1. Initiatives to Improve LTC Direct Care Workforce Retention: What is the Evidence Base? Lauren D. Harris-Kojetin, PhD Institute for the Future of Aging Services www.futureofaging.org Lharris-kojetin@aahsa.org AcademyHealth Annual Research Meeting Boston, MA June 26, 2005

2. Presentation Overview Background Purpose Context/Conceptual Models Research Synthesis –Methods –Key findings on effective interventions Implications Resources

3. Background

4. “Education and training of staff, supervision, environmental conditions, attitudes and values, job satisfaction and turnover of staff, salaries and benefits, leadership, management, and organizational capacity are all essential elements affecting quality of care to residents.” IOM, Improving the Quality of Long-Term Care

5. Over 2.4 M paraprofessional LTC workers form the core of the formal LTC system Turnover ranging from 45% to over 100% Between 2002 – 2012, 888,000 more DCW jobs 27 M Americans are projected to need LTC by 2050 Significant societal factors converging  “care gap”

6. Variety of factors associated with LTC direct care workforce (DCW) recruitment & retention problems –inadequate training, job orientation & lack of mentoring –poor public image of LTC direct care workforce –low pay & insufficient benefits –few opportunities for development within the position –poor supervision –emotionally & physically hard work –workplace stress & burnout –personal life stressors –lack of respect from residents’ families –short staffing

7. Purpose

8. –States, providers & worker groups have designed & implemented a variety of initiatives intended to address DCW LTC problems –Some of these initiatives have been evaluated –Current state of evidence base on relationship between how LTC work is organized/structured & DCW turnover/retention

9. Context/Conceptual Models

10. Local Environment Labor Market Regulation Competitive Strategy Values & Beliefs Structure Profit status Chain Religious status Size Case mix Management Philosophy of Care Medical- custodial Medical- rehabilitative Regenerative Work Organization Teams Training Assignments Human Resources Practices Wages Benefits Hiring Turnover Resident Outcomes Quality of Care Quality of Life Model of Nursing Home Quality – Eaton (2000)

11. Employer-Related Factors Associated with Turnover Job Satisfaction Organizational Commitment Turnover Retention Personal Characteristics & Competing Demands Compensation & Benefits Quality of Work Environment, Job Design, Job Stress Initial & On-Going Training Employer Organizational Characteristics Adapted from Banaszak-Holl and Hines, 1996

12. Research Synthesis

13. Recent Insights about Frontline Long-Term Care Workers: A Research Synthesis 1999-2003 Lauren Harris-Kojetin, PhD Debra Lipson, MHSA Jean Fielding, MGS Kristen Kiefer, MPP Robyn I. Stone, DrPH Funded by ASPE, DHHS

14. Methods

15. Search sources: Ageline, PubMed, Internet searches, personal communications, conferences, initiatives in Stone (2001) Eligible materials: Published & gray literature Search terms (examples): LTC workforce, labor force, recruiting, paraprofessional, job tenure, work environment, intervention Timeframe: 1999 – 2003 Outcomes: turnover and/or retention Data collection: Study documents abstracted & categorized by intervention type, evaluation design & results

16. Types of Interventions Evaluated 1999 - 2003 Alternative labor pools Career ladders Culture change Enhanced staff-family communication Multi-faceted initiatives Peer mentoring Self-managed work teams Wage enhancements

17. Types of Initiatives Evaluated 1999 – 2003 (continued) 15 interventions reviewed –2 had not (yet) had outcome evaluation –2 did not measure actual turnover or retention –8 showed non-significant, negative, or inconclusive results or did not use robust quasi-experimental design –3 showed significant positive turnover/retention results using a pre-post comparison group design

18. Key Findings on Effective Interventions

19. Growing Strong Roots – Peer Mentoring Trained, experienced certified nursing assistants (CNAs) matched with new CNAs Training & manuals for project coordinators & mentors Booster training & newsletters for mentors Mentoring active 8 weeks Salary increase for mentor

20. Growing Strong Roots Evaluation Results 12 nursing homes in New York state Statistically significant improvement in retention among those mentored –18 point increase in average retention rate while increase not significant among comparison group

21. WIN A STEP UP – Education & Payment Incentives 10 modules on clinical skills, interpersonal skills, and communication Nurse aides (NAs) get $70 per completed module Facilities must agree to commit staff time & give either retention bonus ($75) or wage increase (> $0.25/hr) 3 months after completion of modules NAs who complete > 7 modules & stay at facility > 3 months after training get matching $75 bonus from WIN A STEP UP

22. WIN A STEP UP Pilot Evaluation Results 4 nursing homes, 1 home health agency, 1 adult care home in NC Annual turnover rates significantly lower for NAs in the program compared to those in the matched comparison group (15% to 32%)

23. Wellspring – Quality Improvement & Organizational Change Alliance super structure Leadership & clinical training modules Shared advanced practice nurse Coordinator in each facility Care resource teams Systematic collection & use of outcome data Non-hierarchical management philosophy

24. Wellspring Evaluation Results Wellspring facilities fared better than other Wisconsin facilities on retention & turnover –Wellspring CNA retention increased by 6% while other homes decreased by 6% –CNA turnover rates increased for both Wellspring & other homes, but increase was smaller for Wellspring

25. Summary – What Works? 3 of 15 interventions using a pre-post comparison group design had significant improvements in retention and/or turnover –Management buy in & sustained commitment –Facilities commit to give staff time –Direct supervisors committed to working with DCWs –Follow-up & support beyond initial training –Financial incentives to DCW in 2 of 3 interventions –Clear, consistent messages & expectations

26. Implications

27. Strengthen Evidence Base Evaluate innovative workforce improvement models Examine linkages among workforce & quality of care & life outcomes Strengthen evaluation designs –Measure longer-term effects –Measure variation within facilities (units, shifts) –Measure actual behavioral outcomes –Measure outcomes consistently –Use of a comparison group Examine other LTC settings Determine transferability of evidence-based models across settings

28. Promote Evidence Base Provide technical assistance to LTC providers to implement & sustain new models –Give on-going feedback to providers Determine how to replicate effective interventions beyond the initial demonstration (inform technical assistance) Determine how to sustain interventions “Incentivize” the use of evidence-based models –Make the case for evidence-based workforce interventions with payors, regulators and providers

29. Resources Synthesis paper available at: http://aspe.hhs.gov/daltcp/reports/insight. pdf Measuring Long-Term Care Work: A Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes Give me your business card for print copy