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Most nursing home operators understand the importance of improving wages and career opportunities when attempting to solve their staffing crises. Likewise, they're aware of industry studies that show turnover rates for certified nurse's aides (CNAs) that average 76% and vacancy rates near 12%. Without additional reimbursement funding, many feel unable to solve these problems, and the cycle continues.

While long-term care staffing presents a serious challenge, solutions are possible when groups work together. Paraprofessional Healthcare Institute (PHI), a nonprofit organization that provides national consulting services in healthcare employment and policy reform, is developing approaches for retaining direct-care workers and improving the lives of long-term care residents.

Established in 1991, PHI grew out of Cooperative Home Care Associates of South Bronx, New York, a 700-worker, employee-owned company that supplies home healthcare aides to large healthcare providers on a contract basis.

Today the organization provides consulting services across the country, both to home care agencies and nursing home facilities, and is working on public policy in seven states, to improve opportunities for workers and low-income individuals and to improve the quality of care provided to long-term care clients.

PHI has been awarded federal funding to help oversee the National Clearinghouse on the Direct Care Workforce (www.directcareclearinghouse.org)

PHI'S staff and board members have direct experience in running nursing homes and home care agencies, which qualifies them to help direct-care workers improve their skills and career opportunities through education, while helping employers create a culture of staff retention rather than a culture of turnover. The organization trains primarily women, most of whom are former recipients of public assistance. These individuals attend four weeks of on-site classroom instruction, followed by 90 days of on-the-job training.

Addressing Staff Needs

One of the most ironic realities for nursing home direct-care staff is that they themselves often have no healthcare benefits. They are further burdened by a lack of sick and vacation leave, logistically difficult shift work, and limited hourly wages.

These realities confronting direct-care workers in long-term care facilities make it easy to understand why many lack commitment. Yet, nursing homes need committed and trustworthy workers. When the lives of these caregivers are improved, the result is positive not only for them, but also for operators, in the form of reduced turnover and improved resident care.

PHI President Steve Dawson suggests that administrators talk directly to their current employees to determine what motivates them to continue to do this work, as well as asking past employees why they left. Then administrators should listen carefully to what both groups say about working conditions. Dawson says, "In focus groups, many workers tell us that they don't leave their jobs, they leave their supervisors. Frontline workers often quit their jobs because of how they have been treated." He contends that nursing home administrators who really listen can usually find ways to support their supervisors and at the same time respect direct-care workers. The result will be lower turnover and more satisfied residents.

In creating a "culture of retention," Dawson emphasizes that providers must work together on policy changes that will allow them to pay their workers a family sustainable wage. Even committed employees can't stay if they don't make enough money. Part-time staff might need to work more hours just to survive, if they are going to be able to remain in the field that they love. Furthermore, for some workers, leave time and healthcare benefits are just as important as more money.

Models That Work

Massachusetts is one of the states where PHI has worked with providers, consumers, and workers to help improve public policy.

Three years ago in that state, the organization hired Barbara Frank, a former nursing home ombudsman, as its state policy director. She helped develop a coalition of stakeholders in Massachusetts that included, among others, the Massachusetts Extended Care Federation, the Alzheimer's Association, and the Service Employees International Union. Together, the coalition found a champion in Massachusetts Senator Mark Montigny, chairman of the Senate Ways and Means Committee, and went to work crafting the Massachusetts Direct Care Workers Initiative.

The stakeholders in Massachusetts worked with Sen. Montigny on legislation that would provide wage enhancement for nurse's aides, a demonstration program to encourage direct-care-worker retention and recruitment, and a training fund. The legislation passed in 2000. In the first year, it provided $35 million for wage enhancement, $5 million for the demonstration, and an additional $1 million for scholarships. It was renewed in 2001, with total funding for the two years reaching $88 million to benefit direct-care staff.

PHI continues to work in several other states--including New Hampshire, Pennsylvania, and Michigan--helping to strengthen relations between providers, consumers, and labor to improve public policy.

Other organizations are employing similar-industry-specific training strategies. For example, Project QUEST in San Antonio is also building career ladders to help its city address the tremendous shortage of healthcare workers. This program and the Massachusetts coalition are examples of what can be done to improve industry and job opportunities simultaneously.

Project QUEST is an innovative, award-winning job-training program that has met the needs of San Antonio businesses since 1993 by training local residents who would otherwise be out of work or receiving public assistance. San Antonio has approximately 55 nursing homes and assisted living facilities, which are major consumers of Project QUEST services.

Project QUEST is working on a pilot program to help nursing homes keep employees and help them grow and advance. The program allows employed CNAs and home health aides/personal caregivers to obtain basic-skills training in the first year of the program and occupational-skills training as licensed vocational nurses in the second year. This program will result in lower turnover for employers and increased opportunities for employees.

Project QUEST and PHI are excellent examples of why industry-specific strategies work. They are not cookie-cutter solutions. Instead, they involve:

* working directly with businesses in crafting solutions;

* training low-income individuals;

* offering extensive knowledge of their targeted industries; and

* providing catalysts for systems change.

Healthcare is one of 15 industries that employ industry-specific workforce development strategies to create success for low-income people, for businesses, and for the industry overall.

PHI is a member of the National Network of Sector Partners, a membership organization founded in 1999 to encourage industry-specific workforce development strategies that enhance employment opportunities for low-income individuals, families, and communities.

Cindy Marano is executive director of the National Network of Sector Partners (NNSP), Oakland, California. For more information, phone (510) 251-2600. Paraprofessional Healthcare Institute (PHI), Bronx, New York, provides services and counseling in connection with Long-term care staffing. For further information, phone (718) 402-7766. To comment on this article, please send e-mail to marano0103@nursinghomesmagazine.com.