Nursing Aides - Chapter 5

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

Printer Friendly Adobe .pdf (1,970K)

Chapter 5. State-Level Data Issues

This chapter reviews state-level issues related to data on the paraprofessional health workforce, with special attention to findings from fieldwork conducted in California, Illinois, New York, and Wyoming. The fieldwork is described in more detail in Appendix H. The chapter includes the following sections:

Introduction
State-Level Data Issues
Conclusions

Introduction
In the summer and fall of 2001, fieldwork was conducted in California, Illinois, New York, and Wyoming to gather insights about the direct care paraprofessional workforce. Although the discussions addressed a wide range of issues related to the long-term care paraprofessional workforce, the primary objective of the fieldwork was to better understand data sources and data initiatives from a State perspective. The availability, accuracy, and accessibility of data were of primary concern. The fieldwork informants described:

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

To help insure comparability of results, interviewers were provided pre-scripted questions about paraprofessional workforce data, although the actual interview scripts varied across the states. The questions were framed to elicit responses about both the quality and quantity of available data and their relationship to workforce recruitment and retention. Research staff from each of the four collaborating health workforce centers conducted the interviews.

The informants interviewed were identified in a variety of ways, including advice from the Project Advisory Committee and other stakeholders, and the 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 varied across states.

State-Level Data Issues
The fieldwork in the four states confirmed anecdotes heard all during the study that State planners and policymakers do not have adequate data and information with which to assess the adequacy of the long-term care paraprofessional workforce. They are being pummeled with cries for help from nursing homes and home health agencies having difficulty recruiting workers. They hear horror stories of unscrupulous individuals taking advantage of frail senior citizens. They are beginning to realize that they do not have enough information either to design appropriate responses to these situations or to evaluate the ad hoc responses they have implemented to address these and other problems.

Beyond their respective State cooperative labor statistics systems, most states do not have systems that collect data on the paraprofessional workforce. Although the cooperative systems use standard terminology, definitions, and taxonomies, the nomenclature and definitions they use for direct care paraprofessionals suffer from the shortcoming mentioned above.

Some states have developed their own systems for compiling data on direct care paraprofessionals. These systems use local terminology, definitions, and taxonomies that, in general, do not permit ready comparisons with data from other states and linkages to other data systems.

All states have CNA registries, but as currently mandated by the Federal government, CNA registries do not provide an adequate basis for addressing the shortcomings of data systems like the CPS and BLS. Despite specific requirements dictating the kinds of information to include in the registries, the State systems are far from uniform. State nomenclature for workers varies considerably, and definitions of worker categories are inconsistent. Rules and protocols for accessing the data also vary significantly.

The handling of criminal background checks and other worker certifications is also quite different across the states. Some have integrated this function into the CNA registry, while others maintain totally separate data systems. Rules related to access (both registry data and background check data) and privacy also vary substantially.

Most State informants indicated they would be willing to expand existing CNA registries to include additional worker categories in support of paraprofessional workforce policymaking, if funds were provided to cover the additional costs.

State Data Systems
Informants in all four fieldwork states considered data fundamental to understanding the workforce and the demographic characteristics that affect the dynamic employment environment surrounding paraprofessional workers. Informants indicated that data was important to:

Inform planning
Yield insights about the extent of shortages and form strategies for addressing them
Assess the supply of workers in relation to projected demand
Understand the demographics of the workforce and how that affects supply

The four states have made significant efforts to collect, refine, and use data to address long-term care. The following sections summarize each of their existing paraprofessional databases.

California
The Aides and Technician Certification Section (ATCS) Registry lists nurse aides, home health aides, and hemodialysis technicians. The registry has an interactive voice response system that requires the user to have the social security number of a potential employee to process an inquiry. The system response indicates either active approved status or inactive status if it finds a disqualifier. California’s registry listed 66,530 active CNAs, 42,178 dually qualified CNA/HHAs, and 889 HHAs as of September 2001.

The California Office of Statewide Health Planning and Development (OSHPD) compiles reports on long-term care facilities and produces an annual report on home health agencies that includes indicators of staffing in facilities but does not address actual counts of workers.

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. The facility and business data are used for statewide health planning.

PCAs, CNAs, and HHAs are listed in the Illinois Nurse Aide Registry the Illinois Department of Public Health’s Department of Education and Training maintains. The registry is not purged of inactive nurse aides, home health workers, or care attendants.

New York
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.

Nurse aides are the only registered paraprofessionals in the New York State Nurse Aide Registry. The Office of Continuing Care, Bureau of Professional Credentialing in the Department of Health, administers this registry. Assessment Systems Inc. maintains the registry and interfaces with the New York State Department of Health. The registry has both a 24-hour interactive voice response system available to providers to check eligibility of potential workers, as well as public web access to an enumerated list of disqualified employees.

Wyoming
The Board of Nursing (BON) Registry gathers data on CNAs and HHAs. It focuses on the number of positions, both filled and vacant.

The Nurse Aide Registry lists nursing assistants who have met the board qualifications and have passed a criminal conviction background search. Biennial updating is required.

The University of Wyoming and the Wyoming Health Resources Network have collaborated on a statewide health workforce registry that counts and tracks both licensed and allied health workers.

Critical Issues for States
Data Type Variations
The types of data providers and regulators use vary across the states. California informants indicated that the kinds of data stakeholders use are diverse, and familiarity with the data is limited by the user’s needs and technical expertise. New York informants suggest that some of the larger datasets are difficult to manipulate with data dictionaries that are complex or not available. Changes in definition over time and time lags in processing also complicate data use. Researchers in California noted that user expertise or knowledge of datasets varied considerably by interviewee.

Data Inadequacies for Workforce Planning
Current systems for data collection are not designed to support workforce planning. For example, records contained in CNA registries include many inactive workers. In several states, the purging of names occurs only when an aide is disqualified from employment or fails to renew registration. This makes it very difficult to assess, document, or understand the dynamics of shortages.

In Wyoming, there are 12,000 CNAs listed in the Board of Nursing Registry, only 3,657 of whom carry current certification. Only 1,491 of these workers are presently working in a nursing home, a home health agency, or a hospital, filling 1,387 full-time positions. However, Wyoming lists 155 vacant positions in nursing homes, hospitals, or home health agencies despite the high number of registered CNAs. An additional impediment to data collection is that existing surveys and registries track only workers in the formal system in which Medicare, Medicaid, and other third-party payers support services. Anecdotal data suggests that workers in the informal system are numerous. However, counts of these workers are non-existent.

Data Collection Inconsistencies
Data are not comparable and are inconsistent across the range of data collection instruments. According to California and New York informants, a variety of factors make comparison of datasets difficult, including inconsistent definitions of workers, different methods for counting workers, i.e., full-time equivalencies (FTEs) or head counts, self-reporting of data by facilities, and different aggregations of data across categories of workers. There is no single data resource that provides reliable comprehensive information about this segment of the workforce in any of the four fieldwork states. No evidence was found to refute the claim that this lack of a common comprehensive data resource extends to all 50 states.

Untimely Datasets
Datasets are not always timely, inhibiting provider responsiveness in an ever-changing environment. According to New York informants, old data, although useful for understanding trends, are not helpful to local providers when assessing current, critical issues. Aggregate national data are not useful in planning responses to local market fluctuations.

Nomenclature Variation
One of the fundamental requirements for data collection integrity is common and consistent definition of terms. The fieldwork revealed that paraprofessional worker classifications differ across states. This problem is most evident when attempting a search for data about particular workers. In some states, workers are defined by the tasks that they perform. Workers are classified as nursing aides or medication aides regardless of the setting in which services are performed. In other states, workers are defined by the setting in which care occurs, e.g., psychiatric aides, home health aides, hospice workers. These definitions may also overlap by task and setting. In Maine, it is possible to be either a certified medication aide or a certified residential medication aide. In any case, it is apparent that there are numerous titles that address the same workforce.

Paraprofessional workers who are not certified or registered in a State present another example of these classification problems. Providers label workers variously according to the type of consumer they serve or service they provide. A personal care attendant might be called a developmental disability aide, a behavioral assistant, a housekeeper, a homemaker, a respite worker, or a residential habilitation specialist, among other titles. This variation significantly complicates any attempt at data collection.

Inconsistencies are particularly evident in State certification processes. Requirements affecting regulated workers vary according to the worker definitions each State uses. In Wyoming, CNA definition is comprehensive. All persons providing nursing assistance are required to have a minimum of 75 hours of training and qualify as a CNA regardless of the setting in which they provide services. It is necessary for workers in home health to complete an additional 16 hours of training. However, a CNA might work in a nursing home, a hospital, or a home health agency. All qualified CNAs appear on the registry without regard to the setting in which they work. In New York, the definition of a CNA is quite specific and includes only nursing assistants in skilled nursing facilities. CNAs are the only workers New York lists in its nurse aide registry.

State Concerns About Federal Data
The fieldwork in the states also identified a number of parallel concerns about Federal data systems that are summarized below.

Nomenclature and Definitions
The BLS OES survey classifies paraprofessionals in three places. They might be working in a health care support occupation (31-0000) as a “nursing aide, orderly, and attendant” (31-1012) or as a “home health aide”(31-1011). The paraprofessional might also be working in a personal care and service occupation (39-0000) as “a personal and home care aide”(39-9021).

Under Federal definition, nursing aides, orderlies and attendants “provide basic patient care under the direction of nursing staff. Perform duties, such as feed, bathe, dress, groom, or move patients, or change linens.” This category of worker includes both direct care workers and those providing indirect services. It includes both certified and non-certified workers. Home health aides “provide routine, personal healthcare, such as bathing, dressing, or grooming to elderly, convalescent, or disabled persons in the home of patients or in a residential care facility.” This category clearly focuses on care in community residential settings. These workers are generally certified only if they are working in a setting where Medicare is funding the services. Some states do require certification of all home health workers.

Personal and home care aides “assist elderly or disabled adults with daily living activities at the person’s home or in a non-residential facility. Duties performed at a place of residence may include keeping house (making beds, doing laundry, washing dishes) and preparing meals. May provide meals and supervised activities at non-residential care facilities. May advise families, the elderly, and disabled on such things as nutrition, cleanliness, and household utilities.” This category of worker provides non-health related personal services to consumers in any setting. In most states, these workers are not regulated, but some states do address these workers in occupational legislation.

The State labor departments use these definitions when collecting data on behalf of the Federal government and the BLS. Although these worker descriptions seem clear, grouping nursing aides, orderlies, and attendants makes it difficult to separate those providing direct care from those in support services. Counts of nursing aides are particularly hard to ascertain as a result of this alignment. It is also important to consider that existing data systems capture only those workers in the formal, regulated long-term care system. Workers who are self-employed and family members, church associates, and neighbors providing services to the elderly are not included.

Inconsistent Use of Data
Different constituents use different datasets. Those in State policy positions, for instance, may be interested in different benchmarks than businesses operating nursing homes. According to California and New York informants, technical expertise and the ability to use complex datasets also vary, and the purposes for which organizations and providers seek information differ. The kinds of data needed are wide ranging and must be considered when evaluating either existing or proposed new data sources and systems.

Broader Data Requirements
Informants indicated that additional data, beyond counts of workers, are necessary to support effective workforce planning. They were interested in data about:

Training programs and career ladders
Supply and demand
Demographics of the workforce
Staffing patterns
Work distribution

They also considered data on wages, vacancies and turnover, workload, patient waiting lists, and trends in service utilization to be important for further evaluation of employment conditions. New York providers were particularly interested in local or regional data that would yield information about the supply of and demand for paraprofessionals. Other than data collected for the BLS, currently no data collection instruments focus exclusively on characteristics of the workforce. Most information collected on paraprofessionals is incidental to surveys about facilities that provide care or consumers who receive care.

Informants indicated that many different kinds of paraprofessional data are necessary to inform solutions to the problem of attracting and retaining workers. A variety of provider groups are positioned to be professional resources on various aspects of the issue, and collaboration is imperative. In California, key informants suggested government interagency collaboration, public-private agency collaboration, and industry-education program collaboration as ways to develop and implement specific workforce data strategies, including specific data collection efforts.

According to California informants, a national certification database would allow states to provide reciprocal certification and conduct more thorough background checks. New York informants expressed concern about the movement of nurse aides from State to State, and the inability of providers to access information about the backgrounds of those workers from other states. By fostering consistent, uniform data collection efforts in registries, a national database could provide accurate counts of workers at several levels. It would also speed certifications by endorsement, that is, reciprocity in certification. This might eliminate retraining in a new State and would place aides in the workforce more quickly.

According to California and New York informants, aggregated national data may provide a relatively accurate picture of broad trends, but local or regional data is especially important to providers. Providers need data that reflects the markets in which they operate. Benchmarking is often done at the regional level, and detailed knowledge about competitors and peers is critical to these processes.

Data Inaccessibility
Comprehensive data on the workforce are not readily accessible. Anecdotal information is widely available that suggests major shortages of the paraprofessional workforce. This information is widely considered to be a valid reflection of the job market. However, informants are interested in information based on hard data about paraprofessionals. Such data is not currently available. Those interviewed are willing to participate in local data collection efforts by completing surveys as long as the instruments are direct, simple, and focused on workforce. According to New York and Wyoming informants, turnover rates in the workforce were considered to be an important indicator for inclusion on any survey. The definition of turnover should be clear and universally applied to any instrument by all informants.

Data Accessibility
Data about patients, especially regarding utilization, should be available to planners and policymakers. Currently, data on patient utilization is specific to particular functional “silos” in the system. For instance, there are data about individual patients in home care through OASIS or in nursing homes through OSCAR or in hospitals through CMS but no identification of patients who may receive multiple services from different types of provider organizations. A single patient may access care in various settings-hospital, home, and nursing facility-during different episodes of care in the trajectory of illness. That patient would, subsequently, be counted separately in different datasets. According to California informants, fully understanding utilization trends is important to effectively enumerating the future demand for and scope of required services. Such tracking is feasible should Federal planners implement the unique individual identifier presently under consideration.

Variations in Regulations
A feature that complicates collecting worker data is the variation in the nature of regulatory incentives across states. Several factors drive State legislation, none of which appears to be interest in accurate worker counts or characteristics. The primary drivers are usually facility and/or occupational regulation in the interests of public safety. In Oklahoma, occupational legislation requires all direct care workers to be registered and screened, with public safety concerns principally powering the process. In other locations, facility regulation controls State certification. As stated earlier, in New York, nurse aides working in nursing homes are the only category of worker appearing on the registry. The rules that relate to these workers are a direct result of mandated Federal facility regulation of nursing homes from Omnibus Budget Reform Act (OBRA) 1987. Although home health aides working in certified agencies are also required to complete training in compliance with Federal regulations, they are not listed on the registry and remain a separately defined group of workers.

Conclusions
Informants in the four states agreed that data collection and analysis is currently inadequate for policy planning. Current data are fragmented. They are not readily available nor easily usable by analysts. There are no standard data collection instruments specific to collecting information on direct care paraprofessional workers. [An illustrative instrument is shown in Appendix B.] Presently, data for workforce planning are available on an incidental basis based on instruments serving other purposes.

Inconsistency in definitions complicates compiling and understanding existing datasets. The criteria for determining whether information is useful vary by user. For example, providers require data that is different from those policymakers require. However, worker supply and demand data are almost universally necessary at the local, state, and national levels. All informants agree that the most critical data requirement is an accurate estimate of the number of paraprofessionals in the workforce. These data would serve many purposes, including providing documentation in support of legislative initiatives and informing the design of State and local programs. There is an equally pressing need for information about the demographic characteristics of paraprofessional workers. Information about paraprofessionals’ ages, ethnicity, and educational backgrounds would help stakeholders to understand the dynamics of the workforce, suggest viable solutions, and achieve valued outcomes.