Home And Community-Based Workforce For Patients With Serious Illness Requires Support To Meet Growing Needs.

Home health and personal care aides are one of the largest groups of health care workers in the US, with nearly three million people providing direct care for people with serious illness living in the community. These home care workers face challenges in recruitment, training, retention, and regulation, and there is a lack of data and research to support evidence-based policy change. Personal care aides receive little formal training, and they experience low pay and a lack of respect for the skill required for their jobs. High turnover and occupational injury rates are widely reported. There is little research on the factors associated with higher-quality home care, the extent to which worker training affects client outcomes, and how regulations affect access to and quality of home care. Health care leaders should seek to fill these gaps in knowledge, support the establishment of training standards and programs, implement Medicaid reimbursement strategies that incentivize improvements in pay and working conditions, reform regulations that now prevent the full utilization of home care workers, and create sustainable career pathways in home care policies.

Developing a Strong Direct Care Workforce.

The aging population of the United States has led to a need for more direct care workers to provide personal care to older adults and disabled people in their homes. The U.S. Bureau of Labor Statistics predicts employment of paraprofessionals in home care will grow 49% between 2012 and 2022 as the baby boomer generation ages and requires more assistance in activities of daily living. The typical direct care worker is a female aged 25 to 54 years old, a demographic that is projected to remain flat in the coming years. Direct care workers typically are poorly paid for work that is labor-intensive and often work in less than optimal working conditions. It is important that agencies hiring direct care workers understand the challenges these workers face and institute sound hiring practices and provide proper training and ongoing supervision. It is possible to have a quality direct care team. Proper training, role modeling, and supervision will improve employee satisfaction, decrease turnover, and improve care outcomes for patients.

Patient experience and process measures of quality of care at home health agencies: Factors associated with high performance.

We examined the effects of provider characteristics on home health agency performance on patient experience of care (Home Health CAHPS) and process (OASIS) measures. Descriptive, multivariate, and factor analyses were used. While agencies score high on both domains, factor analyses showed that the underlying items represent separate constructs. Freestanding and Visiting Nurse Association agencies, higher number of home health aides per 100 episodes, and urban location were statistically significant predictors of lower performance. Lack of variation in composite measures potentially led to counterintuitive results for effects of organizational characteristics. This exploratory study showed the value of having separate quality domains.

Rehabilitative bodywork: cleaning up the dirty work of homecare.

Care work for elderly people has been characterised as dirty work, owing to its proximity to the (dys)functions and discharges of aged bodies and the notions of disease, decay and death associated with the idea of old age. However, a wave of reform programmes in Danish municipalities promoting rehabilitative care practices aiming to empower, train and activate elderly citizens provides opportunities for homecare workers to renegotiate their status and reconstruct their work and occupational identities with a cleaner and more optimistic image. Drawing on ethnographic fieldwork in two Danish homecare units, this article analyses how rehabilitative care practices, drawing on a narrative of the third age, provide an optimistic and anti-ageist framing of homecare work that informs the development of new occupational identities for care workers as coaches rather than carers in relation to citizens. Furthermore, rehabilitation efforts change the bodywork of care, rendering it more distanced and physically passive, and rehabilitation efforts also involve extensive motivational work aiming to help citizens to see themselves as capable, resourceful and self-reliant. However, while rehabilitation efforts become a new resource in care workers' taint management; they also entail potentially negative consequences in terms of responsibilising and disciplinary approaches to elderly citizens.

Recruitment and retention of home support workers in rural communities.

This qualitative study examined recruitment and retention of home support workers (HSWs) providing home support in rural communities. Thirty-two participants were recruited across four island-based communities located in British Columbia, Canada. Thematic analysis of interview data revealed several key themes: (a) how the rural context shapes HSWs' employment decisions and opportunities; (b) why people become (and stay) HSWs in rural communities; and (c) how rurality influences the nature and scope of HSWs' work. These findings suggest that health human resource policies and programs aimed at HSW recruitment and retention should be tailored to characteristics, strengths, and challenges of rural communities.

Characteristics of home care workers who leave their jobs: a cross-sectional study of job satisfaction and turnover in Washington State.

Attracting and retaining a stable and motivated home care workforce has become a top policy priority. We surveyed 402 former home care workers in Washington State. We compared these "leavers" to current home care workers recently surveyed. Those who left the profession were more highly educated, had higher household income, and were more likely to be White. Those newly employed have better benefits, wages, hours, and career mobility than in their home care jobs. The low status and poor pay of home care workers may result in the inability of the profession to retain those who face better prospects.

How to recruit caring and compassionate HCAs.

Heathcare organisations are faced with the challenge of recruiting staff who have caring and compassionate values so need to ensure these can be identified at interview. We piloted multiple mini-interviews as a possible solution to recruiting healthcare assistants. This article outlines how these were implemented and highlights some of the pitfalls of using this approach. Although the work has not been evaluated formally we decided to share our early experiences of using this approach so others can learn from our practice.

Developing culturally diverse direct caregivers for care work with older adults: challenges and potential strategies.

This discussion presents real-world examples of challenges that occur in geriatric training as a contribution to the ongoing conversation about tailored training for direct caregivers. Numerous discussions are available on the need for more geriatric training in nursing, including aspects of care for patients with dementia, but few if any studies have identified a similar need on behalf of direct care workers, including home health care aides,personal care aides, and nursing assistants who are not part of a licensure track or a baccalaureate-based nursing curriculum. This discussion examines three cultural factors that underlie challenges for nursing educators and supervisors in dementia care who oversee direct care workers: (1) the effect of immigrant cultures and languages; (2) the effect of different intergenerational cultural constructs; and (3) the effect of culturally derived attitudes about aging and dementia. Strategies to address these challenges are offered.

Creating employment opportunities for people with disabilities in healthcare: the Bristol Employment Collaborative.

Unemployment is a significant problem among working-age adults with disabilities. The Bristol Employment Collaborative (BEC), one of five Regional Employment Collaboratives in Massachusetts, brings together State agencies, community employment service providers, educational institutions, local businesses, economic development organizations, and people with disabilities to design and implement regional strategies to enhance employment opportunities and outcomes for people with disabilities. Launched in 2009, BEC has developed an innovative model to train people with disabilities to become personal assistance services workers, a healthcare occupation with high demand. The case study describes the strategic planning process undertaken by BEC partners to develop a certificate program to be offered by the local community college. The first class enrolled in September 2010 and graduated ten weeks later. Innovative approaches such as the one being pursued and developed by the BEC could help address both unemployment for people with disabilities and the labor shortages in the healthcare sector.

What makes migrant live-in home care workers in elder care be satisfied with their job?

PURPOSE: The study aims to examine job satisfaction of migrant live-in home care workers who provide care to frail older adults and to examine the extent to which quality of relationships between the care provider and care recipient and workplace characteristics is associated with job satisfaction. DESIGN AND METHODS: A convenience sample that included 335 dyads of Philippine workers and their frail care recipients were recruited through 2 national home care agencies and snowballing. Multiple regression analyses examined the extent to which workplace characteristics, quality of relationships, care recipient characteristics, and care worker characteristics explain job satisfaction. RESULTS: Scores for job satisfaction, quality of relationships, and workplace characteristics were strongly positive. Overall and intrinsic job satisfactions were explained by workers' qualifications, workplace characteristics, and quality of relationships from the perspective of care recipients, whereas satisfaction with benefits was affected by workplace characteristics and quality of relationships from the perspective of the care workers. IMPLICATIONS: Findings suggest that workers who were better qualified in terms of more years of formal education and more years as care workers and who reported improved workplace characteristics, in particular more job decision authority and variety, reported increased job satisfaction. Therefore, enabling migrant live-in care workers more job decision authority and variety may increase their job satisfaction. More research is needed to deepen our understanding of additional job-related characteristics that explain job satisfaction among this group of care workers.

Creating and sustaining an effective coaching culture in home care: one organization's performance improvement related to aides and aide retention.

Relationships between aides and their supervisors are often challenging. Unproductive disciplinary conversations lead to increased dissatisfaction, low morale, high turnover, and stress levels among staff. This cycle can continue to spiral if not effectively addressed and aimed in a positive direction. This article shares the experience of an organization that addressed this concern through a performance improvement initiative.

Lay health workers and HIV programmes: implications for health systems.

One of the consequences of massive investment in antiretroviral access and other AIDS programmes has been the rapid emergence of large numbers of lay workers in the health systems of developing countries. In South Africa, government estimates are 65,000, mostly HIV/TB care-related lay workers contribute their labour in the public health sector, outnumbering the main front-line primary health care providers and professional nurses. The phenomenon has grown organically and incrementally, playing a wide variety of care-giving, support and advocacy roles. Using South Africa as a case, this paper discusses the different forms, traditions and contradictory orientations taken by lay health work and the system-wide effects of a large lay worker presence. As pressures to regularise and formalize the status of lay health workers grow, important questions are raised as to their place in health systems, and more broadly what they represent as a new intermediary layer between state and citizen. It argues for a research agenda that seeks to better characterise types of lay involvement in the health system, particularly in an era of antiretroviral therapy, and which takes a wider perspective on the meanings of this recent re-emergence of an old concept in health systems heavily affected by HIV/AIDS.

Design and operation of the national home health aide survey: 2007-2008.

OBJECTIVES: This report provides an overview of the National Home Health Aide Survey (NHHAS), the first national probability survey of home health aides. NHHAS was designed to provide national estimates of home health aides who provided assistance in activities of daily living (ADLs) and were directly employed by agencies that provide home health and/or hospice care. This report discusses the need for and objectives of the survey, the design process, the survey methods, and data availability. METHODS NHHAS, a multistage probability sample survey, was conducted as a supplement to the 2007 National Home and Hospice Care Survey (NHHCS). Agencies providing home health and/or hospice care were sampled, and then aides employed by these agencies were sampled and interviewed by telephone. Survey topics included recruitment, training, job history, family life, client relations, work-related injuries, and demographics. NHHAS was virtually identical to the 2004 National Nursing Assistant Survey of certified nursing assistants employed in sampled nursing homes with minor changes to account for differences in workplace environment and responsibilities. RESULTS From September 2007 to April 2008, interviews were completed with 3,416 aides. A public-use data file that contains the interview responses, sampling weights, and design variables is available. The NHHAS overall response rate weighted by the inverse of the probability of selection was 41 percent. This rate is the product of the weighted first-stage agency response rate of 57 percent (i.e., weighted response rate of 59 percent for agency participation in NHHCS times the weighted response rate of 97 percent for agencies participating in NHHCS that also participated in NHHAS) and the weighted second-stage aide response rate of 72 percent to NHHAS.

A dual-driver model of retention and turnover in the direct care workforce.

PURPOSE: The purpose of this study was to understand the factors associated with turnover and retention of direct care workers. We hypothesize that a dual-driver model that includes individual factors, on-the-job factors, off-the-job factors, and contextual factors can be used to distinguish between reasons for direct care workforces (DCWs) staying on the job or leaving the job. DESIGN AND METHODS: We conducted 7 focus groups with 47 participants. We identified key themes they used to describe their experiences focusing on differences between stayers (had been in the same job for at least 3 years) and leavers (had changed jobs within the past 3 years). RESULTS: Five major themes associated with turnover were identified as follows: (a) lack of respect, (b) inadequate management, (c) work or family conflicts, (d) difficulty of the work, and (e) job openings. Themes associated with retention were as follows: (a) being "called" to service, (b) patient advocacy, (c) personal relationships with residents, (d) religion or spirituality, (e) haven from home problems, and (f) flexibility. Themes associated with turnover were different from those associated with retention. IMPLICATIONS: DCW turnover and retention are complex, multifactorial issues. Efforts to stabilize the DCW must address the issues associated with retention as well as those associated with turnover. Specifically, factors that promote retention may be qualitatively different than those that prevent turnover. Treating retention and turnover as simply the obverse of each other may be misleading in addressing the underlying problem of job stability among DCWs.

Migrant care workers or migrants working in long-term care? A review of Australian experience.

Discussion of the role of migrant care workers in long-term care (LTC) that has gained increasing attention in the United States and other developed countries in recent years is of particular relevance to Australia, where 24% of the total population is overseas-born, two-thirds of them coming from countries where English is not the primary language. Issues of interest arise regarding meeting LTC workforce demands in general and responding to the particular cultural and linguistic needs of postwar immigrants who are now reaching old age in increasing numbers. This review begins with an account of the overseas-born components of the aged care workforce and then examines this representation with reference to the four factors identified as shaping international flows of care workers in the comparative study carried out for the AARP Public Policy Institute in 2005: migration policies, LTC financing arrangements, worker recruitment and training, and credentialing. The ways in which these factors play out in Australia mean that while overseas-born workers are overrepresented in the LTC workforce, migrant care workers are not identifiable as a marginalized group experiencing disadvantage in employment conditions, nor do they offer a solution to workforce shortages. The Australian experience is different from those of other countries in many respects, but it does show that the experience of migrant care workers is not unique to LTC and points to the need to extend the search for solutions to workforce shortages and improving conditions of all care workers well beyond LTC systems to wider policy settings.

Paid personal assistance services:an exploratory study of working-age consumers' perspectives.

This study examined the experiences of individuals who use paid personal assistance services (PAS). Structured interview data were collected from a convenience sample of 24 working-age individuals from diverse backgrounds recruited from Centers for Independent Living in nine states. Respondents described their general satisfaction with current paid PAS, but many reported previous experiences with poor care related to the low wages, lack of training of PAS providers, and an inadequate supply of providers. Respondents reported many unmet needs because of a shortage of hours provided by state programs and the lack of help with daily living activities, transportation, childcare, and social activities. The respondents strongly preferred consumer-directed care.

Provider and care workforce influences on quality of home-care services in England.

A key trend in home care in recent years in England has been movement away from "in-house" service provision by local government authorities (e.g., counties) towards models of service commissioning from independent providers. A national survey in 2003 identified that there were lower levels of satisfaction and perceptions of quality of care among older users of independent providers compared with in-house providers. This paper reports the results of a study that related service users' views of 121 providers with the characteristics of these providers. For the most part, characteristics associated with positive perceptions of quality were more prevalent among in-house providers. Multivariate analyses of independent providers suggested that aspects of the workforce itself, in terms of age and experience, provider perceptions of staff turnover, and allowance of travel time, were the most critical influences on service user experiences of service quality.

Enhanced care assistant training to address the workforce crisis in home care: changes related to job satisfaction and career commitment.

Changes in job satisfaction and career commitment were observed as a consequence of a geriatric case management training program focusing on skills development among personal care attendants in home care. A comparison of pretraining and posttraining scores uncovered a statistically significant increase in Intrinsic Job Satisfaction scores for participants 18-39 years of age, whereas levels declined among the group of middle aged participants and no change was observed among participants age 52 and older. On the other hand, a statistically significant decline in Extrinsic Job Satisfaction was documented over all participants, but this was found to be primarily due to declines among participants 40-51 years of age. When contacted 6-12 months after the training series had concluded participants indicated that the training substantially increased the likelihood that they would stay in their current jobs and improved their job satisfaction to some extent. A comparison of pretraining and posttraining scores among participants providing follow-up data revealed a statistically significant improvement in levels of Career Resilience. These results are discussed as they relate to similar training models and national data sets, and recommendations are offered for targeting future educational programs designed to address the long-term care workforce shortage.