Nursing Aides, Home Health Aides, and Related Health Care Occupations -- National and Local Workforce Shortages and Associated Data Needs

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Chapter 1. Project Overview | Chapter 2. Paraprofessional Workforce Supply and Demand | Chapter 3. Important Data Issues | Chapter 4. Existing National Data Sources | Chapter 5. State-Level Data Issues | Chapter 6. Occupation and Industry Classification Systems | Chapter 7. Current Data Collection Practice: CNA Registries | Chapter 8. Conclusions | Appendix A. Project Advisory Committee | Appendix B. Proposed State Data Collection Instrument | Appendix C. Occupational and Industry Definitions | Appendix D. Sample Data | Appendix E. Issues from Four States | Appendix F. CNA Registry Details | Appendix G. Annotated Bibliography | Appendix H. References

Appendix E. Issues from Four States

This appendix describes issues affecting direct care paraprofessionals in four states-California, Illinois, New York, and Wyoming. It includes the following sections:

• Introduction
• State Characteristics
• Long-Term Care Services
• Training and Certification Requirements
• Findings

Introduction
Currently, many long-term care providers report a crisis in their ability to provide medical and personal services due to a shortage of paraprofessional workers. This crisis is affecting access to care, appropriate levels of care, and quality of care, which prompts concern from many levels including providers, State legislators, and Federal regulators.

The lack of consistent, inclusive data hampers understanding the scope and scale of the labor shortage.

To help understand the broader context of the issue, this study included a series of discussions and interviews with healthcare professional organizations and service providers in four diverse states: California, Illinois, New York, and Wyoming. The focus of the fieldwork was on data sources and data initiatives with an emphasis on existing state resources and programs. The availability, accuracy, and accessibility of data were of primary concern. However, in each state, informants also addressed many of the qualitative issues surrounding the problem of recruiting and retaining paraprofessional workers.

The objective of the discussions and interviews was to obtain insights about:

• Existing conditions
• Existing data sources
• Requirements for additional data resources to support planning and policymaking
• Use of data by providers and by professional associations
• Benefits of existing datasets
• Gaps in available data

The interviews used pre-scripted questions about paraprofessional data, although the actual interview instruments varied across states. The questions were framed to elicit responses about both the quality and quantity of data available and their relationship to workforce recruitment and retention. Research staff from each of the four collaborating health workforce centers conducted the personal interviews.

Informants were identified in a variety of ways, including advice of stakeholders and use of Internet and published resources. Those interviewed included providers of direct care services, administrators of nursing facilities, representatives of state regulatory agencies, researchers, acknowledged experts in the field, and consumer advocacy representatives. The mix of informants interviewed varied across states.

This chapter summarizes the results of the fieldwork, with conclusions drawn from the observations of those interviewed. The individual state reports that detail the fieldwork findings are available on request. In general, there was consensus across the states about a distinct shortage of paraprofessional workers and the harmful effect the shortage is having on delivery of care to long-term care consumers. There was some variation in the kinds of data that informants felt stakeholders should have for policy and planning, with differences primarily dependent on stakeholders’ positions in the delivery system.

State Characteristics
To provide a better understanding of the environments in which the informants provide care, this section presents some background information about the four states. It includes physical and demographic characteristics and a snapshot of each state’s long-term care delivery system.

California, Illinois, New York, and Wyoming vary in both geography and demography. Variations in population size and distribution suggest differences in the conditions under which each State provides care and in the environments in which paraprofessionals work. The challenges of rural communities require different employment strategies from those necessary in major metropolitan areas. Three of the states, California, Illinois, and New York, have major metropolitan areas and many rural communities. Wyoming is largely rural with many small towns ranging in population from 2,000 to 5,000 people. States with larger numbers of elderly face challenges different from those states with smaller numbers face. Both New York and Illinois are at or above the national average for population 65 and older, while California and Wyoming are below average. California is the most populous State in the country, while Wyoming is the least. Geographically, California and Wyoming are among the largest states in the U.S., while Illinois and New York rank in the middle.

Table E-1 shows the geographic and demographic characteristics of the states.http://quickfacts.census.gov/qfd/

^Source: U.S. Census Bureau, State and County Quick Facts, 2000, .
*Source: Rand McNally, World Atlas, Imperial Edition

Long-Term Care Services
The following charts represent an overview of the states’ long-term care services. Although there are differences among the states, there are many similarities in their delivery system configurations. The states provide similar options for those needing care through skilled nursing facilities, home care agencies, hospice services, a variety of adult residential or assisted living options, as well as many state-specific programs administered through Medicaid waiver providers and State offices of aging. Much of the variation in long-term care delivery appears in the configurations of state-specific Medicaid and Medicare waiver programs or demonstrations, programs designed to meet the needs of the elderly who remain in community or home settings. Of particular note in this regard is the Program for All-inclusive Care for the Elderly, or PACE, which began at On Lok, a not-for-profit organization in San Francisco. This capitated model, developed as a system of all-inclusive care for the elderly, integrates the needs of consumers within the system by providing seamless care across settings. The program emphasizes keeping the client in the community as long as possible. This model varies considerably from traditional configurations in which care is delivered through silos by individual agencies with no coordination for the consumer along the continuum of care. The PACE program received legislated status as a Medicare provider in the Balanced Budget Act of 1997, making it an available model for all fifty states. ⁸

Skilled Nursing Facilities
Table E-2 shows the number of nursing home facilities in the four states and the number of CNAs working in them in September 2000.

Table E-2. Characteristics of States Related to Nursing Homes, 2000

Source: American Health Care Association, Health Services Research and Evaluation, Spring 2001 from HCFA OSCAR data, September 2000, http://www.ahca.org* (Link accessed 2001. May no longer be available on website.)

Home Health Agencies
Table E-3 shows the number of Medicare-certified home health agencies in each State in January 2000 and home health aides working in them numbered as follows:

Table E-3. Characteristics of States Related to Home Health, 2000

^Source: National Association for Homecare, http://www.nahc.org
+Source: Bureau of Labor Statistics, http://www.bls.gov/oes/

*The numbers of home health aides in California may be distorted by the certification process. It is not only possible but also common to be dually certified as a nurse aide and a home health aide in California. These workers would be counted only once and are probably contained in the numbers of nursing aides. 93,210 people were listed as nursing aides in the BLS data for 1999 in California. This number does not segregate those who are dually certified nor does it provide the location where the aide is employed. Therefore, a dually certified aide working in a home health setting would not necessarily be recorded as a home health aide. In 2001, California’s Department of Health Services Licensing reported 66,000 CNAs, 42,000 CNAs/HHAs and 900 HHAs.

Some home care agencies have certified status, while others operate without licenses or certification. Non-certified agencies are not included in this count of certified home health agencies. By Federal law, only certified home health agencies (CHHAs) can provide care to Medicare beneficiaries. CHHAs and their employees are highly regulated, and data about them is available. However, the other entities that provide home care are inconsistently regulated in states and operate as licensed home care agencies, home health agencies, and staffing agencies, etc. In general, they offer home care services to private pay clients or to Medicaid-insured patients. Additionally, these businesses provide staff to fill temporary needs at certified agencies. A certified home health aide may be employed by a licensed agency but may be contracted to a CHHA. In New York, for instance, licensed agencies provide care through contracts with State social service agencies in a variety of social service programs. In New York, there are over 900 home health agencies employing over 250,000 workers ⁹, only 223 of which are certified agencies. The variation in regulation across states makes these home health businesses and their employees difficult to count.

Hospice Agencies
Table E-4 shows the number of hospice agencies in 2000 by state.

Table E-4.  Characteristics of States Related to Hospices, 2000

+ Source: National Association for Homecare, http://www.nahc.org

Assisted Living Facilities and Adult Day Care Programs
Other types of provider facilities are not easy to enumerate due to the disparities in defining alternative living and care arrangements in a wide variety of regulatory configurations. Assisted living facilities, which are based on a social rather than medical model ¹⁰ , adult day care facilities, and organizations and facilities that serve the mentally retarded and developmentally disabled community are difficult to track because licensing requirements and descriptions vary so significantly from State to State.

In 1998 there were approximately 28,000 assisted living residences housing about 1.15 million people in the United States. ¹¹ Services in these facilities are generally supplied by personal care staff that provide help with personal hygiene, housekeeping, and related activities. The following state-by-state breakdown of such programs is indicative of the difficulty in counting these provider organizations.

California
California had 74 long-term care programs administered by six State agencies in 1998. In 2000, California licensed 11,511 facilities that included 4,593 adult residential facilities, 29 residences for the chronically ill, 6,172 residences for the elderly, 72 social rehabilitation facilities, 599 adult day care centers, and 46 adult support centers. ¹² California licenses residential care facilities that provide specialty, sub acute and rehabilitative care with special provisions in the licensing law for facilities that serve Alzheimer’s patients. However, assisted living facilities are not presently a separate category of licensure.¹³

Illinois
In December 1999, the Illinois General Assembly passed a law effective in January 2001 that required the licensing of assisted living facilities. As a result, no statistics are yet available on the number of these establishments in Illinois. The law states that assistants in these facilities need not be certified as nursing assistants but their direct care staff will be screened through an Illinois health care worker background check.¹⁴ There are approximately 84 organizations and businesses supplying adult day care at multiple sites throughout the state.¹⁵ Through its Department of Aging, Illinois offers a Community Care Program that supplies case management service, homemaker and companion service, and adult day care service to eligible adults. ¹⁶

New York
In 1991, the New York State Legislature passed a bill authorizing the creation of the Assisted Living Program (ALP), which allowed licensing for 4,200 beds. This program substituted ALP beds for the same number of nursing home beds in the State with a commensurate reduction in beds licensed for nursing homes. The State has awarded permission for 4,000 beds but only 3,000 beds are presently operating.¹⁷ There are approximately 135 agencies providing adult day services in the state. There are 59 local county offices for the aging with two additional offices on Indian reservations and one office that is city affiliated in Manhattan.¹⁸ There are numerous social service agencies linking seniors to available programs throughout the state.

Wyoming
In 2001, Wyoming had 26 hospitals, 41 nursing homes (including 13 long-term care units at hospitals) and 43 agencies providing home care. In 1993, the Wyoming legislature defined assisted living facilities and included limited nursing services as part of the definition. The regulations were effective in October 1994 and presently there are seven assisted living facilities operating in the state, two of which are public facilities run by the state. ¹⁹

Home- and Community-Based Waiver Programs
Home- and community-based waivers fund additional programs that provide care to aged and non-aged disabled populations. These are Medicaid-administered programs federally approved under section 1915 of the Social Security Act.²⁰ They serve the mentally and developmentally disabled, the physically disabled, children with special needs who have other qualifying conditions, persons with AIDS, consumers with traumatic brain or head injury, and other eligible populations. Many provider agencies serving the mentally retarded and developmentally disabled community offer personal care services funded through waivers. These services represent a large portion of Medicaid spending in the states. In 1999, Medicaid paid $10.4 billion for waiver services, $3.5 billion for personal care services, and $2.2 billion for home health care. ²¹ Services provided to waiver participants are substantial, and the workforce providing care is numerous. Some estimates suggest that as high as 50% of the paraprofessional workforce is providing care to these consumers. Aides serving the mentally retarded and developmentally disabled populations in the states are generally not certified or licensed. Table E-5 shows the number of Medicaid waiver programs offering funding for services and the populations served in the four fieldwork states.

Table E-5. Medicaid Waiver Programs in the Four States, 2000

** Source: Long-term Care: Implications of Supreme Court’s Olmstead Decision, GAO Report, GAO-01-1167Y, 09/24/01, Appendix 1, Page 25.

Training and Certification Requirements
States have to meet the Federal minimum requirement for educating CNAs working in skilled nursing homes that participate in Medicare and home health aides working in certified home health agencies that supply services to Medicare-insured patients. The requirement is 75 hours of training and includes classroom instruction and clinical experience. However, states have the prerogative to establish individual standards as long as they meet or exceed the national requirements. Maintaining a registry for nurse aides who work in skilled nursing facilities, have received training and certification, and have passed background checks is a compulsory condition of the Federal mandate regulating nurse aides in nursing homes (OBRA 1987).

Once again, there is variation in training, certification, and registration across the four states.

California
In California, nurse aides are required to have 60 hours of classroom training with an additional 100 hours of supervised clinical training. An aide must pass an examination for certification and must register with the Department of Health Services Licensing and Certification Section in the Aides and Technician Certification Section (ATCS) Registry. Home health aides are required to have 120 hours of training, 75 hours of which are in the classroom. CNAs are able to take an extra 40 hours of training and then dually qualify as a HHA. California does not track aides by place of employment, so dual certification makes it difficult to know in what setting an aide might be working. Training occurs in a variety of settings including high schools, community colleges, adult and regional occupation centers, and nursing schools, as well as qualified nursing facilities. Personal care aides are not certified in the state. These workers provide most services under the auspices of the California Department of Social Services through the In-Home Supportive Services (IHSS) program. There are an estimated 230,000 workers providing personal home care to both elderly and disabled clients through IHSS.

They ATCS Registry also lists home health aides and hemodialysis technicians, and they, like nurse aids, must pass a criminal background check.

Illinois
In Illinois, CNAs are required to have 120 hours of training for certification. This includes 80 hours of classroom instruction and 40 hours of practical clinical experience. The titles nursing aide and nursing assistant are used interchangeably in the state. HHAs must meet the same educational requirements. Training is offered through a variety of educational institutions including vocational programs, community colleges, secondary schools, and community organizations.

The Illinois Department of Professional Regulation is not involved in the actual certification of paraprofessionals through authorized educational and vocational programs. No document indicating certification is ever issued to individuals by the registry or by the certifying agency. The employer bears the burden of checking the Illinois Nurse Aide Registry to verify certification and to be sure that the aide is registered.

New York
New York requires training for nurse aides that is of “at least 100 hours duration” and includes at least 30 hours of clinical training. ²² Training occurs in a multitude of settings including high schools, vocational training schools, nursing homes, community colleges, and home health agencies. Nurse aides must file with the Nurse Aide Registry for renewal of their certification every two years and provide proof of having worked at least seven hours in the previous twenty-four months. If the aide is employed at the time of renewal, the employer is required to pay any fees attached to the registration process. ²³ The New York State Department of Health requires HHAs working in certified agencies to complete 75 hours of approved training.

Wyoming
Wyoming requires 75 hours of training for all nursing assistants “regardless of an individual’s title or care setting.” ²⁴ The Wyoming State Board of Nursing maintains the Nurse Aide Registry and also “develops and enforces standards” ²⁵ including regulation of the certification process and training of nurse aides. HHAs must have passed a nurse aide competency assessment and have taken an additional 16 hours of training within two weeks of beginning employment in a home care setting. Therefore, an HHA is qualified as a CNA as well as an HHA. CNAs are required to renew their certification every two years. Although literacy is often required for employment as a nurse aide, Wyoming has a provision for oral examination of the nurse aide to accommodate deficiencies in reading.

Training in Wyoming occurs at some high schools, community colleges, and at many nursing homes. The School of Nursing at the University of Wyoming actually requires that all applicants accepted to the registered nursing program be CNAs. Program directors feel that this assures some direct knowledge of the type of work that a registered nurse will perform. This initiative also augments the CNA workforce if only for a temporary period since all potential nursing students are working, at least for the short-term, as nursing assistants.

Fieldwork Findings: Worker Shortages
The following observations summarize the fieldwork. While the reports varied considerably in their presentations, informants were essentially consistent in their remarks. There was consensus that there are compelling concerns about the interplay of the diminished supply of paraprofessional workers and the increasing demand for services from the community. Many informants felt strongly about the need for planning around workforce issues in the context of delivery, utilization and quality of care. Collection of data is important to aid in developing strategies to address the problem. Improving State and Federal databases was an overriding concern. Informants suggested that current and accurate paraprofessional data would:

• Improve efforts to recruit new workers
• Enhance retention strategies for employees
• Aid in understanding the supply of and the demand for workers
• Help to ascertain the relationship between workforce availability and consumer access to services
• Elucidate the interaction between reimbursement models and provision of care

The following statements in bold type are summary sentiments or observations that relate to informants’ comments. Clarifying information follows each remark.
Too Few Workers to Provide Quality Services

The four states reported shortages of paraprofessional workers. Although informants could not cite data sources or other evidence that precisely document these shortages, there was consensus that shortages exist; that they are significant; and that they require the attention of government policymakers, regulators, providers, and consumers.

All states reported that finding solutions to the shortage will require strategies with many dimensions. There was consensus that the factors leading to the shortage are complex and that solutions require not only new economic strategies, but also alteration of social, educational, welfare, and immigration policies with a focus on enhancing working conditions and pay.

Informants in Illinois, Wyoming, and New York indicated that the worker shortage will affect both the quantity and quality of care.

Informants suggested that adverse incidences in nursing homes are the best testament to the effects of deficient numbers of workers on quality of care. However, there is a disincentive for nursing homes to emphasize such occurrences because of the fear of sanctions. Therefore, any accurate assessment of the link between quality and staffing levels is diminished. The result is often anecdotal information about such problems.

Documenting the Shortage Is Difficult
No comprehensive dataset that addresses paraprofessionals is available to inform researchers about worker shortages. States use a variety of information to inform their workforce policy. For instance, California performed an interesting exercise by reviewing and counting the number of certificates issued to nursing assistants from July 1, 1998 through May 1, 2001. The State compared that number to the number of certificates not renewed for previously certified nursing assistants during the same time period. There were 35,974 new aides certified in that 22-month period. However, there were 46,751 previously certified nurse aides who did not renew their certifications. This resulted in a net loss during that time of 10,777 aides. Another analysis of the number of certificates issued in July 1997 revealed that more than half of the certificates supplied in 1997 had not been renewed in 2001.

Many Factors Affecting the Shortage
The paraprofessional workforce is particularly sensitive to the economy.
There is tremendous competition for entry-level workers from other service industries and retail establishments. In Wyoming, one respondent described the problem as an “employment crisis.” Jobs abound, and workers are scarce. New York informants indicate that this sensitivity to the economy is actually a visible phenomenon. Providers could document that shortages began as retail establishments or tourist venues began expansion in their communities. In New York, this is dubbed “the thruway effect,” because it happens in identifiable ways at identifiable times across the State especially along the New York State Thruway.

There is both internal and external competition for workers.
Informants in California suggest that there is not only external competition for workers but there is also internal competition. Facilities that can offer better salaries, benefits, and working conditions, such as acute care hospitals, can draw potential workers from nursing facilities and home health agencies. In New York, licensed home care agencies appear to have higher turnover rates than either certified home health agencies or nursing homes. This might be attributable to better working conditions, better pay, or more benefits available from larger facilities or integrated delivery systems. Home care agencies provide more part-time employment than institutional nursing facilities and are generally not able to offer extensive advancement or educational opportunities to their employees. Licensed agencies in New York are frequently sole-proprietorship businesses that operate with small margins that limit their ability to offer expanded benefit packages. Note, however, that some of these smaller agencies are creative in their attempts to attract and retain a caring, competent, and stable workforce. Many larger providers commented on the need for these community-based agencies to offer services especially where cultural diversity affects care delivery. Distinct resources available in neighborhoods where workers and consumers share ethnic backgrounds and language are important to the social aspects of providing care.

The problem may not just be one of supply but rather of distribution or working status of the workforce. According to New York and Wyoming informants, even if there are enough trained workers in the State in the aggregate, they may not be active in the workforce. All states report that numbers in their registries include people trained as paraprofessionals who have discontinued their certification or who are not presently providing direct care.

Informants also noted other distribution problems. Some local areas have plenty of workers, while adjacent communities have too few. California’s labor situation illustrates this. Counties across the State have differing pay scales for workers in the In-Home Supportive Services Program. A worker who can earn higher wages in one county than in an adjacent one will logically be drawn to the higher pay.

Other distribution problems may be attributable to population concentrating in large cities, which creates a greater pool of potential workers. This is particularly true in metropolitan areas such as New York City where workers are more abundant than in many of the smaller, rural upstate communities.

The paraprofessional workforce is mobile.
Informants indicate that anecdotal experience with the paraprofessional workforce suggests that workers are very mobile. Wyoming informants indicated that workers “move on” to like facilities or providers of care, “move out” to other jobs in other sectors, or occasionally “move up” with more training to higher levels of assistive care. In New York it is fairly common for workers to leave long-term care and then return to it after doing another job in a sector such as retail.

Influence of Government Regulation And Reimbursement
Federal reimbursement rates are insufficient to allow additional wage or benefit incentives to attract paraprofessional workers.
In Wyoming, “Pay rates for CNAs are very low relative to their importance to long-term care.” Wyoming and New York informants indicated that the work is emotionally difficult and physically demanding with few rewards and that the workforce is largely female and poor and the wage rate does not provide a living wage.

Federal payment policy drives reimbursement policies of other payers.
Private insurance carriers, proprietary agencies, and individuals paying privately for services establish payment rates based on those established by the government. Federal payment rates limit the wages of paraprofessional workers because they drive not only governmentally supported services but also the for-profit, private market as well. Some change in Federal reimbursement policy may, therefore, be fundamental to any remedial efforts focused on improved benefits for paraprofessionals.

California informants indicated that employers play important roles in the market. There is a relationship between provider responsibility, government regulation and payment methodologies.

The problem with the paraprofessional workforce is two-fold. The difficulty of initial recruitment is coupled with the challenge of retention. There is an interesting relationship between factors that complicate recruitment and retention. The low wages that characterize the jobs hinders recruiting workers for employment as paraprofessionals. Once workers are actually hired, limited financial resources hinder employers’ efforts to retain them. Government policies inhibit the ability of an employer to offer expanded benefit packages when reimbursement for caseloads is highly regulated with little inherent flexibility. This is true not only at the Federal but at the state level, as well.

California’s IHSS program is an example of a program the funding of which affects workforce incentives. IHSS is a social services program in which funders participate at various levels. This intent of the program was to meet the needs of the state’s elderly populations for in-home personal care services. IHSS provides care through a variety of delivery mechanisms including contract, county homemaker, and individual provider models.²⁶ The most popular of these is the individual provider model in which consumers hire workers directly. This option is sometimes administered through public authorities within California counties that act as intermediaries that help consumers find and keep workers. The other options include services delivered through contracted agencies that hire and assign workers to caseloads, or care delivered by State social service agency employees.²⁷ This program is funded by the Federal government through Medicaid and through matching funds from both the State and the county in which services are provided. However, wage levels across counties vary considerably. In Los Angeles, for instance, paraprofessional workers earn $6.25 per hour with no benefits. In San Francisco, paraprofessional workers in the same program receive $9.00 per hour with comprehensive medical and dental benefits.²⁸ The discrepancy is attributable to the variation in the degree to which counties provide wages, incentives, and benefits. Many of these workers are unionized through the Service Employees’ International Union (SEIU). This union has been actively campaigning for improved benefit packages in the counties where wages are low. Unionization has benefited these workers.

All stakeholders need to take responsibility for this workforce.
Government policy alone cannot provide the comprehensive solutions necessary to meet future needs. Although Federal policy sets the standard, each system component bears some responsibility in the interaction between policy creation, implementation, and distribution of resources. Society must make a dedicated commitment to care for the elderly and disabled and be willing to make focused contributions to care. An example of distributing responsibility among various parts of the system is wage pass-through legislation, which is intended to supplement hourly pay for paraprofessionals. Individual providers handle these monies differently. It is important to assure that designated wage incentives are reaching their intended target and are not being used for other purposes. Accountability rests with both the payer and the provider employer. Another example of interaction between parts of the system involves family members who contribute substantial unpaid time and resources to caring for elderly relatives. Government regulations and business policies should encourage efforts by family caregivers through enabling legislation that makes available generous employment leave policies or provides tax incentives. These initiatives would support family caregivers who offer help to elders while still permitting them to maintain their own personal and work responsibilities. Effective in January 2000, California has implemented a $500 tax incentive for long-term caregivers who qualify by income, familial relationship, and the need of the individual requiring care. ²⁹

Providing care to the elderly and disabled creates complex challenges that will require creative, collaborative solutions. Considered, deliberate change that engages all parts of the system must occur to encourage stakeholders to find constructive strategies to address the problems. Solutions need to be multi-faceted and address the wide range of issues that affect this workforce.

Many Issues Affect Recruiting and Retaining Paraprofessionals
Retention is a major issue even immediately after training.
Yields from training classes are not high. According to New York and Wyoming informants, new trainees are not always able to pass the competency tests or may not like the work after training. California estimates that half of those trained in one year are lost to the system within three years. In New York, a nursing home cited the example of a training class that graduated 12 new aides in March, only one remained working in the facility five months later in August. In Wyoming, one nursing home reported that typically, from a class of fifteen participants, only three or four will actually qualify and choose to work as a nursing assistant.

Learning about retention strategies is of major interest to employers.
New York and Wyoming informants suggest that recruiting workers is a problem that policymakers must address through enhancement of work status and benefits, but retaining workers is a problem that individual providers must thoughtfully consider and address with creative workplace strategies. Informants were especially interested in information about successful strategies in the industry that enhance paraprofessional retention in organizations and facilities.

Although pay may be important to retention, the key issues are the work and the work environment.
Informants in the industry feel that low wages, the diminished status of the work, and the difficult work conditions all contribute to major difficulties in recruiting and retaining workforce for nursing facilities, home health care, and personal care services. Illinois informants indicated the work is labor intensive, emotionally difficult, and poorly reimbursed. Wyoming informants indicated it is physically and mentally stressful, with paraprofessionals having high rates of work related injuries.

Assessing unmet patient needs could provide an estimate for workforce requirements.
In both California and New York, there was interest in using patients on waiting lists or numbers of clients refused for services to assess unmet need. Informants in California suggested that lists of patients awaiting services needed to be reviewed to evaluate first, the speed of patient access to care, and second, access to appropriate levels of care. California and New York informants suggested that available staffing directly influences both of these aspects of care delivery.

A New York respondent provided the following example to illustrate the difficulties endemic to short staffing. A hospital discharge officer refers a patient for home health services as appropriate care at discharge. Provider agencies deny service due to lack of available staff. The patient needing home services either remains in the hospital (for lack of an available caregiver in the home) or moves to a rehabilitation setting or nursing home until care at home can be obtained. Although a longer hospital stay or transfer to another facility may be necessitated by the immediate health demands of the individual, this is expensive for the payer and counterproductive for the recuperating patient. A long-term care system must be responsive to patient demand and be capable of supplying appropriate treatment at each point in the continuum of care.

Though California and New York informants suggested tracking unmet patient needs as a means of determining worker shortages, there was concern that the statistical integrity of keeping waiting lists or lists that detail refusals of care might be complicated, with duplication if patients seek care unsuccessfully from several provider agencies.

Career options and ladders for the paraprofessional would make the job more attractive.
Many facilities and organizations are interested in providing further opportunities for training. All states report that career ladders are important for retention of the workforce. Nursing facilities and home care agencies may offer opportunities for further training or higher education grants and scholarships for workers interested in receiving more education. New York funds several programs that allow cross training. However, not all organizations can provide these opportunities. Additionally, an aide’s family situation may impede pursuing educational opportunities.

The paraprofessional workforce does not have the strength of a large national organization to represent its interests. Unionization may be important for this workforce.

Advocates often provide compelling voices in support of the groups they represent. Paraprofessional workers do not have a powerful lobby that promotes their interests particularly at the individual state level. In Illinois there is no membership association for paraprofessional workers. In New York and California, unions provide a voice for some of the workforce. In New York City, a union that negotiates benefits and working conditions represents most of the paraprofessional workforce. Unionization keeps wages at the contracted level since pay is negotiated for a period of time. There is a downside to this since union scales make it difficult for providers to meet the market immediately when there is fluctuation that raises pay. This can place the union employer at a disadvantage to non-union agencies when it comes to being competitive with wages at a particular point in time. However, unions do provide many desirable benefits including health insurance and educational opportunities for workers. Informants saw these factors as positive incentives to union membership and to paraprofessionals having the desire to work for providers who are unionized.

There are some national professional organizations that have gained repute for their efforts on behalf of paraprofessionals. The Direct care Alliance, a coalition of long-term care workers, consumers, and concerned providers was advocates reform and encourages policy to ensure quality jobs for a stable, valued, and well trained paraprofessional workforce. ³⁰ The National Association for Home Care formed the Home Care Aide Association of America to provide an organization that advocates directly for home care workers. ³¹ This organization has several goals, including standardizing training for home care aides, promoting a national classification system, advocating effective use of home care aides, and increasing reimbursement for their services. ³²

A system of informal caregivers exists.
New York and Wyoming informants indicated that many caregivers are family members, church associates, neighbors, and friends of the elderly who supply help with a variety of activities of daily living or instrumental activities of daily living. As many as 60% of the elderly infirm may rely exclusively on unpaid caregivers. This informal network is essential to the system.³³ These caregivers provide vital services in an extended support system without the use of public resources. Even those patients who access care from the formal system often supplement that care with substantial help from family members and friends. Over 95% of the elderly with disabilities who are not living in institutions are the beneficiaries of some informal support services. ³⁴ New York informants expressed concern that the system ignores these family caregivers who also need formal support services to encourage their continued contribution. Caregiver tax incentives, respite programs, and programs that allow payment to family caregivers address some of these concerns. Connecticut, Nebraska, New Jersey, New Mexico, and South Carolina are some of the states that have addressed the need for respite care with increased budget appropriations. ³⁵ Several states have established caregiver support programs including Oregon, Pennsylvania, Texas, Florida, Michigan, New York, and Illinois. ³⁶ The Family Caregiver Alliance, National Center for Care giving recently conducted a survey of 15 State programs to determine the kinds of State initiatives that were being directed at family caregivers. They selected five “best practices” programs in California, New Jersey, New York, Oregon, and Pennsylvania for their innovation and the range of options for caregiver support services. ³⁷ Government programs that address the needs of informal caregivers will become increasingly important as the formal system becomes more stressed with finding sufficient paid workforce.

According to New York and Wyoming informants, another component of the informal system is a gray market that consists of privately paid workers who independently contract with the patient consumer. The number of these workers is considered significant enough to be of concern to the formal system and to raise some pertinent questions. For the purposes of this report, there are several issues. How to track these workers and what is their effect on the delivery system? What are the ramifications for quality of care and for patient safety? Fieldwork interviews indicated that the gray market creates a drain on the formal system by diverting potential workers from the pool of available paraprofessionals. There are no controls over work conditions for the paraprofessional, and there is little job security for workers in the informal system. However, this gray market can and often does provide higher wages for the worker since pay is not constrained by public reimbursement rates and since benefits are not generally part of the wage package. According to New York informants, higher wages are attractive to people working at or just above the minimum wage level. The apparent success of this gray market suggests that increased wages in the formal system might have a positive effect on the supply of workers.

New York informants indicated that from the patient perspective, the gray market generates concern about quality of care provided by unregulated workers who may be without formal training or official institutional and organizational oversight. The safety net provided by regulatory mechanisms and established institutions is not active for the consumer who is contracting privately. There is, apparently, greater danger for diminished quality of care and for abuse.

Both the informal network and the gray market make it difficult to assess who is providing care to elderly disabled populations. Informants suggest that the numbers of these providers are significant and that the lack of information about them distorts the ability of the system to plan for the future, further confounding efforts to gather accurate data about paraprofessional workers.

Initiatives
In each location, states have made significant efforts to collect, refine, and use data to address long-term care issues. Informants were consistently interested in understanding the dynamics of the long-term care system, including the relationship of providing care with workforce supply.

California
California has implemented specific strategies to address the problem of staffing issues for long-term care providers. The state’s Aging with Dignity initiative provided a grant of $25 million for a Caregiver Training Initiative. The State also committed over $270 million in the 2000 to 2001 State budget to initiatives that help elderly people remain in their homes. ³⁸ This money is targeted to giving tax credits to family caregivers and to increasing senior caregiver wages among other approaches. California has also established a Long-Term Care Council in the Department of Health and Human Services that focuses on strategic planning to improve access to and quality of long-term care provided to state residents. The state legislature recently commissioned a report on the nurse assistant workforce that is to be published in the coming months. California’s Certified Nurse Assistant Workforce Crisis: A Report on Recruitment, Training, and Retention includes a survey of CNAs in the state. The report is intended to make recommendations about this segment of the health workforce. California’s Employment Development Department recently issued a report titled The Quest for Caregivers: Helping Seniors Age With Dignity. In a survey of 322 employers of nurse aides, 25% responded that it was very difficult to recruit experienced workers and an additional 36% indicated it was somewhat difficult. Twenty-six percent of home health providers, responding to a question about recruitment of experienced worker, indicated that it was very difficult, while 43% point to some difficulty. The report examined a range of employment issues including wages, benefit, work hours, training, physical demands of the job, and a variety of other indicators. The California Office of Statewide Health Planning and Development (OSHPD) compiles reports on long-term care facilities and an annual report on home health agencies that include indicators of staffing in facilities but does not address actual counts of workers.

Illinois
In Illinois, the State Department of Public Health, through its Illinois Center for Health Statistics, collects a variety of data about paraprofessionals from several sources within state government. Long-term care facilities complete an annual survey for the State that includes staffing information about full and part-time counts of paraprofessionals. This information is submitted to the Illinois Health Facilities Planning Board. Additionally, home health agencies are required to complete an annual license renewal questionnaire that has a staffing component. The report requires a count of full- and part-time staff for the month of October for each business operated, total hours worked by employees, and total home health visits. This provides a snapshot of paraprofessional employment in the home health industry as of October each year. The facility and business data are used for statewide health planning.

A report titled Nursing Home Staffing Levels Are Inadequate in Chicago was issued in January 2001 as a minority staff report of the House Committee on Government Reform. This study was commissioned by three members of the U.S. House of Representatives from the Chicago area, Representatives Janice D. Schakowsky, Rod R. Blagojevich, and Bobby L. Rush, to evaluate staffing levels in Chicago nursing homes. The study examined staffing levels in 273 nursing homes and found that 84% did not meet minimum preferred staffing levels. ³⁹ The Chicago Jobs Council conducted a study entitled Understanding Entry-Level Health Care Employment in Chicago that was published in August 2000. Focus groups of employers, job seekers, and educators were convened to discuss demand for entry-level jobs for low income, welfare-to-work, or long-term unemployed workers. The study determined that health care was one of the fastest growing sectors in the economy and that the training of nursing assistants and other entry level workers should be a focus of their efforts. Through its Office of Health Regulation in the Department of Health, Illinois has also created a group called the Nurse Aide Recruitment and Retention Taskforce that focuses on workforce issues. Illinois is investigating creating a new job title called “feeding assistant.” Workers in this category would be employed in facilities such as assisted living facilities.

New York
New York has implemented various initiatives in an effort to better understand pertinent issues and to plan for the care of state residents. A law passed in 1997 called the Long-term Care Integration and Finance Act required the Department of Health to conduct a study of assisted living and the Office of Mental Health to do a similar study of delivery of mental health services in adult care facilities. ⁴⁰ This resulted in a report issued in May 1999 titled Assisted Living In New York: Preparing For the Future. The report discussed demographics, utilization patterns, regulatory oversight, recommendations, and options for program development. The Future of Aging in New York State: Project 2015, is a joint effort of the New York State Office for the Aging and the State Society on Aging. This report was compiled by several experts from information gathered during public forums held throughout the State in 2000. ⁴¹ The issue papers included in the compendium range in subject from informal care giving to elder abuse and neglect to living arrangements for the elderly. Additionally, the New York Association of Homes and Services for the Aging issued a report in 2000 titled The Staffing Crisis In New York’s Continuing Care System: Analysis and Recommendations, which surveyed nursing homes by mail and telephone about staffing issues. The report includes several substantial recommendations for local, state, and national actions to address workforce recruitment and retention. As far back as 1988, New York was interested in workforce issues in long-term care environments. In that year, New York State’s Long-Term Care Policy Coordinating Council conducted the New York State Home Care Worker Study: Phase 1: Agency Survey that surveyed home care agencies about agency, worker, and client characteristics. In 1990, this same group, in coordination with the New York State Department of Social Services, published Recommendations for Action: Recruitment, Training and Retention of Home Care Workers, which suggested strategies to improve recruitment and retention of home care workers.

New York collects data on its home health workers through the Department of Health Licensed Home Care Services Agency Annual Statistical Report, which surveys licensed agencies about patient referrals and discharges, cost of services provided, and staffing.

Wyoming
Several groups have conducted surveys of paraprofessionals in Wyoming in recent years including the State Board of Nursing, the Quality Health Foundation of Wyoming and the Wyoming Health Care Association. The Board of Nursing (BON) survey requested data on CNAs and HHAs working in the state. This survey of all employers of CNAs and HHAs focused on the number of positions available, filled, and vacant. The BON database indicates that in May 2001, there were 3,657 current licenses for CNAs (including HHAs). The Quality Health Care Foundation of Wyoming and the Wyoming Health Care Association, trade associations representing nursing homes and home health agencies in the state, collaborate on mail and telephone surveys of CNAs in Wyoming. A recent wage survey revealed that the lowest paid CNAs in the State made $7.00 per hour while the highest paid workers earned $12.86 per hour.

The University of Wyoming and the Wyoming Health Resources Network are collaborating on a promising endeavor. They are cooperating in the creation of a statewide health workforce registry that will count and track both licensed and allied health workers starting in the summer of 2001. Wyoming’s small size makes quality data collection and management both possible and achievable.

Conclusions
Informants generally agreed on the complexity of the problems related to recruiting and retaining paraprofessionals in the workforce. Specifically, respondents agreed that:

• A significant healthcare worker shortage poses considerable risk to both quality and quantity of care for vulnerable populations.
• Data collection and analysis is inadequate for policy planning.
• Inconsistencies complicate compiling and understanding existing datasets.