Text Transcript

Rutgers University October 24, 2002 Susan Reinhard: Welcome to this audio conference you have just heard and I hope you know that it is on Long-Term Care Workforce: What are states doing? My name is Susan Reinhard and I direct the Community Living Exchange Collaborative at Rutgers Center for State Health Policy. I will be the moderator for the call, but you will hear lots of other people today. This conference is funded by a grant from the Centers for Medicare and Medicaid Services and it has been organized by my Center for State Health Policy in collaboration with ILRU who is our technical assistance exchange partner in Texas. Almost all of you, all of the Systems Change Grantees have told both Richard Petty and I about how concerned you are about recruiting and retaining a committed and qualified workforce for people of all ages and all different support needs. Many of you have been asking us, so what else is going on? What are other states doing? How can we find out so that we can learn from what they are doing from both their mistakes or their challenges as well as their successes? That is what we want to do today. So it is a broad overview and we are going to begin our conference today with presentations by several nationally-known experts. These are people that spent a lot of time thinking about the issues that worry you. They will complete their presentations, rather informally I should say. It is more of a discussion we will be having. We will encourage you to ask questions after their presentations. So that will be roughly around quarter to four or thereabouts. Our conference operator, Gentry, will let you know how to dial in to ask a question when we get to that point. So let me begin by introducing Susan Harmuth. Susan is a long-term care specialist for the North Carolina Department of Health and Human Services. She is responsible for coordinating and implementing direct-care workforce initiatives in North Carolina. Susan is a state person and what strikes me about her is that out of her own curiosity about what states were doing, she began conducting national surveys on direct workforce issues beginning in 1999. So far, she has been conducting four of these surveys. We sent you the website link in our introduction to this audio conference. The latest one is known as the 2002 National Survey of State Initiatives on the Long- Term Care Direct Workforce. This last survey was conducted in collaboration with our second guest, Steve Edelstein, who is a policy specialist with the Paraprofessional Healthcare Institute. Steve is with PHI, a national, non-profit healthcare employment development and policy organization, which is based in the South Bronx. He is the project director of two federally-funded research projects investigating recruitment and retention of direct-care workers and long-term care. He has over 15 years of health policy experience including eight years as a policy analyst and advisor in Washington, D.C. specializing in long-term care and health access issues. Steve's organization has just released an issue brief, which we also call to your attention. That is known as The Right People For the Job: Recruiting Direct-Care Workers For Home- and Community-Based Care. We also provided you the web links to this publication before this call. So welcome to both Susan and Steve. I am going to ask Susan to start us off by telling us more about the purpose of your survey and who do you send it to? Who answers these questions? Susan Harmuth: Thank you, Susan. Generally our purpose has been to collect information from states about public policy efforts to address direct-care workforce issues in their states across the long-term care spectrum, including home-care, assisted living and nursing facilities. Since 1999, it has been very interesting to see the tremendous increase in activity across states to address workforce shortages. We send the surveys to state unit on aging directors and state Medicaid directors as our starting point. Typically, we get responses from one or both of these agencies. In the event that they are not the appropriate entity, they typically will field it out to a more appropriate organization in the state. But we are very grateful to the folks who have taken the time to fill these surveys out because it can be somewhat time consuming and we have had a tremendous response from states for each of the surveys that we have conducted. The most recent survey that we conducted with PHI had several specific purposes. First, we wanted to determine in light of the economic slowdown whether direct-care workforce shortages continued to be a major issue in states and also to determine the extent to which the slowing economy may be impacting the number or the extent of the shortages in states. Another purpose was to determine whether the slowing economy was having any impact on state initiatives to address shortages that were underway or planned. We also wanted to collect any new information we didn't previously have from states about new initiatives. Finally, we thought it might be useful to pull together all the information we have already collected as well as the information PHI had collected so we could have in one document sort of an overview summary on a state-by-state basis of what states have done to date that we were aware of. Susan Reinhard: I noticed you had all of the System Change Grantees, what they are doing. Where did you get that information? Susan Harmuth: We had gotten some information from a compendium of Real Choice Grant activities and tried to pull out from that the states that had workforce activities. Susan Reinhard: Janet O'Keeffe is on the line from RTI. I am sure she is delighted to hear that. Nice to know when your work is being used. So you did this survey. You have done it four times now. What are you finding across the states, particularly that is different than you found four years ago? Susan Harmuth: One thing that we found was similar and we somewhat anticipated this, but of the 43 states that responded to the most recent survey, 86% said that shortages continued to be a major workforce issue. This is not unlike the earlier survey we did in 1999 when the economy was booming, when 88% of states indicated that shortages were a major issue. So it just reinforces the fact that it isn't just a cyclical issue that is tied to the economy. There are indeed barriers to the job and factors about the job that are impacting these shortages statewide. Only four states in the most recent survey indicated that shortages were not an issue in their state. With regard to the economy, there was a mixed impact of the slowing economy on the direct-care workforce shortages. Eight states reported they saw somewhat of a positive impact, however it is important to note that as might be expected, some of the changes they were seeing that were impacting the shortages of workers were somewhat temporary in nature. Primarily due to more people willing to work for lower wages due to job loss. There was a reduced reliance on temporary agency staff, which certainly costs more than regular in-house staff. They saw a slight decrease in an already high turnover rates. There were also negative impacts. Some states indicated that their primary workers were having to relocate to other states and they took with them the secondary workers who very often were working in lower wage jobs. So there was sort of a mixed impact on the economic slowdown. Then we asked the question about the degree to which the slowdown was impacting state initiatives and state funding for specific activities to address workforce issues. Many states indicated they had to readjust their budgets due to the economy. This certainly did have an impact on a number of states. In fact, eleven states reported decreases or termination of planned funding for existing initiatives or planned initiatives. For instance, Connecticut reduced the number of hours of direct care for home-care clients. In Florida, future funding to increase nursing home staffing ratios was in question. Also Montana indicated that their wage pass-through for 2003 was in jeopardy as a result of the economic slowdown and the subsequent budgeting issue states were facing. So there certainly was an impact resulting from the economic slowdown. But to move on to some examples of what states are doing. Generally, state initiatives, and this has been fairly common across the years, fall into several major categories: wages and benefits being one, training and career ladder issues, the establishment of task forces and commissions, a broad category that relates to recognition, public education and awareness, data collection and analysis efforts, which is really somewhat in just the past couple of years we have seen more of that occurring and initiatives related to staffing ratios. But one of the key things we have seen through this most recent survey is the fact that there has been extensive collaboration across state agencies to try to address the problem. Almost half of the states, actually 25 states did indeed report that they were working with other state agencies such as their department of labor or their department of education, community college system, welfare-to-work agencies, boards of nursing. Everybody seems, a large percent realized that they have to collaborate across spectrums in order to have a significant impact. In some states they are using (unclear) to help address workforce issues and training and other funding sources as well. I know there will be some discussion later about some of the Department of Labor initiatives, so I will not concentrate on those. But I do want to talk a little bit about some of the training and career ladder efforts that are underway. With regard to career ladders, a number of states, and we have noted that at least five either are or have developed a medication-aid job category for one or more long-term care settings. Typically the number of hours and the parameters and settings where the aid can work may vary, but that certainly is a job category that has cropped up and been fairly prevalent. Massachusetts has had a major initiative relative to training. They have also had significant funding to put into this. They have had money for CNA training scholarships. They have also funded supervisory training, which we hear often that relationships between frontline workers and supervisors have a significant impact on turnover. They also had funding for English as a second language class and adult basic education to help prepare people for additional training, those frontline workers down the road, career ladder for nursing homes. Some of the other things states are doing with regard to career ladders; Montana has developed an add-on curricula to make it a little bit easier for nurse aids to become licensed practical nurses. Some states have tried to develop new job categories in a career ladder within the paraprofessional framework. For instance, perhaps a senior CNA-type job level or a mentoring- type position. North Carolina is developing a geriatric nurse aid job category. So there are efforts to try to develop within the paraprofessional level some job categories that would be meaningful both for employers from the standpoint of being willing to pay for that type of a job category and making it worthwhile for them to deploy their staff more effectively as well as provide an advancement opportunity for workers. Those are just a few of the examples that relate to training and career ladder initiatives, Susan. Susan Reinhard: Thanks. Let me turn to you, Steve. You have been collaborating on this latest survey. I know that you and your organization, aside from this survey, look at a lot of the issues that Susan has been discussing. One of the things she hasn't talked yet about is about wage and benefit enhancement. I know a lot of the folks on the phone are thinking about those issues. Can you tell us what states are doing? Steve Edelstein: Sure. Thank you, Susan. Basically based on the last survey, we found that approximately 20 states had implemented wage pass- through initiatives; an additional allocation to providers to enhance wages and benefits. I wanted to look into that a little bit more closely to see what the states were doing and what issues they may have had around the implementation. I would say overall that from the provider perspective, generally when they have additional funding for wages, it is appreciated. Sometimes there are issues around how the state implements it in terms of whether they feel they have sufficient notice and instruction about how to implement the wage pass- through and sometimes also issues around the auditing and how burdensome they feel the requirements are there. From the worker perspective, again, generally to have additional money towards wages again is appreciated, but sometimes there can be disappointment if there is not clarity in advance about exactly what workers should expect in terms of an increase. Typically the amount is calculated in one way and there can be a misunderstanding about what that is going to translate when it actually gets to the worker level. So it is important that there is an effort in terms of creating expectations that are reasonable based on what is funded. Beyond that, we have identified several issues that impact on the success of a wage pass-through initiative. For the Systems Change Grantees, an important one is which workers are covered? Oftentimes a legislature might focus specifically on facility-based workers and so additional funding for home- and community-based workers is now provided. So one thing to look at is which workers are being covered by the legislation. Beyond that, other issues, which impact the pass-through include the size of the salary increase, whether it is enough to affect worker behavior and keep them in the jobs. How much specificity is provided to providers in terms of how they can use the funds, whether they have flexibility to use it for things like shift differentials or hiring other workers or is it just limited to increasing base wages? Other issues include whether provider participation is optional or mandatory, the type of accountability that is required by the state, whether there is ongoing funding for the pass-through or whether it is a one-time intervention. This especially could be an issue for both providers and the workers if there is not a certainty that there is going to be money in the next year to fund the increase, then it may have a dampening effect on whether it is effective. Finally, as I mentioned previously, whether providers have sufficient notice and are educated on how to implement the pass-through. Susan Reinhard: Steve, you mentioned, was it 20 states? Steve Edelstein: Twenty, yes. Susan Reinhard: Do you have any sense which ones are looking more at home- and community-based care and which ones are really more nursing homes? Steve Edelstein: I don't have a specific breakdown on that. It definitely is a mix. Some states have looked across settings while other states have limited to a particular sector. But it definitely is a mix. Susan Reinhard: OK. Another area of that is of great interest to a number of grantees has to do with worker registries or worker guilds, associations, a number of different terms and forms for trying to have support for the workers. Does your survey give you any insight into what states are doing? Steve Edelstein: In terms of our look at what the System Change Grantees are doing, certainly they have expressed interest in doing both of those. A number of states have said they are interested in establishing registries. Among them Arkansas, Georgia, Maine, New Jersey and Oregon. Other states have said they are interested in setting up worker associations including Alaska, Maine, North Carolina and Vermont. There are some examples already out there in California as part of their public authorities; the counties have registries as well. A number of state provider associations, excuse me, worker associations already are operative in Iowa, Wisconsin and Michigan. So there are definitely models that the grantees can look to in terms of setting up their own programs. Susan Reinhard: Thanks, Steve. I think there may be some questions about this from some of our participants and we may come back to this. But I want to bring into the discussion at this point two of our other speakers. The first is Dr. Robin Stone. Many of you know her. She is a noted colleague who is the executive director of the Institute on the Future of Aging Services in Washington, D.C. I have worked with Robin and I think the world of her. She is well known in the field of aging and disabilities services. She is one of the chief architects of the Cash and Counseling Demonstration Program, which you heard about last month in one of our audio conference calls and I will bring up again at the end of this conference today. Robin served the White House as Deputy Assistant Secretary for Disability, Aging, and Long-Term Care Policy and as Acting Assistant Secretary of Aging in the Department of Health and Human Services. She has been devoting a lot of her time to this issue on long-term care workforce and she has a major announcement, we hope, that she will make at the end of this call or whenever she feels like doing that, so stay tuned. Joining us also is Dale Lanenga. He is the executive director of the Pennsylvania Intra-Governmental Council on Long-Term Care whose purpose it is to advice the governor on long-term care issues. He has worked in the fields of aging, disability and long-term care in Pennsylvania for 28 years. He designed and implemented the Attendant Care Services Program for Adults with Physical Disabilities, which is a program that has been nationally recognized for its consumer direction. Robin, I know that you have both worked a lot with both Susan and Steve and are very familiar with their survey and that you have done a lot of work from a research perspective and talking to providers around the country. Can you tell us what your thinking is on this issue about what states are doing and what providers should be doing about long-term care workforce concerns? Dr. Robin Stone: Sure. Hi Susan, hi everybody else. I think there is incredible opportunity in looking at this workforce issue for states. I know when we started working on this a couple of years ago, there was a real struggle in trying to identify what the policy levers were. It is clear to us that in addition to wages and benefits and the development of career ladders, that states are significant players in terms of looking at how the workforce can actually be developed. I know there was some discussion previously about the need for collaboration and evidence that there has been increasing collaboration across state agencies. Susan pointed that out in terms of the results of their surveys. But I wanted to highlight the importance of, particularly the folks who work on long-term care and support and the Systems Change Grants. The real importance of looking at Department of Labor dollars and other such dollars that are passed through the states and then to local communities. I am going to speak about just a couple of examples of how states and localities have used some of these monies. I know Dale has some examples from Pennsylvania and I know that both Steve Edelstein and we also have Steve Dawson from PHI listening in on this, may have some input as well. I think the main point here is to recognize that you have other partners in the state that may have access to sometimes substantial resources that need to be leveraged and if you aren't partnering with your counterparts in your state department of labor, whatever that happens to be called, you are really missing out on an opportunity. These are dollars that go through the Department of Labor through a number of different avenues, but the major funding is the Workforce Investment Act. I just want to give you a couple of examples of activities that have been going on in the long-term care arena. Dale may speak to this, but in Lancaster County there has been a major healthcare worker media campaign that was actually supported by both the WIA and health and long-term cares providers coming together. They actually have created a permanent infrastructure with the health and long-term care providers and the local WIB, which is the Workforce Investment Board in Lancaster County, to basically put together a television media campaign to increase the supply of workers in healthcare and long-term care. They have a media campaign that averages about 30 messages weekly during high-profile time slots. The message has a toll-free number and then has healthcare career briefings and a whole lot of other activities that are built into this campaign. Each of the initiatives actually is supplemented by funding from employers themselves because they sell these employer recognition tags for each televised message. So it is truly a partnership and at least anecdotally we have evidence that this has really helped in creating an awareness and in the recruitment of a lot of the frontline workers. That is just one example. Another example, and I don't know whether Dale will talk about this in more detail, actually these are a couple that are happening in Delaware County, Pennsylvania. There is a CNA Training Pilot Project between the Delaware County Workforce Investment Board and the Women's Association for Women's Alternatives, the Delaware County Community College and the Fair Acres Geriatric Center and they work together to reduce turnover rates of entry- level employees by providing them with the skills and support services, enabling them to succeed in a job and move up in a career ladder. We also have examples of capping new worker pools. There is a Migrant Farm Worker Caregiver Training program in Riverside and San Bernardino Counties, California, that uses the local WIB, the California Employment Development Department monies and the National Farm Worker Jobs Programs as well as the California Workforce Association to develop partnerships with these migrant workers and to train these non-traditional populations for the long-term care field. There is another one in Charlotte, North Carolina that looks at students as workers. In this case they were accessing the Perkins Act and State General Revenue's dollars. The Perkins Act is actually vocational training dollars that comes through the Department of Education. Here they are preparing high school students for employment and/or continued education by providing them an opportunity to master a skill set and then expand the number of qualified long-term care workers. So just to give you a sense of this, you have a lot of idiosyncrasies here, but you need to know what resources are out there for you. Because on the training and development side, these partnerships can be invaluable. The other thing that I wanted to say about this, and this is sort of something that has become very clear as I have been going around the country and a number of us have been working on these projects. That is that you can define part of this issue as a workforce issue, but you can also define this issue as a quality issue. Because you cannot provide quality services and supports if you don't have a quality workforce. So for you, for the state folks, to think about couching this workforce issue also in terms of quality improvement and quality assurance and figuring out how you build these activities into any kind of quality efforts that may be going on through the Systems Change Grants, through other efforts on the home- and community-based care side, building on what is happening in the Nursing Home Quality Initiative, which by the way, within the next year or two, the QIO's in each state are going to be responsible not just for nursing homes but for homecare as well. So thinking about how you build in quality initiatives. The whole concept of culture change. Culture change is not about just in nursing homes. It is about culture change in assisted living. It is about culture change in home- care. It is about figuring out how we provide in the consumer-directed model, a better culture for the worker as well. I think there are real opportunities in framing the issue in these terms because there may be funds out there that could be used for quality activities in which you could actually sort of through the back door, be using some of these funds to also work on the workforce issue. I will give you a real quick example. That is that we have had some calls from the Wisconsin Family Care Program people who were interested in looking at a quality improvement activity in Wisconsin in 11 nursing homes, the Well Spring Model. They actually were interested in looking at that and beginning to apply those same principles to their family care workers because one of their major concerns, and there may be some folks from Wisconsin on this line, but one of the major concerns has been actually finding workers to provide the services. So I guess those two messages, one is thinking about partnering with labor and also accessing department of education dollars and other dollars that may be available. And then thinking about this within the quality context as well as within the workforce context. Susan Reinhard: That is good advice. Try to figure out where the money is, where the effort is, and try to hook on to it, if I can be as blunt as that. That is what you are saying, right Robin? Dr. Robin Stone: Yes, definitely. I think partly it is the money. It is also the sort of infrastructure that you can create at the state and local level by partnering with these other agencies and hopefully sustaining your efforts. One of the things that we have seen is that a lot of these activities are sort of one-shot deals and that really may address some of the more real short-term problems. The more long-term systemic problem is that we will see a shortage of workers because of the demographics and we have to find and prepare and sustain quality folks so that we can retain them and actually not have to worry about the horrific turnover that many places have been experiencing. Susan Reinhard: Thanks. Dale, have you been able to find any of those resources and develop those cooperative relationships that Robin is describing in your state? Dale Lanenga: Yes, and thank you Susan, and hello everyone. We have been able to do that. The way I think we have done it is partly by nature of our existing organization, our Long-Term Care Counsel, that has all of the key stakeholders at the table. We have the State Agency Secretaries, we have legislators, and we have associations of providers, consumers, all at the table. So when we started working on workforce issues, we had I think the key players together. What we discovered was that other parts of the industry, especially on the acute care side, had already been doing a lot of documentation of their workforce shortages. So one of the first things we did was to do a study to document what our needs were in long-term care. We covered the spectrum from all direct care workers from nursing homes through adult day care, personal care homes, home-care agencies, etc. But when we designed the study, we designed it so that the data would be collected consistent with workforce investment geographic areas. So we could take our data and go talk with each of our workforce investment boards about our needs. It was that kind of information that got the project going that Robin was referring to in Lancaster County. The Workforce Investment Board picked up on our study and said look, here is the real need and let's try and find some additional money, which they were able to do. The documentation of the study really helped. Simultaneously we wanted to talk with the direct care workers themselves, which is what our focus is on. We have met with them each year now to find out what they see the needs as being. It is not always the same as what the providers are telling us. As a result of that, we have been able to get into our state budgets. This past year about $36 million for a direct-care work initiative. Based on what we have found through our studies within the state, it was clear that the problems are not of recruitment and retention, are not the same in different parts of the state or different parts of the long-term care network. There is some differences between nursing homes and home health agencies, differences between urban areas and some of the very rural areas here in Pennsylvania. So we took the money that we received through the state budget and made it available to local service providers, that they could use it in whichever ways they really thought were most appropriate to meet their local recruitment retention needs. We ensured that they worked with direct-care workers in putting together what they, the plans that they came up with. That has produced lots of small projects having to do with bonuses. Things having to do with training, benefits, the image of direct-care workers, recruitment efforts, a variety of different things. We are now to the point where we have been able to obtain a little additional money and we are wanting to take some of those individual efforts that have been tried in various places around the state and bring them together into more regional kinds of demonstrations. I think we are going to be able to do that. It has been helpful to work with our Workforce Investment Board. They are the ones that have an incredible amount of money for training. Getting several of them to understand what the needs were in long-term care and that was very difficult because their attention was much more focused on acute care. But I think we have been able to get some of them to understand the long-term care needs and they are now starting to develop projects such as the one that Robin mentioned. We are also going to do one other thing. This past year five of the departments in Pennsylvania were able to put together some of their monies that they had for job training outside of the Workforce Investment Boards and came up with is called a Critical Job Training Project. There is about $24 million that was set aside. It was first thought that that money would be used in technology and manufacturing. Much to the surprise of everyone, about 60% of the requests came in from healthcare and specifically from long- term care so that the majority of those funds have gone out now to training efforts in the healthcare field, especially in long-term care. That in itself has helped others in the state to realize that we have this need and there is some things that we need to do. Susan Reinhard: Sounds like a success story. Do you know of other people in other states that have been doing this, Dale? Dale Lanenga: Not in the same way. I know that there are other efforts based on documenting what the need is and trying different things, but I am not aware of anybody who has taken that kind of comprehensive approach and then put the money out to the local agencies determined how they wanted to spend it. Susan Reinhard: So if there are members on this call today that would like to know more about it, are you available to talk with them? Dale Lanenga: Yes I would be. Susan Reinhard: Great. Robin, I just want to come back to some of the work you have been doing with providers and maybe you have said enough on that issue, if not feel free to now. Also about, I am hearing a lot of stuff going on about a major new workforce initiative that you will be directing. I wondered if you are free to tell us about it yet? Dr. Robin Stone: Yes. I am free to tell you about an initiative that we have been working on for over a year in collaboration with the Paraprofessional Healthcare Institute and we have finally put it all together and we have about $12-13 million that we will be putting out in the field. Actually the calls for proposals will be going up on the RWJ website on October 28. These are dollars; this has been jointly funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies, which is a foundation out of New York. It is called Better Jobs, Better Care. My Deputy Director for that program is Deborah Lipson who is here with us at the institute. Our major subcontractor is PHI who will be doing the lion's share of the technical assistance. The two pots of money, there will be two separate calls for proposals. One will be, and some of you know this because we have been sort of scouting around for the past year or year and a half finding out what is going on in states, but one will be we will be funding up to five state-based activities in the area of really changing both policy and practice in the frontline workforce arena. That really means that these projects must represent major coalition or partnership activities that are focusing on some major policy change as well as working at the practice level. The money will go to a non- profit organization, not to the state. The goal of this is really to build on activities that are already going on in states. Trying to solidify them and move them to the next step, which is to get activities statewide and to have potential for sustainability. So one pot of money, on average we are looking at about $1.2 million or $1.5 million per grant over a, there will be a planning period and then an additional three and a half years of work in each of those. Then there will be a separate pot of money for up to twelve grants looking at applied research in the area of the frontline workforce. That really is to test and to assess and to evaluate activities that are already going on out there in the field so that we can learn a little bit more about what works and what doesn't work. The emphasis is across all settings. We are interested in the frontline workforce in all long-term care settings. We are strongly encouraging proposals that focus on home- and community-based services. Susan Reinhard: Robin, this is fantastic news. One main question. Who is eligible for applying for one of the five big grants? Dr. Robin Stone: This will become clearer when the calls come out, but a non-profit organization is eligible. Susan Reinhard: So that is not a state, right? Dr. Robin Stone: Yes, a state is not eligible. This money will not go specifically to a state. However, what we are hoping is that states will be strong participants as partners in these projects. In addition, we are requiring a match. A match that would either be from a state, from a locality, from a state or local foundation, but some evidence that there is commitment at the state and/or local levels to sort of make this happen. The whole goal of this is really to build on what is already out there. I think it is fair to say that states that probably don't have a whole lot of activity in this area to begin with would be at somewhat of a disadvantage because these are not really seen as developmental grants; these are really seen as grants that help move a process along. On the other hand, I think it is also an opportunity for states where there has been a lot of disparate activity going on to really bring it together and coalesce it at the state level. Susan Reinhard: That is fabulous. Just to find those that are interested, they should check the RWJ Foundation Website or yours? Dr. Robin Stone: You should check the RWJ website and we have a very, very large mailing list that will also be receiving a printed copy of this which I think is being mailed out sometime around November 4. Susan Reinhard: Great. Well, congratulations to you and to Steve Dawson and Steve Edelstein. Thank you to Susan, Steve, Robin and Dale for their presentations and we do want to start bringing the participants on the line for questions. Before we do that, I want to encourage all of you to ask questions and also to let us know what we can do as a technical assistance collaborative to provide more information or to focus in on any topic on workforce that comes from this conversation or things that we have not discussed. So please feel free to use this time to tell us or you can certainly contact us after this call. So, Gentry, can you tell our participants how they can get into this discussion? Gentry: Ladies and gentlemen, at this time we will begin the question and answer session. If you have a question, please press the \"*\" followed by the \"1\" on your pushbutton phone. If you would like to decline from the polling process, press the \"*\" followed by \"2\". You will hear a three-tone prompt acknowledging your selection and your questions will be polled in the order that they are received. If you are using speaker equipment, you must lift the handset before pressing the numbers. One moment please for the first question. Susan Reinhard: Thank you. Gentry: Once again, ladies and gentlemen, if you have any questions or comments at this time, press the \"*\" followed by the \"1\". Our first question comes from the line of Jane Church from Michigan. Please go ahead. Susan Reinhard: Michigan? Jane Church: Good afternoon. Susan Reinhard: What was your name? Jane Church: My name is Jane Church. Susan Reinhard: Hi Jane. Jane Church: Hello. I am most interested in hearing about the media campaign that is going on in Pennsylvania and was wondering if Dale could give us some contact information? Susan Reinhard: Dale? Dale Lanenga: Yes, I can give you that information. Do you want it right now or can we do this afterwards? Susan Reinhard: Well, if it is short enough, there may be others that are interested as well. Dale Lanenga: OK, let me try and locate it quickly. Susan Reinhard: Otherwise, you can give it to me and we will send it out to all participants. Dale Lanenga: That would probably be better. It could be more complete that way. Susan Reinhard: All right, that is fine. Jane Church: Thank you. Gentry: Our next question comes from the line of Randall Blume from New Jersey. Please go ahead with your question. Randall Blume: Yes, I am coming from the home and community based perspective, first of all, rather than the nursing facility perspective. I am at the point that there is some degree of additional training, career ladders have been established at some level, and thinking as a payer, what kinds of things can a payer do to verify that a higher-skill level employee is needed? And then make sure that they get one, presuming they have the dollars to pay more? Susan Reinhard: Randy, I just want to verify your question that you want to know how the provider can determine whether a higher skill level... Randall Blume: No. Susan Reinhard: Could you repeat it? Randall Blume: Yes. How the payer, how the third-party payers, for instance, very frequently it would be the state, but whatever the third party source is. Going to home-care, it seems to add a new dimension to authorizing services and specifying the services that one wants. Is that clearer? Susan Reinhard: I think so. Perhaps I should direct that to Susan? Susan Harmuth: I am not so sure how to respond other than to say that the information we have gotten and what we are doing here in North Carolina is to try to respond to employer's need for how to utilize staff better and how to improve the skills of staff and we are in North Carolina realizing that probably from a payer's standpoint there may not be any increase in reimbursement from payers for these services. However, employers have indicated that from a quality standpoint as well as ability to deploy existing staff differently, that that may be more cost effective to them and make them able to offset those increased costs they may incur from these new job categories they are able to put in place. Maybe some other folks on the line can help address that. Susan Reinhard: Is there anyone else who wants to respond to Randy? Dale Lanenga: This is Dale. That is one of the areas that we are looking into with the money that we have put out within the past year into all these different projects. We are now beginning to look at whether or not, what effect it has had in terms of career ladder. We know that there are some of the projects that were attempting to develop a career ladder based on additional compensation and additional training. Shortly we will begin looking to see whether or not that works. Susan Reinhard: Thank you, Dale. Are there other questions? Or Randy, did you have a follow up? Randall Blume: No, I don't think so. Susan Reinhard: OK. Thanks. Gentry: Our next question is from the line of Judy Sitski from Wisconsin. Please go ahead with your question. Susan Reinhard: Hi, Judy? Judy Sitski: I just wondered about those small projects, if there is a report about those projects from Pennsylvania? Susan Reinhard: Dale, do you have any of this written up? Dale Lanenga: We don't have it written up in a lot of narrative. I do have a chart and a matrix as to how the money was spent for what purposes in which areas, whether urban, rural, etc. But we aren't yet to the point of having anything written up in sort of a large narrative. Judy Sitski: Are you planning to do that? Dale Lanenga: Yes we are. Judy Sitski: I wondered if that could be made available to the people on the line too? Dale Lanenga: Yes. Susan Reinhard: Judy, do you mean what he has already or do you want to wait until there is more information? Judy Sitski: I am more interested in the narrative description of the projects. Susan Reinhard: Dale, when do you think you would have that information? Dale Lanenga: That could be a number of months yet before we are able to do that. Susan Reinhard: OK? Judy Sitski: Ok, thank you. Gentry: Our next question comes from the line of Karen Tritz from Maryland. Please go ahead. Susan Reinhard: Hi Karen. Laverne Ware: Hi, actually I am Laverne Ware and I was invited by Karen Tritz so she is here with me along with several others. Susan Reinhard: Laverne, hi. Laverne Ware: Hi. My question actually is to Dr. Stone. My question also is about the Lancaster County and Pennsylvania media campaign with the toll-free numbers. She indicated that there is evidence that this has been helpful. I was just interested in what types of evidence is it that she has seen. Has it been an increased volume of participants? Have there been workers with higher levels of quality or what types of evidence were they actually measuring? Susan Reinhard: Robin, you made the statement, but Dale may want to respond as well. Dr. Robin Stone: I can respond only about the evidence that I was reporting on is purely anecdotal which means that we talked to the folks at the Workforce Investment Board and talked to some of the long-term care providers who were involved in these activities. Feedback was that it had, that there were a lot more people who were actually going to some of the technical schools in the area and that employers saw more people actually coming to work with them, both in the nursing home setting and in assisted living. But to my knowledge, and Dale may know better, I don't think there was any formal evaluation done of that program. Dale Lanenga: I don't believe there was any formal evaluation, but clearly in talking to the people at the Workforce Investment Board there, they were able to document a serious increase in the number of people who inquired at the Career Link sites and at the different providers who were participants in this campaign. Steve Edelstein: Susan? Susan Reinhard: Yes? Steve Edelstein: This is Steve Edelstein. I just wanted to mention also that as part of the project we are collaborating on with Robin and the Institute for the Department of Health and Human Services, we are producing a paper on public awareness campaigns and that should be available before the end of the year. Susan Reinhard: That's great. And how would they get that? Steve Edelstein: They could get it through our website, the Direct-Care Clearinghouse on the Direct-Care Workforce or they could get it through the Institute's website, I am sure. Susan Reinhard: Can you mention your clearinghouse again, Steve, because I don't think you did during your presentation. Just say a little bit about what it is. Steve Edelstein: The clearinghouse was an effort by PHI to make available to the field resources relative to the direct-care workforce. The address is www.directcareclearinghouse.org. Through that site they can access policy papers on the topic. We also are producing a number of resources under these projects, one of which is a database of provider practices that are impacting recruitment and retention and that is actually going up over the next day or so. That is something that the folks out there might be interested in. Additionally, the public awareness paper that I mentioned and other resources and tools are available there as well. Susan Reinhard: That's great, thanks. Is there another question? Gentry: Of course. Our next question comes from the line of Stuart Brinksman from Maine. Please go ahead with your question. Susan Reinhard: Hi Stuart. Stuart Brinksman: Hey Susan, how are you? Susan Reinhard: I'm good, thanks. Stuart Brinksman: My question I guess is both for Robin and for Dale. I was curious whether any of the Workforce Investment Act projects are focusing on changing not just on bringing more people into training programs or expanding training programs, but also if any of them are focused on changing the nature of the training to make it provide more hands-on experience, to give people who are in training a clearer idea of what the work is actually about? I have read in some of the PHI publications that one of the problems, one of the issues is that people go through training programs that don't give them very much hands-on or direct experience and when they actually start doing the work, they realize the work is very different from what they expected when they were in the training. Susan Reinhard: Good question. Robin? Dr. Robin Stone: Yes, I think there are examples of, I mean there are examples that are outside of the Workforce Investment Act, the WIB projects. There are also examples of projects that have used WIB dollars to actually focus much more on not only sort of different kinds preparatory skills including life skills and ongoing peer mentoring and coaching as well as real support once the person is in a particular setting. So I think there are a range of activities out there. In fact, again, I would highly recommend that you rather than going through the litany of them now, we tried to identify some of those in the best practices clearinghouse that Steve was just talking about. As he said, that is going live I think within the next couple of days, but we have about 25 practices up on the clearinghouse already and some of those actually speak to some of the questions that you were raising. Which is really a different kind of investment. I think this is a critical question. We have found that the training that is typically provided is not what is really needed to develop and sustain the workforce. Susan Reinhard: When you say that Robin do you mean it is inadequate? Dr. Robin Stone: It tends to focus on orientation. Very didactic training, sort of your typical educational format that number one doesn't work very well. Number two, that really don't address the full range of skills and needs that people have when both they come to the job and then when they are actually on the job. So a lot of these efforts are really focused on different kinds of training and a lot more, as I said, peer mentoring, coaching, mentoring and following through. Because we know, for example, that a lot of turnover that we see across settings happens in the first three months on the job and even actually shorter than that. So there is a really important transition period for many of these folks and most training historically has not dealt with that. Susan Reinhard: Thanks. Dale, did you have anything you wanted to add? Dale Lanenga: That is exactly what we heard from the direct-care workers across long-term care. When we went out each year to talk to them, the first year they were very clear in telling us what Robin was saying, that the training that they were receiving was inadequate, there was not enough of it, and in many ways was really kind of inappropriate. The example they give, for example, is the person who, they are trained on how to make a bed, but they are not trained on how to make the bed when there is a person in it who may not be cooperative. They are not trained in areas having to do as they said with the softer skills of relating to people. Much of it was very technically oriented when what they really needed was how to deal with the person who may be dying. That sort of area they just did not have the training. So with that knowledge and going back then each year when we talked to them, there seems to be a little bit of improvement, but for the last two years we consistently are hearing from the workers that very little has changed in that area. That is one of our focuses within the state now to try and look at the training to see if there aren't some ways that it can be changed. Susan Reinhard: How would you go about doing that, Dale? Are you going to recommend curricula and training practicums? Dale Lanenga: It is a combination. Again it is a collaborative effort. We know there are a lot of different training programs out there and our intent is to bring together a number of the key areas that are doing training. Some of the community colleges, some of the associations. We will be talking with the Department of Education and getting them together to begin looking at what are their requirements for training and how can we improve that in order to make it more responsive to what the aids are telling us they really need? Susan Reinhard: That sounds like a good way to go about it, to get everybody together. Do we have another question? Gentry: We have a follow-up question from Judy Sitski from Wisconsin. Please go ahead. Susan Reinhard: Judy? Julie Whitaker: Hi, it is actually Julie Whitaker who is sitting in with Judy. Susan Reinhard: Hi Julie. Julie Whitaker: Hi. I was looking through some of the overheads that Robin Stone sent out prior to the conference and was curious about one of the key determinants of job satisfaction that she mentions which was that wages and benefits are not as important as expected and I would like for her or other people who are speaking to kind of clarify what that means that wages and benefits are not as important. I assumed she and others know that they are important because they are talking about wage pass-throughs and other types of initiatives, but could she or others clarify what their research shows to date on the importance of wages and benefits? And also how they disentangle elements of job satisfaction. How did they know that they are not as important? Susan Reinhard: OK. Robin? Dr. Robin Stone: Yes, there isn't a whole lot of empirical work that has been done in this area, but I did a literature review about a year and a half ago and there are really a handful of studies. One in particular on the nursing home side and one in particular on the home-care side. There was a study by Banecheck and Whole that was done on the nursing home side and Penny Feldman's major demonstration work on the home-care side. These are probably the two most scientific studies that have been done that actually look at what happens when workers are actually given these whole range of options so that in the case of Banecheck Whole they had a ten-state study where they looked at the effects of all kinds of interventions; wage increases, enhanced benefits, they looked at the supervisor/frontline relationship, looked at a lot of other job design and working condition factors. And also looked at the, sort of the economic status of the local community in which care was being given. In both of those cases, and this is substantiated in a lot of other smaller studies, the major key elements that came out in the regression analyses and any of the other multi-variant techniques indicated that it was the most important factors had to do with number one, the local economy. Which is to say that if you are in a much more prosperous economy, the market is tighter and you are going to have a lot more issues around turnover. But in addition to that, and probably more important than that were the issues around management, particularly the communication between supervisor and frontline staff. The building in the worker into not just the care planning meetings, but actually having them involved in the actual implementation of the care plan. The wage piece of it in particular wasn't as important as these other variables. Now that doesn't mean that they are not important in and of themselves; it just means in relation to some of these other pieces, empirically it looks like the job design and communication and management relationships were more important. We also, however, I hypothesized that a lot of this has to do with the fact that most of these wage increases were relatively low. So if you are getting a 57-hour increase in wages, the effect of that is not going to be very strong. I don't think we have actually given significant livable wage increase tests, you know, the real tests. So I don't think it should be taken to say that money isn't important. I think it was more to make the point that work environment, job re-design and in particular these management relationships, whether it is in a nursing home, home-care, or even frankly in consumer-directed care, the relationship between the consumer and the person that is employed is really important. Susan Reinhard: Julie, you sent questions ahead of time so I wanted to give you an opportunity to mention your second point which I think members of this call might appreciate about the Community Links Workforce Project in Wisconsin. Can you describe that project a little bit? Julie Whitaker: Well, my job with the Bureau of Aging and Long-term Care just started less than two weeks ago. So (laughing) as a new person on the job, I was hired as a Long-Term Care Workforce Specialist. The person sitting next to me, Judy Sitski, has been with the Bureau for a lot longer than me and actually was much more involved in the project originally, so I am going to hand it over to her just to give you a little bit more of a background on it because she is more knowledgeable. Susan Reinhard: I just thought some of the folks on the call might want to hear this. Thank you. Judy Sitski: Well, we have been studying some state money with counties to let them try different types of projects that they think might help in the workforce areas. We have had one county develop what they feel to be a very successful worker-owned co-op. It is in a very small rural county. Many people said it couldn't be done. There are lots of issues with distance and transportation and those kinds of things, but after about a year and a half of operation they are making a profit. The workers have gotten increased wages. They have health insurance and they have had one round of actual profit sharing. There are about 80 worker-members in the co-op in a county, which has a population in the entire county of about 20,000 people. The county seat has 1,700. I was wondering whether there are any other worker- owned co-ops taking place around the country today that anybody knows of. Especially in a rural model. Susan Reinhard: Thank you. So any participants who want to respond to any of our speakers, we would like to hear from you too. Steve, I know you have the one in Bronx, the Bronx co-op effort. Are there others that you are aware of? Steve Edelstein: There aren't that many out there and it is interesting that the one in Wisconsin happens to be one that we do include in the Provider Practice Database as an interesting example. We happened to touch with people in other locations who are interested in the design, but at present there are not that many similar models out there. Susan Edelstein: OK. If anyone has information, let us know either on this call or otherwise. Is there another question? Gentry: Not at this time, Maam. Please continue. Susan Reinhard: OK. Do any of our speakers want to add anything? We had one question that came from RTI about this was directed to you, Steve. That might also be Susan, about your handout, must have been your handout showing that nine states are collecting and analyzing evaluative data on one or more of the direct-care initiatives and they were wondering if you could share more about what is going on with Minnesota and Montana? Susan Harmuth: We have some very brief information from both of those states. Basically I think that the Minnesota evaluation with regard to their wage pass-through and they do audits of providers and provider plans for how those pass-through funds would be used. They also, excuse me, that was Montana. Also with regard to Montana, I understand that they had legislation that was passed to have the public health department collect wage information and benefit information so they could do an analysis of comparable wage classes and reimbursement rates for those wage classes with public funds. In Minnesota, I think that they were doing evaluative data of their nursing facility turnover data and for their wage pass-through. We did not have any more extensive information from them than that on the survey response we had, but Steve may have some additional information. Susan Reinhard: Thank you, Susan. Steve, did you want to add anything? Steve Edelstein: No. Susan Reinhard: Are there any other questions? Gentry: Yes we do. The next question comes from the line of Janet O'Keeffe from North Carolina. Please go ahead with your question. Susan Reinhard: Hi Janet. Hello? Janet O'Keeffe: Hi. I have a question about the media campaign thing. Was the intent of that solely to bring in new potential workers who would otherwise not be applying for jobs? Has any work been done to see exactly, I mean I think Robin spoke to this a little bit, but exactly how many who inquired actually went on to do training and so on. A lot of the grantees, not a lot, but a number of the grantees, the System Change Grantees who were planning to do these media campaigns, but I had never seen anything, which had kind of documented their effectiveness both in recruiting and more importantly in retention? Susan Reinhard: Robin? Dr. Robin Stone: Hi Janet. There has been very little done in looking at any of these awareness campaigns as far as I could see. We have identified a few others. I think Judy Sitski was talking about some of their community options programs, community links projects in Wisconsin. There has been an effort in Kenosha County to do an awareness campaign and a somewhat sort of formative evaluation was done on that. That was really about trying to attract new people into the field, but also basically raising general awareness of this as a job. Part of this is all about valuing the job as well as actually really getting new recruits. But we don't have a lot of evaluation data out there at all. So unless somebody else is in the audience that has any better information, I don't think we have a lot to learn from what has happened so far other than through anecdotes. Janet O'Keeffe: Do you have any suggestions for, I mean because they said there are a number of states. Susan, I can't remember how many, I think at least four or five of the grantees who were planning to do this. Do you have any suggestions for how they might do some even sort of basic monitoring to see exactly what the impact was? It would be a pity for them to do the activity and not have us really sort of be able to learn from it. Dr. Robin Stone: Obviously you want to have some baseline. You want to have some kind of encounter data in which, whether it is, depending on what activity you are using, what kind of hits or interest have been expressed from whatever interventions are being used in the campaign. I think also sort of making sure that the providers, the agencies or the consumers that are involved in this that are actually looking to hire this workforce register whether they see any effects from it. I think it is a very hard thing to measure because you have a lot of other external noise going on simultaneously. It also depends on what the intervention is. Feedback that I got from folks in Kenosha County for example was that they did not feel that the investment in the more high-tech sort of PSA-type activities was as useful as some of the other things that they did like flyers and working through churches and other types of organizations. So some of this has to do with figuring out even what are the most useful interventions for the workforce, for the potential workforce. Dale Lanenga: If I could just jump in with that. We have not studied it and we would like to find out more about all of our different initiatives. But clearly anecdotally it really does make a tremendous difference what the nature of the area is. In a rural area it is very, very different. There are some things being done by some of our direct service providers that we might even, might sort of almost laugh at and say boy that seems rather a silly approach. But which seems to work in their particular area which we would probably never consider doing in an urban area. And things going on in an urban area that just would not work in a very, very rural area. It really is pretty much dependent on really knowing what works, how your area functions. Janet O'Keeffe: There was a public service announcement on the television, which could be very expensive, would reach a lot of people who simply would have absolutely no interest in it whereas a more targeted approach might like you say, through churches or other institutions, that would have people go to them who might be out, potentially people to work would be more effective? Dale Lanenga: Right. For example, in some of the, I recall one of our rural areas talking about using placemats in restaurants. Paper placemats with information on and response they got from that which probably would not work in certain other areas of the state. Susan Reinhard: Maybe we ought to get some of the grantees that are doing this on the phone together and have this conversation. Janet O'Keeffe: Yeah, I think that would be very useful. Susan Reinhard: Thanks, Janet. I'm sorry, who is this? Gentry: This is Gentry. Our next question comes from the line of Dann Milne from Colorado. Please go ahead. Susan Reinhard: Hi