Direct care workers play a critical role in the success of states’ long-term services and supports (LTSS) systems, but faced with COVID-19, low wages, and few advancement opportunities, states struggle to retain this workforce. Recently, state leaders came together virtually at National Academy for State Health Policy’s annual conference to share strategies to improve recruitment and retention of these workers.
Today, personal care attendants, home health aides, and nursing assistants are on the frontlines, providing care to older adults and people with disabilities. COVID-19 has made direct care work one of the most dangerous professions, while putting an enormous strain on family caregivers and state budgets.
Even prior to the pandemic, states faced a significant direct care workforce shortage due to the low wages and limited advancement, which has contributed to high turnover. The pandemic has exposed other vulnerabilities – nearly six out of ten direct care workers are people of color and almost half live in low-income households.
Tennessee Promotes Workforce Retention
In 2013, the TennCare (Tennessee Medicaid) Long-Term Services and Supports (LTSS) division held listening sessions throughout the state and found that Medicaid enrollees’ quality of life hinged on the quality and consistency of their LTSS workers. That insight led state officials to create a value-based workforce strategy for direct care workers. Using a State Innovations Model (SIM) grant from the Centers for Medicare & Medicaid Services (CMS), the state incorporated workforce recruitment and retention into its value-based payment strategy, and worked across state agencies to implement and incentivize career and educational opportunities for direct care staff.
In consultations with national experts, the state developed a competency-based training program using evidence-based best practices in adult learning. Corresponding with CMS Direct Support Workforce Core Competencies released in 2014, the training uses an online format combined with work-based learning to provide an opportunity to acquire shorter-term credentials with clear labor market value.
Officials from TennCare worked with the Tennessee Board of Regents to award college credit and a post-secondary credential (certificate) for completion of the training. This curriculum is embedded within a variety of existing (and potential new) degree paths through the Tennessee Community Colleges and Colleges of Applied Technology. The state was also able to leverage Tennessee Promise and Tennessee Reconnect funds to defray tuition costs for adult learners, and plans to provide incremental raises to direct care staff who complete the training once the state weathers COVID-19-related budget shortfalls.
At the same time, TennCare has begun to transition its LTSS system to a value-based payment model. Staff training, retention, and job satisfaction are key measures in the state’s quality framework and tied to LTSS provider reimbursement. By aligning Medicaid payment, investments in workforce training, and the state’s higher education goals and resources, Tenncare has established a clear education and career pathway that will help it grow and retain its direct care workforce.
Oregon’s Home Care Workforce Unionized
Because of the relationship between direct care workers and quality of care, the state created the Oregon Home Care Commission, a semi-independent state commission that supports home care workers, personal support workers, and consumers/employers by:
- Defining qualifications of home care and personal support workers;
- Providing a statewide registry of these worker that matches individuals needing in-home care with home care workers;
- Providing training opportunities; and
- Serving as the “employer of record” for collective bargaining for home care and personal support workers who receive service payments that are from public funds.
The Service Employees International Union (SEIU), represents Oregon’s in-home workforce. Full-time equivalent in-home workers must earn an income above the poverty level for a family of four in Oregon. They have health benefits (for 40 hours of work per month) as well as leave time for vacation, sick time, and COVID-19. They also receive training and personal protective equipment (PPE).
The state funds Oregon Care Partners, an education resource that provides in-person and online classes to help family and professional caregivers build the knowledge and skills needed to improve the quality of life of older adults and people living with Alzheimer’s in Oregon. These classes are available to anyone living or working in Oregon and are offered free of charge. Classes include COVID-19 infection control, supporting individuals with Alzheimer’s/dementia, supporting individuals with challenging behaviors, cultural competency, and more.
Oregon’s support of its direct care workers through living wages, sick and vacation benefits, training, and a registry that matches these workers with individuals needing home care helps not only this important workforce but also care recipients and their families. This support has been an important strategy in this state’s longtime effort to successfully rebalance its LTSS system toward home and community-based services.
Both Tennessee and Oregon have had to respond quickly and with enormous flexibility to the challenges presented by the pandemic, maintaining LTSS services through strategies such as provider rate increases and retainer payments, new infection control protocols, and additional protections and benefits for LTSS staff.
While cascading effects of both COVID-19 and state budgets make ongoing investments in the direct care workforce incredibly challenging, the experience of the past few months has also opened up new opportunities: Medicaid waiver flexibilities and the Coronavirus Aid, Relief, and Economic Security (CARES) Act and state funding allowed states to increase payments to stabilize and incentivize the LTSS workforce to maintain care to some of the most vulnerable populations during the pandemic. Telehealth has been transformational. Certain services, such as therapies, care management, and adult day health, moved from face-to-face to virtual encounters. Some states used additional pandemic-related money to provide childcare for essential workers.
As a result of these unprecedented changes, state officials are rethinking how LTSS is delivered, where, and by whom. The future direct care workforce will likely need additional training on managing the spread of infectious disease, delivering care through telehealth and other virtual modalities, and engaging families as critical partners on the care team. State health policymakers may also want to invest in the LTSS workforce as another opportunity to address racial equity within state-funded healthcare systems. While it is too soon to tell which of the many changes wrought by the pandemic in state LTSS systems will be sustained, one thing is certain, as noted by a state health official during the NASHP conference: “Medicaid will never look the same after COVID.”
This conference session and blog is one component of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, which is funded by The John A. Hartford Foundation in collaboration with the Administration for Community Living.