Some Potential Solutions to High Direct-Care Staff Turnover Rates

As all of us in long-term care know well, the worsening shortage of direct-care workers is a serious problem. Recruiting and retaining nursing assistants, home health aides, and personal care aides is increasingly challenging. Exacerbating the difficulty is the growing divide between the number of people in need of direct-care services and those most likely to provide them. By 2030, the number of Americans age 85 or older—the group most likely to need the assistance of direct-care staff—is expected to double, reaching 8.9 million. Over the same period, the number of women in their 20s through 50s—the group most likely to make up the ranks of direct care workers—is expected to rise less than 10%. High turnover among direct-care staff, which is costly, threatens quality of care, and can increase workloads and lower morale among remaining staffers, contributes to further turnover and has long been a problem. According to a nationwide survey, average direct-care staff turnover rates in assisted living facilities were 40% for personal care workers, 39% for certified nursing assistants, and 38% for medication aides in 2001. In 2002, annual direct-care turnover rates at nursing homes ranged from 39% to 98% in states reporting this data. Some surveys have found even higher rates. According to the AARP, a 2002 Wisconsin survey found that turnover ranged from 77% to 164% in assisted living facilities, from 99% to 127% in nursing homes, and between 25% to 50% in home care agencies. There are many contributors. Low pay, poor benefits, inadequate training, limited opportunities for career advancement, and high workloads and workplace injury rates in direct-care are among them. In 2005, direct-care workers were earning an average of $10 per hour. About 25% had no health insurance whatsoever, the Associated Press reported recently. Roughly 70% of funding for direct-care costs is provided through public financing, according to the Direct Care Alliance, a national coalition of direct-care workers, long-term care consumers, and healthcare providers whose shared goal is “to improve the quality of care for consumers through the creation of higher quality jobs and working conditions for direct care paraprofessional workers.” In a 2003 report to Congress, a coalition including the Centers for Medicare & Medicaid Services (CMS) and the Health Resource and Services Administration (HRSA) acknowledged that federal, state, and local governments should play a key role in addressing problems with direct-care recruitment and retention. The report, however, also concluded that the private sector must play a role as well. “While the Federal government has an important role to play, much of what needs to be done will require action on the part of current and new employers who will expand and alter the market itself and shape new solutions,” the report noted. “Other solutions will inevitably be crafted by state and local governments, health care providers and industry associations, education and training institutions, workforce investment systems, faith-based organizations and workers themselves.” A variety of efforts are underway. The federal government, for example, has funded demonstration projects that make health insurance available to direct-care staff, and some states are now providing direct-care workers with insurance coverage. States have also taken steps to boost workers’ wages by increasing payments to long-term care providers and mandating that these higher payments be “passed through” to direct-care staff. (These “pass-through measures” have had a mixed record, with a positive effect in some states but not others, according the Agency for Healthcare Research and Quality (AHRQ).) At the same time, community colleges, with federal and state funding, have begun offering training programs for direct-care employees. To help ease the supply problem, the state of Vermont recently launched an innovative program through which it pays any caregiver—including a relative or friend—$10 an hour to care for an older person who would otherwise be forced to move to a nursing home. Through the Better Jobs Better Care (BJBC) demonstration program funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies, North Carolina’s BJBC coalition has developed a state licensure program for adult care, home care, and nursing homes that recognizes providers with supportive workplace practices. Ultimately, the coalition would like the state to offer higher reimbursement to long-term care providers awarded this special license. At the same time, some long-term care facilities have introduced mentoring programs, taken steps to include direct-care staff in decision making, and offer more flexible work schedules, among other things. More work is needed, however, as is additional information about the effectiveness of potential solutions, the AHRQ notes. The Institute of Medicine’s “The Future Health Care Workforce for Older Americans” study (https://www.iom.edu/CMS/3809/40113.aspx) should help. The study is examining direct-care and other workforce issues related to the aging of the nation. The panel conducting the study, which includes several American Geriatrics Society members, expects to publish its report in March. Regards,