Initiatives to Improve LTC Direct Care Workforce Retention: What is

the Evidence Base?

Lauren D. Harris-Kojetin, PhDInstitute for the Future of Aging Services

www.futureofaging.orgLharris-kojetin@aahsa.org

AcademyHealth Annual Research MeetingBoston, MA

June 26, 2005

Presentation Overview

• Background• Purpose• Context/Conceptual Models• Research Synthesis

– Methods– Key findings on effective interventions

• Implications• Resources

Background

“Education and training of staff, supervision,environmental conditions, attitudes andvalues, job satisfaction and turnover of staff,salaries and benefits, leadership,management, and organizational capacityare all essential elements affecting quality ofcare to residents.”

IOM, Improving the Quality of Long-Term Care

• Over 2.4 M paraprofessional LTC workers form the core of the formal LTC system

• Turnover ranging from 45% to over 100%

• Between 2002 – 2012, 888,000 more DCW jobs

• 27 M Americans are projected to need LTC by 2050

• Significant societal factors converging “care gap”

• Variety of factors associated with LTC direct care workforce (DCW) recruitment & retention problems – inadequate training, job orientation & lack of

mentoring– poor public image of LTC direct care workforce– low pay & insufficient benefits– few opportunities for development within the

position– poor supervision– emotionally & physically hard work– workplace stress & burnout– personal life stressors– lack of respect from residents’ families– short staffing

Purpose

– States, providers & worker groups have designed & implemented a variety of initiatives intended to address DCW LTC problems

– Some of these initiatives have been evaluated

– Current state of evidence base on relationship between how LTC work is organized/structured & DCW turnover/retention

Context/Conceptual Models

Local Environment

Labor Market

Regulation

Competitive Strategy

Values & Beliefs

Structure

Profit status

Chain

Religious status

Size

Case mix

Management Philosophy of Care

Medical-custodial

Medical-rehabilitative

Regenerative

Work Organization

Teams

Training

Assignments

Human Resources Practices

Wages

Benefits

Hiring

Turnover

ResidentOutcomes

Quality of Care

Quality of Life

Model of Nursing Home Quality – Eaton (2000)

Employer-Related Factors Associated with Turnover

Job Satisfaction

Organizational Commitment

TurnoverRetention

Personal Characteristics & Competing Demands

Compensation & Benefits

Quality of Work Environment, Job Design, Job Stress

Initial & On-Going Training

Employer Organizational Characteristics

Adapted from Banaszak-Holl and Hines, 1996

Research Synthesis

Recent Insights about Frontline Long-Term Care

Workers: A Research Synthesis 1999-2003Lauren Harris-Kojetin, PhD

Debra Lipson, MHSAJean Fielding, MGSKristen Kiefer, MPP

Robyn I. Stone, DrPH

Funded by ASPE, DHHS

Methods

• Search sources: Ageline, PubMed, Internet searches, personal communications, conferences, initiatives in Stone (2001)

• Eligible materials: Published & gray literature

• Search terms (examples): LTC workforce, labor force, recruiting, paraprofessional, job tenure, work environment, intervention

• Timeframe: 1999 – 2003• Outcomes: turnover and/or retention• Data collection: Study documents

abstracted & categorized by intervention type, evaluation design & results

Types of Interventions Evaluated

1999 - 2003• Alternative labor pools• Career ladders• Culture change• Enhanced staff-family communication• Multi-faceted initiatives• Peer mentoring• Self-managed work teams• Wage enhancements

Types of Initiatives Evaluated1999 – 2003 (continued)

• 15 interventions reviewed– 2 had not (yet) had outcome evaluation – 2 did not measure actual turnover or

retention– 8 showed non-significant, negative, or

inconclusive results or did not use robust quasi-experimental design

– 3 showed significant positive turnover/retention results using a pre-post comparison group design

Key Findings on Effective Interventions

Growing Strong Roots – Peer Mentoring

• Trained, experienced certified nursing assistants (CNAs) matched with new CNAs

• Training & manuals for project coordinators & mentors

• Booster training & newsletters for mentors

• Mentoring active 8 weeks• Salary increase for mentor

Growing Strong RootsEvaluation Results

• 12 nursing homes in New York state

• Statistically significant improvement in retention among those mentored – 18 point increase in average

retention rate while increase not significant among comparison group

WIN A STEP UP – Education & Payment

Incentives• 10 modules on clinical skills,

interpersonal skills, and communication• Nurse aides (NAs) get $70 per completed

module• Facilities must agree to commit staff time

& give either retention bonus ($75) or wage increase (> $0.25/hr) 3 months after completion of modules

• NAs who complete > 7 modules & stay at facility > 3 months after training get matching $75 bonus from WIN A STEP UP

WIN A STEP UPPilot Evaluation Results

• 4 nursing homes, 1 home health agency, 1 adult care home in NC

• Annual turnover rates significantly lower for NAs in the program compared to those in the matched comparison group (15% to 32%)

Wellspring – Quality Improvement & Organizational

Change • Alliance super structure• Leadership & clinical training modules• Shared advanced practice nurse• Coordinator in each facility• Care resource teams• Systematic collection & use of outcome

data• Non-hierarchical management

philosophy

WellspringEvaluation Results

• Wellspring facilities fared better than other Wisconsin facilities on retention & turnover – Wellspring CNA retention increased

by 6% while other homes decreased by 6%

– CNA turnover rates increased for both Wellspring & other homes, but increase was smaller for Wellspring

Summary – What Works?• 3 of 15 interventions using a pre-post

comparison group design had significant improvements in retention and/or turnover– Management buy in & sustained

commitment – Facilities commit to give staff time– Direct supervisors committed to working

with DCWs– Follow-up & support beyond initial training– Financial incentives to DCW in 2 of 3

interventions– Clear, consistent messages & expectations

Implications

Strengthen Evidence Base• Evaluate innovative workforce

improvement models• Examine linkages among workforce &

quality of care & life outcomes• Strengthen evaluation designs

– Measure longer-term effects– Measure variation within facilities (units,

shifts)– Measure actual behavioral outcomes– Measure outcomes consistently– Use of a comparison group

• Examine other LTC settings• Determine transferability of evidence-

based models across settings

Promote Evidence Base

• Provide technical assistance to LTC providers to implement & sustain new models– Give on-going feedback to providers

• Determine how to replicate effective interventions beyond the initial demonstration (inform technical assistance)

• Determine how to sustain interventions• “Incentivize” the use of evidence-based models

– Make the case for evidence-based workforce interventions with payors, regulators and providers

Resources

• Synthesis paper available at:http://aspe.hhs.gov/daltcp/reports/insight.pdf• Measuring Long-Term Care Work: A

Guide to Selected Instruments to Examine Direct Care Worker Experiences and Outcomes

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