6

Strengthening the Caregiving Work Force

The previous chapter focused on regulatory standards and their enforcement. This chapter examines federal and state personnel standards for various long-term care settings. It reviews the literature on the relationship between staffing and quality of care, and presents recommendations for improvements. This chapter also examines the training and education of personnel; hiring and employment issues, including registries and background checks before hiring; and barriers to a stable workforce, with particular emphasis on wages and benefits. Finally, the chapter discusses the management and organizational capacity needed to improve quality of care.

Provision of formal long-term care to the population requires an adequate, skilled, and diverse work force. Registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants or aides (NAs) and home health aides represent the largest component of personnel in long-term care. Other professionals—including physicians, social workers, therapists (physical, occupational, and speech), mental health providers, dietitians, pharmacists, podiatrists, and dentists—provide many different kinds of essential services to at least a subset of those using long-term care. Non-professionals, who provide the majority of personal care services, such as assistance with eating or bathing, have a major impact on both the health status and the quality of life of long-term care users. In addition to direct care providers (or caregivers), administrative, food service workers, housekeeping staff, and other personnel play essential roles in long-term care.



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Improving the Quality of Long-Term Care 6 Strengthening the Caregiving Work Force The previous chapter focused on regulatory standards and their enforcement. This chapter examines federal and state personnel standards for various long-term care settings. It reviews the literature on the relationship between staffing and quality of care, and presents recommendations for improvements. This chapter also examines the training and education of personnel; hiring and employment issues, including registries and background checks before hiring; and barriers to a stable workforce, with particular emphasis on wages and benefits. Finally, the chapter discusses the management and organizational capacity needed to improve quality of care. Provision of formal long-term care to the population requires an adequate, skilled, and diverse work force. Registered nurses (RNs), licensed practical nurses (LPNs), and nursing assistants or aides (NAs) and home health aides represent the largest component of personnel in long-term care. Other professionals—including physicians, social workers, therapists (physical, occupational, and speech), mental health providers, dietitians, pharmacists, podiatrists, and dentists—provide many different kinds of essential services to at least a subset of those using long-term care. Non-professionals, who provide the majority of personal care services, such as assistance with eating or bathing, have a major impact on both the health status and the quality of life of long-term care users. In addition to direct care providers (or caregivers), administrative, food service workers, housekeeping staff, and other personnel play essential roles in long-term care.

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Improving the Quality of Long-Term Care As shown in Chapter 2, in 1998, nursing homes, personal care facilities, residential care, and home health and home care agencies accounted for nearly 3.2 million jobs. Of these jobs, 1.18 million, or 37 percent, were paraprofessionals (including nursing assistants, personal care aides, and home health care aides), 9 percent were RNs and 8 percent were LPNs (BLS, 2000). Approximately 57 percent of the paraprofessional workers were employed by nursing facilities, 28 percent by home care agencies, and 15 percent by residential care facilities or programs in 1998 (BLS, 2000). Long-term care services are labor intensive so the quality of care depends largely on the performance of the caregiving personnel. Personnel standards vary considerably across long-term care settings. For purposes of this report, “staffing levels” include numbers of staff, ratios of staff to residents, and the mix of different types of staff in nursing homes and residential care facilties. In home care, staffing levels cannot be discussed in these terms since each client is served individually and agencies are staffed to meet client needs. Rather, the committee considered the amounts and types of services provided to clients with various needs. In a labor-intensive field such as long-term care, the numbers, training, and competence of staff are widely viewed as critical to the quality of services. Most of the research on the relationship between quality of long-term care and the number and type of staff and their expertise and skills relates to nursing homes. Some studies have examined home health care workers, but few of these studies have examined the relationship between work force characteristics and quality of care. Little is known about the relationship of staff to quality of care in other long-term care settings. In addition to staffing levels, a key issue is whether the work force in long-term care has adequate education and training to provide high quality of care to individuals. Federal standards have been set for some personnel in nursing homes and home health agencies, but not for personnel providing care in other types of long-term care settings. Some states also have their own requirements for personnel, particularly for the regulation of health professionals and long-term care administrators. These requirements vary across states. This chapter discusses the caregiving work force separately for each setting. The committee examined existing standards and reviewed the available empirical evidence and research literature on the relationship of staffing patterns and quality. The committee deliberated on the need for changes in standards, education and training issues, and the work environment.

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Improving the Quality of Long-Term Care NURSING HOMES Federal and State Nursing Home Staffing Standards To participate in the Medicare or Medicaid programs, long-term care facilities must meet federal certification requirements established by the Health Care Financing Administration (HCFA, 1994). The Nursing Home Reform Act, embedded in the Omnibus Budget Reconciliation Act of 1987 (OBRA 87), included a number of provisions related to staffing, which were implemented by the HCFA in a series of regulations and transmittal letters (HCFA, 1994, 1995a–c). The legislation required increased nurse staffing and social work services and set minimum training requirements for nursing assistants. Specifically, OBRA 87 requires nursing facilities certified for Medicare and Medicaid to have licensed nurses on duty 24 hours a day; an RN on duty at least 8 hours a day, 7 days a week; and an RN director of nursing. The statute permits the director of nursing and the RN on staff for 8 hours a day to be the same individual. Furthermore, each nursing home is required to have a medical director responsible for the medical services of the facility residents. Facilities with 120 or more beds must have a full-time person with a bachelor's degree in social work or a related field. HCFA regulations also require social activities; medically related social services; dietary services; physician and emergency care; and pharmacy, dental, and rehabilitation services (including physical, speech, and occupational therapies, which are mentioned explicitly) (HCFA, 1995a–c). More generally, the law requires “sufficient staff” to provide nursing and related services to attain or maintain the “highest practicable level” of physical, mental, and psychosocial well-being of each resident. The federal law and the implementing regulations, however, do not provide specific standards or guidance about what constitutes “sufficient staffing.” Registered and licensed nurse requirements are not adjusted for facility size or casemix. The HCFA survey and certification program does not have procedures for auditing staffing levels or for monitoring the accuracy of staffing data reported by facilities. In addition to federal requirements, some states have licensing requirements for staffing in nursing facilities that go beyond the federal staffing requirements, although they vary widely across states (NCCNHR and NCPSSM, 1998). In a recent survey, 21 states reported legislative action or interest in increasing staffing standards (NCCNHR and NCPSSM, 1998). California increased its minimum nursing home requirements for direct caregivers to 3.2 hours per resident-day (excluding administrative nurses) (California State Budget Act, 1999). The committee generally endorses the

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Improving the Quality of Long-Term Care OBRA 87 standards and the states' efforts to improve the staffing requirements in nursing facilities. Current Staffing Levels in Nursing Homes Staffing data are available from the On-Line Survey and Certification Assessment Reporting (OSCAR) System, the Medicare time studies conducted by HCFA, and periodic national sample surveys conducted by the federal government. OSCAR System. OSCAR data, collected during the certification surveys by state agencies that verify compliance with all federal regulatory requirements, show staffing data reported by facilities for the two weeks prior to the survey. Figure 6.1 presents the available OSCAR data on all staff in nursing facilities in the United States during calendar year 1998. It shows that average total staffing hours were 5.9 hours per resident-day for all nursing facilities in the United States in 1998. Nursing staff represented 59 percent of the total personnel hours. Housekeeping and other staff was the second largest category, with 0.77 hour (46 minutes) per resident-day, and dietary staff had 0.71 hour per resident-day. The activity staff averaged 0.16 hour (10 minutes) per resident-day. All other staff were less than 7 minutes per resident-day. Table 6.1 shows that the average number of hours for registered nurses (including nurse administrators) was 0.74 hour per resident-day. LPN hours were 0.69 hour per resident-day and NA hours were 2.09 hours in 1998. Total nurse staffing per resident-day was 3.52 hours. When the total hours are divided by three (8-hour) shifts per day, each resident was receiving about 15 minutes of RN time per shift, 14 minutes of LPN time, and 42 minutes of nursing assistant time per shift. Averages for the country as a whole, however, mask substantial variation among states and among facilities within states. As seen in Table 6.1, there are wide variations in staffing levels for different types of facilities. Hospital-based nursing facilities had almost twice as many total hours of nursing care and 4 times as many registered nurse hours as freestanding nursing facilities. Skilled nursing facilities (SNFs) for Medicare-only residents had 2.3 times as many total nursing hours and 6 times as many registered nursing hours as facilities with Medicaid-only residents. Larger facilities had higher nurse staffing hours than smaller facilities. Some facilities report very low nurse staffing levels. Table 6.2 shows that of the total certified nursing homes, 2,701 facilities (19 percent) provide less than 2.7 nursing staff hours per resident-day.

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Improving the Quality of Long-Term Care FIGURE 6.1 Mean staffing hours per resident day for nursing facilities in the United States surveyed in calendar year 1998. NOTE: Facilities with inaccurate resident data or incomplete staffing data (497 facilities) were removed. Facilities with staffing levels in the lower 1 percent and the upper 2 percent (1,211) (calculated separately for Medicaid only facilities and Medicare certified facilities) were removed. Medicare Staffing Time Studies. In 1990, Congress passed legislation requiring HCFA to develop a Nursing Home Casemix and Quality Demonstration program (OBRA, 1990). This HCFA project developed a method for classifying nursing home residents into 44 different Resource Utilization Groups (RUGs) based on a study of resident characteristics in relation to the facility staff time expended to provide care, including nursing and therapy staff (Fries et al., 1994).1 These studies were then used to develop 1   For details of the methods, see Fries et al. (1994). For information about the quality indicators developed from Minimum Data Set data, see Zimmerman et al. (1995).

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Improving the Quality of Long-Term Care TABLE 6.1 Nursing Staff Levels per Resident Day, by Facility Type and Region for Nursing Homes: United States, 1998   Nursing Staff Facility Characteristics Number of Facilities Percent of Facilities Total Registered Nurses Licensed Practical Nurses Nursing Assistants   Mean Hours Total 13,396 100.0 3.52 0.74 0.69 2.09 Type of facility Hospital based 1,702 12.4 5.79 2.13 1.22 2.44 Non-hospital based 11,991 87.6 3.20 0.54 0.62 2.04 Certification Skilled nursing facilities for Medicare only 1,054 7.7 6.95 2.91 1.50 2.53 Skilled nursing facilities for Medicare or Medicaid 10,909 79.7 3.28 0.58 0.63 2.07 Nursing facilities for Medicaid only 1,730 12.6 2.98 0.43 0.58 1.97 Size 1–99 beds 6,843 50.0 3.78 0.91 0.73 2.14 100+ beds 6,850 50.0 3.26 0.56 0.66 2.04 Region West 2,030 14.8 3.63 0.81 0.61 2.21 South 4,487 32.8 3.63 0.67 0.84 2.11 Northeast 2,481 18.1 3.62 0.84 0.62 2.16 North Central 4,695 34.3 3.32 0.72 0.62 1.98 SOURCE: Harrington and Carrillo, 2000. a Medicare payment system for use by the five states participating in the demonstration starting in 1995. Ultimately, Congress adopted a Medicare prospective payment system (PPS), implemented by HCFA in 1998. Prior to the implementation of the PPS, HCFA commissioned three major studies to measure staff time in nursing facilities. The purpose of these studies was to define the relationship between resident resource utilization and nursing and therapy staff time. The RUGs were derived in

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Improving the Quality of Long-Term Care TABLE 6.2 Distribution of Combined Nursing Hours per Resident Day in All Certified Nursing Facilities: United States, 1998 Percentile Average Hours per Resident Day Number of Hours Cumulative Number of Hours 0–9 0.90–2.45 1,343 1,343 10–19 2.46–2.70 1,358 2,701 20–29 2.71–2.88 1,320 4,021 30–39 2.89–3.04 1,397 5,418 40–49 3.05–3.20 1,347 6,765 50–59 3.21–3.37 1,428 8,193 60–69 3.38–3.58 1,360 9,553 70–79 3.59–3.91 1,381 10,934 80–89 3.92–4.65 1,386 12,320 90–100 4.66–16.67 1,373 13,693 NOTE: Median (50th percentile) = 3.21 hours per resident day. Mean = 3.52 hours per resident day. N = 13,693 certified nursing facilities. Facilities with inaccurate resident data or incomplete staffing data (497 facilities) were removed. Facilities with staffing levels in the lower 1 percent and the upper 2 percent (calculated separately for Medicaid-only facilities and Medicare-certified facilities) (1,211 facilities) were removed. SOURCE: Harrington and Carrillo, 2000. part and updated based on these time studies. The 1995 and 1997 time studies were used primarily to set reimbursement rates for a Medicare prospective payment system (Burke and Cornelius, 1998; Reilly, 1998). From the perspective of staffing requirements, the major concern with these studies has been that nursing and therapy time was based on existing practices in facilities and not on the staffing time required to meet the needs of residents. The average time per resident-day for different types of nursing staff from HCFA time studies in 1995 and 1997 (averaged together) includes direct and indirect (e.g., administrative) nursing time. Table 6.3 compares HCFA time study data with OSCAR staffing data. The average time, based on HCFA time studies, was 4.17 total nursing hours per resident-day (Burke and Cornelius, 1998). This figure was higher than the 3.52 hours reported on OSCAR, probably because the time studies focused on facilities with high numbers of Medicare residents rather than on those with only Medicaid residents. The new Medicare PPS pays nursing facilities based on the resident casemix. The Medicare payment formula was based on the amount of time that nurses and therapy staff are expected to provide for Medicare residents with different types of impairments. Nursing facilities are not, however, required by HCFA to provide the hours of time for which they

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Improving the Quality of Long-Term Care TABLE 6.3 Comparison of Average Nursing Hours per Resident Day for OSCAR Data, HCFA Time Studies, and Time Proposed by Experts Nursing Staff OSCAR Data, 1998a HCFA Time Studies 1995–1997b Time Proposed by Expert Panelc   Average Hours per Resident Day Total 3.52 4.17 4.55 Registered nurses 0.74 1.15 1.15 Licensed practical nurses 0.69 0.70 0.70 Nursing assistants 2.09 2.32 2.70 NOTE: times listed include all administrative nursing time and indirect care. aHarrington et al., 1999. b Burke and Cornelius, 1998. c Harrington et al., 2000. are paid under Medicare. Thus, payment is not tied directly to staffing levels in nursing facilities. There are some indications that staffing ratios have increased somewhat in recent years. The total nursing hours per resident-day reported on OSCAR data for all facilities has gradually increased. Figure 6.2 shows that the total number of hours per resident-day in nursing facilities, as reported in OSCAR, was 3.0 hours in 1991. By 1998, this total was 3.5 hours per resident-day. Much of the increase in hours was due to increases in RN hours over that period. The slight increase (less than 10 percent) observed may be attributed in part to the requirements of OBRA 87 and in part to the increased acuity of residents and the consequent staffing required to care for residents who need specialized services. Relationship of Staffing and Quality of Care Many factors influence the quality of care provided to residents by staff and the quality of life of the residents. Staffing levels and staff characteristics are critical structural elements. In addition, education and training of staff, attitudes and values, job satisfaction and turnover of staff, salaries and benefits, and management and organizational capacity of the facility are all factors affecting quality. As reviewed in the 1996 Institute of Medicine report on the adequacy of nurse staffing in hospitals and nursing homes (IOM, 1996a), a number of studies have shown a positive association between nurse staffing levels and the processes and outcomes of nursing home care (see for example

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Improving the Quality of Long-Term Care FIGURE 6.2 Average nursing hours per resident day in all certified nursing facilities: United States, 1991–1998. SOURCE: Harrington and Carrillo, 2000. Linn et al., 1977; Nyman, 1988b; Munroe, 1990; Cherry, 1991; Spector and Takada, 1991; Aaronson et al, 1994; Cohen and Spector, 1996). Nyman (1988b) found that nursing hours per patient-day were positively related to three quality measures. Kayser-Jones and colleagues (1989) found that inadequate staffing resulted in poor feeding of residents and inadequate nutritional intake, which contributed to resident deterioration and hospitalization. Munroe (1990) found a positive and statistically significant relationship between the quality of care (measured by deficiencies) and higher ratios of RN and LPN hours per resident-day and lower turnover rates. Spector and Takada (1991) found that higher staffing levels and lower RN turnover rates were related to improvements in resident functioning. Lower staffing levels were associated with high urinary catheter use, low rates of skin care, and low resident participation in activities. Braun (1991) found that higher RN hours were related to lower mortality rates. Cherry (1991) also found that increased RN hours were positively associated with a composite of good outcome measures (fewer decubitus ulcers, catheterized residents, or urinary tract infections, and less antibiotic use). Cohen and Spector (1996) found that higher ratios of RNs to residents, adjusted for resident casemix, reduced the likelihood of

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Improving the Quality of Long-Term Care death and that higher ratios of LPNs significantly improved resident functional outcomes. The relationship between inadequate staffing and malnutrition, starvation, dehydration, undiagnosed dysphagia, and poor oral health of residents has been documented (Kayser-Jones, 1996, 1997; Kayser-Jones et al., 1997; Kayser-Jones and Schell, 1997). Kayser-Jones and colleagues (1999) showed that nearly all nursing home residents studied in two facilities had inadequate fluid intake. They attributed this finding to inadequate staffing supervision to provide care to nursing home residents with dysphagia, severe cognitive and functional impairment, and aphasia or inability to speak English. A study of Minnesota nursing homes found that in the first year after admission to a nursing home, the licensed nursing hours (but not nonlicensed) were significantly related to improved functional ability, increased probability of discharge home, and decreased probability of death. However, when limited to chronic care residents the role of professional nursing hours disappeared (Bliesmer et al., 1998). Harrington et al. (2000h) showed that higher nurse staffing hours, particularly RNs, were associated with fewer nursing home deficiencies. In contrast, one longitudinal study of nursing home residents in Massachusetts found that better health outcomes (e.g., survival time, functional status, incontinence, and mental status) were not related to higher RN staffing levels (Porell et al., 1998). Bowers and Becker (1992) found that nursing assistants reported inadequate time to provide high quality of care and the widespread use of techniques for cutting corners required to manage the workload. Foner (1994) reported that workload demands for productivity in nursing homes were in conflict with the need to provide individualized care. Two studies identified reports of psychological and physical abuse of residents by nursing assistants, which were found to be related to the stressful working conditions in nursing homes (Pillemer and Moore, 1989; Foner, 1994). Some of the staff problems can be directly related to poor wages, limited or no health benefits, and high turnover rates (IOM, 1996a). The most important factor in determining staffing levels should be the resident casemix within facilities. Previous studies have shown a strong positive relationship between casemix adjusted resident characteristics and nurse staffing time (Arling et al., 1987; Cohen and Dubay, 1990; Zinn, 1993a,b; Fries et al., 1994). Thus, facilities with higher casemix levels should require more nursing staff time to meet resident needs. Several studies have shown the importance of nursing management by professional nursing staff and gerontology specialists in making improvements in quality of care (Schnelle, 1990; Schnelle et al., 1990; Hawkins et al., 1992). The knowledge, hands-on care, and leadership of RNs were essential to sustained quality improvement interventions (Schnelle, 1990).

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Improving the Quality of Long-Term Care Other studies have demonstrated the important role that gerontological nurse specialists and geriatric nurse practitioners play in improving quality (Kane et al., 1988; Mezey and Lynaugh, 1989, 1991). Improved outcomes of care and fewer hospitalizations with the use of gerontological nurses have been documented (Mezey and Lynaugh, 1989, 1991; Buchanan et al., 1990; Mor, 1999). Mor (1999) found lower rates of risk-adjusted hospitalization (but not mortality) for residents in facilities that have a nurse practitioner or physician assistant, but he did not find an effect of RN staff ratios on hospitalization rates. The 1986 IOM Committee on Nursing Home Regulations encouraged nursing homes to employ specially trained gerontological nurses. The committee supports the recommendation of the IOM Committee on the Adequacy of Nurse Staffing in hospitals and nursing homes that nursing facilities use geriatric nurse specialists and geriatric nurse practitioners in both leadership and direct care positions (IOM, 1996a). Most nursing homes, however, do not employ nurse practitioners in direct care positions. In summary, the research evidence suggests that both nursing-to-resident staffing levels and the ratio of professional nurses to other nursing personnel are important predictors of high quality of care in nursing homes. Research provides abundant evidence that participation of RNs in direct caregiving and the provision of hands-on guidance to NAs in caring for residents is positively associated with quality of care. The research literature, however, does not answer the question of what particular skill mix is optimal (IOM, 1996a). Nor does it take into account possible substitutions for nursing staff and ways to best organize all staff. Moreover, as discussed later in this chapter, nurse staffing levels alone are a necessary, but not a sufficient, condition for positively affecting care in nursing homes. Training, supervision, environmental conditions, leadership and management, and organizational culture (or capacity) are essential elements in the provision of quality care to residents. Overall, there is a need for sufficient, well-trained, and motivated staff to provide consumer-centered care in nursing homes, as required in OBRA 87. A few studies have examined the contributions to residents' well-being of other types of staff providing non-nursing services in nursing homes. One example is therapy. A study of physical and occupational therapy services in a clinical trial found therapy to have positive benefits for functional status and costs of care (Przybylski et al., 1996). Another clinical trial showed only modest benefits of physical therapy on mobility (Mulrow et al., 1994). A retrospective study of medical records reported that patients receiving high-intensity physical therapy had positive outcomes (Chiodo et al., 1992). A survey of nursing homes found that facility administrators perceived a positive relationship between the provision of daily rehabilitation therapy and the discharge of patients (Kochersberger et al., 1994). In a recent study, direct care staffing hours for these profes-

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Improving the Quality of Long-Term Care workers, and the extent of these requirements varies considerably (Scala and Mayberry, 1997). A recent study found that California and Illinois both required 120 hours of home health aide training, New Hampshire required 100 hours, Kansas and New Jersey required 90 hours, and Texas required 80 hours (Harrington et al., 2000e). The United Hospital Fund of New York (1994) suggested increased training to improve the quality of home healthcare. It recommended three weeks of training at a minimum for home health aides after two weeks of classroom work and demonstration of competence in required skills. In addition, it recommended special training and support for home health aides who manage difficult-to-serve clients, such as those with Alzheimer's disease or AIDS. The federal training requirements may also need updating. The training should ensure the skills necessary to provide high quality of care, promote autonomy, and monitor changes in patients' conditions. In addition to general competencies, home health aides should be trained and tested to ensure they can provide appropriate care when they are working with special populations such as demented clients, children, individuals with AIDS, and other groups. Concern has been expressed by the community of people with disabilities needing long-term personal attendant services that Federal Medicare and Medicaid training requirements do not include instruction for providing consumer-directed services. For example, Scala and Mayberry (1997) have argued that the lack of adequate training and information for both consumers and staff is a major barrier to consumer-directed programs. A study of consumer-directed home and community-based services conducted by the National Council on the Aging also identified such training as a major issue (Cameron, 1996). HOME CARE As noted in the previous sections, the home care work force includes workers in home health and home care agencies, including personal care agencies, and those workers who are independent care providers. All of the problems with the home health care work force are also seen in home care, but very few studies have examined home care personnel issues and their relationship to quality. Most of the literature is on access to, and satisfaction with, consumer-directed models of personal care service discussed in earlier chapters. In these models, consumers select, train, and supervise personal care workers (DeJong et al., 1992; Fenton et al., 1997; Scala and Mayberry, 1997). Benjamin (1998) conducted a study of California's personal care services program and examined the differences between agency model services and independent providers with client-directed care. The study

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Improving the Quality of Long-Term Care found benefits and negative features of both models. The independent provider model provided more paid and unpaid hours to clients, but the worker compensation was much lower than in the agency model. Overall, clients were satisfied with both models. Clients receiving care from independent providers, however, reported more positive outcomes about how they felt in the service relationship and in their satisfaction with the technical and interpersonal aspects of care (Benjamin, 1998). In states that have licensing requirements for personal care attendants, many require attendants to be supervised by an RN who visits the client every 60 to 180 days. Beyond these requirements, most states have few specific regulations regarding personnel in home care agencies or independent providers (Harrington et al., 2000e). It is unknown to what extent states monitor personnel requirements and the extent to which personnel issues are of concern. As indicated in Chapter 3, although professionals involved with families in home care must meet basic standards of professional accreditation and licensure, demonstrate special expertise in the area of children's care, and have explicit training in areas related to the specific child in home care, families face particular problems in the long-term care of children. Many children receive needed care without difficulties, but many home care providers may not have the training or experience in the care of children. Instead, they come from a background of providing care for elderly patients (Feinberg, 1985). Moreover, agencies or programs may lack personnel equipped to supervise home and community-based care for children. EDUCATION AND TRAINING RECOMMENDATIONS As the discussion above indicates, the education and training requirements for formal long-term care providers and informal care providers are clearly important for ensuring high quality of care. The training should be directed to all professionals, not only nurses but also therapists, respiratory care providers, social workers, as well as other caregiving personnel. Although some minimum standards have been set for Medicare- and Medicaid-certified providers, these are generally weak, especially in light of the changing characteristics of those receiving care. Overall, the federal education and training requirements may not be adequate to ensure high quality of long-term care. Providers themselves are principally responsible for ensuring adequate training and competency of their work force. As a general principle, the work force must have the education, training, and commitment to provide care that is consistent with the needs of the individuals being served. The problem is that little research is available

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Improving the Quality of Long-Term Care for many long-term care settings and services to show what appropriate amounts and types of education are necessary to achieve this. Emphasis in the future should be placed not only on the content of training programs but more importantly on competency testing of skills for both formal and informal care providers. Training programs should be tailored to provide appropriate care to special population groups such as individuals with developmental disabilities or AIDS, children, and other groups. Providers also have to be trained and be competent in providing care that uses the most current clinical practice standards for different conditions such as dementia, diabetes, traumatic brain injury, and others. Professionals have to be competent in care assessment and planning, supervision of care workers, coordination of care services, and client- and family-centered care. Increased attention to the education and training of the long-term care work force is needed to ensure that staff has both the knowledge and the skills to provide high quality of care, with particular attention to client-directed care and the needs of special population groups. Recommendation 6.3: The committee recommends that for all long-term care settings, federal and state governments, and providers, in consultation with consumers develop training, education, and competency standards and training programs for staff based on better knowledge of the time, skills, education, and competency levels needed to provide acceptable consumer-centered long-term care. For such education and training programs to work, strict policies for certification will be needed to establish improved standards for this work force. Both basic and ongoing training should promote the development of observational skills to monitor changes in resident or client conditions (including physical, cognitive, social, and psychological status) and to adjust care accordingly. LABOR FORCE ISSUES As stated earlier in this chapter, in addition to staffing levels and staff characteristics, the education and training of staff, job satisfaction, turnover, and salaries and benefits also affect the quality of care provided. The 1996 IOM report on the adequacy of nurse staffing included a review of the literature on labor shortages and the unstable labor pool for the nursing home market and the factors contributing to these problems (IOM, 1996a).

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Improving the Quality of Long-Term Care A serious shortage exists in the long-term care work force. The booming economy is worsening the shortage of nurses, home health aides, certified nursing assistants, and personal care workers (Ryan, 1999; Rimer, 2000). As higher-paying jobs with better working conditions have opened up for the women who have typically held these jobs, workers are hard to find. With the national unemployment rate falling to 3.9 percent in April 2000 (3.5 percent for adult women), it is likely to remain difficult to attract staff into the long-term care industry (BLS, 2000). Shortage of home care workers is the subject of state task forces in Florida, Pennsylvania, and Maryland (Rimer, 2000). The problem of recruiting workers is likely to worsen over time as the number of people needing long-term care increases relative to the population 20–64 years old, which makes up the work force (Lewin Group, 1999). The Bureau of Labor Statistics projects that jobs in the long-term care sector will increase by 1.64 million, or 53 percent, between 1996 and 2006 (BLS, 1998). Reflecting the growing emphasis on the provision of long-term care at home or in alternative residential settings rather than in institutions, total employment in nursing facilities is projected to grow less quickly than in other long-term care settings. BLS estimated that jobs in nursing and personal care facilities would increase by about 37 percent over 1996–2006 compared to increases of 59 percent in residential care facilities and 90 percent in home health. The vast majority of these additional jobs will be for low-paid, low-benefit, low-skill home health aides, personal care workers, and certified nursing assistants. Obviously, an economic downturn could end the current shortage, but the long-run demographic imbalance between the demand for and supply of workers can only worsen over time, making it difficult to recruit the staff needed to achieve higher staffing levels. Personnel Turnover The American Health Care Association (1999) reported that in 1997 the turnover rate in nursing homes was 93 percent for NAs and 51 percent for RNs and LPNs. The turnover rate for directors of nursing was 32.5 percent, and for administrators was 22 percent (AHCA, 1999). Relatively high turnover rates of administrators and key supervisory personnel are worrisome for the operation of facilities, given the concerns about the caregiving work force and the vulnerability of many of those receiving long-term care. Although little research has been conducted in this area, it is widely recognized that administrative leadership is a crucial factor in improving the quality of care. Turnover rates were also high in the home health care sector (Burbridge, 1993; MacAdam, 1993; Close et al., 1994; Crown et al., 1995).

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Improving the Quality of Long-Term Care Feldman et al. (1994) reported that turnover rates for home health care workers were much higher in private than in public agencies. The United Hospital Fund (1994) reported a 40 percent turnover rate of home health care workers; while Crown et al. (1992) reported 40 –60 percent. High turnover rates are not the only important factor in current labor force problems in long-term care. The length of employment is also important. A high turnover rate among a small percentage of employees in a facility is less likely to have an adverse impact on the quality of care, although it may affect certain care users and certain services. However, a high turnover rate for a large percentage of employees in a facility is likely to have a more widespread effect on quality of care. Data on tenure of leadership positions, turnover rates, and work force stability at the facility level are not available from any public source at this time. Yet in other businesses, such changes in leadership are reported in the press, and the Securities and Exchange Commission asks for this information from all publicly traded corporations so that stockholders have this information when making investment decisions. Such information is equally important for long-term care organizations. Periodic shortages of personnel in long-term care can be attributed to cyclical economic conditions that increase the competition for unskilled workers and to structural features of the industry (Feldman et al., 1994; Feldman, 1996). Although cyclical economic conditions significantly affect the demand for unskilled workers, low wages and benefits along with difficult working conditions and heavy workloads also make recruitment difficult, even when unemployment rates are relatively high. Wages and benefits for home and home health care workers, and for those in nursing homes, are significantly lower than for those in acute care settings (Crown et al., 1995; Feldman, 1996; Leavitt, 1998). For example, in 1996, RN wages in nursing homes were almost 19.7 percent lower than RN wages in hospitals. Wages of long-term care nursing assistants were 21 percent lower than hospital NA wages, although LPN wages were about the same as hospital LPNs (AHCA, 1997; Moses, 1997). Wages of RNs in home health and public health nursing were reported to be nearly 10 percent lower than those of RNs in hospitals in 1996 (Moses, 1997). Compared to hospital and nursing home workers, home care aides tended to work fewer weeks per year and were less likely to work fulltime (Crown et al., 1995). Until wages and benefits in the long-term care sector are brought closer to parity with those of hospital workers, hospitals will continue to be the sought-after place of employment. Restrictions related to the level of payment and benefits for independent care providers raise significant concerns (Litvak et al., 1987; Tilly and Bectel, 1999). Many consumer-directed long-term care programs base their service payments on assumptions of low hourly rates for caregivers and

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Improving the Quality of Long-Term Care prohibit consumers from paying higher rates. To the extent that these prohibitions limit consumers' ability to pay competitive wages and benefits, they are likely to limit the ability of consumers to attract and retain more capable and skilled caregivers. If the current tight labor market persists and if recommendations for better pay for caregivers in nursing homes are adopted, restrictions on consumer-directed payments are likely to have an even greater impact on the availability of skilled caregivers. Wages in other industries such as the fast food industry are sometimes higher than those of nursing assistants and home care aides in long-term care settings, and working conditions of the former may also be viewed as better. Even small differences in wages at that level influence where people are willing to work. Many paraprofessionals working in long-term care services earn, on average, only the minimum wage, which puts their income at less than the federal poverty level, and most have no benefits such as health insurance. Since many paraprofessionals are women and minorities who are supporting families, the low wages are a serious problem. Some workers take on two jobs or work extensive overtime to increase their income. Such conditions lead to fatigue and inefficiency, and could have a detrimental effect on the quality of care provided. Factors contributing to low wages and benefits in long-term care include the limitations of Medicare and Medicaid reimbursements, high reliance on self-paying patients with limited financial resources, the profit orientation of many providers, and barriers to unionization (Burbridge, 1993; Close et al., 1994; Feldman, 1998). The low rates built into Medicare and Medicaid reimbursement rates are particularly important because these programs are the major payers for both nursing home and home health care services. Unless wages and benefits are set at levels that allow the long-term care industry to be competitive in the labor market, the work force is structured for instability. On the other hand, raising reimbursement rates will not by itself ensure that providers pass these increases on to workers unless accountability is built into the payment system. Moving toward parity would undoubtedly be expensive for Medicare and Medicaid. Nonetheless, if improvement is to be made in the quality of nursing home care, a stable and well-motivated work force is needed. Government payers and providers of care must focus on improving compensation and working conditions. Recommendation 6.4: For all long-term care service workers and settings, the committee recommends that federal and state governments, as appropriate, undertake measures to improve work environments including competitive wages, career devel-

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Improving the Quality of Long-Term Care opment opportunities, work rules, job design, and supervision that will attract and retain a capable, committed work force. Important as wages and benefits are, Feldman (1998) and Close et al. (1994) found that work settings and management are critical in mediating the impact of compensation on turnover rates for paraprofessionals. Cohen-Mansfield (1997) and Blegen (1993) found that employee turnover rates are related to the adequacy of training, methods for managing workload and schedules, opportunities for career advancement, respect from administrators, organizational recognition, social climate and work level, staffing levels, clarity of roles, and participation in decision making. Much can be done to improve the working environment and the design of jobs for long-term care workers as part of a strategy to reduce turnover rates (Feldman et al., 1990; Feldman, 1993; Banaszak-Holl and Hines, 1996; Wilner, 1999). Criminal Background Checks Nursing homes and home health agencies are required under Medicare and Medicaid regulations to maintain written personnel policies and procedures. Federal regulations specify that nursing home residents and home health agency clients have the right to be free from abuse and neglect and to be in a safe and secure environment (OIG, 1998). To help facility managers screen out personnel with a record of abuse, each state under federal law is required to establish and maintain a registry of nursing aides that includes information on any finding by the state survey and certification agency of abuse, neglect, or misappropriation of property involving the elderly. Federal law does not require registries for registered nurses or licensed practical nurses, but state regulatory agencies monitor professional licenses, which may be suspended or revoked for breaches of conduct such as abuse of patients. There is no national system in place by which states can share information about known abusers, so workers can now evade state registries by moving from state to state. Moreover, current federal law does not require national criminal background checks of those working in long-term care. The Office of the Inspector General (OIG, 1998) conducted a survey of states to determine their requirements for background checks of current and prospective employees of long-term care facilities and to see if states were maintaining registries on health workers. OIG found that 33 states required criminal background checks, but the coverage of such checks varied widely and not all facilities serving the elderly were included. They also found that a majority of states required checks of nurses aides

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Improving the Quality of Long-Term Care seeking employment, but did not require checks of already employed aides or other personnel such as nurses. The sources for the criminal checks also varied. The same study found that all 37 states contacted maintained registries for NAs, LPNs, RNs, and medical practitioners. Yet, 94 percent of the states did not initiate criminal background checks of personnel when they applied for certification or licensing, 29 percent did not require prior arrest or conviction information on renewal applications, and 13 percent did not have any provision for penalties for false statements on licensing or certification applications. OIG (1998) collected criminal records at eight randomly selected nursing homes and found that 5 percent of employees had been convicted of a variety of crimes including many serious offenses such as assault, robbery, and theft. OIG recommended federal requirements for criminal background checks of all workers in nursing homes and other long-term care facilities, and assistance in the development and expansion of a national abuse registry and state registries. It also recommend requiring states to improve reporting of abuse (OIG, 1998). At the present time, certified nursing homes and home health agencies are not required by Medicare or Medicaid to conduct a criminal record check before hiring personnel. The American Health Care Association has also recommended the development of a national abuse registry and criminal background checks for workers. The Assisted Living Quality Coalition (1998) likewise recommended that a criminal record check and a check of any aide registry that is available should be conducted three days prior to employment for all new staff. It further recommended that staff not be retained if they have been convicted of a felony or any crime involving the abuse, neglect, or exploitation of others. HCFA recommended new legislation (HCFA, 1998a) to require criminal background checks for all nursing home personnel. This proposal is currently under study by members of the U.S. Senate Special Committee on Aging. In 1999, Senators Kohl, Reed, and Byrd introduced legislation for the Patient Abuse Prevention Act (S. 1445) to require criminal background checks for personnel in nursing homes, intermediate care facilities for the mentally retarded, home health agencies, hospices, and other facilities that receive Medicare or Medicaid funds. The legislation would also require the creation of a national registry to list all long-term care employees including professional and non-professional staff who have been found to have abused, neglected, or mistreated residents. The registry would be incorporated into the existing provider database created by the Health Insurance Portability and Accountability Act of 1996. There are issues about where the national registry would be housed and who would pay for the background checks. Because of the vulnerability of all individuals receiving long-term

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Improving the Quality of Long-Term Care care services, the committee considers that measures are needed to protect clients. Recommendation 6.5: The committee recommends federal legislation requiring timely performance of criminal background checks before hiring for all personnel in all long-term care settings. Long-term care providers should not hire or retain people convicted of a felony or misdemeanor that involves abuse or neglect of others. Federal support is needed to ensure that criminal background checks can be conducted in a timely fashion, especially because the high turnover of the work force demands quick responses in hiring. Involvement of Informal Caregivers Client and family involvement in the provision of long-term care services, generally on an unpaid basis, is of critical importance in the provision of long-term care. As indicated earlier in this report, family members provide an estimated 80 percent of the long-term care for elderly people (Barusch, 1991), and they provide homes and daily support for 90 percent of the people with developmental disabilities (Bass, 1990). Under some state programs and some federal demonstration projects, family members sometimes have been paid for such care. The role of families in long-term care for children with special health care needs is given emphasis particularly in home and community-based services. Children generally do better, in terms of both physical growth and development and cognitive and educational development, in these settings than in institutional settings (Burr, 1985; Quint et al., 1990; Patterson et al., 1992; Perrin et al., 1997). However, data from a qualitative in-depth study of everyday family life experiences suggest that families of young children with severe disabilities continue to seek out-of-home placement. Without exception, the primary desire of all families was to care for their child at home. However when placement was considered, even if remote, the most frequently reported reasons were family “survival” and mitigating circumstances. The finding that one-quarter of the families had already sought or were considering placement for children in a young age range is provocative for policy and practice (Llewellyn et al., 1999). The impact of chronic conditions on the family is one of the major problems confronting the health care system today (Coyne, 1997). Family care-giving is a critical but finite resource. Evidence, including results of

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Improving the Quality of Long-Term Care randomized trials, suggests that supports for family caregivers can have positive effects on the health outcomes and well-being of those receiving care (e.g., Zimmerman, 1984; Meyers and Marcenko, 1989; Singer et al., 1989; Herman, 1991; Yoon et al., 1993; Agosta and Melda, 1995; McFarlane et al., 1995; Mittelman et al., 1996). These studies range from those in which the intervention consisted entirely of psychosocial support to family caregivers (e.g., Singer et al., 1989; McFarlane et al., 1995; Mittelman et al., 1996) to one study in which caregivers were part of a multi-element intervention (Yoon et al., 1993). Some states are beginning to provide client and family training in caregiving activities for clients living at home so they can be involved in the hiring, supervision, and management of care at home. The benefits of client and family involvement in care are obvious in providing services beyond the formal caregiving services, but the major benefit may be in the involvement of client and family in monitoring the quality of care. The committee believes that state and local government long-term care programs should make educational and ongoing support available to consumers and their families who are actively involved in the hiring, training, or supervision of caregiver-staff at home and encourage efforts to foster more interaction and cooperation between formal and informal caregivers. Another set of concerns expressed about informal caregivers involves liability for personal injuries. However, agencies that supply privately hired caregivers have faced little litigation charging negligence (Kapp, 1991). Perhaps more serious is the risk of liability for personal injury to independent care providers who are not covered by workers ' compensation insurance. Scala and Mayberry (1997) have suggested that liability concerns for consumers and programs can be minimized by making the consumer the employer of record, delineating the responsibilities of the program and the consumer, educating and assisting consumers in the selection and supervision of care providers, encouraging consumers to require criminal history checks for their providers, and providing workers' compensation as a part of the benefits package. CONCLUSION To succeed, efforts to improve the quality of long-term care require a work force that is sufficient in size, with the necessary skills, competence, and commitment to provide the needed health and personal care services and to manage the delivery of this care in a supportive environment. This committee has serious concerns about each of these requirements and believes that numbers, skills, training, assessment, and positive management of frontline caregivers must become a higher priority for policy makers, managers, advocacy groups, health professionals, and researchers.

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Improving the Quality of Long-Term Care The committee recognizes that the recommendations presented in this chapter would entail additional costs for providers of care. Substantial improvements in the long-term care work force are not possible without increased resources for providers of care. Government policies of reimbursing for long-term care have an important influence in improving quality of care. Reimbursement issues are discussed further in Chapter 8.