Ensuring an Adequate, Well-Trained Workforce for Long-Term Services and Supports

Background

The care provided in long-term services and supports Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ( LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ) settings is only as good as the personnel who provide it. Indeed, workforce challenges abound in the LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… industry and need to be addressed swiftly if the nation is to respond to the growing need for high-quality care. Lack of staff, inadequate training, and an insufficient number of bilingual workers and workers sensitive to different cultures are all serious problems. So are workers who have committed abuse or have criminal backgrounds.

Education and training for direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… certified nurse assistants (CNAs), who generally work in nursing facilities, and home health aides (HHAs), who are employed by Medicare Authorized in 1965 under Title XVIII of the Social Security Act, Medicare provides health insurance coverage for people age 65 and older and for some disabled people under age 65. This federal program consists of Part A (Hospital Insurance), Part B (Supplemental Medical Insurance), Part… -certified home health agencies and provide personal care and some clinical care under the direction of nurses or other licensed medical staff, are required by federal law to have at least 75 hours of training, pass a competency exam, or both. At least 16 hours of this training must be hands-on clinical care under the supervision of a registered nurse (see also Chapter 7, Health - Workforce and Education: Financing, Education, and Training for additional information and policies on training).

Personal care workers, who provide help with activities of daily living Eating, bathing, toileting, dressing, or transferring in or out of bed or a chair. and instrumental activities of daily living Eating, bathing, toileting, dressing, or transferring in or out of bed or a chair. , cannot by law provide the clinical care that CNAs and HHAs provide. These workers (also called personal assistance workers, home-care A range of services provided in the home, including health care, personal care, and supportive services. aides, and personal care attendants) include independent providers, people hired through agencies, and family members who provide services in participant-directed programs. Unlike agency workers, individual providers are hired, screened, trained, and supervised by consumers.

At the federal level, CMS’ National Direct Service Workforce Resource Center developed a set of core competencies for the direct service workforce. These core competencies can help states develop a more comprehensive and standardized approach to training and performance improvement practices. Having a competent direct service workforce will improve the quality of life for care recipients.

Gerontological/geriatric nurse practitioners Advanced practice RNs with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging. ( GNPs Advanced practice RNs with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging. )—research demonstrates that GNPs Advanced practice RNs with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging. improve the quality of care for older people across health care settings. Care provided by Advanced Practice Registered Nurses, such as GNPs Advanced practice RNs with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging. , results in fewer falls, fewer hospital admissions and readmissions, and higher patient, family, and physician satisfaction. GNPs Advanced practice RNs with specialized education in the diagnosis, treatment and management of acute and chronic conditions often found among older adults and generally associated with aging. excel in chronic-care management and care transitions. They diagnose and treat a wide range of health problems and serve as advocates and role models for nursing staff in all LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… . This group should receive stronger financial and professional incentives to enter the LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… field.

Registries—all states are required to have registries with information on nurse aides eligible to work in nursing facilities. Some states have expanded their registries to include other direct service workers, including medication aides, home health aides, and developmental disability aides.

Worker recruitment, retention, and vacancies—many types of qualified LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers are in short supply; notably, registered nurses, licensed practical nurses), and direct service workers, such as home health aides, personal care attendants, and CNAs. These shortages are cause for serious concern (see this chapter’s section Quality and Consumers’ Rights Across Settings—Nursing Facilities and Other Settings).

Direct service workers provide most paid LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… , yet people who can afford home-care A range of services provided in the home, including health care, personal care, and supportive services. services often have difficulty locating competent, trained people to do the job because wages are low and benefits, such as sickness and vacation pay, are not provided. In 2017, the median hourly wage for home health aides was $11.16. Low wages (and few benefits) contribute to high staff turnover and low-quality care. Historically, federal regulations excluded home-care A range of services provided in the home, including health care, personal care, and supportive services. workers from the minimum wage and overtime protections mandated by the Fair Labor Standards Act (FLSA). However, in 2013, the Department of Labor promulgated a rule that covers most home-care A range of services provided in the home, including health care, personal care, and supportive services. workers under the FLSA’s minimum wage and overtime provisions—an important step in recognizing the value of these workers in helping older adults and people with disabilities to continue living independently in their own homes.

In addition, broadening the scope of clinical responsibilities may help attract and retain direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… . Finding ways for all professionals to provide services to the full extent of their current training, experience, and skills could go a long way toward easing access-to-care issues caused by personnel shortages (see also Chapter 7, Health for information on scope of practice).

Criminal background checksAll states are required to have registries with information on nurse aides who are eligible to work in nursing facilities and some include other direct service workers. However, because no national registry of abusive workers exists, people who have a record of abuse or serious crimes in one state can simply travel to another state to find work. They can also move from working in nursing facilities to home health agencies and assisted living settings without undergoing a criminal background check.Although the federal government does not require criminal background checks of LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers, increasing numbers of states do. Certain states require statewide or national criminal background checks for certified nursing assistants (CNAs) and assisted living staff. In addition, states that require statewide criminal background checks may also mandate a national background check under certain circumstances, such as when applicants have recently relocated from other states. Some states bar employment if certain offenses are found. A 2011 study by the U.S. Health and Human Services Office of the Inspector General reported that 43 states required nursing facilities to conduct a Federal Bureau of Investigation (FBI) or a statewide criminal background check on prospective employees; ten required FBI and statewide checks. State laws vary considerably in terms of who is screened and exempted, what convictions preclude employment and for how long, what provisional employment is permitted while checks are conducted, and who pays for screening. Some state laws have an exemption clause for workers hired directly by the care recipient.

ENSURING AN ADEQUATE AND WELL-TRAINED WORKFORCE FOR LONG-TERM SERVICES AND SUPPORTS: Policy

Education and training

In this policy: FederalState

Funds should be provided for education and training for long-term services and supports Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ( LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… ) workers, especially those in short supply, such as certified nursing assistants.

Federal and state governments should encourage education and training programs to require gerontology courses and practical experience for all appropriate health professions.

Schools should be encouraged to include LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… -related specializations in the curricula for nurses and physicians.

States should allow registered nurses to train—and delegate certain nursing tasks to— direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… in home-care A range of services provided in the home, including health care, personal care, and supportive services. settings to help ease the burden on family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. .

States should establish competency-based training requirements for personal care workers in home- and community-based settings hired through agencies. However, when requested by the beneficiary, states may allow exceptions for family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. and other nonagency providers when hired through self-directed programs—as long as competency, established by state standards, is demonstrated. The core training competencies needed by personal care workers—those who are agency-hired as well as those hired by consumers—and the means by which such competency-based training should be provided should be evaluated in state demonstrations.

Workers who are paid to provide care in home and community settings should meet state-established competency-based training requirements, be evaluated for competency, undergo a period of probationary supervision, and fulfill annual continuing education requirements.

States should establish competency-based training requirements for personal care workers in home- and community-based settings hired through agencies. However, when requested by the beneficiary, states may allow exceptions for family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. and other nonagency providers when hired through self-directed programs—as long as competency, established by state standards, is demonstrated.

The core training competencies needed by personal care workers—those who are agency-hired as well as those hired by consumers—and the means by which such competency-based training should be provided, should be evaluated in state demonstrations.

Training should include both classroom instruction and practical experience, such as simulations and real-person or clinical training.

Training should include the concept of participant-directed care.

Training should also convey the interpersonal aspect of culture change, teaching the personal rewards and positive outcomes associated with culture change.

States should require home-care A range of services provided in the home, including health care, personal care, and supportive services. agencies and community care providers to be responsible for regular training, supervision, and documented performance evaluations of aides and other workers.

Quality assurance measures must include participant preferences and satisfaction as key quality measures and should evaluate whether a participant is receiving all the services in his service plan and whether there are unmet needs.

States should provide training in dealing with dementia and in personal assistance for all direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… in nursing facilities and assisted living residences, and for staff employed by home-care A range of services provided in the home, including health care, personal care, and supportive services. agencies.

Training should be completed before staff begins working independently with consumers.

Training and continuing education also should focus on maximizing quality of care while supporting the independence, autonomy, dignity, and privacy of consumers.

States should provide training in dealing with dementia and in personal assistance for all direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… in nursing facilities and assisted living residences, and for staff employed by home-care A range of services provided in the home, including health care, personal care, and supportive services. agencies.

In participant-directed programs, participants should be allowed to train their workers and hire workers who meet qualifications based on the participants’ needs and preferences. Each person’s needs are highly individualized, and a standardized training curriculum may not address the specific needs of a particular individual. However, states should make available training opportunities for those participants who prefer that their workers receive standardized training.

Federal and state governments should encourage education and training programs to require gerontology courses and practical experience for all appropriate health professions.

Goals of state training programs

In this policy: State

Training should be completed before staff begins working independently with consumers.

Training and continuing education also should focus on maximizing quality of care while supporting the independence, autonomy, dignity, and privacy of consumers.

States should provide training in dealing with dementia and personal assistance for all direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… in nursing facilities and assisted living residences, and for staff employed by home-care A range of services provided in the home, including health care, personal care, and supportive services. agencies.

In participant-directed programs, states should be required to allow participants to train their workers, and participants should retain the right to hire workers who meet qualifications based on the participants’ needs and preferences. Each person’s needs are highly individualized, and a standardized training curriculum may not address the specific needs of a particular individual. However, states should make available training opportunities for those participants who prefer that their workers receive standardized training.

Ensuring a sufficient number of gerontological/geriatric nurse practitioners and other advanced practice registered nurses in long-term services and supports settings

In this policy: FederalState

Policymakers should remove barriers to the effective use of Advanced Practice Registered Nurses (APRNs), such as geriatric nurse practitioners, in all LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… settings. APRNs should be permitted to certify people for home health and hospice services and should be eligible to perform the admission physical for skilled long-term care. Arbitrary restrictions on APRN care, such as not permitting nurse practitioners to serve as medical directors of skilled-nursing facilities, should be removed.

Medicare Authorized in 1965 under Title XVIII of the Social Security Act, Medicare provides health insurance coverage for people age 65 and older and for some disabled people under age 65. This federal program consists of Part A (Hospital Insurance), Part B (Supplemental Medical Insurance), Part… and Medicaid should directly reimburse APRNs for their services in all LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… settings.

Recruiting and retaining qualified workers

In this policy: FederalState

Federal and state governments must ensure that Medicaid and other public program reimbursements are sufficient to pay wages that will attract and retain LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers.

Federal and state governments should support programs to increase the supply of health care personnel with geriatric training.

Policymakers should improve labor standards for the direct-care workforce including home-care A range of services provided in the home, including health care, personal care, and supportive services. and home health aides, including minimum wage and overtime pay protections, meal breaks, sleep time, and time off. So as not to place an undue burden on LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… consumers and family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. , however, these standards must be appropriately tailored to address the realities of LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… . It should be taken into consideration that services are provided in private homes, services are often arranged by a family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. living in another home or another city, services are provided under different models (including participant-directed models that allow family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. to be paid), and services are provided to individuals with physical, mental, and/or cognitive impairments.

Federal and state governments should support payment reform and the provision of adequate health and retirement benefits, educational opportunities, and career ladders to encourage recruitment and retention of LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers.

States should work with state nursing associations and regulatory agencies to allow nurses to delegate and teach certain health-related tasks to direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… and family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. . Nurses must ensure that the direct-care worker or family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. demonstrates competency to perform the specific task for that consumer. State nurse practice acts should provide adequate consumer protections including appropriate follow-up and appropriate liability protections for nurses.

Living wages and salaries should be commensurate with others in the region and with the time, skill, and effort required to render high-quality services and supports.

Medicaid reimbursement rates should be rebased and updated regularly to take into account relevant economic and financial information, including provider costs.

Federal and state governments should require pass-throughs (i.e., using additional LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… funding) or other mechanisms to increase compensation for direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… .

There should be adequate accountability procedures, such as audits, to ensure that reimbursement increases designated for staffing costs are used for that purpose.

Federal and state governments should document the shortage of workers and their training needs, and support research to identify effective ways to address these problems.

The federal government should offer matching funds or incentives and technical expertise to help states collect data and annually assess the supply and competency of LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers.

Bilingual workers (State) State governments should offer incentives for providers to hire bilingual workers, when appropriate, to assist non-English-speaking consumers and train all staff to be culturally competent.

States also should establish incentives for providers to ensure that workers not proficient in English get training in English as a second language.

Recruiting and retaining direct-care workers

In this policy: FederalState

Federal and state governments should initiate efforts to promote changes in the work environment that encourage staff recruitment and retention.

Such changes could include:

  • expanding roles for direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… commensurate with their demonstrated competency to take on additional roles with greater compensation;
  • requiring adequate staffing;
  • providing adequate salaries and benefits;
  • dedicating staff to specific units;
  • encouraging workers’ participation in decisions on resident care;
  • offering training in accordance with government standards;
  • ensuring appropriate supervision and in-service training;
  • providing programs, career ladders, and educational incentives to facilitate advancement; and
  • providing day care for children of staff

AARP supports increasing the flow of immigrants who could serve as direct-care workers Health care workers such as certified nursing assistants (CNAs), home health aides, and personal care aides who provide hands-on long-term care and personal assistance to older adults, people with disabilities, or people suffering from chronic conditions. Examples of tasks performed by… .

Using criminal background checks and national registries to protect consumers

In this policy: FederalState

Policymakers should require nationwide criminal background checks prior to employment for all LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers other than licensed professionals. Individuals who have been convicted of burglary, larceny, violent crimes, or crimes involving abuse or neglect of vulnerable individuals should be prohibited from employment in all LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… settings. Although people in self-directed programs may request background checks, they should not be required for parents, spouses, partners, close relatives, or close friends when hired through self-directed programs.

The national background checks should be affordable, conducted in a timely manner prior to employment, and include a fingerprint check.

States should require that providers notify appropriate state licensing or registration boards of all employees convicted of a felony, resident abuse, or having knowledge of but failing to report abuse.

After due process, the state board should consider suspending or revoking the employee’s license, registration, or certification.

National registry of long-term services and supports workers

In this policy: FederalState

The federal government should create a national registry of certified nursing assistants and home health aides that documents training, lists references, and includes findings of abuse, neglect, misappropriation of individual property, and other criminal conduct.

The federal government should consider broadening the registry to include other unlicensed workers who provide LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… , including staff in assisted living and other supportive housing A setting for long-term services and supports that includes board and care homes, assisted living facilities, and group homes that provide or arrange for services and help with activities of daily living (see separate entry) in a residential setting. settings.

Providers should be required to clear potential employees through the registry before hiring them.

In the absence of a national registry of LTSS Also known as Long-term Care (LTC), LTSS encompass a broad range of assistance needed by people of all ages who have cognitive or mental impairments and who may lack the physical ability to function independently.  In their basic form, LTSS consist of help with self-care and… workers, states should ensure that ombudsmen have access to the registry and develop a national clearinghouse for sharing information.