebeen conducted in nursing homes, with less attentionfocused on home care and virtually no empirical workon this issue in residential care.

Nursing Home Research

A number of researchers have examined the factors asso-ciated with job satisfaction, burnout, and turnover innursing homes. In the 1980s, several small, qualitativestudies of nursing assistants identified the managementstyle of the organization (e.g., supervisors with goodpeople skills, promotion of worker autonomy) as themost important predictor of higher job satisfaction andlower turnover rates (Waxman et al. 1984; Tellis-Nayakand Tellis-Nayak 1988). In a diagnostic study of NA jobsin 21 nursing homes, Brannon and colleagues (1988)assessed levels of skill variety, task significance, auton-omy, and feedback. They identified several areas of jobdesign warranting significant improvement and, in par-ticular, the need for administrators and supervisors toincrease NA autonomy.

Bowers and Becker (1992) conducted in-depth, qual-itative interviews with NAs in nursing homes whereannual turnover rates ranged from 120 to 145 percent.They found that NA trainees were given a lot of infor-mation during their orientation but received little guid-ance about how to respond to multiple simultaneousdemands. The “long stayers” had the ability to integratemultiple demands, learned how to effectively juggleresponsibilities, and had the autonomy to do so; thosewho left often did not.

22

WhoWill Care

for Us?

Banaszak-Holl and Hines (1996) examined factorsaffecting NA turnover in 254 facilities in metropolitanareas of 10 states. They assessed the effect of intrinsicrewards (e.g., job satisfaction and sense of belonging),extrinsic rewards (e.g., wages and benefits), in-housetraining, workload, and elements of job design (e.g., howoften NAs are included in resident care assessment andplanning). They also examined the role of facility char-acteristics, such as ownership patterns, bed size, and per-centage of Medicaid patients at the facility, as well as theeconomic health of the community.

Not surprisingly, local economic conditions had thestrongest effects on turnover rates; stronger economieswith greater low-wage market competition were associ-ated with greater NA turnover. Among thefacility characteristics, only owner-ship status proved significant,with for-profit facilitiesreporting higher turnoverrates than homes in othercategories. One of thisstudy’s most importantfindings was thathomes in which nursesupervisors acceptedNAs’ advice or simplydiscussed care plans withthe aides reportedturnover rates that wereone-third lower than thosewithout these practices. Turnoverrates were not affected by increases inaide training or greater involvement in resi-dent assessment.

In interpreting these findings, the authors suggestedthat NA involvement in care planning meetings mightgive the aides a greater sense of responsibility for andauthority over actual resident care, as well as makingthem feel like part of a team. Input into resident assess-ments is not sufficient; frontline workers must be able toobserve a direct link between the information theygather about residents and subsequent action taken. Thisstudy also underscores the importance of formal com-munication between management and the paraprofes-sional staff, and the value of group problem solving.

One approach to managing staff that studies show haspositive effects on staff turnover and work performance

is the use of self-managed work teams (SMWTs).SMWTs are groups of employees, typically ranging from3 to 15 people, who are responsible for the managementand technical aspects of the job. Several researchers haveused this strategy, originally applied in manufacturingsettings, in health care settings (Becker-Reems 1994).Yeatts and Seward (2000) differentiate between interdis-ciplinary teams and SMWTs, using the former to referto a small group of professionals who come together toaddress a specific task and the latter to describe groupswho work together daily, depending on each other androutinely making management decisions related to theirwork. In a qualitative study of SMWTs operating at dif-ferent performance levels in a Wisconsin nursing home,

Yeats and Seward identified a high- and alow-performing team, each consisting

of three NAs with a registerednurse (RN) supervisor. The

teams were expected to makedecisions such as whoshould serve which resi-dents, the procedure tobe followed in servingthe residents, and whowould have time off onmajor holidays. Mem-

bers of the high-perform-ing team were more

involved in the decisionmak-ing, and the information they

used for making these decisionscame directly from their experiences

working with the residents. Members of thelow-performing team had much less opportunity tomake decisions; the RN made most of the decisionswithout consulting the NA team members.

Burgio and Seilley (1994) have emphasized the needfor supervisors to be actively involved, using frequentmonitoring, performance feedback, and incentives. Thisthesis is supported by findings from a study of the effec-tiveness of a prompted-voiding procedure to treat uri-nary incontinence (Schnelle et al. 1990). The researchersfound that without a staff management system in place,aides did not maintain the intervention in spite of hav-ing been assigned only responsive residents and havingreceived both classroom and “hands-on” training inprompted-voiding procedures. Other studies have

23

WhoWill Care

for Us?

underscored the importance of including NAs in careplanning and helping them understand the linksbetween interventions and resident outcomes throughongoing feedback (Hawkins et al. 1992; Schnelle et al.1993). Burgio and Burgio (1990) have proposed abehavioral supervisor model for nursing homes thatbuilds on a staff management system developed andevaluated by Reid and colleagues (1989) for individualswith developmental disabilities. The system incorporatesparticipative management procedures that require activeinvolvement of NAs in the management process.

As part of a larger study of nursing home turnoverand absenteeism among six self-identified high-qualitynursing home members of the Kansas Association ofHomes and Services for the Aging, Long and Long(1998) used an ethnographic approach to examine pre-disposing factors, organization-based reinforcing andenabling factors, and interpersonal reinforcers influ-encing turnover, absenteeism, and internal rewards oforganizations. The researchers found that paraprofes-sional behavior is driven by predisposing circumstancesthat can set up a cycle of powerlessness and unfamiliar-ity with the skills and rewards associated with perfor-mance and achievement in the workplace. Suchsituations are compounded by the NAs’ place in theorganizational hierarchy, at the bottom of the formalpower structure, leading them to seek control throughinformal, and often inappropriate, means (e.g., ignor-ing nurse supervisors’ instructions about schedules;sabotaging care plans). This, in turn, leads to organiza-tional policies that are intended to alleviate staffingshortages but that end up punishing reliable and high-performing aides (e.g., requiring the best performers towork overtime; assuming that the best performers arebetter able to work when the facility is short of staff ).There is also a widespread mutual lack of empathyamong workers of differing ranks and roles, leading toa negative interpersonal climate that encourages work-ers to look for other jobs. In addition, most aides (aswell as nurses and managers) have poor interpersonalskills that fuel misunderstandings, resentment, andwork conflict. NAs, furthermore, see nursing homes asa place of grief at the death of residents, fostering thebelief among potential employees that such work isunrewarding and unappealing. Finally, nursing homesare seen as places where the residents, but not the work-ers, are valued.

Home Care Research

Research on home care workers has been more difficultto conduct because there are fewer opportunities toobserve the interpersonal dynamics between supervisors,workers, and other stakeholders within individualhomes. Interventions targeted to home health and homecare aides employed by certified agencies are easiest toassess because there are some parameters within whichthe employees are hired, trained, and retained. The mostcomprehensive study of home care worker satisfactionand turnover was conducted over a decade ago (Feldmanet al. 1990). Feldman and colleagues designed a case-control study with a sample of 1,289 workers in fivecities. They assessed the impact of salary increases,improved benefits, guaranteed number of service hours,and increased training and support on worker retention.The Ford Foundation subsidized the costs of theimprovements, with total costs ranging from 6 to 17 per-cent above reimbursed rates.

In the aggregate, the interventions reduced turnoverrates by 11 to 44 percent. The study found that financialrewards were important to worker satisfaction, motiva-tion, and retention, but several job qualities proved to beeven more important. Workers were more satisfied andlikely to remain in the job if they felt personally respon-sible for their work and received ongoing feedback fromtheir supervisors. The researchers concluded that goodpersonal relationships between management and work-ers and between the worker and the client are essentialfor successful recruitment and retention.

One of the most disconcerting findings from thisstudy was that all the agencies participating in theproject reverted to their former practices when the foun-dation’s study was finished and funding was withdrawn.This demonstrates the need for mechanisms to ensurethe long-term sustainability of interventions. As one par-ticipant of an evaluation currently being conducted bythis paper’s author noted, “Work-life change is like los-ing weight. You can’t go on and off a diet; it has tobecome a way of life!”

The first major study of independent home careworkers, funded by the U.S. Department of Health andHuman Services and conducted by Benjamin and col-leagues (2000) in California, did not specifically addressworker turnover and retention issues. These researchersdid find, however, that those workers indicating greater

24

WhoWill Care

for Us?

choice or discretion about how they do their workreported less stress (about family issues, client behavior,and negative personal emotions) and more job satisfac-tion (more independence and flexibility). While workerchoice in the workplace may be constrained by eithersupervision from a home care agency or direction froma client, the degree of (perceived) choice within the worksetting seems to have consequences for the frontlineworkers.

Public and Private Efforts to Develop a Qualified, Stable Frontline Workforce

State and Local Efforts to Address Frontline Worker Concerns

As noted previously, problems with recruiting andretaining frontline long-term care workers have becomea priority for many states. This crisis has also raisedawareness, at least rhetorically, about the need to developand sustain a qualified, caring workforce. Several studiesover the past several years have documented the range ofstate legislative and administrative initiatives that areeither being implemented or on the drawing board(NCDFS 1999; NCDFS 2000; NCCNHR 2000; GAO2000). The major categories of activities are identifiedand briefly described below.

Wage Pass-Throughs

The most prevalent state initiative is the “wage pass-through” (WPT), in which a state designates that someportion of a reimbursement increase for one or morepublic funding sources for long-term care (typicallyMedicaid, but sources may also include Older Ameri-cans Act Funds, state appropriations, etc.) is intended tobe used specifically to increase wages and/or benefits forfrontline workers. Typically, WPTs have been imple-mented either by designating that some specified dollaramount per hour or client/resident day be used specifi-cally for wages/benefits or by designating that a certainpercentage of a reimbursement increase be used forwages/benefits.

WPT initiatives are not new. Massachusetts, forexample, passed WPT legislation in the early 1980s, andagain later in the decade, to address episodic labor short-ages (Feldman 1994). According to the 2000 NCDFS

survey, 18 states had recently approved or implementedsome form of WPT: 9 targeted only home care workers,6 targeted nursing home aides only, and 3 targeted both.States reported being satisfied with their accountabilityprocedures for monitoring whether the WPTs were usedas intended. Few data exist, however, to substantiatewhether this mechanism has directly influenced recruit-ment or retention in long-term care settings. Historicaldata from Michigan show an overall drop in aideturnover rates between 1990 and 1998, which the stateattributes, at least in part, to WPT implementation (asreported by the NCDFS 2000 survey). There have, how-ever, been no evaluations examining the short- or long-term effects of the WPT strategy and differences inoutcomes based on variations in the methodology.

Some policymakers and providers have expressedgreat skepticism about WPTs’ potential to significantlyameliorate long-term recruitment and retention prob-lems. WPTs are used primarily when labor markets aretight, and therefore offer only temporary relief. Whilethe NCDFS survey respondents reported having littleconcern about their ability to monitor WTP implemen-tation, a recent Sacramento Bee (2001) article highlight-ing the failure of many nursing homes to pass increasesdirectly on to frontline workers underscores the diffi-culty of tracking this mechanism’s effectiveness.

Financially strapped providers in a number of states(e.g., Wyoming, Minnesota) did not accept the WPTsbecause of their concern about the employer’s share offringe benefits required to be paid to staff receivingincreased wages. The president of the Minnesota Healthand Housing Alliance, the state association of nonprofitlong-term care providers, notes that apparent successescan come with costs (AAHSA 2000). The Alliance led acoalition of providers, consumers, and workers that con-vinced the state legislature to provide an extra $30 mil-lion in Medicaid dollars in the form of a 3 percent WPTfor direct caregivers and a 3 percent cost-of-livingincrease. This pass-through, however, could be used onlyto increase wages for current staff, not to hire additionalstaff. In addition, the WPT did not take into considera-tion the additional costs to the facilities of paying moretaxes as a result of the wage increases. The campaign toenact the legislation, furthermore, raised workers’ expec-tations and created major conflicts between current andnewly hired aides, who would not benefit from the pass-through.

25

WhoWill Care

for Us?

The Minnesota experience highlights the limitationsof the WPT strategy and underscores the need forpolicymakers, providers, and consumers to pay attentionto the details and unintended consequences of suchinitiatives. More importantly, the WPTs have been rela-tively small increases in hourly wages, and have not beendesigned to markedly improve the financial status offrontline workers.

Enhancement Incentives

States can use other mechanisms to increase reimburse-ment rates and encourage quality of care. Rhode Island,for example, has passed legislation that ties nursinghome and home care reimbursement rates to increasedperformance by both providers and staff (NCDFS1999). While not yet fully implemented, this legislationhas set up varying reimbursement rates based on severalmeasures, including the level of client and worker satis-faction, the level of resident/client disability, theprovider’s accreditation, and the extent of care continu-ity. This initiative also provides higher reimbursementrates for workers on night or weekend shifts. Californiais offering monetary awards to nursing homes that pro-vide exemplary care to the highest number of Medicaidresidents, as well as financial grants to stimulate innova-tive programs. While these initiatives may be wellintended, successful implementation of these effortsdepends on the extent to which outcomes such as degreeof care continuity, client and worker satisfaction, and“exemplary” care can actually be defined and measuredin specific facilities.

Health Insurance Coverage

As noted earlier, the lack of or inadequate access to ben-efits such as health insurance may discourage potentialworkers from entering or remaining in long-term carejobs. Several states have programs or are exploring mech-anisms to expand health insurance coverage (NCCNHR2000). Hawaii and Vermont have strong safety-net pro-grams for all low-income workers to obtain health insur-ance and access to prescription drug coverage. Over thelast decade, many states (e.g., Hawaii, Minnesota, Ver-mont) have relied on Medicaid Section 1115 researchand demonstration waivers to extend health care cover-age to families and other working adults; more recently,

states have begun to expand coverage through MedicaidSection 1931 disregards (Academy for Health ServicesResearch and Health Policy 2001). In 1998, RhodeIsland, which already covered children whose familyincome was up to 250 percent of the federal poverty level(FPL) through the state’s 1115 Medicaid waiver, begancovering parents of eligible children with incomes up to185 percent FPL. After observing that significant num-bers of enrollees switched from commercial products tothis program, the state enacted Health Reform RI 2000,which establishes a premium assistance programdesigned to support, but not replace, existing privatecoverage. Massachusetts and Wisconsin have receivedfederal approval to pay for private family coverage usingState Children’s Health Insurance Program (SCHIP)funds in cases where it is cost effective. Wisconsin’s Bad-gerCare Program is providing coverage to all children upto age 18 (and their parents) not covered by Medicaidwhose family incomes are up to 185 percent of the FPL(Alberga 2001). Combining Medicaid expansion withSCHIP coverage may provide better access to healthinsurance to low-income workers, including thoseemployed in long-term care settings. Inadequate out-reach efforts associated with all these initiatives, however,have limited worker awareness about coverage oppor-tunities (Academy for Health Services Research andHealth Policy 2001). Furthermore, there are no esti-mates of the number of long-term care aides who arecurrently receiving coverage through any of theseprograms.

New York’s Health Care Reform Act of 2000 (HCRA2000) authorizes the establishment of a state-fundedhealth insurance initiative to cover uninsured home careworkers. The legislation, however, only applies to work-ers in the New York City/Long Island area, a decisionattributed to the strong unionization in that area(NYAHSA 2000). The New York Association of Homesand Services for the Aging (NYAHSA), the state associ-ation for nonprofit long-term care providers, has recom-mended that this legislation be expanded to cover allhome care workers, as well as workers in nursing homesand residential care settings across the state. New Yorkand Washington have also developed health insuranceinitiatives to help small employers—including long-term care providers—gain access to coverage for them-selves and their employees.

26

WhoWill Care

for Us?

Transportation Subsidies

Several states have included transportation reimburse-ment as part of an incentive package to attract and retainworkers. Washington, for example, will reimburse agen-cies for the commuting time that is required for homehealth aides and personal care workers to get from oneplace to another (NCDFS 1999). Florida’s Departmentof Elder Affairs is also exploring the possibility of pro-viding transportation reimbursements for NAs andhome care workers (Bucher 2000).

Career Ladders

Several states are exploring thedevelopment of career laddersfor frontline workers byestablishing several job lev-els in their public pro-grams, their trainingrequirements, or theirreimbursement deci-sions (NCDFS 1999).Illinois, for example, hasa bill pending to create a“resident attendant” cate-gory for nursing homeworkers; individuals wouldundergo training to providebasic supportive services tofully trained, experienced NAs.Delaware is considering developing athree-level career ladder—intern, teammember, and team preceptor—that would betied to increases in pay.

In the early 1990s, the New York City HumanResources Administration supported a study to test theeffectiveness of a new home care position: the field sup-port liaison (FSL), a home care worker hired and trainedto visit attendant workers in order to identify problemsand provide peer support in the community. A case-con-trol evaluation found that agencies employing FSLsreduced their turnover by 10 percent over a two-yearperiod, compared with those not using FSLs (Feldman1993). This demonstration, however, never became anoperational program because of a lack of city and statefunding.

As part of a comprehensive, multi-year workforcestrategy, Massachusetts has created a $5 million Ex-tended Care Career Ladder Initiative to support thedevelopment and implementation of career ladder pro-grams using innovative caregiving and workplace prac-tices. Grantee nursing homes must form partnershipswith workforce development organizations and otherlong-term care providers (e.g., home health agencies,assisted living providers, vocational rehabilitationproviders), and must provide paid release time (at least50 percent of workers’ time) for work training and

project participation. Researchers affiliated withthe Corporation for Business, Work, and

Learning in Boston are currentlyevaluating this demonstration.

Training

Approximately one-thirdof the states have regula-tions mandating hoursof training above thefederally required 75hours for NA certifica-tion (NCCNHR 2000).California, Maine, and

Oregon are at the highend, requiring at least 150

hours of training. At least 10states are currently exploring

strategies to improve training offrontline workers in all long-term

care settings; California and Oklahomaare focusing special attention on dementia care.

Nine states have been able to use civil monetary penaltyfunds resulting from nursing home enforcement activitiesto strengthen their worker training programs.

States have developed training initiatives for long-term care workers over the past two decades. In the mid-1980s, for example, New York awarded $2 million ingrants to 39 organizations to develop basic home caretraining programs and programs focusing specifically onAlzheimer’s and related dementias. By 1993, however,the budget had been cut to $578,000, raising the ques-tion of the initiative’s long-term sustainability(NYAHSA 2000). As part of a larger initiative, Massa-chusetts recently appropriated $1.1 million for training,

27

WhoWill Care

for Us?

including adult basic education and job supports, andanother $1 million for a scholarship program. In 2000,California passed new legislation creating a statewidetraining initiative focused on innovative nursing homepractices. North Carolina is funding a pilot project in 10 sites across the long-term care continuum to test theeffects of seven new training programs (NCDFS 2000).The state will provide financial incentives to encourageaides to complete the training, and will evaluate the sub-sidized program’s effects on aide retention. North Car-olina also intends to develop a statewide mentoringprogram for NAs and home care workers, and the NorthCarolina General Assembly appropriated $500,000 forthe State Board of Community Colleges to develop on-site internet training in nursing homes and other inno-vative programs to help increase recruitment andretention.

Developing New Worker Pools

Given the current labor shortage and projections that thepool will continue to shrink over time relative toincreased demand, states are looking for alternativesources of workers. Some states have already experi-mented with attracting high school students to the fieldthrough programs established by the School to WorkOpportunities Act of 1994. Wisconsin, for example,received funds to create a Youth Apprenticeship Programfor NAs in nursing homes and assisted living. SeveralColorado public high schools created a specific NAtraining curriculum through the state’s School-to-CareerPathway program.

Many states, including New Jersey, New Mexico,Florida, and Arkansas, are trying to broaden the pool ofpotential aides by considering former welfare recipientsas candidates (NCDFS 1999). New York has used someof its Welfare-to-Work grants to develop training pro-grams for former welfare recipients and to encourageplacement in a range of long-term care settings. Arecent NYAHSA (2000) survey of its members foundthat providers have had mixed results with this popu-lation. While turnover rates were no higher for formerwelfare recipients than for other workers, someproviders expressed concern about not being able toadequately screen out inappropriate candidates. Thisproblem translated into wasted training and adminis-trative costs.

Data from one study of a targeted NA training pro-gram offered by the New England Gerontology Acad-emy, a consortium of public and private institutions ofhigher education in Rhode Island, substantiate problemswith relying on former welfare recipients (Filinson1994). The training program consisted of an intensivethree-week, 120-hour curriculum covering a range ofclinical, ethical, and management issues. Clinicalplacements in nursing homes alternated with didactictraining, beginning on the fourth day, for a total of 40 hours of clinical training. Special efforts were madeto recruit displaced (divorced) homemakers, welfarerecipients, immigrants, and other disadvantaged groups.Staff provided child care and transportation assistance.In addition, efforts were made to help graduates find fur-ther education. Students were not required to paytuition, and received their uniforms and shoes free ofcharge. The researcher sent questionnaires to 460 grad-uates of the program, with a 90 percent response rate.The impact of training was measured by employment atthree and six months following graduation, currentemployment status, public assistance status, and educa-tion or training pursued after the program. The most sig-nificant predictor of success was being a nonrecipient ofpublic assistance at entry. The training programappeared to be best suited for those in transition—homemakers recovering from a divorce, the recentlyunemployed, and new immigrants—and inadequate forthose who have been more permanently removed fromthe labor force.

On the other hand, many providers have had positiveexperiences with the welfare-to-work strategy. The Ser-vice Employees International Union (SEIU) Local 250developed a nurse aide training program in Californiathat draws primarily from a pool of former welfare recip-ients. All participants must complete a two-week jobreadiness course, followed by an intensive eight-weektraining program that addresses clinical and other jobskills, as well as a range of issues, such as how to deal withdiversity of residents and staff, and personal skills devel-opment (e.g., money management). Graduating traineesare guaranteed a job in a nursing home, and are paid aregular NA salary during the training period. In its initialyear, the program graduated 14 participants, all of whombecame NAs.

In the early 1990s, the Colorado public school systemexperimented with a novel but somewhat risky strategy:

28

WhoWill Care

for Us?

partnering with local homeless shelters to recruit and train NAs. “Operation Opportunity” offered a 100-hour, fast-track curriculum to pre-screened home-less individuals. The program was a community collab-oration: Homeless shelters provided training in job skillsand counseling; local nursing students served as men-tors; nursing homes offered clinical space; and local busi-nesses provided cash grants to help support the program.In 1990, 91 homeless people were trained, with an 81 percent employment rate. There was no formalevaluation, and the current status of this program isunknown.

In 1997, the Borough of Manhattan CommunityCollege (BMCC) in New York City developed a directcare worker training demonstration funded by the U.S.Department of Labor’s Employment and TrainingAdministration (Melendez and Suarez 2001). NineteenHispanic students completed a six-month program ofbilingual vocational training to become paraprofession-als in the field of mental retardation and developmentaldisabilities. Designed and taught by instructors withyears of practical experience in the field, the programprovided training, financial, and academic assistance andan internship in a community residence or treatmentagency. It also offered ongoing supervision and advocacyservices for participating students. The program wasdesigned as an entry point for a career ladder in thehealth industry, offering English language skill develop-ment in the context of job-related content and basic aca-demic skills. To structure contextual and experientiallearning, this demonstration combined classroominstruction with a 126-hour workplace internship. Bythe end of the program, students were matched withemployers and also earned state certifications and threecredits toward a college degree.

Evaluators found that 80 percent of the studentscompleted the program, and 63 percent were placed injobs. Interviews with program staff, students, andemployers indicated that the initial success of this effortwas based on a strict selection of students who hadreceived prior orientation and counseling, the availabil-ity of support services, and the active participation ofand connection to employers and the industry. Thewhole curriculum was designed to integrate vocationaleducation with English as a Second Language and otherscientific concepts necessary to work in the mentalretardation field.

Injury and Accident Prevention

Since worker injury and accident rates may be a deter-rent to recruitment and retention as well as a barrier toquality of care, states should pay attention to this aspectof the workforce issue. In the decade prior to 1993,Maine had one of the worst rates of workplace injuriesin the nation. The Maine OSHA office developed a pilotto target the 200 employers in the state that were expe-riencing the highest number of injuries, illnesses, andfatalities in 1991. Twenty-two nursing homes wereamong the 40 health care industry employers targetedthrough this project (Wise 1996). Those who agreed toparticipate were placed on a Secondary Inspection List.The major incentive for participation was the oppor-tunity to develop a relationship with OSHA based onthe premise that if the employers were proactive, thenOSHA would recognize that effort, assist whenever pos-sible, and avoid issuing citations and penalties if theemployers were operating in good faith. Employersagreed to implement comprehensive safety and healthprograms with employee involvement, designed toreduce injuries and accidents and bring the workplaceinto compliance with current OSHA standards.

The Maine Department of Labor’s Safety and HealthConsultation Service provided assistance to the nursinghomes, including technical presentations to assist in thetransfer of knowledge about “best practices.” Nursinghomes established injury prevention programs aimed atreducing musculoskeletal stress, primarily by eliminat-ing single-person lifting/moving of residents. A review ofthe injury and illness data for the 40 health care facili-ties, including the nursing homes, between 1991 and1996 indicated that 63 percent reduced their injuryrates. This program is still operational, and has receivedthe Innovations in American Government Award fromthe Ford Foundation.

Involvement of Public Authorities

Independent home care and personal care workers notemployed by a formal organization have few avenues foraddressing issues related to wages, benefits, and job qual-ity and security. Consumers who choose to direct theirworkers also need assistance in fulfilling their role asemployers. In the early 1990s, California consumers andworkers were looking for ways to improve the publicly

29

WhoWill Care

for Us?

funded In-Home Supportive Services program, in which84 percent of clients received care from independentproviders (San Francisco IHSS Public Authority 1998).Barriers to quality included difficulty finding screenedworkers, very low wages and few fringe benefits, and alack of training opportunities. In 1995, the Board ofSupervisors of San Francisco City and County voted tocreate the IHSS Public Authority, a quasi-governmentalagency with four objectives: to create and operate a cen-tral registry of screened workers; to provide for andarrange training and support services for consumers andworkers; to become the employer of record for IHSSindependent providers; and to provide formal opportu-nities for consumer and worker leadership in programand policy development. Other California counties withpublic IHSS authorities include Los Angeles, Alameda,and Sacramento. San Francisco collaborates with theseother public authority councils to address commonissues such as how to increase wages and benefits.

Building a Positive Image

In 1999, the Wisconsin Bureau of Aging and Long-TermCare Resources awarded grants to 28 counties throughits Community Options Program to help strengthen orexpand the workforce serving community long-termsupport participants. Believing that the shortage of long-term care workers is an issue of more than wage andbenefits, the Kenosha County Division on Aging and theKenosha County Long-Term Care Staffing Task Forceused their grant to develop a campaign to improve theimage of work in this field (KCDHS 2001). This initia-tive targeted four groups: newly retired or recently wid-owed adults looking to supplement income or fill emptyhours; college students looking for part-time work orhigh school students looking for job options; retail orfood-service workers looking for more meaningful jobs;and homemakers looking to be paid for their caregivingskills. A community outreach specialist worked with asocial marketing consultant and a community advisorycommittee to develop the campaign strategy, logo andslogan, and dissemination plan. Strategies includedmailing postcards; posting ads in the newspaper and onthe radio, billboards, and bus boards; distributingposters, including information in payroll slips andchurch bulletin inserts; and distributing notepads andnote cards. All materials featured a number to call for

information about jobs and training. A project coordi-nator was hired to do outreach presentations, assist withcalls, collect campaign data, develop training opportu-nities, and forge relationships with employers.

The project’s gerontological consultant conducted adescriptive pre-post evaluation (no control or compari-son group) that examined retention, turnover, andworker satisfaction. Findings suggest that the campaignmay have contributed to increased retention rates andimproved employee attitudes in a range of long-termcare settings. The campaign was less effective in increas-ing the number of new applicants or reducing theturnover among newer employees. It did, however, resultin more inquiries and enrollees for the local technicalcollege’s nursing assistant classes. The evaluation alsofound that lower-cost marketing techniques (e.g.,mailing postcards) were more effective than moresophisticated, multi-media advertising. The campaignorganizers are now exploring the possibility of astatewide replication of this imitative.

Provider Initiatives

Providers across the long-term care continuum haveexperimented with a range of interventions to enhancetheir ability to recruit and retain workers and to developa quality workforce (Straker and Atchley 1999;NYAHSA 2000). Nursing home, home care, and resi-dential care providers are responding to the current laborshortage by offering signing, retention, and referralbonuses; annual raises; subsidized child care and trans-portation; tuition assistance; and other financial in-centives to attract frontline workers. Many haveimplemented special recognition and award programs,and have instituted career ladders to encourage workersto remain with their organization. Providers have alsodeveloped special training programs focusing on specificclinical or management issues or special populations,such as people with dementia. Some have created men-toring and peer support initiatives to enhance workers’self-image and to encourage them to grow in their jobs.

The literature contains descriptions of programs innursing home and home care settings that haveattempted to address problems related to the recruit-ment, retention, and ongoing maintenance of the para-professional long-term care workforce. The vast majorityof these initiatives have not been evaluated, so these “best

30

WhoWill Care

for Us?

practices” are meant to be illustrative rather thancomprehensive.

In the nursing home industry, the Pioneer homesapproach to culture change in long-term care is receiv-ing attention from providers, consumer advocates, poli-cymakers, and the media. Nursing Home Pioneers is aninformal association of providers who have a sharedvision of how life and care in facilities must be trans-formed. The media have extolled the virtues of the EdenAlternative, a model developed by Dr. William Thomasto combat loneliness, helplessness, and boredom in nurs-ing facilities. While not specifically focused on recruit-ing and retaining workers, this modelcelebrates community by linking thefacility to the outside world—plants and animals abound, chil-dren interact with residents,and workers are empoweredas an essential part of thecare team. Several states,including New Jersey,New York, and Texas,have provided financialincentives for providersto “edenize” their facili-ties. Evaluation projectsare currently underwayat some of these sites, but findings are not yetavailable.

Some Pioneer homes (e.g.,Evergreen and Lakeview in Wis-consin; Fairport Baptist Home inRochester, NY; Mount St. Vincent Nurs-ing Home in Seattle) have focused special atten-tion on innovative environmental design as well assignificant management transformation. Each facilityhas created neighborhood units, with kitchen and din-ing areas serving as focal points. NAs are empowered todevelop teams and to provide individualized care andattention to residents. All food is cooked to order and theresidents are encouraged to participate in meal prepara-tion. Housekeeping staff are assigned to “neighbor-hoods” and are cross-trained as NAs.

Researchers at the Institute for the Future of AgingServices, the University of Wisconsin-Madison, andTexas A&M University are currently evaluating the

Wellspring model of quality improvement in Wisconsin(Reinhard and Stone 2001). Wellspring is a consortiumof 11 freestanding nursing homes that developed analliance in the mid-1990s to facilitate group purchasingand to market their services to managed care. While themanaged care opportunity never materialized, the con-sortium soon recognized their collective potential forimproving quality in their respective facilities. Top man-agement made a philosophical and financial commit-ment to a continuous quality improvement initiativethrough the consortium. The centerpiece of this activityis a major management change/job redesign effort, in

which NAs become essential members of careteams and are empowered to make deci-

sions that affect the quality of lifefor residents and workers. The

consortium hired a geriatricnurse practitioner, who has

developed a series of clini-cal and managementtraining modules andwho serves as the liaisonbetween managementand nursing staff acrossfacilities. Professionaland line staff (i.e.,

administrative, nursing,and non-nursing staff )

receive intensive trainingoffsite, and, through a train-

the-trainer and mentoringapproach, all staff members learn

to work in teams around a range ofclinical protocols (e.g., incontinence, skin

care, and pain management). Nursing coordina-tors and NAs collect data related to these clinicaldomains and periodically analyze, assess, and comparetheir outcomes within and across the Wellspring facili-ties. This model has already expanded to several otheralliances in Texas and Illinois. Findings from the Com-monwealth Fund–supported evaluation are anticipatedin late 2001.

The St. Martin’s Outreach Certified Nursing Assis-tant Program, established in 1994 in Hartford, Con-necticut, by St. Martin’s Episcopal Church and theSeabury Retirement Community, was designed todevelop job opportunities for the primarily low-income,

31

WhoWill Care

for Us?

West Indian population in the surrounding area.Seabury has helped to develop this state-licensed NAtraining program and has made its skilled nursing andassisted living center available as the clinical training sitefor this outreach program. Classroom and seminar spaceare also provided at the retirement community. As of1999, 250 students had graduated from the training pro-gram (with a 200-person waiting list), and the majorityare gainfully employed as aides in nursing homes,assisted living, or home health care. This program’s suc-cess has been measured as a reduction in unemploymentin Hartford’s large West Indian community.

An innovative program at Luther Manor inDubuque, Iowa, trains experienced NAs in the skillsthey need to effectively mentor new nursing assistants.This user-friendly program gives participants informa-tion about teaching methods, such as effective presenta-tion and communication skills, providing constructivefeedback, and managing individual behavior. LutherManor has reported improved retention of new hires,higher morale among NA staff, and improved quality ofcare as a result of the program, which is being promotednationally and is currently being piloted in several otherstates.

In 1989, the Masonic Home of New Jersey instituteda preceptor program for experienced NAs to orient newfrontline workers to the unit, act as a clinical resource,aid in the socialization of new staff members, assess newworkers’ performance, and provide positive feedback aswell as suggestions for improvement (Shemansky 1998).Mentors receive two days of training and then areassigned to a new NA, with whom they work closelyduring the orientation period. The preceptors meet reg-ularly to share progress and problems, and participate inprogram evaluations every six months. During the men-toring period, the preceptors receive an additional 50 cents an hour, as well as recognition with identifica-tion tags. Internal evaluations of the program over thepast nine years show a reduction in turnover rates andhigh satisfaction ratings among old and new employees.This program received the 1997 National GeriatricNursing Association Innovations in Practice Award.

In the early 1990s, Genesis Eldercare, a multi-facilityprovider headquartered in Pennsylvania, developed acomprehensive three-level career ladder program. Geri-atric Nursing Assistant Specialists (Level 1) had to com-plete a six-month training program at a local community

college. Senior Nursing Assistants (Level 2) served asteam leaders for NAs after 30 hours of leadership train-ing. Senior Aide Coordinators (Level 3) assumed man-agement responsibilities for teams of NAs and served asliaisons between direct care workers and nurse supervi-sor. Although this program was never formally evalu-ated, Genesis management staff reported a decrease inturnover rates and improved worker morale as a result ofthe implementation of this career ladder initiative.Unfortunately, financial problems and corporate restruc-turing have reduced the commitment of top manage-ment to this program, and its future is uncertain.

The Wisconsin Alzheimer’s Institute at the Universityof Wisconsin–Madison is working with three assistedliving providers and one home care agency to test theefficacy of a multi-faceted approach to recruiting andretaining frontline workers in residential care. This pro-ject, sponsored by the John A. Hartford, RetirementResearch, and Helen Bader Foundations, combinesintensive life-skill training (adapted from a North Car-olina program for training child care workers), peermentoring, and financial incentives from employers.Researchers at the University of Wisconsin are currentlyevaluating this project, including the extent to which theintervention reduces turnover and increases retentionrates.

Cooperative Home Care Associates (CHCA),founded in 1985 in the Bronx and replicated in Bostonand Philadelphia, employs more than 400 workers, withan annual turnover rate of 18 percent (Wilner and Wyatt1998). After three months’ employment, the worker canpurchase shares in the company. All employees are mem-bers of worker councils; 6 of the 10 board members areworker-owners. Prospective employees are carefullyscreened and receive extensive training. Their wages arehigher than the average for home care aides, and theyreceive fringe benefits as well as guaranteed hours. Work-ers are encouraged to advance their careers and earnhigher pay and status as associate trainers or by assum-ing administrative positions. Former welfare recipientscomprise almost 85 percent of the workforce. The orga-nization’s success at enterprise development distin-guishes it from many other efforts at job training or atpromoting transition from welfare to work. It has inte-grated its training program with its capacity to create andsustain employment opportunities and its social goalswith business planning and management skills. As noted

32

WhoWill Care

for Us?

by Pitegoff (1999,112), “It is fundamentally an eco-nomic development approach driven by social values—an employer-based sectoral strategy to create quality jobsfor workers and upgrade the status of the home healthcare work force, to provide quality home care for clients,and to demonstrate the capacity of poor working womenfor sophisticated enterprise.”

As part of a demonstration project, the HuntingtonMemorial Hospital Senior Care Network in Pasadena,California, built a consortium of eight home care agen-cies in the early 1990s to recruit, train, and place work-ers and to collectively develop retention strategies(Beeman 1994). Formerly competitors, theseagencies developed common standards andprocessed all referrals through one orga-nization. Unfortunately, the formalconsortium dissolved after thedemonstration ended, althoughanecdotal reports suggest thatthe agencies continue to infor-mally share ideas and practices.

Worker Initiatives

Many frontline long-termcare workers have developedtheir own initiatives to im-prove their status, compensa-tion, and job opportunities. TheIowa Caregivers Association is aformal membership organization ofcertified nursing assistants that advo-cates for workers in Iowa and otherstates, offers targeted education and training,and conducts research from the worker perspec-tive. The National Network of Career Nursing Assis-tants, created in Ohio nearly 25 years ago, providesinformation and education for workers and conductsboth leadership conferences and national forums onnursing assistant issues. The Direct Care Alliance(DCA), housed at the Paraprofessional Healthcare Insti-tute in the South Bronx, is a new national grassrootscoalition of direct care workers, consumers of long-termcare, and concerned healthcare providers. They havecome together to pursue a common goal of stimulatingbroad-based reforms—within both public policy andindustry practice—to ensure a stable, valued, and well-

trained direct care workforce that can meet consumers’demands for high-quality paraprofessional services.DCA has begun several activities, including cross-stake-holder dialogues, public education, advocacy, and thedevelopment of a national clearinghouse on legislation,regulations, and best practices.

Unions in general, and the Service Employees Inter-national Union (SEIU) in particular, have made majorinroads in organizing both nursing home and home careworkers in selected states across the country. SEIU hasfocused special attention on organizing California’s inde-pendent home care workers, who are some of the lowest-

paid individuals in the field and who have hadgreat difficulty obtaining benefits and

training. In addition to using collectivebargaining, SEIU has developed sev-

eral innovative training programswith local providers and hasexplored various strategies forexpanding health insurancecoverage to this population.

Although they have devel-oped collaborative relation-ships with the unions in somecommunities, many providersstrongly resist unionization.For example, Human Rights

Watch cited several case studiesof significant provider resistance

to unionization among southFlorida nursing homes (Compa

2000). Compa also reported the viewthat the problem is related to excessive

regulation, not unionization, quoting onemanager as saying, “We are very pro-worker, but

when a union comes in they can’t do anything about thewage base or benefit base. . . . Union facilities get poorersurveys from state regulators because unions make it hardto get rid of bad employees. . . . It’s all sales and market-ing. The union comes in and promises everything. . . .They promise what they can’t deliver.”

Developing Policy through a Research andDemonstration Agenda

This broad overview of the frontline long-term careissues has identified a number of knowledge and infor-

33

WhoWill Care

for Us?

mation gaps that need to be addressed if we are to createpolicies that further the development of a qualified, sus-tainable workforce. Some would argue that research sup-port is a wasted investment, that we know what to doand just need to move forward. But as this discussion hasemphasized, the labor shortage and quality problemshave existed for the past 20 years and are only expectedto worsen in the future. Consequently, we do need tohave a better understanding of the sources of the prob-lem, the interactive effects of policy interventions, andthe elements of success and failure in the differentapproaches to solving the problem.

First, we need an updated profile of the frontlineworkforce across settings—workers’ demographic char-acteristics, wages and benefits, racial and ethnic diversity,geographic distribution, levels of education and healthliteracy, and other critical information—to help us makeinformed policy decisions. We need to compare workers’characteristics, skills, training, and responsibilities acrosssettings to determine the extent to which potential work-ers are similar and could be affected by similar initiativessuch as cross-training.

We also need to better understand the magnitude ofthe long-term problem in developing this workforce, thebarriers to such development, and the possible conse-quences of different policy interactions on the natureand scope of the problem. The workforce issue is com-plicated and complex, and requires multidisciplinaryresearch that examines both micro- and macro-level fac-tors and their interactions.

Although states are forging ahead with a number ofstrategies to ameliorate the short-term crisis, there is littleevaluative information to guide these decisions. What canwe learn from state initiatives? What impact have wagepass-throughs, career ladder strategies, enhanced trainingefforts, and other mechanisms had on recruitment, reten-tion, and quality? We also need to look at whether andhow such strategies can be replicated in other areas andhow best to translate findings into practice.

The literature is replete with self-reported “best prac-tices,” but there is very little information about whatreally works. Although policymakers and providers aresearching for a “magic bullet,” we all know it does notexist, so we need to have a better understanding of theconstellation of interventions that is optimal for devel-oping and sustaining the frontline workforce. Coming

to such an understanding will involve developing bettermeasures of both the interventions and success. Assum-ing we do identify the optimal set of interventions, wewill also need to figure out how to sustain the successover time.

Finally, we need to explore creative ways of develop-ing new pools of workers who can meet the demand forthese services in the future. Large influxes of immigrantsor cadres of former welfare recipients will not solve theproblem. It is imperative that we develop and test newstrategies for expanding the potential pool, includingexposing young students and elderly retirees to the pos-sibility of obtaining quality jobs that improve the lives ofthe people in their care.

Federal and state agencies and private foundationshave begun to invest in applied research that will helpprovide some solutions to this dilemma. The U.S.Department of Health and Human Services’ (DHHS)Health Resources and Services Administration is sup-porting several efforts to explore trends in the supply anddemand for frontline workers, and the Department ofLabor is funding training research and demonstrationsin injury prevention in long-term care settings. TheAgency for Healthcare Research and Quality has severalnew initiatives focused on patient safety and worker con-ditions in a range of settings and has sponsored a work-shop and teleconference on the issue for state policyofficials. DHHS’ Office of the Assistant Secretary forPlanning and Evaluation has collaborated with theRobert Wood Johnson Foundation to support three pan-els that will examine in more detail a number of theissues raised in this paper. Other private foundations,including the Commonwealth Fund, the John A. Hart-ford Foundation, the Mott Foundation the United Hos-pital Fund, Retirement Research Foundation, the HelenBader Foundation, the California Endowment and theCalifornia Healthcare Foundation, and the Kate B.Reynolds Foundation, have also supported efforts in thisarea.

The future of the frontline long-term care worker is,in many ways, a barometer for the health of our agingcommunities. Stakeholders at the federal, state, and locallevels and in the public and private sectors must cometogether to find creative solutions. We must bridge theworlds of policy, practice, and research to develop viablealternatives.

34

WhoWill Care

for Us?

References

AAHSA. See American Association of Homes and Ser-vices for the Aging.

AHCA. See American Health Care Association.Academy for Health Services Research and Policy. 2001.

State of the States. Prepared for the Robert WoodJohnson Foundation’s State Coverage Initiatives,Washington, D.C.: Academy for Health ServicesResearch and Health Policy.

Alberga, J. 2001. “Wisconsin’s BadgerCare ProgramOffers Innovative Approach for Family Coverage.”State Coverage Initiatives of the Robert Wood John-son Foundation. Washington, D.C.: Academy forHealth Services Research and Health Policy.

Alecxih, L.M. 1997. “What Is It, Who Needs It, andWho Provides It?” In Long-Term Care: Knowing theRisk, Paying the Price, edited by B.L. Bryd. Washing-ton, D.C.: Health Insurance Association of America.

American Association of Homes and Services for theAging. 2000. “Lessons Learned in the Staffing Short-age Trenches.” Currents 15 (6): 1, 9.

American Health Care Association. 1999. InfoPack;Staffing Issues in Long Term Care Catalog #5113.

Atchley, R.C. 1996. Frontline Workers in LTC Recruit-ment, Retention and Turnover: Issues in an Era ofRapid Growth. Oxford, OH: Scripps GerontologyCenter.

Banaszak-Holl, J., and M.A. Hines. 1996. “Factors Asso-ciated With Nursing Home Staff Turnover.” TheGerontologist 36 (4): 512–17.

Bayer, E., R. Stone, and R. Friedland. 1993. Developingan Effective and Caring Long-Term Care Workforce—Final Report to Kaiser Family Foundation. Washing-ton, D.C.: Project Hope Center for Health Affairs.

Becker-Reems, E.D. 1994. Self-Managed Work Teams inHealth Care Organizations. Chicago, IL: AmericanHospital Publications.

Beeman, M. 1994. “Building a Consortium of DiverseHome Care Agencies.” In Challenges and Innovationsin Home Care, edited by J. Handy and C.K. Schuer-man. San Francisco: University of California.

Benjamin, A.E., R.E. Matthias, and T. Franke. 2000.“Comparing Consumer-Directed and Agency Mod-els for Providing Support Services at Home.” HealthServices Research 35 (1, Part II): 351–66.

BLS. See Bureau of Labor Statistics.

Bishop, C. 1998. “Health Care Cost Containment:What It Will Mean for Workers and Local Econ-omies.” Public Health Reports 13 (2): 203–13.

Bowers, B.J., and M. Becker. 1992. “Nursing Assistantsin Nursing Homes: The Relationship between Orga-nization and Quality.” The Gerontologist 32 (3):360–66

Brannon, D., M.A. Smyer, M.D. Cohn, L. Borchardt,J.A. Landry, G.M. Jay, A.J. Garfein, E. Malonebeach,and C. Walls. 1988. “A Job Diagnostic Survey ofNursing Home Caregivers: Implications for JobRedesign.” The Gerontologist 28 (2): 246–52.

Bucher, M. 2000. “FANA Reviews Florida’s CNAStudy.” Journal of Nurses’ Assistants October: 12–14.

Burbridge, L. 1993. “The Labor Market for Home CareWorkers: Demand, Supply and Institutional Bar-riers.” The Gerontologist 33 (1): 41–46.

Bureau of Labor Statistics. 2000. “The Employment Sit-uation: May 2000.” United States Department ofLabor News. Washington, D.C.: U.S. Department ofLabor.

———. 1998–1999. Occupational Outlook Handbook.Washington, D.C.: U.S. Department of Labor.

Burgio, L.D., and K. Seilley. 1994. “Caregiver Perfor-mance in the Nursing Home: The Use of Staff Train-ing and Management Procedures.” Seminars in Speechand Language 15 (1): 313–22.

Burgio, L.D., and K.L. Burgio. 1990. “Institutional StaffTraining and Management: A Review of the Litera-ture and a model for Geriatric Long-Term Care.”International Journal of Aging and Human Develop-ment 30: 287–302.

Camarota, S.A. 1998. “The Wages of Immigration: TheEffects on the Low-Skilled Labor Market.” Washing-ton, D.C.: Center for Immigration Studies.

Christopherson, S. 1997. Childcare and Elderly Care:What Occupational Opportunities for Women? LaborMarket and Social Policy Occasional Papers No. 27.Paris: Organization for Economic Co-Operation andDevelopment.

Clark, R., J. Turek-Brezina, C. Hawes, and C. Chu.1994. “The Supply of Board and Care Holes: Resultsfrom the 1990 National Health Provider Inventory.”Presentation at the Gerontological Society of Amer-ica, Atlanta, GA.

Compa, L. 2000. Unfair Advantage: Worker Freedom ofAssociation in the United States under International

35

WhoWill Care

for Us?

Human Rights and Standards. New York: HumanRights Watch.

Cousineau, M.R. 2000. Providing Health Care Insuranceto IHSS Providers (Home Care Workers) in LA County.Report to the California Health Care Foundation.

Crown, W.H. 1994. “A National Profile of Home Care,Nursing Home, and Hospital Aides.” Generations 18(3): 29–33.

Crown, W.H, D.A. Ahlburg, and M. MacAdam. 1995.“The Demographic, Employment Characteristics ofHome Care Aide, and Other Workers.” The Geron-tologist 35 (2): 162–70.

Crown, W.H, D.A. Ahlburg, M. MacAdam, and E. Sad-owsky. 1992. Health Aides: Characteristics of AidesEmployed in Hospital. National Health Service: HomeCare. Waltham, MA: Brandeis University.

Feldman, P.H. 1997. “Labor Market Issues in HomeCare, Nursing Homes and Home Care.” In Home-Based Care for a New Century, edited by D.M. Foxand C. Raphael (155–83). Malden, Mass.: Black MillPublishing Inc.

———. 1994. “Dead End Work or Motivating Job?Prospects for Front-Line Paraprofessional Workers inLong-Term Care” Generations 18 (3): 5–10.

———. 1993. “Work Life Improvements for HomeCare Workers: Impact and Feasibility.” Gerontologist33 (1): 47–54.

Feldman, P.H, A. Sapienza, and N. Kane. 1990. “WhoCares for Them? Workers in the Home Care Industry.”Westport, Conn.: Greenwood Press.

Filinson, R. 1994. “An Evaluation of a GerontologicalTraining Program for Nursing Assistants.” The Geron-tologist 34 (6): 839–43.

Fix, M., and J.S. Passel. 1994. Immigration and Immi-grants: Setting the Record Straight. Washington, D.C.:The Urban Institute.

Frank, B.W., and S.L. Dawson. 2000. “Health CareIssues in Massachusetts.” Issue brief prepared for theMassachusetts Health Policy Forum, June.

GAO. See General Accounting Office.General Accounting Office. 2000. Nursing Homes: Sus-

tained Efforts are Essential to Realize Potential Of theQuality Initiatives. GAO/HEHS–00-197. Washing-ton, D.C.: General Accounting Office.

Hawes, C., M. Rose, C.D. Phillips, and V. Lannac-chione. 1999. A National Study of Assisted Living forthe Frail Elderly. Beachwood, OH: Menorah ParkCenter for the Aging.

Hawkins, A.M., L.D. Burgio, A. Langford, and B.T.Engel. 1992. “The Effects of Verbal and WrittenSupervisory Feedback on Staff in Compliance withAssigned Prompted Voiding in a Nursing Home.”Journal of Organizational Behavior Management 13:373–76.

HCIA-Sachs and Arthur Andersen LLP. 2000. TheGuide to the Nursing Home Industry. Baltimore:HCIA, Inc.

Hoechst Marion Roussel. 1996. 1996 Institutional Digest.Kansas City, Missouri: Hoechst Marion Roussel.

Home Care Association of New York State, Inc. 2000.“New York Is Experiencing a Shortage in Personnelfor Home and Community-Based Services.” Albany,NY: Home Care Association of New York State, Inc.

Judy, R. 2000. “Testimony to the Subcommittee onOversight and Investigation, Committee on Educa-tion and the Workforce.” U. S. House of Representa-tives, February 17, 2000. Indianapolis: HudsonInstitute, Indiana Press.

Kane, R. 2000. “Long-Term Care and a Good Qualityof Life: Bringing Them Closer Together.” The KentAward Address, 53rd Annual Meeting of the Geron-tological Society of America, Washington, D.C.

———. 1997. “Boundaries of Home Care: Can aHome Care Approach Transform Long-Term CareInstitutions?” In Home-Based Care for a New Century,edited by D. Fox and C. Raphael. (23–46). Malden,Mass: Black Mill Publishing Inc.

Kapp, M.B. 1997. “Who is Responsible for This?Assigning Rights and Consequences on Elder Care.”Journal of Aging and Social Policy 9 (2): 51–66.

Kayser-Jones, J., and E.S. Schell. 1997. “The Effect ofStaffing and the Availability of Care at Mealtime.”Nursing Outlook 36 (7): 267–70.

KCDHS. See Kenosha County Department of HumanServices.

Kenosha County Department of Human Services. 2001.Wisconsin Community Links Workforce Projects,1999–2000. Kenosha, WI: Kenosha County Depart-ment of Human Services.

Konrad, T.R. 1999. “Where Have All the Nurses AidesGone?” Unpublished paper. North Carolina Instituteon Aging.

Kramer, A., T. Eilertsen, M. Lin, and E. Hutt. 2000.“Effects of Nurse Staffing on Hospital Transfer Qual-ity Measures for New Admissions.” In Health Care

36

WhoWill Care

for Us?

Financing Administration Report to Congress,Appropriateness of Minimum Nurse Staffing Ratios inNursing Homes.

Kunkel, C.R., and R.A. Applebaum. 1992. “Estimatingthe Prevalence of Long-Term Disability for an AgingSociety.” Journal of Gerontology: Social Sciences 47 (5):S253–60.

Leon, J., and S. Franco. 1998. Home- and Community–Based Workforce. Final report prepared for the Henry J.Kaiser Foundation. Bethesda, MD: Project Hope.

Leon, J., J. Marainen, and J. Marcotte. 2001. Penn-sylvania’s Frontline Workers in Long-Term Care: TheProvider Organization Perspective. Jenkintown, PA:Polisher Geriatric Institute at the Philadelphia Geri-atric Center.

Long, M., and M.J. Long. 1998. Identifying BehaviorChange Intervention Points to Improve Staff Retentionin Nursing Homes. Report and Recommendations tothe Kansas Association of Homes and Services for theAging.

MacAdam, M. 1993. “Home Care Reimbursement:Effects on Personnel.” The Gerontologist 33 (1):55–63.

Manard, B., and J. Feder. 1998. Repeal of the BorenAmendment: Potential Implications for Long-TermCare. New York: The Commonwealth Fund.

Manchester, J. 1997. “Aging Boomers and Retirement:Who’s at Risk?” Generations 21 (2):19–22.

Manton, K.G., L. Corder, and E. Stallard. 1997.“Chronic Disability Trends in Elderly United StatesPopulations: 1982–1994.” Proceedings of the NationalAcademy of Sciences of the USA 94: 2593–98.

Massachusetts Health Policy Forum. 2000. “HealthCare Workforce Issues in Massachusetts.” Issue Brief,Schneider Institute for Health Policy at the HellerSchool, Brandeis University.

Melendez, E., and C. Suarez. 2001. Opening CollegeDoors for Disadvantaged Hispanics: An Assessment ofEffective Programs and Practices. Paper presented at the Workforce Investment Institute Conference,Phoenix, AZ, January 24–27.

MHPF. See Massachusetts Health Policy Forum.National Academy on Aging. 1997. Facts on Long-Term

Care. Washington, D.C.: National Academy onAging.

National Citizens’ Coalition for Nursing Home Reform.2000. “Proposed Minimum Staffing Standards for

Nursing Homes.” Washington, D.C.: National Citi-zens’ Coalition for Nursing Home Reform.

NCCNHR. See National Citizens’ Coalition for Nurs-ing Home Reform.

NCDFS. See North Carolina Division of FacilityServices.

New York Association of Homes and Services for theAging. 2000. The Staffing Crisis in New York’s Contin-uing Care System. Albany, NY: New York Associationof Homes and Services for the Aging.

North Carolina Division of Facility Services. 1999.Comparing State Efforts to Address the Recruitment andRetention of Nurse Aide and Other ParaprofessionalAide Workers. North Carolina Division of FacilityServices.

———. 2000. “Results of a Follow-Up Survey to Stateson Wage Supplements for Medicaid and Other PublicSettings.” NCDFS Web site: http://facility-services.state.nc.us.

NYAHSA. See New York Association of Homes and Ser-vices for the Aging.

Paraprofessional Healthcare Institute. 2001. Prospects forParaprofessional Health Care Workers: The UnnecessaryCrisis in Long-Term Care. Submitted to the DomesticStrategy Group of the Aspen Institute.

———. 2000. National Survey on State Initiatives toImprove Paraprofessional Health Care Employment.Unpublished paper.

PHI. See Paraprofessional Healthcare Institute.Pillemer, K. 1996. Solving the Frontline Crisis in Long-

Term Care. Cambridge, MA: Frontline Publishing Co.Pitegoff, P. 1999. “Shaping Regional Economies to Sus-

tain Quality Work: The Cooperative Health CareNetwork. In Hard Labor, Women, and Work in thePost-Welfare Era, edited by J.F. Handler and L. White(96–115). Armonk, NY: M. E. Sharpe.

Reid, D.H., M.B. Parsons, and C.W. Green. 1989. StaffManagement in Human Services: Behavioral Researchand Application. Springfield, IL: Charles C. Thomas.

Reinhard, S.C., and R. Stone. 2001. Promoting Qualityin Nursing Homes: The Wellspring Model. Field Report.New York: The Commonwealth Fund.

Rhoades, J.H., and N.A. Krauss. 1999. Nursing HomeTrends, 1987 and 1996. Agency for Health Care Pol-icy and Research. AHCPR Pub. No. 99–0032.

Robert Wood Johnson Foundation. 1996. Chronic Carein America: A 21st Century Challenge. Eatontown, NJ:Robert Wood Johnson Foundation.

37

WhoWill Care

for Us?

Rogers, A., and J. Raymer. 2001. “Immigration and theRegional Demographics of the Elderly Population inthe United States.” Journal of Gerontology: SocialSciences 56B (1): 544–55.

Rimer, S. 2000. “Home Care Aides for the Frail Elderlyin Shorter Supply.” New York Times, January 3, 1A.

Ruzek, J.Y., L.E. Bloor, J.L. Anderson, M. Ngo, and theUCSF Center for Health Professions. 1999. The Hid-den Healthcare Workforce: Recognizing, Understanding,and Improving the Allied and Auxiliary Work Force. San Francisco, CA: UCSF Center for the HealthProfessions.

RWJF. See Robert Wood Johnson Foundation.Sacramento Bee. 2001. “In-Home Care Workers May

Get Pay Raises.” Sacramento Bee, April 25, B3.San Francisco IHSS Public Authority. 1998.The First

Report. San Francisco, CA: San Francisco IHSS Pub-lic Authority.

Schnelle, J.F., D. Neuman, and T. Fogarty 1990. “Man-agement of Patient Continence in Long-Term CareNursing Facilities.” The Gerontologist 30: 373–76.

Schnelle, G. F., D. Neuman, M. White, J. Abbey, K.A.Wallstrom, T. Fogarty, and M. Ory. 1993. “Main-taining Continence in Nursing Home Residentsthrough the Application of Industrial Quality Con-trol.” The Gerontologist 33: 114–21.

SEIU. See Service Employees International Union.Service Employees International Union. 1997. Caring

’til it Hurts: Nursing Home Work is Becoming the MostDangerous Job in America. Washington, D.C.: ServiceEmployees International Union.

Shemansky, C.A. 1998. “Preceptors in Long-TermCare.” Geriatric Nursing 19 (4): 232–34.

Spillman, B., N. Krauss, and B. Altman. 1997. A Com-parison of Nursing Home Resident Characteristics:1987–1996. Unpublished paper. Rockville, Md.:Agency for Health Care Policy and Research.

Stone, R.I. 2001. “Frontline Workers in Long-termCare: Research Challenges and Opportunities.” Gen-erations 25 (1): 49–57.

———. 2000. Long-Term Care for the Elderly with Dis-abilities: Current Policy, Emerging Trends, and Impli-cations for the 21st Century. New York: MilbankMemorial Fund.

Straker, J.K., and R.C. Atchley. 1999. Recruiting andRetaining Frontline Workers in Long-Term Care: UsualOrganizational Practices in Ohio. Oxford, OH:Scripps Gerontology Center.

Tilly, J., S. Goldenson, J. Kasten, C. O’Shaunghessy, R. Kelly, and G. Sidor. 2000. Long-Term Care ChartBook: Persons Served, Payors, and Spending. Washing-ton, D.C.: Congressional Research Service.

Tellis-Nayak, V., and M. Tellis-Nayak. 1988. NursingHome Exemplars of Quality: Their Paths to Excellence.Springfield, IL: Charles C. Thomas.

U.S. Bureau of the Census. 1998. “Percent of People 25Years Old and Over Who Have Completed HighSchool or College, by Race, Hispanic Origin and Sex:Selected Years, 1940–1998.” Http://www.census.gov/population/socdemo/education/tablea–02.txt.

Waidmann, T.A., and K.G. Manton. 1998. “Interna-tional Evidence on Disability Trends among theElderly.” U.S. Department of Health and HumanServices, Assistant Secretary for Planning and Eval-uation. Http://www.aspe.hhs.gov/daltcp/reports/trends.htm.

Waxman, H.M., E. Carner, and G. Berkenstock. 1984.“Job Turnover and Job Satisfaction Among NursingHome Aides.” The Gerontologist 24(5): 503–09.

White, M. 1994. “Homecare Consortium AddressesFrontline Worker Issues.” Generations 18 (3): 54–56.

Wilner, M.A., and A. Wyatt. 1998. Paraprofessionals onthe Front Lines: Improving Their Jobs—Improving theQuality of Long-Term Care. The Fifth Quality of LTCConference. Background paper prepared for theAARP LTC Initiative. Washington, D.C.: AARP.

Wise, D. 1996. “An OSHA You Could Love.” Businessand Health (October): 28–30.

Wunderlich, G.S., F. Sloan, and C.K. Davis, eds. 1996.Nursing Staff in Hospitals and Nursing Homes: Is itAdequate? Institute of Medicine: Committee on theAdequacy of Nurse Staffing in Hospitals and NursingHomes. Washington, D.C.: National Academy Press.

Yeatts, D., and R. Seward. 2000. “Reducing Turnoverand Improving Health Care in Nursing Homes: ThePotential Effects of Self-Managed Work Teams.” TheGerontologist 40 (3): 358–63.

Zahrt, L.M. 1992. “The Cost of Turnover in a HomeCare Agency.” Caring 11 (4): 60–66.

38

WhoWill Care

for Us?

Robyn Stone, a noted researcher on health care and aging policy,

established and serves as executive director of the Institute for the

Future of Aging Services, housed within the American Association of

Homes and Services for the Aging. Dr. Stone has held senior research

and policy positions in both the U.S. government and the private sec-

tor. During the Clinton administration she served in the U.S. Depart-

ment of Health and Human Services as Deputy Assistant Secretary

for Disability, Aging, and Long-Term Care Policy and as Assistant

Secretary for Aging. In the 1980s and early 1990s, she was a senior

researcher at the National Center for Health Services Research and at

Project HOPE’s Center for Health Affairs. Dr. Stone has been on the

staff of two national task forces, the 1989 Bipartisan Commission on

Comprehensive Health Care (the Pepper Commission) and the 1993

Clinton Administration Task Force on Health Care Reform.

Joshua M. Wiener is a principal research associate at the Urban Insti-

tute’s Health Policy Center, where he specializes in research on health

care for the elderly, Medicaid, and long-term care. He is the author or

editor of seven books and over 80 articles on these topics. His recent

projects include research on the long-term care workforce, the Urban

Institute’s Assessing the New Federalism project, Medicaid home and

community-based services, consumer-directed home care, and

Medicaid and end-of-life care. Prior to coming to the Urban Institute,

Dr. Wiener did policy analysis and research for the Brookings Insti-

tution, the White House, the Health Care Financing Administration,

the Massachusetts Department of Public Health, the Congressional

Budget Office, the New York State Moreland Act Commission on

Nursing Homes and Residential Facilities, and the New York City

Department of Health.

39

A B O U T T H E A U T H O R S