RAND Long-Document Template

Strengthening the Entry-Level Health

Care Workforce:

Finding a Path

The Office of the Assistant Secretary for Planning and Evaluation (ASPE)

at the U.S. Department of Health & Human Services

December 2020

The Office of the Assistant Secretary for Planning and Evaluation

The Assistant Secretary for Planning and Evaluation (ASPE) advises the Secretary of the U.S.

Department of Health and Human Services (HHS) on policy development in health, disability,

human services, data, and science; and provides advice and analysis on economic policy. ASPE

leads special initiatives; coordinates the Department's evaluation, research, and demonstration

activities; and manages cross-Department planning activities such as strategic planning,

legislative planning, and review of regulations. Integral to this role, ASPE conducts research and

evaluation studies; develops policy analyses; and estimates the cost and benefits of policy

alternatives under consideration by the Department or Congress.

This research was funded by the Office of the Assistant Secretary for Planning and

Evaluation (Task Order Number: HHSP23337008T, under contract HHSP233201500038I)

and carried out within the Payment, Cost, and Coverage Program in RAND Health Care.

Introduction

Demands on the healthcare system have been increasing due to the aging of the population,

increased prevalence of chronic disease, and continuing high levels of mental and substance use

disorders. There is a maldistribution of existing health care resources, resulting in shortages in

some provider types in many settings and geographic areas, which may worsen over time as

demands increase. The COVID-19 pandemic disrupted health service delivery and has prompted

a re-examination of how best to meet the population’s health care needs and build a health

system that maximizes value.

Better use of the entry-level health care workers (EHCW) can be a partial solution to some

service gaps, but their expanded effective use faces many challenges. The EHCW workforce

(defined as healthcare workers with less than bachelor-level education) is heterogeneous. It is

made up of many types of workers, who work in a wide variety of health care settings, including

long-term care, behavioral health, primary and acute care, and community health. Despite their

differing roles, there are common challenges:

• Licensing, certification, training, and job requirements vary across worker type and

across states, which can hinder these workers being used to their full potential.

• In general, EHCW receive low pay and may lack benefits and economic security. They

may be exposed to personal risk and stress in their work. (The COVID-19 pandemic has

reinforced this point). They also often lack clear paths to career advancement and access

to high-quality training programs.

• Federal efforts addressing these workers are spread across several Departments, and HHS

programs have been limited. Where the Department does support efforts to utilize these

types of workers, evaluations of such efforts is, in most cases, scant. The Health

Profession Opportunity Grant Program in the Agency for Children and Families is a

notable exception.

• Basic data on these types of workers is scarce.

Addressing these challenges is important because of the contributions of these workers in

expanding access to care, supporting value-based care in a variety of settings, and in building

their own rewarding career path. Benefits can accrue to the health system, patients, and

importantly to the workers and their families.

The country has recently lost millions of jobs as a result of the COVID-19 public health

emergency. Many of these jobs may not come back for some time, and given the increasing

needs in the healthcare sector, expanding the role and size of the EHCW may be one promising

approach to increasing employment opportunities, particularly for younger workers.

Background

At the request of Deputy Secretary Eric Hargan, the Office of the Assistant Secretary for

Planning and Evaluation (ASPE) contracted with the RAND Corporation to assess opportunities

to strengthen and expand the EHCW workforce. The following report assesses gaps in the

existing health care workforce, challenges facing the EHCW, current EHCW training programs

and contexts where they are used effectively, and potential strategies and policy opportunities to

strengthen the EHCW. As part of this work, RAND also conducted 10 case studies with EHCW

employers, training programs, and funders. This introduction summarizes key findings from the

RAND report. It is important to note that RAND’s work for this report was conducted prior to

the COVID-19 Public Health Emergency (PHE). However, the PHE has had a significant impact

on these workers, has reinforced their importance, and has revealed new opportunities going

forward. In many cases, the EHCW serve on the frontlines of caring for COVID-19 patients.

Who are Members of the Entry-Level Health Care Workforce?

In this report, the term “entry-level health care worker” (EHCW) encompasses a large and

heterogeneous group of health care workers who require less than a bachelor’s degree and

minimal prior training. Together, these workers constitute a significant proportion of the overall

health care workforce. Entry-level health care workers in the long-term care sector, in particular,

constitute one of the largest and fastest-growing workforces in the country, playing a vital role in

job creation and economic growth, particularly in low-income communities.

A few examples of these types of workers include:

• Community health workers

• Behavioral health peer support specialists, including peer counselors, peer navigators,

and peer educators

• Long-term care direct care workers, including home care workers and residential care

aides (home health aides, personal care aides, and nursing assistants)

• Medical/dental assistants

• Licensed vocational nurses

• Respiratory therapist assistants

Members of the EHCW work in a wide variety of roles across the health care system. Just a few

examples include:

• Direct care (including providing hands-on personal assistance with activities of daily

living to the elderly, persons with disabilities, and those with other chronic conditions;

and helping people to remain engaged in their communities)

• Care coordination (including scheduling patients, coordinating referrals, updating

medical records, and helping patients navigate the health care system)

• Chronic pain management (including treating pain, coordinating other care and providing

supportive counseling)

iii

• Peer support (including providing emotional support and supporting self-management

and attainment of recovery goals)

Context for the Entry-Level Health Care Workforce

The United States is facing a shortage of health care workers across professions, in general, and

among the EHCW specifically. Reports forecast shortages of clinicians and other health workers

in communities throughout the U.S., particularly in rural areas, as well as those serving

racial/ethnic minorities or working in certain sectors such as behavioral health and long-term

care.

However, there is a lack of basic data on the EHCW, including how many individuals are

working in these jobs and where, making it difficult to assess how they are used, where they are

needed, and how to assess their performance.

Although EHCW are not a replacement for clinicians, strengthening and expanding the role of

the EHCW is one option for expanding the capacity of the clinical workforce, while addressing

individual health care needs and promoting population health.

The Need for Improved Job Quality

The report highlights the overarching challenges related to recruiting, retaining, and utilizing

entry-level workers to their fullest capacity. The COVID-19 pandemic has underscored the

important role that the long-term care segment of the EHCW workforce is playing in the lives of

the extremely vulnerable people they serve. It has also reminded us that they are frontline

workers who face extraordinary health risks and mental stress along with the physical challenges

and work-related stress inherent in these positions. The need for investment in entry-level

workers has never been greater. Yet, there are many challenges facing these workers, which are

barriers to raising the floor of job quality.

Weak Training Standards – Entry-level health care worker training and job

requirements are not standardized, resulting in inconsistencies in training and unclear

scopes of practice. For example, only six states require the 120 hours of training for

home health aides recommended by the National Academy of Medicine (the federal

requirement is 75 hours). Some states have no training requirement for some EHCW

occupations.

The Health Resources and Service’s Administration’s Bureau of Health Workforce Analysis regularly produces

reports analyzing the supply and demand for various types of health care professional and health care worker. Their

reports have addressed some components of the EHCW, such as community health workers

(https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/community-health-workers-2016-2030.pdf

) and

direct care workers (https://bhw.hrsa.gov/sites/default/files/bhw/nchwa/projections/hrsa-ltts-direct-care-worker-

report.pdf). HRSA also funds university-based centers for workforce studies. The Center for Health Workforce

Studies at the University of Washington (https://depts.washington.edu/fammed/chws/hwrc/allied-health/) specializes

in studies related to allied health occupations; the University of Michigan Behavioral Health Workforce Research

Center (

http://www.behavioralhealthworkforce.org/projects/) focuses on behavioral health; and University of

California at San Francisco Health Workforce Research Center focuses on Long-Term Care

(

https://healthworkforce.ucsf.edu/). This report draws on the work of these three centers.

• Limited Career Advancement Opportunities – Unlike some occupations that build

distinct ladders for workers to advance on their career paths, often through apprenticeship

programs that provide skills-based education that prepares workers for well-paying jobs,

EHCWs have limited opportunities to become more “highly-skilled” and more “highly-

valued” and to move forward in career paths.

• High Turnover, Limited Replacements – EHCWs leave their jobs for other industries,

primarily because of poor quality jobs. Challenges with recruitment and retention stem

from low wages, limited benefits, inconsistent and inflexible schedules, lack of career

ladders or opportunities for advancement, and challenging work conditions that include

emotionally and physically taxing work and lack of consistent support and supervision.

Federal Government Programs that Address the Entry-Level Health Care

Workforce

The Veterans Health Administration is making major use of peer specialists to help support

recovery from mental illness among veterans, and in some cases is expanding peer specialist

roles to primary care. Most federal grant support for training and education of the EHCW is

found at the Departments of Labor and Education.

While the Department of Health and Human Services (HHS) maintains a broad array of health

workforce-related programs, in agencies including the Health Resources and Services

Administration (HRSA), the Indian Health Service, and the Agency for Children and Families

(ACF), in general, its efforts are not heavily focused on entry-level health care workers.

Programs often take the form of loans and scholarships, frequently with a service obligation, and

provide support for educational institutions that train health personnel, often through innovative

projects. However, these workforce programs are generally targeted to members of the

healthcare workforce who have, at a minimum, a bachelor’s degree and often to workforce

members with post-baccalaureate training including physicians and dentists, advanced practice

nurses, physician assistants, psychologists, and social workers.

There are exceptions to this general rule. Notably, the Health Professions Opportunity Grant

(HPOG) program, administered by ACF, was created to provide education and training to

Temporary Assistance for Needy Families program recipients and other low-income individuals

for occupations in the health care field that pay well and are expected to either experience labor

shortages or be in high demand. Since its inception in 2010, two rounds of 32 grantees each

have been funded in this demonstration program, with the second round of projects approaching

completion. The most common training programs funded include those for nurse aides, home

health aides, licensed and vocational nurses, registered nurses, medical assistants, pharmacy

technicians, and phlebotomists. Evaluation of this program has yielded an extensive portfolio of

studies (see: https://www.abtassociates.com/projects/evaluating-hhss-health-profession-

opportunity-grants-program). Results of these analyses are mixed. For example, a third-year

impact study of the first cohort of grantees found that when compared to a control group, the

HPOG treatment group had completed more training, were more likely to be employed in health

care, and experienced greater career progress; however, earnings were similar in each group.

In addition, the Community Health Aide Program (CHAP) within the Indian Health Service

serves the dual purpose of helping fill the need for health care services in remote areas of Alaska,

while increasing the skill set of entry-level workers through a structured graduated training

program. In areas where other care options may not be available, community health aides can

progress through training and gain competency in providing first-line care. While the program

has been limited to Alaska, there are plans for its expansion to other tribal areas in the United

States pending available funding.

One of the more relevant examples of training support for entry-level workers provided by

HRSA is the Behavioral Health Workforce Education and Training (BHWET) program. Among

its multiple purposes, this program provides behavioral health training for individuals to become

community health workers, outreach workers, social services workers, mental health workers,

substance abuse/addiction workers, youth workers, and peer workers.

Looking Forward

This report underscores the need to identify short-term strategies and longer-term approaches to:

• bolster and maximize the role of the EHCW to expand healthcare delivery capacity;

• support value-based care across health care settings;

• improve career ladders, working conditions, and wages;

• increase employment; and

• address the impact of the COVID-19 pandemic on this workforce.

The report has made clear the need to better identify workforce needs in the context of a

healthcare system that demands value and to work more closely with the Departments of Labor,

Education and Veterans Affairs, with whom we share common concerns.

The report recommends future actions including:

Scaling Innovative Efforts:

• Promote accelerated adoption of evidence-based models of care, support public-private

partnerships and identify how funding from multiple sources such as CHAP can advance

the EHCW.

https://www.acf.hhs.gov/sites/default/files/opre/hpog_three_year_impacts_nov_2019.pdf

Evaluating Existing Models:

• Improve evaluation of promising models. Evaluations of training and standardized

training curricula are relatively weak in the empirical literature.

Fostering Learning at the Community Level:

• Localities tend to have specific EHCW needs and challenges, which require local

solutions that can draw upon lessons learned from other communities. Gathering leaders

of innovative efforts from around the country—employers, educators, employee

associations, and other stakeholders—can create learning networks, develop best

practices, and identify opportunities for additional, or replicated, investments.

Addressing Gaps in the Research:

• How can open jobs be best filled and how can those who need jobs be best matched to

appropriate job opportunities?

• What are the evolving roles that members of the EHCW are playing in facility- and

community-based settings? Have competency-based curricula adapted accordingly?

• What are the relative costs and benefits of EHCW roles, both current and expanded,

including potential cost savings and population health gains achieved?

• What are the effects of scope of practice laws on the EHCW, and on the populations that

the EHCW serves?

• What is the role of alternative payment models in shaping the roles played by EHCWs?

Expanding the Use of Technology:

• The COVID-19 PHE has underscored the role telecommunications technology is

currently playing in training and health service delivery. Identifying how this transition

to greater use of telecommunications technology can best be applied to the EHCW is an

emerging issue. The expanded use of technology requires new workforce skills and

tailored training, but also offers opportunities for new roles for these workers and

efficient remote training opportunities.

Report

Strengthening the Entry-Level Health Care

Workforce

Finding a Path

Shira H. Fischer, Ryan K. McBain, Laura J. Faherty, Jessica L. Sousa, Vishnupriya

Kareddy, Allyson D. Gittens, Grant R. Martsolf

RAND Health Care

PR-A712-1

September 2020

Prepared for The Office of the Assistant Secretary for Planning and Evaluation (ASPE)

iii

Preface

This project report provides potential approaches to expand and strengthen the entry-level

health care workforce in the United States, with a primary focus on seven occupations: nurses,

medical assistants, dental assistants and hygienists, health aides, community health workers, peer

specialists, and other specialized providers.

This research was funded by the Office of the Assistant Secretary for Planning and

Evaluation (Task Order Number: HHSP23337008T, under contract HHSP233201500038I) and

carried out within the Payment, Cost, and Coverage Program in RAND Health Care.

RAND Health Care, a division of the RAND Corporation, promotes healthier societies by

improving health care systems in the United States and other countries. We do this by providing

health care decisionmakers, practitioners, and consumers with actionable, rigorous, objective

evidence to support their most complex decisions. For more information, see

www.rand.org/health-care, or contact

RAND Health Care Communications

1776 Main Street

P.O. Box 2138

Santa Monica, CA 90407-2138

(310) 393-0411, ext. 7775

RAND_Health-Care@rand.org

Contents

Preface............................................................................................................................................ iii

Figures........................................................................................................................................... vii

Tables ........................................................................................................................................... viii

Summary ........................................................................................................................................ ix

Acknowledgments........................................................................................................................ xvi

Abbreviations ............................................................................................................................. xviii

Part 1. Background, Methods, Data, and Framework (Chapters 1–3) .......................................... 23

1. Introduction ............................................................................................................................. 24

The EHCW ............................................................................................................................................. 24

The EHCW and Changing U.S. Health Care Needs ............................................................................... 24

The EHCW Supply and Demand Mismatch and Barriers to Entry ........................................................ 25

Motivation for This Project: Challenges and Opportunities ................................................................... 26

Study Objectives ..................................................................................................................................... 27

A Note on Terminology .......................................................................................................................... 28

2. Methods and Data ................................................................................................................... 29

Environmental Scan ................................................................................................................................ 29

Key Informant Discussions .................................................................................................................... 35

Case Studies............................................................................................................................................ 36

Limitations .............................................................................................................................................. 38

3. Framework .............................................................................................................................. 39

EHCW Program Objectives.................................................................................................................... 39

Part 2. Training and Development (Chapters 4–5) ....................................................................... 43

4. Objective I: Strengthen Training Quality ............................................................................... 44

Improved and Broadened Curricula ....................................................................................................... 44

Training Requirements ........................................................................................................................... 47

Licensing and Certification Requirements ............................................................................................. 49

Standardization of the Curriculum ......................................................................................................... 50

Apprenticeships with Credit from Educational Institutions ................................................................... 51

Continuing Education for EHCW Members .......................................................................................... 52

Training Duration ................................................................................................................................... 53

Training for Patient-Centered Care ........................................................................................................ 54

For-Profit Training Organizations .......................................................................................................... 55

Policy Opportunities ............................................................................................................................... 56

5. Objective II: Expand Training Opportunities ......................................................................... 58

Flexible and Accessible Training via Technology ................................................................................. 58

Collaborative Partnerships for Training ................................................................................................. 59

Expanded Recruitment for Training ....................................................................................................... 61

Financial and Nonfinancial Resources for Trainees ............................................................................... 61

Increased Capacity for Training ............................................................................................................. 63

Policy Opportunities ............................................................................................................................... 64

Part 3. Recruitment (Chapters 6–7) .............................................................................................. 65

6. Objective III: Expand Recruitment Strategies ........................................................................ 66

Broadened Hiring Pool Composition ..................................................................................................... 66

Targeted Recruitment ............................................................................................................................. 67

Collaborative Partnerships for Recruitment ........................................................................................... 68

Financial Incentives for Recruits ............................................................................................................ 70

Nonfinancial Incentives .......................................................................................................................... 71

Expanded Recruitment Venues .............................................................................................................. 72

Immigrants .............................................................................................................................................. 72

Policy Opportunities ............................................................................................................................... 73

7. Objective IV: Match the Best-Fit Candidates to Jobs ............................................................. 75

Clarified Job Qualifications to Improve Matching with Candidates ...................................................... 75

Evidence-Based Screening ..................................................................................................................... 76

Internships with Job Placement .............................................................................................................. 77

Policy Opportunities ............................................................................................................................... 77

Part 4. Retention (Chapters 8–9) ................................................................................................... 79

8. Objective V: Create Career Pathways..................................................................................... 80

Career Ladders ........................................................................................................................................ 80

Support for Ongoing Training for Skill Development ........................................................................... 84

Role Expansion Through Skill Development ......................................................................................... 85

Policy Opportunities ............................................................................................................................... 86

9. Objective VI: Improve Work Environment ............................................................................ 88

Performance Recognition ....................................................................................................................... 88

Positive Work Environment and Supportive Supervision ...................................................................... 89

Burnout ................................................................................................................................................... 90

Work Flexibility and Predictability ........................................................................................................ 92

Policy Opportunities ............................................................................................................................... 93

Part 5. Health System Strengthening (Chapters 10–14) ............................................................... 95

10. Objective VII: Improve Workforce Distribution .................................................................... 96

Target Training and Recruitment to Areas of Need ............................................................................... 96

Use Compensation to Improve Distribution ........................................................................................... 97

Policy Opportunities ............................................................................................................................... 98

11. Objective VIII: Empower the Workforce ............................................................................... 99

Role of Unions ........................................................................................................................................ 99

Role of Cooperatives ............................................................................................................................ 100

Role of Coalitions ................................................................................................................................. 101

Policy Opportunities ............................................................................................................................. 102

12. Objective IX: Recognize the Financial Value of the EHCW ............................................... 103

Wages ................................................................................................................................................... 103

Wage Policy.......................................................................................................................................... 104

Reimbursement Policy .......................................................................................................................... 105

Demonstrating Cost Savings ................................................................................................................ 107

Unpaid Roles ........................................................................................................................................ 107

Policy Opportunities ............................................................................................................................. 108

13. Objective X: Use Technology to Support the EHCW .......................................................... 109

Telehealth and Teleconsultation ........................................................................................................... 109

Devices ................................................................................................................................................. 110

Coordination and Communication ........................................................................................................ 111

Limits to Technology: Access and Training ......................................................................................... 111

Policy Opportunities ............................................................................................................................. 112

14. Research Needs ..................................................................................................................... 113

More Data, More Coordination ............................................................................................................ 113

Addressing Gaps in Research ............................................................................................................... 115

Policy Opportunities ............................................................................................................................. 115

Part 6. Conclusions (Chapter 15) ................................................................................................ 116

15. Conclusions ........................................................................................................................... 117

I. Scale Innovative Efforts .................................................................................................................... 118

II. Evaluate New Models of Care ......................................................................................................... 120

III. Convene Stakeholders to Foster Learning ...................................................................................... 121

IV. Address Gaps in Research .............................................................................................................. 122

V. Expand the Use of Technology........................................................................................................ 124

Other Considerations ............................................................................................................................ 126

Concluding Thoughts ........................................................................................................................... 126

Appendix A. Case Studies .......................................................................................................... 128

Alaska’s Community Health Aide Program ......................................................................................... 128

Peer Specialists in the Veterans Health Administration ....................................................................... 135

Advancing Peer Support in Integrated Care Settings: The Hogg Foundation for Mental Health’s Work

in Three Community Health Centers in Texas ............................................................................... 144

Kaiser Permanente’s Training and Recruitment Efforts in Southern California .................................. 149

Care Connections Project in New York City ........................................................................................ 155

The Individualized Management for Patient-Centered Targets Model in Philadelphia, Pennsylvania 159

Health Professions Pathways Consortium ............................................................................................ 168

Service Employees International Union Multi-Employer Training Funds ........................................... 176

Peninsula Homecare Cooperative for Health Aides ............................................................................. 182

Mercy Health System in West Michigan .............................................................................................. 187

Appendix B. Key Informant List ................................................................................................ 191

Appendix C. Process and Outcome Indicators for EHCW Research ......................................... 193

References ................................................................................................................................... 195

vii

Figures

Figure 1.1. Home Health Aides: Projected State Workforce Gaps by 2025 ................................. 26

Figure 3.1. Conceptual Framework for EHCW Strengthening ..................................................... 39

Figure A.1. Alaska Village Clinics and Training Centers Participating in CHAP, 2016 ........... 130

Figure A.2. Collaborative IMPaCT Decision Aid ...................................................................... 164

viii

Tables

Table 2.1. Sample List of Search Terms ....................................................................................... 31

Table 2.2. Programs Identified by Year and by Occupation, 2009–2019 ..................................... 33

Table 2.3. Occupations and Objectives of Identified Programs ................................................... 34

Table 2.4. Case Study Descriptions .............................................................................................. 37

Table 15.1. Policy Options, by Category .................................................................................... 117

Table 15.2. Successful Innovative Programs .............................................................................. 119

Table 15.3. Research Needed and Implications .......................................................................... 124

Table 15.4. Matrix of Objectives and Policy Opportunities ....................................................... 127

Table A.1. Selected Peer Support Job Titles and Definitions, Both Inside and Outside the VHA

............................................................................................................................................. 136

Table A.2. Kaiser Foundation Overview .................................................................................... 150

Table A.3. Co-Grantee Colleges in the Health Professions Pathways Consortium .................... 169

Table A.4. Partner Organizations in the Health Professions Pathways Consortium .................. 169

Table A.5. 1199SEIU TEF and SEIU UHW Joint Employer Education Fund Programs .......... 179

Table B.1. Overview of Key Informants .................................................................................... 191

Table C.1. Potential Measures for Success of Workforce Development .................................... 194

Summary

Background and Purpose

Projections indicate that the United States faces an anticipated health care workforce

shortage. Strengthening and expanding the role of the entry-level health care workforce

(EHCW)—a heterogeneous group that we define as health professions at the prebaccalaureate

level that directly support patient care—is one potential option to help fill gaps in the existing

health care workforce. EHCW members include licensed practical nurses, home health aides,

community health workers (CHWs), and numerous other professional groups. Members of the

EHCW serve critical functions in the U.S. health care system, such as scheduling patients;

coordinating referrals; updating medical records; helping patients navigate the health care

system; monitoring symptoms; and providing health coaching, patient education, and literacy

support. They also can play a key role in hands-on care, emotional support and cultural

competency, self-management, and the attainment of recovery goals. Cumulatively, these

functions are essential for supporting individual health care needs and promoting population

health. Moreover, when they are effectively coordinated, these functions reduce the workload on

doctors, nurse practitioners, and physician assistants, allowing these providers to spend more

time in direct consultation with patients.

1,2

However, in such professions as primary care

physicians and specialty providers, shortages also exist in the EHCW.

The EHCW constitutes a significant percentage of the overall health care workforce: about

half of the health care workforce in the nation’s 100 largest metropolitan areas.

However,

current estimates predict substantial shortages in the health care workforce in general and among

the EHCW specifically, with especially concerning shortages in rural areas; in locations with

limited health infrastructure; and in specialty sectors, such as behavioral health care and long-

term health care.

4-11

Anticipated shortfalls across major segments of the health care workforce—

including the EHCW—are partially attributable to the aging of the U.S. population and a

growing prevalence of complex, chronic conditions.

12-14

There are many reasons to strengthen this workforce. Enabling the full potential of entry-

level health care workers ultimately supports a vision of team-based care that is consistent with

the patient-centered medical home, which includes care coordination between visits and settings

by a diverse array of professionals.

3-5

In addition, improving career pathways for EHCW

members should bolster opportunities to increase individuals’ scopes of responsibility and

promote job satisfaction and retention.

15-17

At this point, career ladders are not well defined for

many EHCW occupations, with many workers in low-paying positions lacking opportunities for

advancement. Real wages have been stagnant over the past 40 years for a preponderance of

Americans, and the development of career pathways for EHCW members could counter this

stagnation by offering vocational and financial growth in one of the largest sectors of the U.S.

economy.

18,19

Despite the value inherent in this proposition, there are also significant gaps within the

EHCW—including in the training and skill sets, recruitment, and retention of these individuals.

Cumulatively, these shortfalls represent a major barrier to enhancing the quality, equity, and

efficiency of the U.S. health care system.

The goal of this research was to review evidence on promising strategies—including

innovative policies and programs—to strengthen and expand the EHCW and identify potential

opportunities for stakeholders to consider based on this review. In the following sections, we

describe the approach we took to identify policy opportunities, various key challenges facing this

segment of the workforce, strategies to strengthen the EHCW, and policy opportunities based on

the findings of our work.

Study Purpose and Approach

To identify policy opportunities, we addressed three research questions:

1. What is known from the academic and gray literature (and on the ground) about

challenges facing the EHCW in its efforts to support the wider health care workforce

and address patient needs?

2. What innovative strategies are being used to strengthen the role of the EHCW? What

lessons can be learned and generalized from these strategies?

3. What are the potential public policy opportunities to further strengthen the EHCW,

potential barriers to their implementation, and examples of where such barriers have been

addressed?

To answer these questions, we performed an environmental scan of academic and gray

literature on relevant programs and policies, conducted key informant discussions, and

developed ten case studies of promising programs. Our environmental scan identified 228

programs and 284 articles from the academic and gray literature, and we conducted key

informant discussions with 41 experts. We uncovered additional literature and information

sources through conversations with experts, bibliographical review, and web searching.

Challenges Facing the EHCW

Current projections indicate that the demand for health care workers—particularly home

health aides—is expected to grow over the next ten years, reflecting a sharper upward trend

when compared with any other occupational category.

However, supply is forecasted to grow

at a slower pace, ultimately resulting in larger workforce shortages among several professional

groups.

These trends make a compelling case for strengthening and expanding the EHCW. In

addition to an insufficient supply of EHCW members in particular occupations, there are

concerns about the geographic maldistribution of the EHCW.

Furthermore, this workforce

includes many low-income individuals

21,22

and many whose current positions provide limited

opportunities for advancement. Strengthening this workforce would benefit the workers and

address issues of access to health care.

We identified four overarching challenges to expanding and strengthening the EHCW to

address workforce gaps:

• training: Broadly speaking, the supply of EHCW candidates with appropriate training

and skills is insufficient to meet the growing need.

In addition, EHCW members have

different levels of preparation for their roles, and there is inadequate standardization of

training and job requirements relative to that in other areas of the health care workforce.

Beyond expanding training programs for the EHCW, there might be opportunities to

expand the scope of competency-based curricula to ensure that training meets the needs

of employers and patients.

• recruitment: EHCW roles are not always considered fulfilling, well compensated, or

well supported.

25-27

For instance, national statistics indicate that EHCW members have

low incomes relative to the national average across all occupations, although these

figures vary by occupation.

20,28

These shortcomings might reduce interest among those

applying for EHCW roles and might drive up vacancy rates.

Moreover, EHCW

positions often have varying licensure and certification requirements, unclear scopes of

practice, and limited support and supervision. All of these factors can make EHCW

positions unattractive to new candidates and might undermine existing workers’ ability to

seek work across employers or state lines.

• retention: Turnover among EHCW members tends to be high, in part because entry-level

health care workers might perceive little opportunity for career advancement and skill

development.

30,31

The likelihood of turnover might be compounded by low salaries,

limited benefits packages, inflexible or inconsistent schedules, and demanding work

environments. High turnover also can place stress on peers and managers who are

responsible for repeatedly orienting and training new hires.

33,34

• systems: In addition to the above challenges, we identified system issues that create

obstacles to the advancement of, opportunity for, and optimal use of entry-level health

care workers, including suboptimal workforce distribution, financing, and technology.

These systemic issues shape training, recruitment, and retention efforts.

Strategies to Strengthen the EHCW

To answer our second research question, we identified a variety of policies, programs, and

activities aimed at addressing the four identified challenges:

• training: One set of programs was designed to expand workforce roles through training;

for example, by broadening training curricula or by offering continuing education to

members of the existing EHCW. A second set of programs aimed to expand training

opportunities to more individuals; for example, by offering more-flexible and more-

accessible curricula, expanding recruitment for training, and increasing institutional

capacity for training. A third segment of programs focused on strengthening training

quality (for example, by reforming curricula, establishing core competencies,

xii

standardizing training content, or offering apprenticeships along with classroom-based

pedagogy).

• recruitment: We identified two types of programs to address recruitment problems.

First, programs have expanded job opportunities by diversifying the racial and ethnic

composition of the hiring pool, establishing partnerships between employers and

academic institutions, offering financial and nonfinancial incentives for prospective

employees, and expanding recruitment venues. Second, to ensure that qualified

candidates are matched to appropriate jobs, programs have clarified job qualifications for

hiring, used evidence-based screening practices, and established internships with the

potential for job placement if those internships go well.

• retention: We identified two sets of programs addressing difficulties with retention. One

type of program created career pathways for the EHCW, including formal career ladders

leading to changes in job titles and on-the-job support for new skills development. A

second set of programs created a workplace environment that encourages retention

through, for example, performance recognition programs, supportive supervision, and

flexible work hours.

• systems: Systemic efforts to address EHCW challenges throughout the pipeline included

(1) targeted training and recruitment for geographic areas in greatest need of providers

and enhanced compensation to incentivize redistribution; (2) workforce empowerment

through encouraging the participation of unions, establishing the growth of cooperatives

and alternative business models, and strengthening local coalitions; and (3) financial

mechanisms to support the EHCW (e.g., through wage and reimbursement policies and

cost savings that result from greater involvement of the EHCW). Several larger health

systems are in the process of implementing data analytic platforms to optimize the

distribution and career pathways of EHCW members and piloting new workforce cadres

that support care in the community and at home.

We provide specific examples of each of these kinds of programs in the main body of this

report.

Policy Opportunities

Through our work on this project, we identified a variety of potential opportunities that

entities could consider undertaking to enhance the role of the EHCW in the United States. These

opportunities pertain to encouraging the adoption of best practices and the use of promising

technologies, fostering learning through collaborative models, and identifying and funding

research priorities. We briefly summarize these opportunities in the following sections and

discuss them in greater depth in Chapter 15: Conclusions.

Scale Innovative Efforts

Even when programs had evidence behind them, the strategies implemented to strengthen the

EHCW often lacked sustained support. However, we also found several important exceptions.

For example, the Florida Community Health Worker Coalition has achieved scale by bringing

colleges and universities, government agencies, health organizations, and employees together

xiii

around a focused set of objectives for almost a decade, which represents a sustained effort. In

another example, Alaska’s Community Health Aide Program (CHAP) has conducted evaluations

that demonstrate its success,

35,36

and CHAP is being adopted more broadly by the Indian Health

Service (see the CHAP case study in Appendix A). To increase the frequency of these sorts of

implementation successes, potential opportunities for consideration include

• identifying successful models supported by evidence. As detailed in the following

sections, evaluation is needed to identify successful models of care, which should be the

focus of accelerated adoption.

• supporting public-private partnerships. Given the degree of innovation in the private

sector to address workforce needs, public-private partnerships might be particularly

relevant frameworks for scaling models of care that have shown success on a smaller

scale in research and academic settings.

• identifying how existing sources of multisectoral funding can be applied to the EHCW.

Some of the innovative programs we identified emerged from local creativity rather than

because the mechanism that funded it was intended to address EHCW needs (for

example, as highlighted in one of our case studies, home care cooperatives funded by

resources that are not specifically intended for health care). Individuals that are closest to

the needs of local markets and community members often are in the best position to

facilitate the vision and structure of programmatic efforts in their community and they

may want to consider, where appropriate, how existing sources could be used to test and

implement new models of care that incorporate the EHCW.

Evaluate New Models of Care

Where evidence is lacking but innovation is evident, more-rigorous program evaluation could

be encouraged. This includes evaluating effective configurations of care, including how entry-

level health care workers can be used most efficiently

and how their contributions to health

care delivery can be maximized.

Likewise, and as noted later in the report (see Chapter 4),

evaluations of EHCW training initiatives and standardized training curricula are relatively weak

in the empirical literature and represent additional areas for inquiry.

Foster Learning

We found that localities tend to have unique EHCW needs and challenges, which require

local solutions that could draw on lessons learned from other communities. For example, one key

informant from an integrated health system in Michigan said that the state’s transitioning

manufacturing economy was an opportunity to leverage job training initiatives: The system

harnessed a government-supported “Michigan Works” program to bring together educators and

employers to sponsor training and jobs placement for new medical assistants. In another

discussion, we learned that parts of Washington that have large elderly populations have

endorsed home health cooperatives as a business model to advance long-term care and a public-

private partnership has helped support this effort.

xiv

An entity with convening authority could play a role in supporting such local efforts by

gathering leaders of these efforts from around the country—e.g., employers, educators, employee

associations, and other stakeholders—to identify opportunities for additional or replicated

investments. Conversations could be structured around key topics to allow officials to hear

firsthand about various challenges, such as those faced by employers in obtaining appropriately

skilled workers, and to identify opportunities to facilitate local solutions that draw on lessons

learned in other communities.

Address Gaps in Research

Although much research has been conducted on the EHCW, including critical work by

Health Resources and Services Administration–funded Health Workforce Research Centers cited

throughout this report, significant gaps remain in the research agenda on EHCW issues.

Examples of specific research questions that could benefit from further research include the

following:

• What is the current and projected supply and demand for specific EHCW groups, such as

home health aides and CHWs, and is it updated on a routine basis?

• How can open jobs be best filled, and how can those who need jobs be best matched to

appropriate job opportunities?

• What are the evolving roles that EHCW members are playing in facility- and community-

based settings? Have competency-based curricula been adapted accordingly?

• What are the relative costs and benefits of EHCW roles, both current and expanded,

including potential cost savings and population health gains achieved?

• What are the effects of scope-of-practice laws on the EHCW and on the populations that

the EHCW serves?

• What is the role of alternative payment models in shaping the roles played by EHCW

members?

Findings of such research could be disseminated through various mechanisms, including

learning collaboratives, as we discussed earlier.

Expand the Use of Technology

Technology can support the expansion of workforce practice and training in rural and remote

areas of the United States and make trainings more accessible and standardized. For example, the

U.S. Department of Agriculture has developed a downloadable, computer-based curriculum to

train peer counselors on best practices that include supporting new mothers’ breastfeeding goals,

with participation demonstrating improvements in breastfeeding initiation and duration.

Technology presents special opportunities in long-term care settings, such as assistive

technology for cognitive or functional disabilities, and in behavioral health, by allowing access

to providers while offering differing levels of privacy or anonymity.

40-42

Access to and fluency

with technology can and should facilitate learning opportunities. Specific steps to promote

technology adoption include

• supporting the expansion of broadband access: Access to online curricula for

prospective EHCW members would be enhanced by greater broadband internet

availability across the United States, particularly in rural communities. Fewer than 60

percent of rural Americans have broadband internet at home, compared with 70 percent

of suburban Americans.

• supporting telehealth infrastructure and reimbursement: Telemedicine relies on a

trained person onsite to enable remote providers to assess patients or provide treatments.

EHCW members could serve in this onsite role. In addition, telemedicine infrastructure

can enable EHCW members to work remotely or can expand the roles they can fill.

• supporting remote training: The internet and associated technologies allow for remote

education, which can be used for training the EHCW. Although in-person training has

advantages, a blended approach using some remote education could address logistical

barriers to continuing education.

• supporting training in technology, including electronic health records (EHRs):

EHCW performance increasingly depends on technological literacy, including

understanding and interacting with widespread EHRs, such as Epic. Training in

technology, even if not directly related to patient-facing duties, would enable the EHCW

to communicate with other members of the health care workforce, access client

information, and share their contributions in a formally documented way.

xvi

Acknowledgments

We would like to thank members of the U.S. Department of Health and Human Services

Office of the Assistant Secretary for Planning and Evaluation for their guidance and feedback on

the development of this report—including Erin Bagalman, Andre Chappel, Rose Chu, Nancy De

Lew, Judith Dey, Marie Squillace, Caroline Taplin, and Gina Turrini. We also would like to

thank several colleagues at the RAND Corporation for their feedback on a penultimate version of

this report—Scott Ashwood, Esther Friedman, and Katherine Kahn—along with editorial,

contract management, and research support staff for their assistance, including Paul Butler,

Spencer Case, Clifford Grammich, Kayla Howard, Erin Johnson, Jody Larkin, Steve Oshiro,

Orlando Penetrante, Lee Remi, and Blair Smith. Furthermore, we would like to thank our

internal reviewers, Christine Eibner and Paul Koegel, for their insightful feedback, and we thank

Lisa Turner for managing the quality assurance review process. We are also grateful to internal

RAND reviewer Matthew Baird and external reviewer Bianca Frogner.

We are deeply grateful to the dozens of individuals who participated in the almost 40

discussions that served as the foundation for the case studies and background for this report:

Yener Balan (Kaiser Permanente), Candace Baldwin Robinson (Capital Impact Partners), Angela

Beck (Behavioral Health Workforce Research Center, University of Michigan School of Public

Health), Donald Bradburn (Kaiser Permanente Southern California), Meghan Boynes (University

of Pittsburgh Medical Center [UPMC]), Debra Bragg (Community College Research Initiatives,

University of Washington), Daniel Bustillo (Healthcare Career Advancement Program),

Matthew Chinman (U.S. Department of Veterans Affairs and RAND), Deborah Craig

(Northwest Cooperative Development Center), Angelina Del Rio Drake (PHI), Robin Fernkas

(U.S. Department of Labor), Stephanie Fitzpatrick (Center for Health Research, Kaiser

Permanente), Heather Fox (Office of Community College Research and Leadership, University

of Illinois), Bianca Frogner (Center for Health Workforce Studies, University of Washington),

John Galley (UPMC), Diane Gasaway (Northwest Cooperative Development Center), Gabriella

Gonzalez (RAND), Sarah Hastings (U.S. Department of Labor), Colleen Horton (Hogg

Foundation for Mental Health), Shreya Kangovi (Penn Center for Community Health Workers,

University of Pennsylvania), Deborah King (National Domestic Workers Alliance), Anne Klee

(U.S. Department of Veterans Affairs), Evelyne Kruger (Penn Center for Community Health

Workers, University of Pennsylvania), Sharon Lee Miller (U.S. Department of Education), Matt

Lege (Service Employees International Union–United Healthcare Workers [SEIU UHW] West),

Brion Lieberman (Geisinger), Frederick Nardei, Jr. (U.S. Department of Veterans Affairs), Leah

G. Newkirk (Kaiser Permanente), Dan O’Brien-Mazza (U.S. Department of Veterans Affairs),

Robert Onders (Alaska Native Tribal Health Consortium and Alaska Pacific University), Mark

Redding (Community Health Access Project and Pathways Community HUB Institute), Sarah

xvii

Redding (Community Health Access Project and Pathways Community HUB Institute), Douglas

W. Roblin (Kaiser Permanente), Sonya Shin (Harvard Medical School and Brigham and

Women’s Hospital), Susan M. Skillman (Center for Health Workforce Studies, University of

Washington), Joanne Spetz (Healthforce Center, University of California, San Francisco), Craig

Stambaugh (UPMC), Robin Streeter (National Center for Workforce Analysis), Jodi Sturgeon

(PHI), Kim Vitelli (U.S. Department of Labor), Sandi Vito (1199 Service Employees

International Union [SEIU] Training and Employment Funds), Michelle Washko (National

Center for Workforce Analysis), Kippi Waters (Peninsula Homecare Cooperative), Toni Terling

Watt (Texas State University), Shana Welch (Mercy Health), and Rick Ybarra (Hogg Foundation

for Mental Health). We also thank the other experts who contributed their time and knowledge

but are not listed here by name. We extend our thanks to LaTanga Bell (SEIU UHW West and

Joint Employer Education Fund), Joselyn Calderon (Penn Center for Community Health

Workers, University of Pennsylvania), Angela Cormier (Mercy Health), Lisa Daly (1199SEIU

Training and Employment Funds), Shannon Dembowski (UPMC), Rica Lilly (Kaiser

Permanente), and others not listed here for their help and support with scheduling.

We also would like to thank the many individuals who helped identify resources,

information, and key informants for the report; specifically, Elizabeth Bayliss (Kaiser

Permanente), Angela Fallon (Indian Health Service), Laura Ginsburg (U.S. Department of

Education), John Haigh (U.S. Department of Education), Christopher Halliday (Indian Health

Service), Barbara Head (Kaiser Permanente), Jean Moore (Center for Health Workforce Studies,

University at Albany, State University of New York), and Geoffrey Wilkinson (Boston

University School of Social Work).

xviii

Abbreviations

Abbreviation

Definition

ACA

Patient Protection and Affordable Care Act

ACG

Appalachian Consulting Group

ACO

accountable care organization

ANTHC

Alaska Native Tribal Health Consortium

ASPE

Assistant Secretary for Planning and Evaluation

BACH

Baltimore Alliance for Careers in Healthcare

BHA

behavioral health aide

BHP

behavioral health practitioner

BHWET

Behavioral Health Workforce Education and Training Program

BLS

U.S. Bureau of Labor Statistics

BSN

Bachelor of Science in Nursing

CCP

Care Connections Project

CCSA

care connections senior aide

CDC

Centers for Disease Control and Prevention

CHA

community health aide

CHAP

Community Health Aide Program

CHCA

Cooperative Home Care Associates

CHP

community health practitioner

CHR

community health representative

CHW

community health worker

CMMI

Center for Medicare & Medicaid Innovation

CMS

Centers for Medicare and Medicaid Services

CNA

certified nursing assistant

COPE

Community Outreach and Patient Empowerment

CUNY

City University of New York

xix

Abbreviation

Definition

dental assistant

dental hygienist

DHA

dental health aide

DHAT

dental health aide therapist

DOL

U.S. Department of Labor

EBSP

Evidence-Based Selection Process

ECCLI

Extended Care Career Ladder Initiative

ECH

Employee and Community Health

EHCW

entry-level health care workforce

EHR

electronic health record

emergency room

ESL

English as a second language

FCHWC

Florida Community Health Worker Coalition

FQHC

federally qualified health center

General Schedule

H2P

Health Professions Pathways

HCA

home care aide

HCW

home care worker

HHA

home health aide

HIT

health information technology

HPOG

Health Profession Opportunity Grants

HRSA

Health Resources and Services Administration

IHS

Indian Health Service

IMPaCT

Individualized Management for Patient-Centered Targets

IOM

Institute of Medicine

Kaiser Permanente

LPN

licensed practical nurse

LTC

long-term care

Abbreviation

Definition

LVN

licensed vocational nurse

medical assistant

MARAP

Medical Assistant Registered Apprenticeship Program

MCO

managed care organization

MRAHPTP

Montana Rural Allied Health Professions Training Program

NGO

nongovernmental organization

nurse practitioner

NWCDC

Northwest Cooperative Development Center

NYP

New York–Presbyterian Hospital

ORR

observe, report, and record

PACIO

Post-Acute Care Interoperability

PACT

Patient-Aligned Care Team

PCA

personal care aide

PCH

Pathways Community HUB

PCMH

Patient-Centered Medical Home

PCS

Personal Care Services

PHCAST

Personal and Home Care Aide State Training

RAS

Recovery Assessment Scale

RCT

randomized controlled trial

registered nurse

SAT

Scholastic Aptitude Test

SEIU

Service Employees International Union

SEIU-UHW

Service Employees International Union–United Healthcare

Workers

SNAP

Supplemental Nutrition Assistance Program

technical assistance

TAACCCT

Trade Adjustment Assistance Community College and Career

Training

TCN

Transitions Clinic Network

xxi

Abbreviation

Definition

TEF

Training and Employment Fund

UPMC

University of Pittsburgh Medical Center

USDA

U.S. Department of Agriculture

U.S. Department of Veterans Affairs

VHA

Veterans Health Administration

xxii

Part 1. Background, Methods, Data, and Framework

(Chapters 1–3)

1. Introduction

The United States is facing an impending shortage of health care workers. Enhancing the

entry-level health care workforce (EHCW) could help address this shortage. This report

identifies promising strategies—including innovative policies, programs, and initiatives—for

enlarging and strengthening this workforce and assesses the evidence base for the effectiveness

of these efforts.

The EHCW

The EHCW is a heterogeneous group that includes licensed practical nurses (LPNs), home

health aides (HHAs), community health workers (CHWs), peer workers, and numerous other

professional groups. We are defining entry-level to encompass professions considered an entry

point into the health care workforce and that might be a springboard for further professional

development. More specifically, EHCW positions might be considered to meet three conditions:

they (1) do not require a bachelor’s degree or higher degree; (2) require minimal prior work

experience; and (3) are in the health care industry and directly support care provision. (See the

section on terminology at the end of this chapter for more information about the term.)

EHCW members constitute a significant proportion of the overall health care workforce: In

an analysis of the American Community Survey from 2000 to 2011, the Brookings Institution

found that health care workers without a bachelor’s degree or more-advanced degrees account

for nearly one-half of the total health care workforce in the nation’s 100 largest metropolitan

areas.

According to the U.S. Bureau of Labor Statistics (BLS), as of 2014, median annual earnings

among EHCW members varied significantly, from roughly $20,000 to $25,000 among those

with a high school diploma to $50,000 or more among those with an associate’s degree.

Across

all health care support occupations in the BLS, the 2018 median annual wage was $29,740,

which is lower than the median annual wage for all occupations in the economy.

Many

individuals in the EHCW have incomes that are low enough to qualify for public benefits, such

as Medicaid or the Supplemental Nutrition Assistance Program (SNAP). An estimated 24

percent of home care workers (HCWs) and 17 percent of nursing assistants live in households

below the federal poverty line, compared with 9 percent of all U.S. workers.

21,22

The EHCW and Changing U.S. Health Care Needs

Bolstering and expanding the roles of the EHCW can help meet evolving U.S. health care

needs. This is particularly important today in the context of an aging population,

12,13

the growing

burden of chronic health conditions,

and sizable gaps in the health care service delivery

workforce. Reports have forecasted shortages of primary care physicians and specialists in

communities throughout the United States,

44-46

particularly in rural areas and among specific

populations, such as racial and ethnic minorities.

One way to address these expected shortages

is to broaden the scope of work among EHCW members to enable providers to work at the top of

their license and training.

1,2,48

Doing so would support team-based care that is consistent with the

Patient-Centered Medical Home (PCMH) model, through which clients have their needs met at

facilities and within their communities by a diverse array of service providers, including HHAs,

CHWs, nurses, and peer specialists.

15-17

In addition, the development of career pathways for

EHCW members would offer vocational and financial opportunities in one of the largest and still

growing sectors of the U.S. economy.

18,19

However, the United States faces significant

challenges in maximizing the potential of the EHCW. There are barriers to worker training,

recruitment, and retention. Cumulatively, these challenges represent obstacles to enhancing the

quality, equity, and efficiency of the U.S. health care system.

The EHCW Supply and Demand Mismatch and Barriers to Entry

The size of (and demand for) the EHCW—which is measured in the number of jobs

available, both vacant and filled—is growing rapidly.

According to the BLS, employment in

health care occupations is projected to grow by 18 percent from 2016 to 2026 (compared with 7

percent for all occupations), adding about 2.4 million new jobs.

For certain positions, the

projected percentage change in employment is far greater: Growth in personal care aides (PCAs)

is projected to be 41 percent, in medical assistants (MAs) is projected to be 29 percent, and in

dental assistants (DAs) is projected to be 19 percent—cumulatively accounting for more than

half of all new positions (1.3 million) to the health care labor market.

49-51

This contrasts with

more-modest expected growth for physicians (13 percent) and nurses (12 percent), representing

roughly 400,000 new positions over the same period.

52,53

Physicians particularly take a long time

to train (more than a decade) and increasingly work part-time, which are reasons that physicians

represent a decreasing share of this expanding health workforce.

However, numerous EHCW workforce gaps are projected, and demand for these professions

is estimated to outstrip supply. For example, by 2025, there will be an estimated shortfall of

446,000 HHAs (see Figure 1.1) and 95,000 nursing assistants.

This is further reflected in high

vacancy rates, time-to-fill durations, and turnover rates among members of the EHCW.

By way

of illustration, a 2017 health workforce survey in Missouri found a vacancy rate close to 10

percent.

A national survey conducted in 2019 of more than 3,000 hospitals found a 32-percent

turnover rate among certified nursing assistants (CNAs).

That compares with 22 percent across

all professions in the U.S. companies.

This increased demand poses an opportunity to employ a

population looking for employment or for better-paying, more-stable employment.

In addition to an insufficient supply of EHCW members in particular occupations, there are

concerns about the geographic maldistribution of EHCW, which is linked with other larger

system barriers, including long travel distances to the nearest health care provider, low insurance

reimbursement rates, and lengthy wait times, as well as with non–health system issues, such as

the affordability of housing. To illustrate the maldistribution of entry-level health care workers,

2017 data from Texas show that the licensed vocational nurse (LVN) vacancy rate ranged from

3.1 percent in East Texas to about 16 percent in the Panhandle region, and the vacancy rate

ranged from 2.9 percent in East Texas to 18.6 percent in West Texas for HHAs and nursing

aides.

An additional barrier to entry is familiarity: Many physicians and nurses might not know

what entry-level workers do and what training they have and, therefore, they might not know

how to employ them effectively.

Figure 1.1. Home Health Aides: Projected State Workforce Gaps by 2025

SOURCE: Mercer Strategy and Analytics, External Labor Market Analysis of the U.S. Healthcare Market.

Used with

permission.

Motivation for This Project: Challenges and Opportunities

On one hand, the mismatch between EHCW supply and demand represents a formidable

challenge for the U.S. health care system. On the other hand, there is an opportunity for

stakeholders to design and implement policies and programs that address the underlying factors

that contribute to this mismatch. Increasing workforce development resources for EHCW

members has the potential to realize multiple goals, including expanding access to care,

enhancing worker economic opportunity, reducing health care costs, and improving health care

outcomes. There is untapped potential for new positions for entry-level workers that could fill a

growing need that responds to the shifting U.S. demand.

Improving opportunities for career advancement among entry-level workers across various

sectors, including health care, is a priority of the federal government, as demonstrated by the

American Apprenticeship Act of 2017,

which provided funding to states for tuition assistance

programs and defrayed the cost of instruction in apprenticeship programs.

In 2019, the

Pathways to Health Careers Act (H.R. 3398) was passed in the U.S. House of Representatives,

although it has not become law as of the time of this writing. It renews the Health Profession

Opportunity Grants (HPOG) program, which we describe in more detail later, and suggests

increasing support for the EHCW.

The U.S. health care system is poised to confront this EHCW employment challenge. Health

care is one of the largest and fastest-developing industries in the United States, and the sector is

undergoing a transition from traditional fee-for-service payment to value-based models of care

delivery.

Within these new payment environments, health care will be delivered most

effectively and efficiently by a diverse health care workforce that is able to function in

interdisciplinary teams and that has appropriate skills and training.

Furthermore, health systems are increasingly emphasizing value-based care by creating

PCMHs,

emphasizing prevention, and delivering care within the community rather than inside

the walls of clinics and hospitals,

which lends greater weight to the roles of care coordinators,

peer specialists, and CHWs.

Recent legislation at the state and local levels might further

influence the shape of the EHCW, including through minimum wage reform;

licensing;

policies that enhance aspects of worker well-being, such as occupational safety;

and policies on

such issues as service reimbursement levels, payment models, and immigration.

Study Objectives

The Assistant Secretary for Planning and Evaluation (ASPE) contracted with the RAND

Corporation to examine existing efforts—including innovative programs, policies, and

initiatives—that might offer insight into potential solutions to the impending EHCW shortage.

This study addresses the following research questions:

1. What is known from the academic and gray literature (and on the ground) about

challenges facing the EHCW in its efforts to support the wider health care workforce

and address patient needs?

2. What innovative strategies are being used to strengthen the role of the EHCW? What

lessons can be learned and generalized from these strategies?

3. What are the potential public policy opportunities to further strengthen the EHCW,

potential barriers to their implementation, and examples of where such barriers have been

addressed?

In the main findings chapters of this report, we provide answers to each of these questions. In

the conclusions chapter, we organize the policy opportunities that are derived from the findings

throughout the report to form a potential policy agenda that can address the challenges in

training, recruitment, and retention that underpin the EHCW shortage.

A Note on Terminology

The term entry-level health care workforce has limitations as a designation for the variety of

roles in which members serve and that many individuals might consider permanent. However,

the term is widely used by news sources, universities that train professionals, and hiring

agencies.

71,72

Alternative terms, such as allied health professional, also have shortcomings. Title

42 of the U.S. Code of Federal Regulations defines allied health professional as someone who

holds a certificate, post-baccalaureate training, or an associate’s, bachelor’s, master’s, or doctoral

degree in health care who “shares in the responsibility for the delivery of health care services or

related services.”

Organizations have raised issues with this term,

asserting that it is not well

defined and encompasses an overly expansive variety of occupations and degrees.

To enhance the precision of the term EHCW, we have selected a focused set of occupations

within this umbrella that often are the first steps of a potential career pathway. These are

presented at the beginning of the next chapter.

2. Methods and Data

We used two methodological approaches to identify and assess the quality of programs and

policies to strengthen and expand the EHCW. First, we conducted an environmental scan of the

academic and gray literature to identify relevant policies, programs, and initiatives in this space

and the evidence base underpinning them. Second, we conducted a series of key informant

discussions with leading experts on health care workforce issues, including researchers in

academia, government officials, and heads of talent acquisition departments in large health care

organizations. We used a subset of these discussions to develop closer looks at specific

successful programs in the public and private sectors. These case studies can be found in

Appendix A.

Environmental Scan

Our goal was to identify innovative EHCW programs, policies, and initiatives using internet

searches, literature searches, and key informant conversations. We did not conduct a systematic

review of the literature. Instead, we implemented a focused search, employing an iterative

process that was intended to identify prominent programs.

Search strategy. We surveyed academic and gray literature identified through Google

Search and Google Scholar. Specifically, we implemented a Boolean search procedure based on

keywords under three domains: job categories or occupations of interest (domain 1), terminology

indicative of gaps in labor supply and quality (domain 2), and terminology connoting solutions to

these gaps (domain 3). Table 2.1 provides an overview of terms selected. The Boolean search

queries combined all terms within domains using “or” statements and linked across domains 1

through 3 using “and” statements.

With respect to occupations of interest, we restricted our search to those health care

workforce positions that require training below the baccalaureate level (pre-baccalaureate) and

offer some form of direct patient care, services, or care coordination, as noted in Chapter 1. For

our search, we included

1. nurses, including LPNs, LVNs, and registered nurses (RNs) without a Bachelor of

Science in nursing (BSN)

2. MAs

3. DAs and dental hygienists (DHs)

4. health aides and other direct care workforce members, including CNAs, HHAs, PCAs,

HCWs, and psychiatric aides

5. CHWs, including community health representatives (CHRs), community health aides

(CHAs), and health outreach workers

6. peer specialists, including peer counselors, peer navigators, peer educators, and health

educators

7. other health professionals with a specialist focus, including substance use disorder

counselors and social workers in behavioral health.

iii

In conjunction with the systematic Google Scholar search, research team members also

conducted a formal academic literature search of four databases—PubMed, Embase, PsycInfo,

and Business Search Complete—from 2009 to 2019, using the same Boolean search procedure.

We also inspected bibliographies of relevant articles identified from this process for additional

search content.

iii

Although social workers usually hold a master’s degree, there was interest in exploring the challenges for these

roles as well, particularly around behavioral health. In this report, we clearly delineate which occupations are being

addressed.

Table 2.1. Sample List of Search Terms

Domain 1: Occupation

Domain 2: Supply Gap

Domain 3: Resolution

Licensed practical nurse

Shortage

Train*

LPN

Gap

Educat*

Licensed vocational nurse

Supply

Certificat*

LVN

Workforce

Recruit*

Medical assistant

Burden

Task shift

Dental assistant

Access

Incentive

Dental hygienist

Distribution

Repayment

Health aide

Turnover

Compensat*

Home health aide

Burnout

Benefit

Home health worker

Demand

Opportunit*

Nursing aide

Need

Program

Nursing assistant

Policy

Psychiatric aide

Policies

Community health worker

Legislation

Community health representative

Regulation

CHW

Licens*

Health educator

Hir*

Peer counselor

Employ*

Peer educator

Ladder

Peer navigator

Curricul*

Health outreach worker

Promot*

Substance use disorder counselor

Substance abuse counselor

Social worker

NOTE: Search terms with an asterisk connote truncation for the Boolean search procedure.

Social workers generally hold masters degrees. They were included in our search to ensure that we identified

members in the behavioral health sector.

Policy and program selection. We limited our search to content available in English, with a

focus on programs, policies, and initiatives (hereafter referred to collectively as programs)

implemented in the United States over the past ten years. Although the academic search was

specifically restricted from January 1, 2009, to March 1, 2019, we incorporated content from the

gray literature from earlier dates where the policy or program was deemed novel and relevant.

We evaluated each program based on four criteria: (1) relevance, in terms of serving the

occupations of interest; (2) content that focused on strengthening the workforce through training,

recruitment, and retention efforts, as well as broader policies; (3) significance, with respect to

scope and/or scale, meaning that programs with broader reach and that serve more people were

prioritized; and (4) importance, with respect to novelty and innovation (i.e., the program

demonstrates creative thought in its design, method, or intent). Based on these criteria, research

team members independently assigned programs a classification of highly relevant, relevant, or

not relevant. Members of the research team reviewed each other’s assignments on a weekly basis

to ensure consistency in grading across programs.

Data abstraction. Programs meeting the threshold of highly relevant or relevant were

subject to data abstraction. For each program, the following information (where available) was

abstracted: program title and description, Uniform Resource Locator (URL), relevance,

implementing institution, applicable occupations, program location, program start and end dates

(if applicable), program activities, program objectives, funder, level of investment, and whether

an evaluation of the program was conducted. For each entry, a second research team member

was tasked with reviewing abstracted data, with reference to the original URL or Portable

Document Format (PDF) to ensure accuracy and completeness.

Data synthesis. We synthesized content according to program activities (i.e., training,

recruitment, and retention). These activities align with the overall EHCW objectives of (1)

expanding the numbers and scope of the EHCW (through training), (2) linking more individuals

to economic opportunities in the EHCW (through recruitment), and (3) creating financially

sustainable and fulfilling careers through career pathways and a positive work environment

(through retention efforts). We also identified a broader general category that encompasses

issues concerning the distribution, empowerment, and funding of the EHCW outside the training,

retention, and recruitment continuum.

To make programs more accessible for readers, we developed an interactive data platform,

accompanied by data visualizations that allow the user to sort and filter programs and

publications based on the occupations they cover, the year they were published, and more. An

interactive map of the United States allows viewers to quickly identify locations associated with

programs and select individual states for further inspection.

The tool, which we created in

Tableau 2019.4,

allows viewers to identify policies and programs based on various features,

including those outlined earlier.

Descriptive Results from the Environmental Scan

Through a review of academic literature, gray literature, and web searches, we identified 228

programs, policies, and initiatives (hereafter referred to as programs) on strengthening the

EHCW. One hundred seventy-eight were related to training, 112 to recruitment, 118 to retention,

and 54 were related to more-general systems. Programs could (and often did) address multiple

objectives. Table 2.2 provides a breakdown of programs over the most recent ten-year period

reviewed.

Table 2.2. Programs Identified by Year and by Occupation, 2009–2019

Year

CHWs

HHAs

MAs

Dental Health

Nurses

Peer Support

Other

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

Total

NOTE: 2019 recorded lower numbers because data collection ended in April 2019. Several identified programs did

not record a start date and therefore were not incorporated into this table.

Programs spanned more than 150 organizations in all states—including local and federal

government entities, academic institutions, nonprofit and for-profit organizations, and public-

private partnerships. Of the 148 programs with a documented start date, 97 (66 percent) were

initiated between 2009 and 2019. In addition to programs, we identified 114 manuscripts, policy

reports, and white papers within the gray literature that provided valuable content and resources.

We reviewed 1,636 articles from the results of searches across four academic databases. Of

these, 159 discussed approaches for strengthening the EHCW or examined root causes of the

workforce shortage. Of these 159, 21 described a specific program, policy, or initiative and were

incorporated into the program inventory. Table 2.2 presents an overview of the number of

programs identified, broken down by occupation, from both the gray and academic literature

over the past ten years. We see, among other indications, that the number of identified programs

has trended upward over time, particularly for such occupations as HHAs and MAs. For more

information about programs and policies affecting the EHCW, and for lists of the academic and

grey literature used in this report, see the workforce data website.

We organized the programs based on their main objectives and associated occupations. Table

2.3 provides an overall characterization of the number of programs in each objective; for

example, we identified more programs for expanded training opportunities for CHWs and fewer

programs for skills development for social workers.

Table 2.3. Occupations and Objectives of Identified Programs

Objectives

Cadre

T: Expand

Training

Opportunities

T: Expand

Workforce

Roles

Strengthen

Training

Quality

REC:

Expand

Job

Opportunities

REC:

Strengthen

Candidate

Quality

RET: Build

Sustainable

Workforce

RET:

Create

Career

Pathways

RET:

Develop

Skills

HSS:

Expand

and

Empower

Workforce

HSS:

Recognize

Financial

Value of

EHCW

HSS:

Improve

Workforce

Distribution

Total

CHWs

Dental

health

HHAs

MAs

Nurses

Peer

support

Social

worker

SUD

counselor

Other

Total

114

228

SOURCE: Data were abstracted from the workforce inventory and were collected by members of the research team.

Programs can support multiple

programmatic objectives and multiple occupations.

NOTES: HSS: health system strengthening. REC = recruitment. RET = retention. SUD = substance use disorder. T = training.

Key Informant Discussions

Key informant selection. We selected key informants based on three criteria: topical

expertise, background experience, and institutional role. More specifically, we sought individuals

with recognized expertise in health care workforce issues, with a specific orientation toward

entry-level workforce members. Moreover, for individuals serving in institutional settings, we

aimed to speak with those at a managerial or directorship level who possessed a broad overview

of operations and experience addressing workforce-related challenges. We also spoke to some

members of the EHCW for our case studies (see Appendix A).

We identified an initial set of candidate informants by reviewing lead and senior authors on

peer-reviewed and policy reports captured in the environmental scan, along with lead

implementers of the programs and policies that we identified. We then employed a snowball

sampling technique, whereby we solicited additional key informants from those initially

identified, asking them to offer names of individuals with whom they were acquainted and who

they believed would offer valuable insights on the topic. To ensure that we selected a diverse

pool of candidates in terms of content expertise and institutional roles, we created a sampling

frame from which individuals were drawn into categories across multiple domains, including

occupation focus (nursing, home health, office-based care, community-based care), institutional

setting (government, academia, health care delivery, nongovernmental organizations [NGOs]),

position or role (executive, researcher, advocate), and key topic areas (behavioral health, long-

term care [LTC], primary care). Throughout the key informant identification process, we ensured

that each domain was represented by asking key informants to identify other individuals who fit

into each of these domains.

Procedures. Key informants were contacted by email, and subsequently by phone, from

February to July 2019. Individuals were invited to participate in a 60-minute discussion to share

their perspectives on EHCW challenges and innovative solutions. The email also identified the

sponsor and the research orientation of this work. The research plan was reviewed by RAND’s

Human Subjects Protections Committee and RAND’s institutional review board and was deemed

exempt from further review.

Discussions took place on a private conference line with a dial-in access code. Invitees

included research team members from RAND, staff at ASPE, and the key informant. In a few

instances, multiple experts were included in a single conversation (e.g., when they were

members of the same organization or had overlapping topical expertise in a content area of

interest). All participants on the call were asked to introduce themselves, after which key

informants provided oral consent for the discussion to proceed. Discussions were recorded with

permission for notetaking purposes and stored on an encrypted, password-protected server to

which only RAND team members had access.

Discussion protocol. Discussions were oriented around a discussion guide that was approved

by RAND’s institutional review board. Questions followed a semistructured format, allowing

key informants to address content in topic areas specific to their expertise and experience, and

were customized to key informant expertise and institutions. Major themes covered over the

course of the discussion included organizational goals and objectives at the individual’s

institution, perceived EHCW-related challenges, perceived EHCW-related solutions to those

challenges, and overall assessment of the EHCW landscape and where it was headed. Key

informants also were asked about relevant published and unpublished resources, and snowball

sampling was used to identify other potential key informants.

Using the findings from the environmental scan, outcomes from discussions with ASPE staff,

and a careful list of programs for closer exploration, we selected 45 key informants to invite for a

discussion; 25 responded affirmatively and participated. Through snowball sampling with the

first cohort, we identified an additional pool of 32 candidates, of whom 16 ultimately

participated.

In terms of composition, six discussions (15 percent) were conducted with members of

government entities involved in EHCW issues, 12 (29 percent) were conducted with experts in

different academic areas, four (10 percent) were conducted with leaders at nonprofit

organizations, seven (17 percent) were conducted with representatives from advocacy

organizations, one (2 percent) was conducted with a spokesperson from a private company, and

11 (27 percent) were conducted with executives and administrators at various types of health

care delivery organizations. We provide further detail on the composition of this key informant

list in Appendix B.

Case Studies

We pursued in-depth examinations of innovative programs that were intended to expand and

strengthen the EHCW. In these case studies, or close analyses of a specific program, we

identified program goals and activities, barriers to success, and key takeaway messages that were

informed by the perspectives of program implementers. We identified ten programs to be

explored in case studies (see Table 2.4) with input from ASPE and informed by the

environmental scan. Programs were selected in part because they represented diversity in

location, profession, and type of intervention or program. The main goal in our selection process

was to ensure that each case would reflect an innovative approach to addressing a different

challenge facing the EHCW, with a specific focus on addressing LTC and behavioral health.

Whenever possible, we identified key informants at each organization who complemented the

published literature and publicly available information on a program.

The discussion guides for case studies focused on individuals’ specific knowledge of the

policy or program with which they were associated. Case study discussion questions were

structured according to the following themes: (1) motivation for inclusion, (2) brief history, (3)

distinctive features, (4) challenges encountered, and (5) lessons learned. The ten case study

descriptions and rationale for inclusion appear in Table 2.4, and the full case studies can be

found in Appendix A.

Table 2.4. Case Study Descriptions

Program

Relevant Occupations

Distinctive Features and Rationale for Inclusion

Alaska’s Community Health

Aide Program (CHAP)

CHAs, community health

practitioners (

CHPs)

This is a unique program that offers flexible training

and career progression to employees

who come from

the communities that they serve.

Peer specialists in the

Veterans Hea

lth

Administration (VHA)

Peer specialists

The VHA is a leader in integrating peer specialists into

substance use disorder programs.

Kaiser Permanente (KP),

Southern California

CHWs, MAs, other entry-

evel health professionals

KP Southern California is part of KP, an integrated

health care system,

and takes many approaches to

developing its entry

-level workforce, including building

relationships with schools, running their own training

institution, and conducting extensive internal hiring.

Health Professions Pathways

(H2P)

Consortium

LVNs and LPNs, nursing

ides, CHWs, MAs, DAs,

ursing assistants, other

ntry-level health

rofessionals

This consortium of nine community colleges in five

states aims to share and implement best prac

tices to

improve training

in the health professions. Initiatives

include partnerships with health care facilities to create

flexible medical assisting programs for incumbent

workers and streamlined curricula for LVNs seeking an

associate’s degree.

Care Connections Project

(CCP)

HCWs

The CCP was designed to test an advanced role for

experienced

HCWs and enhance skills for entry-level

HCWs

, with a goal of strengthening care transitions for

consumers.

Individualized Management

for Patient

-Centered Targets

(IMPaCT)

CHWs

IMPaCT’s CHW model was designed to address such

challenges as staff turnover, poor integration

, and

infrastructure. The Penn Center for Community Health

Workers also conducts its own research on the

IMPaCT model, and it provides technic

al assistance to

help organizations create and sustain their own CHW

programs.

Service Employees

International Union (SEIU)

Multi

-Employer Training

Funds

LPNs and LVNs, MAs,

ental hygienists

The SEIU implements programs, such as the Training

and

Employment Funds, to ensure that EHCW

members have cutting

-edge resources to expand their

skills.

Advancing peer support in

ntegrated care settings: The

Hogg Foundation

’s work in

hree community health

centers in Texas

Peer specialists

The Hogg Foundation awarded $300,000 to each of

three Texas communi

ty-based health centers to

advance peer support in the delivery of integrated

health care, with a focus on mental health services.

Peninsula Homecare

Cooperative for

health aides

HCWs

In this Washington state rural home care agency, the

workers are the owners, meaning

that they have a

stake in the company

’s success, share company

profits, and determine how it is run.

Mercy Health System in West

Michigan

MAs

This large integrated health system has collaborated

with community colleges and other employers to

implement an apprenticeship program for MAs.

Limitations

Several limitations to our approach exist. First, our review was thorough but not exhaustive:

Search engines produced hundreds of pages of returns, and we limited ourselves to the first ten

pages of each search, prioritizing returns based on relevance to the topic at hand. Second, our

search was parameterized based on a fixed set of terms, implying that we might have overlooked

programs that did not include language corresponding to these terms. Third, we were unable to

contact some individuals for case studies. Therefore, our conclusions are limited to what we

heard from a small sample of organizations serving the EHCW.

3. Framework

The challenges facing the EHCW are multifaceted.

Using the programs we identified in the

environmental scan, the literature we identified through the literature search, and conversations

with key informants, we derived an overarching framework organized around ten program

objectives, which we describe in more detail in this chapter. These objectives were grouped

under four overarching workforce challenges. We use these four challenges—training,

recruitment, retention, and health system strengthening—as an organizing principle for

presenting findings (see Figure 3.1).

Figure 3.1. Conceptual Framework for EHCW Strengthening

NOTE: Obj = objective.

EHCW Program Objectives

We determined the objectives of EHCW programs using a grounded theory approach in

which we identified and grouped programs, policies, and additional evidence into themes that

emerged from the data, aggregated from the environmental scan and qualitative discussions.

Using content analysis, an approach for synthesizing qualitative data,

we refined our

analysis of the program objectives and related activities as we reviewed more information. For

each program, we gathered and analyzed four kinds of evidence: (1) the rationale for the type of

program; (2) examples of programs within each program type; (3) evidence from the literature

that indicates the effectiveness of the program, including evaluations, when available; and (4)

expert opinion from key informant discussions and advocacy groups. Limited evidence was

found regarding programs in behavioral health and the challenges facing this workforce. We

derived action steps based on the programs that possessed the strongest evidence, along with

indications of feasibility for scale-up in terms of resource requirements. We identified ten

objectives from the programs we identified, which we describe in more detail in the following

sections.

Training

Training is the first step in the EHCW pipeline. We conceptualize training to include formal

education in a classroom setting and less-formal on-the-job training that more closely resembles

an apprenticeship or mentorship model. We also consider new kinds of roles and positions that

workers can fill as they develop new skills.

• Objective I. Strengthen training quality: Training quality can be improved by

upgrading curricula, standardizing training, increasing training duration and intensity,

implementing patient-focused training, and developing apprenticeship-based training

programs. Quality also can be enhanced by expanding training to additional content areas

that appropriately equip individuals with new skills for broader scopes of practice,

particularly in conjunction with licensing and certification requirements.

• Objective II. Expand training opportunities: Training opportunities can be expanded

by lowering financial, logistical, cultural, and language barriers to EHCW training and by

broadening existing programs and establishing new partnerships and programs to increase

capacity for training opportunities and open jobs to new applicants.

Recruitment

Recruitment is the next stage of the EHCW pipeline. Recruitment means identifying

individuals who are well trained from a diverse array of backgrounds and life experiences and

guiding them to EHCW opportunities that are good fits for their skills.

• Objective III. Expand recruitment strategies: Numerous activities can increase the

awareness and attractiveness of job opportunities to individuals from a diverse array of

backgrounds. These activities include expanding recruitment outreach to a more-diverse

group of potential employees in new venues, providing financial and nonfinancial

incentives, and establishing partnerships for recruitment.

• Objective IV. Match the best-fit candidates to jobs: Successful recruitment ensures

that recruits have the skills to fill open positions and that they are ready to thrive in their

new roles. This can be accomplished through the refinement of job qualifications,

recruitment standards, and selection techniques; promotion from within institutions based

on observed performance; and tests of readiness through internships.

Retention

Job retention is the third stage of the pipeline. Addressing retention problems can reduce

costly leakage in the EHCW which can result from burnout, low wages and benefits, competition

with other industries, and underrecognition of contributions. Providing skills development and

career ladders for employees is critical to successful retention.

• Objective V. Create career pathways: A career ladder or pathway is a clear opportunity

for steps to job promotion leading to higher levels of pay, responsibility, or authority, but

these opportunities often are lacking for the EHCW. Career pathways for EHCW

members should ensure that talented individuals have the opportunity for promotion,

greater responsibility, and improved wages over time. Mechanisms to achieve this goal

include developing programs that lead to career growth and subsidizing educational

opportunities outside employment that lead to career progression after initial training.

Individuals who acquire new skills and stackable credentials (i.e., a sequence of

credentials that can be accumulated over time for advancement along a career pathway

but that are not necessarily designed for a specific degree) also might receive formal

recognition through promotion in title and/or a wage increase. New skills can increase job

satisfaction and give new opportunities to high-performing workers. Although career

pathways could result in turnover within a specific job role, individuals might decide to

continue progressing in their careers with the same employer, or, at the very least,

continue to contribute to filling gaps in the overall health care workforce.

• Objective VI. Improve work environment: Efforts can be made to create positive work

environments in a variety of ways; for example, through performance recognition, work

flexibility and predictability, safeguards against burnout, education for other members of

the care delivery team in advance of recruitment regarding the unique contributions of the

EHCW, and competitive compensation and benefits that increase with experience.

Health System Strengthening

This category represents programs, initiatives, policies, and legislation that are structural and

meant to alter the underlying landscape in which the EHCW pipeline operates. These often are

government-led initiatives at the state or federal levels, or sometimes are public-private

partnerships that bring together multiple actors to make comprehensive, systemic reforms.

Scope-of-practice and licensing and certification issues, which we discussed earlier in the

training section, are also relevant here.

• Objective VII. Improve workforce distribution: Improved distribution of the EHCW

refers to legislation, programs, partnerships, and forms of regulation that aim to address

the existing maldistribution of the workforce—for example, the scarcity of EHCW

members in rural, low-income, and minority communities.

• Objective VIII. Empower the workforce: There are several paths to achieving an

expanded and empowered workforce—meaning the degree of power EHCW members

have to represent their own interests—such as legislation and regulations; programs and

partnerships; and bottom-up efforts from the community of workers, such as

cooperatives, coalitions, and unions.

• Objective IX. Recognize the financial value of the EHCW: We explore the varied

mechanisms by which EHCW members are paid for their work, including wage policy,

payment and reimbursement models supported by the public and private sectors, and

efforts to evaluate cost savings associated with leveraging the EHCW.

• Objective X. Use technology to support the EHCW: Technology is increasingly being

used in health care and, in many cases, it can reduce the burden on, expand the role of,

and empower the EHCW. We explore tools that can be used to support the EHCW.

The following ten chapters address each of these objectives. These chapters identify

innovative approaches, specific activities, and potential policy implications for each of these

objectives. In Chapter 14, we discuss research needs, and in Chapter 15, we identify policy

opportunities to further these objectives.

Part 2. Training and Development

(Chapters 4–5)

4. Objective I: Strengthen Training Quality

Successful training provides a starting point for EHCW members to begin careers with the

competencies necessary to thrive in their work environments and serve health systems well.

77,78

Effective training has the potential to improve job satisfaction and retention.

Given increasing

population health care needs and the ongoing workforce shortages in the United States,

effective training also implies broadening and strengthening the competencies of the EHCW to

better respond to health care trends, such as increased home-based care

and treatment for high-

prevalence conditions, such as diabetes.

Training can be both formal and informal, and both

types of training play important roles in career development. In this chapter, we focus on

educational training, on-the-job training through more-formal mechanisms, and less-formal

opportunities.

Current training efforts vary considerably in terms of their quality, especially for nonlicensed

roles. For example, home care aides (HCAs) have little supervision and, in the absence of

national guidelines, training efforts are highly heterogeneous; research indicates that these

individuals frequently receive little to no training.

83,84

PCA training is particularly lacking

relative to that of HHAs and CNAs, according to the University of California, San Francisco

Health Workforce Research Center. Members of the center remarked that “there exists wide

variation in minimum training requirements between states and between programs within

states.”

Nurses often are allowed to delegate tasks to direct care workers that they oversee, but

those workers have little training and the nurses themselves have no management training.

There are several ways to improve the quality of training and potentially expand workforce

roles through training; specifically, by (1) improving and broadening curricula; (2) standardizing

training, licensure, and certification requirements; (3) developing apprenticeship-based training

programs; and (4) providing continuing education to existing members of the EHCW. In this

chapter, we also note the proliferation of for-profit training organizations (according to

information provided to us by an anonymous key informant in a phone conversation on June 24,

2019).

Improved and Broadened Curricula

Several key informants raised the issue of training quality, although there was insubstantial

evidence concerning the quality of existing training programs. Ensuring the quality of curricula,

which we define as the learning experiences planned and implemented by educational

providers,

entails designing the structure and content of training to effectively convey

knowledge and skills to students. A competency-based curriculum for a profession with clearly

defined competencies aims to impart the knowledge, skills, and attitudes that define a profession,

while assessments measure the performance of those competencies.

Most EHCW training curricula are developed and offered by community colleges and

technical institutes.

88-91

In the community college context, professional curricula are determined

by committees, often with oversight from a state community college board. Curriculum content

therefore largely reflects the competencies perceived at a local level to have the greatest value

for entry into the profession. Therefore, there is a potentially fruitful connection between

community colleges and health care delivery organizations, the needs of which the curricula are

intended to meet. This connection could create a built-in incentive to broaden curricula to

respond to the increasingly diverse needs of these employers. For some on-the-job training that

attempts to broaden the competencies of the existing workforce, content is determined at the

discretion of employers, typically with an emphasis on specific skills that employers need.

Broadening the competencies incorporated into EHCW training curricula achieves several

goals. First, it allows prospective employees to prepare for a variety of tasks that might be

required of them. Against the backdrop of evolving and increasingly complex health system

needs, the roles and responsibilities of EHCW members have expanded. For example, MAs in

primary care settings might function as health coaches, medical scribes, language translators for

patient-provider interactions, health navigators, panel managers, health screeners, referral

coordinators, and supervisors of other entry-level health care workers.

92,93

To accommodate

these expanded roles, curricula should incorporate relevant workplace competencies, taking into

account laws that might limit expanded scopes of practice.

94-96

Second, a broadened scope increases the autonomy of EHCW members by enabling them to

assume more-advanced functions in their work environments. For example, the Win a Step Up

program—a 33-hour workforce development curriculum and initiative for nursing assistants in

North Carolina—has trained nursing assistants to assume supportive leadership roles, which has

resulted in higher retention rates among participants.

97,98

Expanded training of the EHCW has the

further benefit of promoting task-sharing responsibilities within team-based provider settings,

thereby allowing primary care providers to allocate a greater proportion of their time to

consultation with clients. Third, to the extent that training content is modular, expanded training

creates opportunities for workforce specialization. This approach has been instituted in a variety

of community colleges and universities—such as the certificate programs at the University of

Illinois

and Northampton Community College

100

—where students can select a course track that

provides educational content intended to equip them to serve specific populations or for certain

settings.

Expanded training curricula have contributed to the broadening of EHCW roles throughout

the United States. These efforts include initiatives instituted at individual health centers and

community colleges,

101

along with regional- and state-level efforts. For example, through support

from the Health Resources and Services Administration (HRSA), the High Plains Community

Health Center—a federally qualified health center (FQHC) in Colorado—has cross-trained

medical assistants to take on office roles, including such positions as health coach, patient

navigator, and CHW.

102

This has increased productivity from an average of 1.8 patients per

provider hour to 2.7 patients per provider hour and has led to increased revenue while facilitating

improved patient outcomes.

102

Different providers (e.g., medical doctors [MDs], nurse

practitioners [NPs], physician assistants) experienced differing levels of productivity. Regional

and national efforts have also shown promise,

103

including the Loving Support Peer Counseling

program, which the U.S. Department of Agriculture (USDA) has implemented in selected state

Women, Infants, and Children (WIC) agencies. This program has trained peer counselors on best

practices for breastfeeding, resulting in higher breastfeeding rates and longer breastfeeding

durations among new mothers who are recipients of the program.

104,105

Training initiatives are

taking place throughout the United States to expand the scope of the EHCW, and the collective

body of evidence suggests that such efforts can lead to improved patient outcomes, cost savings,

and greater efficiencies in care provision.

106-111

Once a core set of competencies has been identified, the curricula can use different forms of

pedagogy. For example, adult-centered learning methods and field experiences—in which

students actively learn skills and competencies, as opposed to passively listening to lectures and

reading text—can enrich these core competencies.

112,113

Apprenticeship models that build on

competencies gained through curricular training are discussed later in this chapter.

One example of a program that combines a competency-based curriculum with other

curriculum quality improvement strategies is Personal and Home Care Aide State Training

(PHCAST). Although states adapted what was the Paraprofessional Healthcare Institute’s (now

PHI’s) Providing Personal Care Services to Elders and People with Disabilities core-

competency curriculum to meet individual state requirements,

114

each of the grantees covered ten

core competencies, from health care support skills to self-care skills for the aide.

115

Importantly,

several curricula incorporated modules focused on job readiness and customer service in addition

to the core competencies. Grantees also incorporated other methods of improving curriculum

quality, such as lab-based learning, practical assessments, academic counseling, and principles of

adult learning theory and learner-centered instruction.

116

Outcomes suggest that this multitude of

methods strengthened training quality at least to some extent: Four of the grantee states that

assessed knowledge scores reported an average increase of between 11 and 28 percent.

115

Supervisors found that PHCAST aides required less assistance once they were on the job,

believed that those aides were more likely to remain on the job, and observed that they were well

positioned to advance along career pathways. The evaluation of this program, however, did not

disentangle the impact of other training and recruitment programs and policies, such as child care

assistance and the recruitment of qualified individuals, implemented alongside the core

competency–based curriculum and other curriculum improvement activities.

115

Another example of a competency-based curriculum was created for Navajo Nation CHRs by

a New Mexico–based nonprofit organization called Community Outreach and Patient

Empowerment (COPE). COPE’s curriculum covers health education, behavior change, and self-

care, and it also uses competency assessments. An interview-based study found that 80 percent

of CHRs felt strongly positive that the COPE model training was useful.

117

Such evaluations

suggest that curriculum quality improvement mechanisms can be valuable tools to improve

training quality.

Key informants expressed enthusiasm for the implementation of competency-based core

curricula. In a phone conversation on July 10, 2019, one H2P Consortium stakeholder expressed

admiration for a program in Kentucky that facilitates the adaptation of the H2P core curriculum

for health professions throughout its community college system. Stakeholders also identified

other ways to improve curricular quality. One individual from PHI shared in a phone

conversation on May 28, 2019, that they incorporate role-playing and demonstration in their

curriculum. Another key informant, from Alaska’s CHAP, noted in a phone conversation on June

20, 2019, that training quality depends on how tailored the curriculum is for community health

assistants. To reduce the quantity of learning required by trainees, they included only training

content that was “urgent” or “emergent” in the curriculum.

At the same time, several key informants remarked that expanding roles for the EHCW was

an important goal, although the link of new roles to increased training often was implicit rather

than explicit. For example, one individual with knowledge of a large, integrated health system

observed in a phone conversation on May 3, 2019, that the system had made organizational

efforts to embed CHWs in primary care and to leverage this integration by training CHWs in

specific competencies, such as diabetes self-management techniques, motivational interviewing,

and problem-solving therapy. In a similar fashion, a key informant in the U.S. Department of

Veterans Affairs (VA) noted that peer specialists are trained to assume new roles in the primary

care setting, such as supporting whole-person care, which includes connecting patients with

supportive housing programs, vocational services programs, intensive case management, and

rehabilitation services. Referencing this expansion of scope through training, this person

remarked in a phone conversation on June 7, 2019, that “peer support is growing, expanding,

becoming more specialized, and it is Medicaid billable in 45+ states.”

Training Requirements

The standardization of training requirements has two purposes: to ensure that all trainees

have a minimally adequate set of competencies that facilitate workforce readiness and to

establish the groundwork for certification and licensure, which permits trainees to move more

easily across state lines and between employers.

118-120

Standardization also helps ensure quality

training, although the evidence for this is limited,

121-123

and it is not clear who should be

responsible or at what level standardization should occur. Roadmaps to restructure curricula so

that they are better tailored to workforce functions, as described earlier, often go hand-in-hand

with some standardization; recommendations for the EHCW emphasize regional

standardization.

124

Indeed, training standards for certain EHCW positions, such as direct care workers, CHWs,

and peers—where they exist—vary considerably across states.

125,126

Some states have no

standardized training for certain occupations. For example, according to a May 3, 2019, phone

conversation with one key informant, only 37 states have educational standards for peer

specialists. Only six states require the 120 hours of training for HHAs that is recommended by

the National Academy of Medicine, and the federal requirement for HHAs in the Medicare

program is 75 hours of training.

127

When they are in place, training standards also tend to be

inadequate, according to one key informant, who said in a phone conversation on June 24, 2019,

that there is “no sense of sector-based efforts. Education providers say they reach out to

employers; employers say it’s not their job to educate. But it kind of is. And on-the-job training

is inadequate across the board.” This lack of standards makes it difficult for employers to assess

competency and hinders hiring. Furthermore, no single group is responsible for standardization.

Such an effort could be led by state licensing agencies or professional societies as in other

specialties, such as the curriculum competencies in nursing detailed by the American Association

of Colleges of Nursing for baccalaureate and graduate-degree programs.

128

Although organizations and experts endorse the importance of standardization, the evidence

base on the specific impacts of standardization for the EHCW is limited and is largely derived

from nonempirical studies or expert opinion. One more-rigorous example comes from the

implementation of the Personal and Home Care Aide State Training demonstration program

supported by HRSA.

129

Within this demonstration program, Michigan’s Building Training,

Building Quality program created a Model Personal Care Services (PCS) curriculum comprising

77 hours and 22 modules of adult learner–centered training.

130

The curriculum was successfully

implemented in four separate regions of the state and it conducted an evaluation using a pre-

/post-test design. The program demonstrated that the PCS curriculum led to a 25-percent increase

in correct responses on core knowledge content areas, with almost all participants reporting that

they believed that they had mastered new skills (91 percent) and felt better able to support clients

in maintaining or improving self-care (94 percent).

130,131

One occupation for which there is relatively more evidence is CHWs. A study published in

2009 by the Massachusetts Department of Public Health conducted a literature review, held

focus groups, and conducted surveys to develop recommendations for the state’s future CHW

workforce development efforts. CHWs, CHW employers, CHW funders, and providers agreed

that certification could maximize CHW contributions by creating a standardized knowledge

base.

132

Another study assessed the impact of the state certification of CHWs on primary care

team climate and found little effect.

133

A third study, relying largely on qualitative interviews,

concluded that CHW certification at the state level provides the potential for enhanced

recognition of work and earnings, along with feelings of personal fulfillment among members of

the profession.

134

More empirical data are needed.

Alaska’s CHAP initiative represents an example of how the standardization of training

curricula has led to expansions in scope of practice—in this case for CHAs. When CHAP was

initiated in the 1950s, the training of CHAs focused on skills for addressing specific health issues

affecting rural Alaskans, including tuberculosis and high infant mortality.

135

Since then, a

process for routinely updating the statewide standardized curriculum has expanded the list of

competencies to include a much broader set of skills.

136

CHAs at the highest level of

certification—with the title of CHPs—support certain primary care and emergency medical

service needs in 170 rural Alaskan villages. Evaluations of CHAP document success in achieving

positive health outcomes for rural communities where CHAs are located,

137

and the model is

planned for scale-up in tribal regions of the lower 48 states by the Indian Health Service

(IHS).

138,139

We found a variety of additional efforts to standardize curricula—in states from New York

140

and California

141

to Iowa

116

and Minnesota.

142

These efforts are most needed for EHCW

positions where standardization is lacking, such as for direct care workers

143

and CHWs.

144

Several of these efforts reported process evaluations and, more rarely, impact evaluations.

145

Where evidence for curricular standardization exists, it is generally positive, particularly in

conjunction with efforts to formalize roles of specific types of EHCW members.

Licensing and Certification Requirements

Licensing is a process overseen by the government, usually at the state level in the United

States, conferring the right to work in a given occupation. Certification is not regulated by the

government; it acknowledges acquired skills above those legally required to work in a given

occupation. This is a similar concept to physician specialization. These processes offer avenues

for educational institutions, employers, state agencies, and provider associations to establish the

knowledge and competencies needed for individuals to work in a given occupation and to

solidify the formality of particular roles within a health system.

146,147

Licensure and certification

bodies can take several actions to increase the standardization of training requirements. For

example, bodies can set minimum hours of practice to ensure that individuals have relevant

experience and can require license and certification renewal at regular intervals to ensure that

individuals are staying abreast of current information in their fields and are maintaining

proficiencies.

148

In addition, licenses and certificates help establish a set of expectations for

employers with regard to the competencies of new hires.

147

Some EHCW professions have

nongovernmental national bodies, such as for nursing assistants and nurses, that provide

licensure or accreditation of training institutions.

149-151

Others, such as home health aides and

CHWs, do not have such bodies. Lack of national organizations is partly a product of the way

that these positions have organically emerged in the United States to meet local needs.

146,152

An unrealized attempt to move toward national certification standards was reflected in the

Patient Protection and Affordable Care Act’s (ACA’s) Title V (Subtitle D, Sec. 5302), which

included support for demonstration projects to expand certification programs for personal and

home care aides throughout the United States, including guidelines with respect to training

duration, trainer-to-student ratios, trainer qualifications, content of written certification exams,

and continuing education requirements.

153

No funds were appropriated for this program, and it

was never implemented. States have taken their own actions toward adding certification

categories.

Additional grassroots efforts can be found with respect to other types of positions. For

instance, 13 states have voluntary certification programs and 11 states are examining statewide

certification.

154

The 11 states include nine with official training and certification programs, with

Minnesota representing an example in which CHW training programs were standardized

throughout the state.

155

Meanwhile, the Michigan Community Health Worker Alliance—

comprising health care organizations, insurers, professional associations, and foundations—has

worked to advance CHW certification and core competency standards since 2012.

156

This has

included the development of a Michigan CHW alliance certification registry,

157

a statewide

database of CHWs who have achieved core competencies.

Information about the specific impacts of certification and licensure efforts on wages,

retention, and patient outcomes is limited. One conclusion from the literature is that licensure at

the national level (whether through a single body or through a shared standard or interstate

compact) appears to lead to greater mobility of licensed providers,

158

which theoretically could

drive workers toward high-need communities if there were appropriate incentives. However,

significant variability in licensing persists across states.

159,160

Variability in licensure across states was reflected in key informant discussions, where, for

example, one workforce expert remarked in a phone discussion on June 24, 2019, “In some states

[health aides] can do very complex stuff but in some states . . . you cannot even put eye drops in

somebody’s eyes for dry eye.” Whether positive outcomes are observed as a function of

licensing and certification also might reflect the rigor of the certification process itself. For

instance, one key informant who was discussing peer specialist roles stated in a phone

conversation on May 3, 2019, that “Certification training that peer specialists get varies by state,

but it is usually a one- or two-week course. Usually, on-the-job training and good ongoing

supervision is also needed for peer specialists to continue to build their skills.” Greater

consistency of standards across states that respond to the amount of training required for

satisfactory job performance could address both sources of variation.

Standardization of the Curriculum

Stakeholders have expressed support for the standardization of training. PHI, a nonprofit that

works with direct care workers “to transform eldercare and disability services,”

161

recommends

that the federal government adopt training standards for PCAs and that state governments

increase the number of HHA training hours to 120 to meet the National Academy of Medicine’s

recommendation.

Standardization is relevant to a variety of worker types. For example, Medicare has a

standardized number of HHA training hours through requirements set for participation.

162,163

At a

2018 summit at the University of California, San Francisco, on how the community-based health

care workforce can meet the needs of seriously ill patients, experts recommended that

competency-based training requirements be made uniform across the country.

164

In separate

phone conversations on May 28, 2019, and June 13, 2019, key informants recounted the

challenges posed to workers who would not be able to easily move across states. Similarly, the

nonprofit organization COPE is helping the Navajo Nation implement a CHW certification

program by working with a tribal liaison within New Mexico’s Office of CHWs. According to a

phone conversation with a key informant on April 18, 2019, COPE recently ensured that New

Mexico would approve CHRs trained in other states to work in New Mexico.

Apprenticeships with Credit from Educational Institutions

Apprenticeships are an “earn and learn” model of training that enable entry-level students to

gain hands-on experience and become proficient in their skills while earning an income.

165

The

U.S. Department of Labor has supported apprenticeships through its Registered Apprenticeship

program as a “way to train long-term care workers and address some of the workforce issues

including recruitment and retention, training a quality workforce and improving quality of

patient care.”

166

The Department of Labor states that the apprenticeship model has the potential

to increase skill levels without high costs, create jobs with higher wages, and reduce the work

burden on nurses and doctors.

166

We found little peer-reviewed literature evaluating the impact of apprenticeships for entry-

level health care workers, although the few peer-reviewed evaluations we found are positive,

such as those of mental health providers in low-resource countries.

167

In other fields and

industries, apprenticeships have been shown to decrease youth unemployment and increase

wages,

168

although they are used less often in the United States than in other countries.

169

Stone

and Harahan highlight the Department of Labor’s Long-Term Care Regional Apprenticeship

Program as a way to improve the supply of people entering the field.

Similarly, in 2010, ASPE

reviewed the Long-Term Care Registered Apprenticeship Program, of which the largest subset of

apprenticeships were for CNAs. Although limited outcome data were available, the sponsors

reported that the apprenticeships produced a more-skilled workforce.

170

However, the program

was limited by a lack of qualified candidates and a lack of sustainability.

170

Other local initiatives

have also shown modest indications of success, such as a State of New Jersey partnership with

Rutgers University to implement a CHW apprenticeship. The New Jersey Department of Labor

and participating employers supported 50 percent of CHW salaries for the first six months, with

the health systems providing the remaining funding.

171

Experts and stakeholders agreed that the apprenticeship strategy holds the potential to

improve the quality of training. According to Shana Welch, executive director of talent

acquisition and workforce programs at an integrated managed care organization (MCO) in West

Michigan, “With the medical apprenticeship program, not only were we filling the need to

develop a pipeline of talent because we had a shortage in our region, but it was also important to

us to make sure we were reaching into our own colleagues, giving our entry-level colleagues an

opportunity to get on a career track to more of a middle-wage job.” Researchers at the Health

Workforce Research Center at the University of California, San Francisco, conducted

conversations with key informants and concluded that registered apprenticeships allow

employers to tailor training to workforce needs and different learning styles. Additionally,

apprenticeships provide “practical experience, mentorship, and formal academic learning as an

important value add.”

172

Experts argued for more apprenticeships, better financing, and expanded eligible

opportunities, for example, by expanding the definition of a registration agency in the National

Apprenticeship Act. As one key informant explained in a phone conversation on May 23, 2019,

there is a need to “think on a larger scale on how to massively increase skilled labor,” and

“apprenticeship is one solution. It can touch a lot of people and it doesn’t require massive public

investment, and then private industry can take over.” Funding opportunities exist for expanding

eligibility through the Federal Work-Study program and through the allocation of funds from

state departments of labor in addition to federal funding.

165,173

Continuing Education for EHCW Members

Continuing education, also called professional development, represents a common strategy

for meeting the needs of employers, with many institutional initiatives taking place throughout

the United States.

174

From an employee perspective, professional development offers a way for

individuals to learn new skills, diversify their daily routine, and earn higher wages. Often,

additional training can offer a formal pathway for career progression—for example, community

college programs can provide an expedited path from LPN to BSN nursing roles.

175

In other

instances, professional development might take the form of retraining, providing the opportunity

for members of an existing professional group to transition to a new role entirely.

There are several large-scale public-sector initiatives designed to support a wider distribution

of much-needed entry-level health care workers through continuing education and retraining. For

example, a Navajo Nation collaboration with the New Mexico Dental Association supports

continuing education for CHRs to serve as community dental health coordinators, addressing a

large demand for oral health services.

176

In New York, a $245 million incentive package (funded

through Medicaid) trains CNAs for the long-term health care sector, responding to the needs of

an aging population in the state.

177,178

Other interventions have been spearheaded by private-

sector health care organizations looking to fill a gap in their workforces. As part of the Medical

Assistant Registered Apprenticeship Program (MARAP) in West Michigan,

179

local health

systems in need of MAs have partnered with community colleges to train individuals in these

positions—including by retraining staff currently serving in other roles. Partnerships with

educational institutions have established career pathways in other contexts. For example,

Fitchburg State University and Worcester State University in Massachusetts have partnered with

vocational technical schools to create an LPN-to-RN curriculum that allows enrollees to apply

credits from their LPN programs and clinical work, in addition to a mentorship component, for

receipt of a BSN.

180

This model has been applied to other occupations, such as DAs, where a

national certification board—the Dental Assisting National Board—has a formal pathway for

progressing to the level of certified dental assistant with expanded functions.

181

Evaluations of these training initiatives are relatively absent in the literature. One exception

to this is curricular evaluations of LPN-to-RN programs, which have been evaluated from

qualitative and developmental perspectives.

182-184

These evaluations are more common because

such programs have been functioning since the 1980s,

185

and, perhaps, because academic

institutions—where these programs are based—are more apt to publish results than the private

sector. The evaluations found that participants expressed satisfaction with the program

184

but

also had unreasonable expectations about the program’s benefits.

182

A second exception is the

IMPaCT model for the standardized training of CHWs, in conjunction with the Penn Center for

Community Health Workers:

186

The program features modular training with accompanying

manuals and culminates in certification, and more than a dozen articles have indicated the overall

effectiveness of this model among trainees in terms of improving patient outcomes, such as

chronic disease control.

187

There is also evidence that on-the-job and continuing training predicts job satisfaction in

LTC settings: Workers who perceive better on-the-job training, characterized by the usefulness

of continuing education and job orientation, report higher job satisfaction.

A model of this is

the Baltimore Career Ladder project—a partnership among the workforce development

organization, Baltimore Alliance for Careers in Healthcare (BACH), and local hospitals—which

provided on-the-job skill-building opportunities with the goal of advancing worker skills and

earning potential. Three HPOG-funded programs have developed similar work-based training for

a small number of CNAs with the goal of increasing pay and skills.

∗

However, there is limited

evidence about the best format or the effects of continuing education for these workers.

More-thorough evaluations of publicly supported initiatives, including those described

earlier, could help clarify the benefits of such programs for providers, patients, and employers.

To this end, many public-sector training initiatives, such as those supported by Medicaid Section

1115 waivers, have an evaluation requirement and are currently in process.

188

Training Duration

One potential way to strengthen training would be to increase the duration of training.

However, there is no agreement about optimal training length. For example, for MAs, training

∗

Text updated in March 2021 to clearly indicate that the Baltimore Career Ladder is not an HPOG-funded program.

length can vary greatly.

Although some programs touted the increased duration of their

trainings, others focused on mitigating barriers to training by decreasing its length. Duration of

training varies from program to program, state to state, and occupation to occupation. For

example, a report on HPOG training programs for CNAs notes that “movement along [the]

career pathway [from CNA to LPN/LVN and other health care occupations] can be challenging.

It requires time and financial commitment to longer periods of education and higher academic

skills than for a CNA position.”

The HPOG program has funded numerous grantees, and some

have offered academic credit for CNA training toward nursing training, while others offered

short-term trainings to become certified medication technicians, medication aides,

electrocardiogram technicians, and phlebotomists to augment CNA salary and expertise without

as much of an investment of time. We discuss stackable credentials further in Chapter 8.

Some experts recommended specific training durations and increasing the amount of training

in certain topics to at least a minimum standard. Although setting minimum requirements is

important, some trainees need more than this minimum time to achieve competency. For

example, in the Dental Health Aide Program, which is modeled after CHAP, trainees are

required to complete a preceptorship after successful completion of an approved educational

program. Although each preceptorship has minimum requirements in terms of procedures and/or

hours, the supervisor assesses competency and has the authority to “extend the length of the

preceptorship as he or she sees necessary.”

148

One argument against extended training was made

by a key informant in a phone conversation on June 24, 2019: Long and expensive training

programs might teach things that trainees do not need to know, could be expensive, and might

keep trainees away from their communities, which, in the case of CHWs, is the source of their

expertise.

Training for Patient-Centered Care

The National Academy of Medicine recommends that the ability to provide patient-centered

care be a core competency across all health professions.

It specifically recommends that health

professions trainees should have “frequent and reinforcing experiences with learners in the other

health professions” to prepare them to deliver effective team-based care to patients, and it further

states that these experiences should “be less hospital based and instead based more in the

community to align with the needs of patients.”

This competency, as defined by an expert panel

convened in 2003, includes the ability to “identify, respect, and care about patients’ differences,

values, preferences, and expressed needs; relieve pain and suffering; coordinate continuous care;

[and] listen to, clearly inform, communicate with, and educate patients.”

Even when members

of the EHCW are well trained and focused on patient-centered care, particularly among CHWs,

the current reimbursement system and scope-of-practice laws limit the ability of many of these

workers to play a strong role in patient care. These challenges are discussed elsewhere but are

relevant to providing patient-centered care.

Innovative examples of patient-centered care training include La Clínica del Pueblo’s

program for CHWs in Washington, D.C., which offers onsite training in Spanish for CHWs to

work with recent Spanish-speaking immigrants. The program complements in-house training by

bringing in experts from other institutions to provide training on such topics as diabetes and

hypertension, improving trainees’ ability to discuss clinical issues with patients.

189

The Bronx

Healthcare Learning Collaborative for entry-level health professionals in New York offers

training on care coordination, patient-centered care, and linguistic and cultural competency for

MAs, care managers, LPNs, CHWs, patient care technicians, RNs, social workers, and mental

health counselors to increase the availability of workers to support quality care for a Spanish-

speaking Latino population in New York City. The curriculum for the training programs was

developed by the 1199 Service Employees International Union–United Healthcare Workers

(SEIU-UHW) East, employers, and the 1199SEIU Training and Employment Funds, with the

goal of supporting new models of health care delivery.

190

Another innovative example is an

effort to address mental illnesses after Hurricane Katrina, in which 400 staff members, including

CHWs, were trained in collaborative care for depression. Preliminary findings from this effort

suggested that “CHW participation in post-disaster mental health outreach may bolster

community resilience by increasing interagency collaboration, building trust, and alleviating

mental health–associated stigma.”

191

In addition, experts have suggested that interpersonal communication skills—which are

important for team-based care and patient-centered care—should be a focus of training.

164,192

a 2018 conference on preparing the workforce to provide care to people with serious illnesses in

community settings, experts and stakeholders observed that there were no standards for

communication skills training in clinical education, but that there were “successful models that

[could] be leveraged to increase training capacity, both for those in pre-professional education

and in continuing education.”

164

Summit attendees and other experts also specifically

recommended culturally competent training.

164,193

For-Profit Training Organizations

Certification and licensure ostensibly are designed to protect patients and consumers by

ensuring that health care workers meet minimum standards of professional competence.

However, certification requirements can be a double-edged sword: They can also be a barrier to

entry,

194,195

and, according to key informants, can lead to misaligned motivations. For example,

certifying organizations might not be motivated to ensure training quality and are instead

rewarded by volume. The most-egregious examples are predatory training organizations, which

charge high fees for training that could be acquired elsewhere at a lower price and possibly with

higher quality or that offer training and/or certifications that are not recognized or in demand

within the industry. As states work to encourage certification (for example, of CHWs), predatory

training programs might take advantage of those obligations without benefiting students or

patients.

As one key informant commented in a phone conversation on June 24, 2019, “One area that

needs more public attention is the role of for-profit education programs, and their quality or lack

thereof.” This person noted that the cost of those programs is very high relative to the potential

wages that their graduates will earn, and they described growth in proprietary education

programs in ethical terms: The business model relies on identifying people from low-income

backgrounds who have restricted educational access and getting them into this for-profit program

when they often cannot find jobs afterwards. An example of this is in California, where the

number of respiratory therapy graduates doubled from 1999 to 2009; 70 percent of this gain was

attributable to for-profit programs.

196

There is also continuing concern about the oversupply of

certain entry-level graduates in some geographic areas, while hospitals in other areas have

vacancies because of maldistribution of both trainees and training centers. Thus, although the

total number of graduates might be greater than the number of jobs, the workers are not in the

same place as the work. This leads to wasted resources on training, unemployment, and workers

leaving the industry.

Quality of training is a major issue as well: Some educators and employers have expressed

concern that, for example, “entry-level respiratory therapists were not sufficiently prepared for

work duties.”

196

Studies support this: A recent analysis of the performance of nursing programs

based on ownership status found that for-profit status was a statistically significant predictor of

lower first-time pass rates on the standardized nursing exam, specifically focusing on LPNs,

Associate’s Degree in Nursing degree holders, and BSN degree holders.

197

Participants at an IOM workshop, titled Allied Health Workforce and Services, noted the

problem of predatory training programs as well, stating that “Proprietary schools sometimes prey

on the students who are most ambitious and least sophisticated, and the professional lives of

these students can be put in jeopardy because of a lack of effective policy.”

The workshop

participants suggested that private capital needs to be available within a regulatory framework

that makes sense and does not take advantage of this population.

Policy options include better oversight by—and of—accrediting bodies and, where possible,

penalties for offending institutions by, for example, withholding access to federal loan money.

The U.S. Department of Education did this when ITT Technical Institute was in violation: It

barred ITT from enrolling new students who depended on federal aid and required ITT to warn

current students that accreditation was in jeopardy. ITT shut down as a result.

198

The government

also could require institutions to disclose basic information, such as pass rates and loan default

rates, although this relies on students knowing how to access that information.

Policy Opportunities

The activities identified in this chapter are interrelated training strategies that prioritize job

readiness. After taking stock of programs and policies, as well as recommendations by

stakeholders, we outline the following potential opportunities for stakeholders to consider that

could help strengthen EHCW training:

• Considering standardization of training, licensure, and certification. The EHCW—

and particularly direct care workers, peer specialists, and CHWs—might benefit from

efforts to develop core sets of competencies and align standards for such competencies

across states, as defined through national certification or licensure. There has been a trend

in this direction over time,

199

accompanied by calls to action from experts. However,

progress has been slow, and more evaluative data are necessary to see whether effects are

positive and mirror effects in other industries. Multiple experts—including a key

informant in a phone conversation on May 16, 2019—who expressed a desire for stronger

and more-uniform training standards also recommended studies on what models are

worthy of being scaled up, similar to IMPaCT.

162,164

Along these lines, implementation

science evaluations could consider studying individual implementation activities, such as

a competency-based curriculum, in isolation from other features. The existing literature

predominately evaluates programs that incorporate various types of training, recruitment,

and retention activities, which could be successful or unsuccessful for several reasons

pertaining to specific activities.

• Increasing local investment in training. In addition to coordination for training

standards, local funding and organizing are required. We found that funding efforts

yielding high-quality and sustained results relied on local coalitions that brought together

educators, employers, professional associations, and government entities. These often

were grassroots efforts and were motivated by the needs of health care organizations

102,200

or local public health concerns.

135,145,201

Funders wishing to support training efforts might

want to engage with local stakeholders to listen to their concerns and develop a flexible

sponsorship program. These examples suggest the importance of activities at the local

level, although many of these examples were at the state level. Furthermore, evidence

indicates that, when efforts focus on establishing local coalitions, the longevity of

initiatives is sustained beyond initial funding periods.

202

• Valuing hands-on training. According to a phone conversation with a key informant on

June 24, 2019, and according to the published literature, apprenticeships

173

are one

method for focusing training on a select set of skills that support readiness among the

EHCW.

172

Curricula can also leverage field experiences and lab training to better prepare

students for job duties.

203

• Scaling successes around training. The IHS is supporting the expansion of the Alaska

CHAP model, facilitated by flexible scope of practice within tribal areas.

139

We did not

encounter many models of success that were widely replicated elsewhere, apart from

IMPaCT. Such models as Michigan’s Building Training, Building Quality

130

and

PHCAST in North Carolina

204

also offer promising potential for adoption. One way to

support funding for replication would be to establish formalized venues where workforce

experts share their successes and evaluation results with funders, who, in turn, would

provide bridge funds to test replication of the model elsewhere.

• Protecting entry-level health care workers and trainees from predatory training and

credentialing practices. Government can protect students from predatory institutions

and unfair practices with better oversight, reporting requirements, and increased

penalties.

5. Objective II: Expand Training Opportunities

In this chapter, we focus on expanding opportunities for prospective EHCW members to

access training. Prospective EHCW workforce members often face substantial financial and

logistical barriers to training.

These barriers might be especially pronounced for those who live

in rural or otherwise underserved communities.

205

Fewer training programs might be available to

these individuals, and they might be unable to afford the costs of training or have less time to

participate. They also might lack information about available training and training resources.

Significant structural barriers also exist related to the capacity of training programs to grow and

expand.

Many organizations have pursued a variety of activities that are intended to increase the

opportunities through which individuals can receive training. These activities include making

training more flexible and accessible, expanding training through collaborative partnerships,

expanding recruitment efforts, providing resources directly to individuals to participate in

training, and expanding the capacity of training programs.

Flexible and Accessible Training via Technology

One important approach to reducing barriers to training is to make training more flexible and

accessible via technology. Potential and current EHCW trainees often come from low-income

communities. They might have ongoing family and work responsibilities, and they might live in

regions that do not have direct access to formal training and educational institutions.

These

barriers often make it difficult for current and potential members of the EHCW to participate in

brick-and-mortar programs that are offered on set schedules. One approach to making training

programs more flexible and accessible is to use distance education and other e-learning

mechanisms.

206-208

These technologies allow individuals to complete training on their own time

and without leaving their communities (given internet access and time), and might be cost-

effective compared with more-traditional education programs.

206

One program that is intended to make training more flexible and accessible for the EHCW is

the PHCAST program. PHCAST was a three-year demonstration initiative funded through the

ACA for fiscal years 2010 through 2012. Programs in six states (California, Iowa, Maine,

Massachusetts, Michigan, and North Carolina) were given a total of $5 million annually for three

years to deliver training that provided required certification for personal and home care aides.

115

To expand access to this training program, PHCAST was delivered online through a web portal

that provided access to the training materials, although the Maine program also used an in-person

classroom format. The program allowed students to work at a flexible pace through at least 50

contact hours, in most cases offering core and specialty training within LTC facilities and

ultimately training 220 individuals.

115

Many EHCW experts remarked on the importance of providing flexible and accessible

training to a variety of individuals. However, there are also downsides to technology-based

programs, including access for those who lack the technology, lack of face-to-face interaction

when it is used, and the inability to teach certain skills without physical interaction. Therefore,

many of the key informants we spoke with found it important to combine online and onsite

training. In a discussion on June 20, 2019, one key informant stressed the importance of these

blended programs, calling them “primarily distance-available with what we call low-residency

programs; so [students] may come in intermittently for face-to-face sessions.”

Other ways to expand access to training, such as through stackable credentials, are addressed

in Chapter 8.

Collaborative Partnerships for Training

Work-based learning models that help frontline staff gain competencies through a

combination of onsite, hands-on, and in-class learning often are best delivered when employers,

educational institutions, and other community institutions work together. Partner institutions can

analyze workforce data to identify gaps, determine the needed skills, recruit candidates, and

provide training in coordination to produce the most effective workforce.

209

Employers are

especially important participants in such partnerships because they are the most knowledgeable

about workforce needs and challenges.

209,210

However, although employers are knowledgeable

regarding specific workforce needs and require well-trained EHCW members, they often lack the

resources or skills to deliver training on their own. Other community-based organizations,

especially community colleges, are best equipped to identify and recruit potential EHCW

members and provide them with the classroom portion of the training. Some organizations even

ask for feedback from the health care organizations they serve. For example, Shana Welch of

Mercy Health and Saint Joseph Mercy Health System said “Community colleges want us to be at

the table. They want us to be reviewing their curriculum; they want us to be part of their teaching

team. . . . We could go back and say, for example, that your medical assistants don’t know how

to draw blood. They are asking for feedback, and we are providing it.” However, partnerships

can be difficult to initiate and cultivate, requiring extensive time and commitment to make them

work.

One innovative program focuses on developing multilevel partnerships to improve training of

the EHCW. The H2P Consortium, which brings together nine community colleges in Illinois,

Kentucky, Minnesota, Ohio, and Texas, aims to share and implement best practices to improve

training for LVNs and LPNs, nursing aides, CHWs, MAs, DAs, nursing assistants, and other

health care professionals. Across the different states, initiatives include partnerships with health

care facilities to create flexible MA programs for incumbent workers and streamlined curricula

made available in a learning resources collection online.

211

Another example of such a program is BACH, which is a nonprofit corporation founded in

2005 that works with local partners to train residents of Baltimore, Maryland, to enter the

EHCW. BACH lists dozens of partner organizations across the community, including 11 health

care organizations (e.g., The Johns Hopkins Hospital), five government agencies (e.g.,

Maryland’s Governor’s Workforce Investment Board), and 20 educational institutions and

nonprofits (e.g., Baltimore City Community College). The program offers several training

opportunities. BACH works directly with health care institutions to provide tools to facilitate

career counseling to entry-level workers at each health care institution. This coaching model has

worked with more than 400 entry-level health care workers at six health systems and two LTC

facilities.

Discussions with experts revealed the importance of partnerships to meet regional needs for

the EHCW. One respondent noted that these efforts must be region-wide to address regional

problems that cannot be addressed by a single entity. In a conversation on July 18, 2019, one

respondent in Western Michigan noted that “There is no way I could have done this myself and I

would have gone crazy if I had tried. Do this as a sustainable partnership.” They also noted that

broad partnerships are key to the success of the program, adding that “The secret in the sauce is

the trifecta of relationships: our Workforce Board (government entity), community colleges

(educational partners), and champion or lead employers.” This public-private model holds great

promise for supporting this workforce, especially when including educational institutions.

A specific example of where partnerships could make a meaningful difference relates to

making clinical settings available for training after coursework is complete. In a phone

conversation on June 11, 2019, one key informant at a large health system discussed the

challenges of providing clinical rotations for EHCW members. This respondent explained that “a

big obstacle for entry-level health care is clinical training. Colleges shared that they want to

increase capacity but are limited by companies willing to allow clinical rotations. Operational

leaders shared that there is no funding for clinical rotations so many consider it a resource drain.”

Partnerships to enable clinical training are critical for these workers, as are the needed resources

to fund those clinical positions.

Faced with the challenge that funding is often short-term, some partnerships and coalitions

are more successful at continuing than others. Local efforts with broad coalitions are most likely

to succeed. According to one analysis of community coalitions after federal funding has ended,

“characteristics associated with sustainability include coalition leadership, membership diversity,

coalition structure, vision guiding action, and resources.”

202

This is true for coalitions around

training and for those around recruitment and retention.

Expanded Recruitment for Training

Another approach to reducing barriers to participation in training the EHCW is to broaden

recruiting into training programs. For example, many programs recruit within low-income

communities, which gives health care providers a supply of potential entry-level health care

workers and develops the workforce in underserved communities.

212

Efforts to begin engaging

younger individuals, such as high school students, are part of this strategy.

208,213,214

Such efforts

channel younger people toward health care professions and expand health occupation programs

in high schools.

Several programs have focused on expanding the recruitment base for EHCW training. For

example, Phipps Neighborhoods is a nonprofit organization in New York City that helps

children, youth, and families in low-income communities rise above poverty. It focuses on

reducing barriers to self-sufficiency by providing training and educational programs throughout

the city. In its Career Network: Healthcare program, Phipps Neighborhoods works with

Montefiore Health System and Hostos Community College to provide health care exposure and

instruction to individuals from low-income neighborhoods.

212

The program includes 13 weeks of

sector-based career exploration and training. In 2016, the health care program graduated 88

students, a 75-percent completion rate. The completion rate for the 223 students in ten cohorts

over time was 72 percent.

215

Students graduating from this program had salaries that were 25

percent higher than the median income for that age group in their neighborhoods.

The San Marcos High School Health Careers Academy in California is a three-year program

that provides students with the opportunity to learn about the health care industry with practical,

hands-on experience while in high school. The students take several health care–related courses,

including medical terminology, biology, and kinesiology. Those completing the program are

prepared to enter the EHCW or seek further education. Students who pursue the nursing track

can graduate as nurse’s aides, and the program can be a launching point for further education as a

nurse.

216

As of 2016, the academy had graduated 422 students, of which 244 had graduated as

CNAs.

214

Financial and Nonfinancial Resources for Trainees

One of the greatest barriers to expanding training for the EHCW is the costs that individuals

incur for participating in training programs. Costs are significant and can be both direct and

indirect.

Primary direct financial costs include tuition paid to the training institution;

equipment, such as computers; and the certification and licensing fees that must be paid when

training is completed. There are several approaches to reducing the costs of EHCW training.

217

These approaches can include scholarships, tuition repayment, and directly providing supplies.

Often, these resources are made contingent on providing service to a sponsoring institution, such

as a hospital, or, in the case of government-sponsored scholarships and loan repayment

programs, service in an area of high need. Indirect costs of program participation include

foregone wages and the costs of such items as transportation or childcare. Some programs cover

indirect costs through paid internships and traineeships or direct reimbursement for trainee-

accrued costs, such as counseling.

One particular federally funded program that has focused on providing direct and indirect

financial support to trainees is the Behavioral Health Education Center of Nebraska behavioral

health paraprofessionals program. This program is the result of a $1.1 million grant from HRSA,

and it provides full tuition for 70 students each year to become CHWs and provisionally licensed

addiction counselors. Students must commit to working in rural or medically underserved areas

of Nebraska.

218

Tuition assistance, as well as other forms of financial support, also has been cited as a key

strategy for retaining entry-level health care workers.

219,220

The VA provides financial benefits

and incentives for its nursing staff, including LPNs and nursing assistants. Specifically, VA

medical centers provide an Employee Incentive Scholarship Program that provides funds for

nurses—including LPNs and nursing assistants—who are pursuing further education. The

program also supports the VA National Education for Employees Program, which provides

scholarship and replacement salaries for those in an approved full-time program.

27,221

Another

program at the VA is the Education Debt Reduction Program, which reimburses qualifying

education loan debt for staff, including nurses, in hard-to-recruit positions. In one VA medical

center, of the six nurses that began the program since 2010, five completed the five-year service

agreement and remained VA employees.

Another VA medical center reported that 23 nurses

completed the Employee Incentive Scholarship Program between 2006 and 2015, and, by the end

of the program, 21 of those nurses remained employees at the medical center.

Additionally, the American Federation of State, County, and Municipal Employees union

1199C operates the Training and Upgrading Fund in Pennsylvania. The fund supports a wide

variety of education and training programs across the state in health care industries, including a

training program with 120 employers focused on reducing turnover through a coaching model. In

2017, the training fund served more than 3,500 members and 1,600 community members. One

important program within the Training and Upgrading Fund is the health care apprentice

program, which provides training in various EHCW careers, including behavioral health and

direct support specialists, home health aides, nursing aides, CHWs, advanced MAs and addiction

counselors.

222,223

These apprenticeships are aimed at low- and middle-income individuals from

18 to 24 years of age. At the end of the program, students receive 24 college credits, which can

be important, given the time investment. In 2017, the Training and Upgrading Fund facilitated 16

apprenticeships; all were placed in full-time positions.

222

A related, nonfinancial benefit is housing and transportation. The Montana Rural Allied

Health Professions Training Program (MRAHPTP) is supported by a grant that enables rural

training opportunities for health professions students in Montana. The program covers housing

and transportation costs during the students’ clinical rotations if the rotations are completed at a

rural training site. The program’s overall goal is to provide these students with rural, community-

based clinical training rotations and eventual employment with a rural health care provider.

208

Key informants regularly cited the importance of financial and nonfinancial support for

training, especially direct financial support, such as for tuitions and salaries. In a phone

conversation on July 12, 2019, one respondent noted that students, especially those from low-

income communities, cannot forgo a year of salary to pursue education: “We know that people

need benefits and wages to be able to continue and advance . . . for the most part, workers

need—if you have family and people you need to support, you cannot go without your benefits

and you cannot go without your paycheck.”

We also heard from key informants about existing disparities in access to education as an

important related consideration. In a phone conversation on July 10, 2019, one key informant

told us that “[people of color] are not starting on equal ground to compete and . . . we compound

that if we place them in a year-long program that they might not be able to afford, even before

they are competing.” This person pointed to the importance of financial aid to create better

opportunities for students of color.

Increased Capacity for Training

Finally, to improve access to training for EHCW members, there must be increased training

capacity. Lack of capacity for training affects a wide swath of health care professions. The best-

known educational capacity issues are highlighted in the nursing literature. Of particular concern

is the aging of nursing school faculty. The American Association of Critical Care Nurses

estimates that there are more than 1,500 faculty vacancies, and more faculty reach retirement age

each year.

224

The growth in nursing programs further strains nursing faculty. Relatively less is

known about capacity needs for other EHCW occupations. In some cases, programs at

community colleges turn away qualified applicants because of lack of faculty and other

resources, such as clinical sites and classroom resources.

225

Several national and regional programs have been developed to expand the capacity of

EHCW training across the United States. For example, Massachusetts has invested resources in

training CHWs, recovery coaches, and peer specialists, along with their supervisors, as part of

the Massachusetts Delivery System Reform Incentive Payment Program, its 1115 Demonstration

waiver.

226

This is part of a bigger program that funds accountable care organizations (ACOs) and

community partners directly, but there is a dedicated funding stream for this training because of

the impact on enrolled individuals. Specifically, as noted in a 2019 report on the effects of

behavioral health workforce innovations on CHWs and peers in Massachusetts and New York,

“CHWs and peer specialists have a unique ability to engage and help improve the health of

MassHealth enrollees who are most likely to be disconnected from health care, and they expect

to increase the size of this workforce.”

226

Although MassHealth does not reimburse for these

services directly, the ACOs can choose to hire trained workers using program funding.

Another capacity-building program is the Appalachian Consulting Group (ACG) Catalysts

for Recovery program for peer specialists in the United States. ACG, which evolved from a

certified peer specialist curriculum created in Georgia in 1999, has trained peer specialists in 35

states. ACG also has a program to expand the capacity to train peer specialists, known as the

Peer Specialist Core Recovery Curriculum Train-the-Trainer. ACG has developed the curriculum

to train current peer specialists to be trainers in future peer specialist training programs.

227

This

training can be used to rapidly scale peer support training capacity.

228

This program is operating

where peer specialists already exist, but it is not able to facilitate the introduction of peer

specialists where none exist.

Policy Opportunities

There can be substantial challenges to providing access to training for EHCW members.

Programs across the United States have experimented with efforts to address these barriers.

Some opportunities to expand training drawn from programs we reviewed include the following:

• Increasing the role of remote or blended training. Many potential entry-level health

care workers cannot access brick-and-mortar training opportunities within normal

business hours. Programs identified in the literature search and in discussions with key

informants suggested the importance of training programs, especially for CHWs and peer

specialists, that were offered remotely through online or blended learning.

115

Stakeholders could encourage the development of curricula that can be delivered in

multiple formats or convert course curricula that are currently designed for face-to-face

delivery to blended or online formats.

• Targeting younger prospective members of the EHCW and those from low-income

communities. EHCW programs might want to consider recruiting younger candidates

from low-income communities. Often, entry-level health care workers enter the field later

in life, when they have many responsibilities that make it difficult to commit to training.

Furthermore, these jobs are important means by which members of low-income

communities can obtain stable employment. Specifically, programs that engage high

school students in low-income communities can be an important way to foster interest in

entry-level health care work and begin preparation as part of a standard secondary

education.

213,216

• Examining capacity requirements and increase capacity where needed. Much has

been published about the shortages of nursing faculty, but relatively less has been written

about other disciplines, such as CHWs and MAs, which limits the ability to capacity-plan

within these training fields.

• Promoting public-private partnerships for program and curriculum development.

Partnerships between varied public and private institutions are key for promoting training

programs that meet the needs of employers, those who ultimately will hire entry-level

health care workers. Partner institutions can work together to determine the actual skills

needed by employers and to develop and deliver training programs that provide the skills

and competencies that meet those employer needs.

Part 3. Recruitment

(Chapters 6–7)

6. Objective III: Expand Recruitment Strategies

In this chapter, we focus on recruitment-related topics. Expanding the pool of prospective

workforce members through recruitment is a key strategy for addressing the impending

workforce shortage. At a systems level, the goal is to improve the match between supply and

demand—that is, to ensure that there are enough workers fill job openings and that these jobs are

both fulfilling and contributive to improved population health. Employers, community partners,

workforce entities, and other stakeholders undertake many different activities to serve the dual

purpose of expanding opportunity for greater numbers of workers and increasing successful

hiring for employers. Two ways to increase the number of prospective candidates are: (1) to

reach out to a broader and more diverse pool of potential applicants and (2) to recruit members

of specific populations that are suitable for such positions and might otherwise encounter

challenges obtaining employment (e.g., veterans, people with disabilities, people who have been

dislocated because of mass layoff or natural disasters).

Broadened Hiring Pool Composition

The composition of the EHCW is not representative of the diverse U.S. patient populations

served, and efforts to attract and recruit underrepresented groups represent one strategy to

address this imbalance. Within health care overall, African American and Latino workers are

more likely than white and Asian American workers to work in low-wage jobs or occupations

that require less formal education, and people of color make up one-third of the health care

workforce, similar to the United States population.

229

For example, racial and ethnic minorities

are proportionally underrepresented within the nursing workforce,

230

as are men.

231

As of 2019,

among all hospital workers, inclusive of MAs, lab technicians, and numerous other positions,

there is 75 percent female representation, 72 percent white representation, and only 16 percent

African American and 11 percent Hispanic representation.

232

Against this backdrop, it is

important that diversity be enhanced throughout the EHCW and the larger workforce.

To cite one example, at the Medical Assistant Registered Apprenticeship Program in West

Michigan, which we discuss elsewhere (see the Mercy Health case study in Appendix A), racial

and ethnic minorities were underrepresented compared with their regional benchmarks. Mercy

Health used a variety of different strategies to recruit a more diverse workforce into its entry-

level positions, specifically targeting people of color.

233

According to a phone conversation with

a key informant on May 13, 2019, Mercy Health sees this as its social responsibility, and it

prioritizes local hires in addition to racial diversity. The same person noted that, during its first

year, the program struggled to recruit diverse applicants, so the talent-management leadership

modified its approach to create a community sourcing team to recruit more intentionally through

community-based partners. The revised recruitment strategy was a success, and as a result of the

diverse population recruited through this MA program, the hospital was able to increase the

diversity of MAs from 18 percent to 36 percent people of color.

Targeted Recruitment

Recruiting low-income people into the EHCW—as well as those with less formal education

(e.g., young male veterans

234

)—can offer a potential path out of poverty and its consequences.

235

Targeted recruitment and concerted efforts at inclusion might increase employment for

underrepresented groups.

236,237

If they are successful, such strategies have the potential to

ameliorate disparities in unemployment and poverty and facilitate professional advancement. We

defined targeted recruitment to include outreach programs and policies that seek to identify

individuals with some common characteristic.

There were several different programs in the gray and academic literature that employed

targeted recruitment strategies for specific populations. Some programs focus generally on low-

income individuals or those who have been unemployed for an extended period. The Career

Network Health Care Program, funded by the J.P. Morgan Chase Foundation, aims to place low-

income individuals into education and training programs that will lead to useful credentials and

long-term professional success in such jobs as HHAs, CNAs, LPNs, patient care technicians, or

other kinds of aides and assistants.

212

Turnaround Tuesday is a program operated by nonprofit

Baltimoreans United in Leadership Development—a “non-partisan, interfaith, multiracial

community power organization”

238

in Baltimore, Maryland, that works to improve housing,

education, and economic opportunity for Baltimoreans. Another program, the Home Care Aide

Workforce Initiative in New York, developed a novel recruitment and adult-centered training

model for HHAs,

140

with targeted efforts in low-income communities and tools to screen best-

suited applicants prior to enrollment. PHI, a partner organization, worked with the City

University of New York and guided the three participating home care agencies in conducting a

17-day training, which included hands-on simulation, peer mentorship, coaching support, and

employer input. By virtue of receiving tailored recruitment and training efforts with

employment-focused skills, those who participated in the program stayed in their new roles for a

longer period.

239

Turnaround Tuesday works with community partners to create partnerships between

employers and community-based organizations to promote jobs for people who are reentering the

workforce after incarceration or long periods of unemployment.

240

Another program that recruits

formerly incarcerated individuals is the Transitions Clinic Network (TCN), which was

implemented across the country to help clinics provide effective health care services to

chronically ill people recently released from prison.

241

The TCN trains formerly incarcerated

individuals to become CHWs, and it has been supported by private foundations and the Center

for Medicare and Medicaid Innovation (CMMI).

242

A study from 2007 to 2009 in San Francisco,

California, demonstrated that TCN training had a positive impact. Individuals who were

randomly assigned to receive care at the TCN had one-half as many emergency room visits

compared with others who were recently released from prison.

242

Targeted recruitment discussion themes tended to vary by occupation. According to a phone

conversation with key informants in LTC on July 17, 2019 , several experts advocated for

bringing young people into the EHCW, given that many older workers are aging out of the

workforce in the next several decades. According to another key informant conversation on July

16, 2019, middle age is the typical point at which new workers enter into the LTC workforce,

and with rising demand, there is a need to be more deliberate with future recruitment strategies.

Interests shaping targeted recruitment also might vary by employer. We heard from a key

informant at KP on May 20, 2019, that the recruitment of veterans is important, and it is working

with community-based agencies to recruit veterans to its facilities. KP has several other

initiatives for targeted recruitment, including Project Search, for introducing people with

developmental disabilities into the workforce, and High-Impact Hiring, in which KP is targeting

different communities of people that are facing barriers to entry into the workforce. The key

informant also noted that KP talent management holds recruitment programs in middle and high

schools, including summer youth programs that allow 17- and 18-year-olds to be exposed to

different positions, with the goal of recruiting youth into EHCW positions at KP.

Collaborative Partnerships for Recruitment

Collaborative partnerships can expand recruitment opportunities by facilitating economies of

scale that make it possible to recruit in ways that individual employers might not otherwise have

been able to manage. Workforce boards; community-based organizations; education and training

programs and institutions; and city, state, or regional institutions are all examples of potential

workforce partners. Collaboration is important on several levels. Partnerships might seek to

influence workforce policy, establish new recruitment programs, share resources and

information, or engage in other efforts. Collaboration can facilitate stronger connections between

employers and prospective employees,

243

and many health care employers perceive economic

advantages to participating in collaborative partnerships, which can affect workforce issues in a

broader way.

209

Programs aimed at recruiting certain kinds of workers commonly partnered with a primary

institution to provide those services. For example, the Community Health Worker Initiatives

operates a program called Community Access to Resources and Education New Mexico for

CHWs in which a network of MCOs partner with FQHCs to employ CHWs.

244,245

Because

training is a necessary prerequisite to many entry-level positions, many partnerships feature an

educational institution as the primary partner. For example, the Quality Home Care Workforce

Pilot Program in New York, run by PHI, a nonprofit in New York City, connects New Yorkers

with jobs as HHAs by offering an enhanced training model and an assessment by a consultant to

look at scheduling and supervisory practices.

140

The program partners with employers to smooth

the path from training to employee.

Other programs use partnerships to facilitate recruitment as a component of a larger strategy

for developing career pathways and supporting workforce development. For example, the Adult

Community Health Worker Program for CHWs in New York City trains CHWs through a

partnership between New York–Presbyterian Hospital (NYP) and four community-based

organizations. CHWs are trained and managed jointly by NYP and the organizations: NYP pays

for the CHWs’ salaries, benefits, office space, and daily stipends, while organizations recruit the

CHWs from the local community. NYP also has a CHW Committee that allows CHWs to

provide the hospital with input on community priorities.

245

Another form of partnership for workforce recruitment is a joint multiemployer and union

partnership. Unions and employers share leadership of such partnerships to create education,

training, and expanded advancement opportunities for eligible incumbent workers. Union leaders

who are familiar with the activities of SEIU training labor-management funds (which is one

example of such partnerships) shared that the local unions fund education and training programs

with employment potential in mind—they implement only training programs that ensure that

members will be able to find jobs after investing the time and energy required. According to a

phone discussion with key informants on July 9, 2019, these assurances are built into the

collective bargaining agreements between employers and unions. Some large health care

institutions have their own unique partnerships with training and educational institutions for the

purpose of recruitment. As one executive at a large health system told us in a phone discussion

on May 20, 2019, “We have several partnerships with local colleges, nursing schools, [and]

universities.” The health system partners with vocational technical schools for certification of

diagnostic imaging clerks, MAs, and LVNs, and it has a variety of partnerships that vary

regionally depending on need, all of which improves the prospect that trainees will easily find

job opportunities after completing training. In speaking with a key informant about LTC on July

16, 2019, we learned about a community summit held on the caregiver shortage crisis that was

useful for recruitment. Moving forward, officials and participants from this summit will meet as

an organized workforce collaborative on the issue of aging and the caregiver shortage crisis; the

key informant believes that this type of arrangement will be particularly helpful for “figuring out

who the [key] players are [in workforce development].”

Several programs also sought to address recruitment earlier in the pipeline through training

and education. For example, in January 2020, KP, a large integrated health system, and SEIU-

UHW West announced a joint venture called Futuro Health,

246

a “nonprofit organization

dedicated to growing the largest network of certified health care workers.”

247

It plans to train

10,000 new health care workers in the next four years with an affordable education-to-work plan,

starting in California and eventually spreading across the country.

247

Arlene Peasnall, senior vice

president and interim chief human resources officer for KP, emphasized both the recruiting and

retention goals of the program in the initiative’s press release: “In addition to attracting new

talent to the health care industry, it will help existing workers advance in well-paying, fulfilling

careers.”

247

Financial Incentives for Recruits

Financial incentives include higher salaries, relocation or signing bonuses, and such benefits

as tuition reimbursement and loan forgiveness. Evidence regarding the effectiveness of financial

incentives on entry-level workforce recruitment is nuanced,

248,249

and indicates that effectiveness

might be contingent on the size and duration of the incentives offered.

84,108

For instance, wage-

related incentives (which we discuss in Chapter 12) continue into the future and are different

from one-time bonuses.

We identified several programs that use financial incentives for recruitment. Most

commonly, these incentives are hiring bonuses. The Mission Health recruitment and retention

initiatives for CNAs and RNs in North Carolina include bonuses for nurses depending on

employment commitment, a partnership with a community college to create scholarships for

CNA candidates associated with the organization, the development of an RN liaison position to

help with recruiting, and the hiring of a vice president focused solely on problems nursing staff

face at Mission Health.

250

Other employers have raised salaries or plan to do so: The University

of Pittsburgh Medical Center (UPMC) reported that it plans to raise the minimum wages of all

urban nonunion employees to $15 per hour by January 2021.

We heard from several key informants about the importance of financial incentives for

recruitment. In speaking with key informants familiar with the Peninsula Homecare Cooperative

on July 17, 2019, we learned of another type of financial incentive: partial share in business

ownership for HCWs. In addition to being co-owners of the company, workers provide input on

agency policies and operations. Leaders there explained that co-ownership is a recruitment

incentive and that HCWs are recruited with another financial benefit: the promise of

reimbursement for training expenses once they become members of the cooperative. The experts

also noted the challenge of incentivizing workers financially to take a position as an entry-level

health care worker. Specifically, competition from other industries with higher wages makes

many financial incentives less compelling. This is particularly true for many EHCW roles that

might be more challenging relative to fast food jobs and other entry-level work. In a May 16,

2019, phone discussion, one expert explained that “My experience is that implementing ‘best

practice’ training programs will not resolve the issues of recruitment and retention in this sector

unless a competitive minimum wage and wage progression as workers acquire additional skills

are implemented.”

Job benefits, such as health insurance, life insurance, and retirement benefits, also can be

used as a recruiting tool. We found little evidence of benefits being used to recruit for the

EHCW, but one study found great variability in benefits given to LPNs and RNs and found that

employers try to enhance benefits in the context of a shortage to retain employees.

251

In a phone

discussion on May 8, 2019, one of our key informants highlighted a lack of benefits as a key part

of the challenge this workforce faces, along with low pay.

Nonfinancial Incentives

Nonwage forms of compensation also might be significant tools for recruitment. The

availability of affordable child care and transportation have been shown to influence the decision

to enroll in educational and training programs,

229

and these factors could play a role in shaping

decisions prospective workers make about employment. Broadly speaking, recruitment

incentives include personal and vacation days, comprehensive health insurance, overnight

accommodations and other supports for commuters, shuttle service or transportation subsidies,

parking, onsite childcare, training, and gym access.

We identified several nonsalary incentives for recruitment pertaining to housing and

transportation. For example, the free accommodation incentive for nurses at West Virginia

University of Medicine offers a free place to stay for nurses (e.g., LPNs) commuting long

distances to recruit them to Morgantown, West Virginia.

252

Recruitment can be facilitated using

training benefits as well, particularly if such benefits are accompanied by a guaranteed job

placement. The partners patient care associate training program for CNAs at Partners HealthCare

in Boston, Massachusetts, provides free training and dual nursing assistant and HHA certificates

and job placement in the Spaulding Rehabilitation Network in Boston. The program pays for

exam fees for the state CNA exam, which must be completed within 30 days of program

completion.

253

Publicly sponsored job centers, including the American Job Centers System coordinated by

the U.S. Department of Labor, can also provide services to increase recruitment. For example, in

Missouri, job centers provide education and training, career advising, and continuing support to

individuals in the health care workforce as part of their services connecting individuals with

jobs.

243

Despite several examples of nonfinancial incentives for workforce recruitment in our

review of the gray and academic literature, there were no evaluation findings for any of the

policies or programs we identified.

Discussions with experts in LTC suggested the need for affordable housing and the impact of

housing affordability as a major limitation on recruitment in certain areas. According to a phone

conversation with key informants on July 17, 2019, if HCWs cannot live affordably in a given

area, there will be a corresponding shortage of caregivers there. Although affordability is distinct

from financial incentives, it has a similar impact insofar as it limits individuals’ disposable

income—sometimes to such an extent that job retention is undermined.

In some cases, the appeal of a particular workplace serves as its own incentive. As one VA

peer specialist told us over the phone on June 7, 2019, “There were a lot of things about

[working at the VA] that appealed to me. Number one was the fact that it was for the VA

working with veterans.” By virtue of its mission as a source of treatment for veterans, the VA

can use brand recognition for recruitment.

Expanded Recruitment Venues

It is standard practice to recruit workers externally through online job sites and social media,

both of which connect prospective employers with a broader talent pool

254

and are less expensive

than traditional methods.

255

For dental workers in particular, advertisements in local journals and

recruiting from local dental societies are common recruitment strategies.

256

Other common

strategies include career fairs, third-party hiring management firms, and internal recruitment

advertising to incumbent workers. Expanded recruitment venues build on these strategies.

The initiative to train CHRs and DAs as community dental health coordinators in New

Mexico recruited students, about half of whom were Navajo CHRs, to undergo yearlong

community dental health coordinator training at Central New Mexico Community College.

176

This initiative was part of the American Dental Association’s larger community dental health

coordinator certification program, which has been implemented through training programs across

the country and has produced about 305 community dental health coordinators.

176

Although electronic recruitment offers great potential, we learned in a May 20, 2019, phone

conversation with one expert that there can be downsides to using electronic systems for

recruitment and hiring. In the past, if a person sent a resume in for a position, a hiring team might

hold onto it until the appropriate position became available. Now that these systems are

automated, the personal element of that process is lost and otherwise qualified candidates might

be overlooked.

Kippi Waters, founding member of the Peninsula Homecare Cooperative, told us that “The

majority [of our employees] have come to us from other agencies by word of mouth.”

Recruitment is more challenging in rural areas, where shortages of entry-level health care

workers are exacerbated by the unwillingness of urban workers to relocate. Rural, geographically

isolated areas are also less well served by job websites because of their limited access to

broadband and because of the websites’ concentration on positions and job seekers in or near

urban centers.

Immigrants

A 2019 Health Affairs article on the health care workforce estimated that immigrants, both

naturalized citizens and legal noncitizens, are overrepresented among the direct care

workforce,

257

both because they cannot translate their experience in other countries into jobs in

the United States and because U.S.-born citizens are not willing to do these jobs. This analysis of

immigrants working in the U.S. health care system found that the system is dependent on the

work of more than “three million immigrants, who account for 18.2 percent of all health care

workers,” which is greater than immigrants’ 15.5-percent representation in the population more

generally.

257

Legal noncitizen immigrants, who made up only 5.2 percent of the total population,

made up 9 percent of direct care workers (meaning nurses, HHAs, and PCAs), and naturalized

citizens, who made up only 6.8 percent of the total population, accounted for another 13.9

percent of direct care workers.

257

In addition, undocumented immigrants are estimated to make

up 4.3 percent of direct care workers.

257

An analysis of foreign-born health care workers from 2013 found similar numbers and noted

racism and discrimination in the workplace against foreign-born direct care workers.

258

work finds that “nursing homes and home care agencies have experienced increased difficulty

recruiting among immigrant communities and that immigrant workers are expressing grave fears

about losing their jobs or being deported,”

145

with researchers expressing concern that the

environment will be a barrier to the recruitment of workers. Given the increased demand, policy

opportunities for consideration include facilitating direct care workers’ entry into the United

States, potentially by expanding the purview of existing visa programs to include this needed

workforce. Such a program would need to include oversight to make sure that visas are used

correctly and to ensure that there is no abuse of workers who rely on their employer for income

(and for a visa). Without such oversight, they would be left with limited or no recourse to protest

mistreatment.

258

Policy Opportunities

There is much to be done to address the challenges and scale up the successes associated with

recruitment activities designed to expand job opportunity. We identified the following policy

opportunities in this area:

• Developing recruiting partnerships that include health care employers; educational

institutions, such as community colleges; and local workforce planning boards.

Partnerships between employers and training institutions help ensure congruence between

training and job needs, and they facilitate the successful hiring of individuals into EHCW

jobs, particularly when employers play a strong leadership role.

24,209

The economies of

scale achieved through partnerships help spark change at the system level that is more

lasting and more responsive to workforce needs.

209

However, many community-based

agencies, private employers, and educational institutions do not have experience

collaborating with health care workforce partners, and coordination support might be

needed to establish and maintain successful partnerships.

Partnerships can help focus

resources in areas with the greatest need and the least ability to recruit needed workers.

• Providing incentives for recruitment. Better research is needed about the most-

effective kinds of incentives, but a lack of benefits and low wages are known to be

particular challenges for this workforce.

• Focusing on all aspects of the career pipeline, from training and education to

retention. Education and training determine the size and composition of the EHCW and

are inextricably linked to recruitment.

• Supporting those entering the workforce. Consider ways to provide training, visas, and

stability for vulnerable populations who serve in these roles, particularly immigrants in

direct care.

7. Objective IV: Match the Best-Fit Candidates to Jobs

A key aspect of recruitment is identifying individuals who are well trained (and from a

diverse array of backgrounds and life experiences), and channeling them into EHCW

opportunities that are a good fit. Successful recruitment ensures that identified job candidates are

ready to thrive in their roles. Skill mismatches are more of an issue for job dissatisfaction than

educational mismatches

259

and cannot be made up for by increased salaries.

260

Slotting the right candidates into the right jobs can be accomplished through clear job

qualifications, evidence-based screening techniques, and hands-on internships that lead to jobs.

Although recruitment can precede training, we specifically address steps in matching trained

candidates to jobs by clarifying job qualifications, screening candidates to avoid bias, matching

candidates to jobs that suit their personal characteristics, and using internships for recruitment.

Clarified Job Qualifications to Improve Matching with Candidates

To attract appropriate and able candidates, job qualifications have to be clear. As one key

informant put it during a phone conversation on May 16, 2019, “Certification requirements are

integral to training and clarification of worker scope of practice. However, there are no national

certification requirements for home health aides, so there are no national training standards, and

there are no standard job descriptions. This also affects worker upward mobility and career

path.”

Sometimes, clear qualifications are introduced into law, such as Minnesota Statute

256B.0625, which permits CHWs to be reimbursed by Medicaid for the provision of care

coordination and patient education services. It allows payment for both certified CHWs and for

those without certification but with at least five years of experience (working under

supervision).

261

The PHCAST Demonstration Program, which was established under the ACA in

California, Iowa, Maine, Massachusetts, Michigan, and North Carolina, supported efforts to

provide competency-based training for personal and home care aide certification, which is

another way to clarify qualifications and ensure that candidates possess certain competencies.

115

Lack of clarity in job qualifications and descriptions can be a barrier to hiring quality

workers. This is particularly true for new job roles, such as peer specialists. As another key

informant told us over the phone on June 13, 2019, “I talk a lot about competencies, how we

developed our competencies and [peer support] career ladder, how we wrote job descriptions.

Peer support is not familiar to everybody and they still see [the peer counselors] as [other]

patients instead of . . . as a profession that has unique and valuable skills so we try to help people

define it.”

A key informant from one large integrated system, UPMC, noted in December 2019 that

sometimes listed requirements are not really needed. “We started to look at job descriptions in

our management roles and found they had these bachelor’s degree requirements and found they

weren’t necessary and [were] prohibitive and we removed those.” Changing these requirements

opens up opportunities for more workers.

Evidence-Based Screening

Evidence-based screening, or using objective tests and standardized interview questions

rather than intuition, is recommended by many to “help remove unconscious bias in the

interview process.”

Bias can lead to favoring certain candidates in hiring,

262

sometimes of those

who are less qualified. To implement unbiased screening, employers need to identify the skills

and competencies needed for specific roles, assess candidate skills and competencies with

objective tests and standardized interview questions, and decide how screening results will

inform hiring decisions.

Without clear job descriptions, qualifications, or hiring criteria, hiring

practices could be unfair and employers might miss out on high-quality workers.

Standardized job descriptions and qualifications and evidence-based screening are related.

Standardized and systematic hiring practices also buffer against bias that comes from usual

practices, such as hiring people who are similar to the recruiter.

263

One key informant told us in a

phone conversation on May 13, 2019, that their role is “to ensure they have innovative best

practices addressing core talent acquisition—identifying, sourcing, and attracting talent—and

ensuring they have an effective pipeline of talent to meet in-demand jobs for today and in the

future. Within that, at the foundation of workforce is our evidence-based selection process on the

talent acquisition process.”

This approach has helped Mercy Health in West Michigan both to improve first-year

retention and increase the diversity of their staff. As Shana Welch of Mercy Health and Saint

Joseph Mercy Health System, members of Trinity Health, told us, “Mercy now does this system-

wide. We have eight regions and through the leadership of our [vice president] of diversity and

inclusion at Trinity Health, every region has to train all of their leaders on implicit bias. That

practice started in the Michigan region and has been scaled.” Additionally, Mercy Health and

Saint Joseph Mercy Health System have implemented an evidence-based selection process for

recruiting and hiring. Welch reported that, since that implementation, they were recruiting a

higher percentage of African American individuals—moving from 18 percent to 36 percent—

and credited this approach with also improving quality: “[We are] ensuring our process is fair,

removing as much unconscious bias as we can so we can ensure we are bringing the very best

people into the organization.” Mercy’s evidence-based selection process has used objective tests

for specific skills and standardized interview questions to assess competencies for new

candidates for both entry-level and other health professionals, leading to reduced time-to-fill jobs

from 37 to 31 days and reducing one-year turnover from 25 percent to 19 percent. The idea

behind these efforts—beyond simply reducing turnover—is that reaching “diverse, highly

competent, compassionate talent is essential” for excellence in health care, and that evidence-

based selection processes lead to better patient outcomes and patient satisfaction.

264

Internships with Job Placement

In addition to apprenticeships, which we discussed in Chapter 4, internships provide in-

person training (although they often occur after training is complete) and can provide a testing

ground to help match candidates with jobs. Internships are generally not considered part of

employment, but can lead to jobs, while an apprenticeship is itself a job. Some internships are

paid, while others are not; some offer formal educational credit. All give job experience that can

help qualify someone for a position. Internships also can address issues of incomplete training,

employee confidence and independence, and employer confidence, and they can lead to better

job retention.

For example, the Connecticut State Health and Life Sciences Career Initiative, which was

funded by a $12.1 million U.S. Department of Labor Trade Adjustment Assistance Community

College and Career Training grant, set a goal of creating 360 internships and 2,000 jobs because

“It is well established that students with internship experience have more success in finding and

retaining jobs.”

265

Other programs provide internship training to create a pool from which they

can recruit, such as the Health Care Training and Employment Program for Entry-Level Health

Professionals at Partners HealthCare in Boston, Massachusetts, which provides members of the

community with free training, clinical internships, and employment opportunities.

266

In a phone

conversation on July 18, 2019, one key informant identified internships as a way to increase

exposure to more-diverse potential candidates, which leads to a more-diverse workforce.

Policy Opportunities

In earlier chapters, we found evidence that training improves the quality of candidates and

employees. In this chapter, we identified activities that can improve the quality of candidates

who are recruited, including ways to identify and attract better candidates. The following

considerations emerged from these findings:

• Pursuing evidence-based practices for hiring. These practices can improve the quality

of hires by increasing diversity and reducing bias that could favor lower-quality

candidates or overlook qualified ones. Most people have unconscious biases that affect

their assessments of others;

267

tools designed for interviewing or evaluation can decrease

such bias.

• Clarifying job descriptions. To improve the match between jobs and candidates, and to

improve quality, job satisfaction, and retention, employers might want to consider

developing clearer job descriptions, which might enhance their ability to attract qualified

candidates.

• Developing internships. Internships provide an opportunity to evaluate whether a

candidate is the right fit for a job and might increase diversity in the workforce by

increasing opportunities to access jobs.

Part 4. Retention

(Chapters 8–9)

8. Objective V: Create Career Pathways

Retaining entry-level health care workers in the health care industry is critical to addressing

the current health care worker shortage in the United States.

When workers do not have the

opportunity to learn new skills and advance in their careers, they are more inclined to leave their

jobs.

268

This ultimately hurts the employer and the health care system as a whole, both

financially and in terms of quality of care.

268

Ideally, turnover for specific jobs should not be

high because this takes a toll on employees and employers in terms of investment of time and

money (turnover in the direct care workforce was estimated to cost the government $2.5 billion

per year in 2004

269

). Some turnover is positive, of course. Successful professional development

brings advancement to new job titles, which is a boon for workers and the employers whose

employees remain within their system. Similarly, some employees might decide over time that

they want to switch careers or need to follow the career of a spouse to a new location.

There are various strategies that the private and public sectors can implement to prevent

excessive turnover of EHCW employees. In this chapter, we focus on creating career ladders,

offering tuition assistance (along with pay and benefits, as discussed earlier), and offering skills

development and opportunities for new roles.

Career Ladders

A career ladder is an opportunity for job promotion, leading to higher levels of pay,

responsibility, or authority. The problem of inadequate career ladders in the EHCW has been

well documented, for example, for nursing aides, MAs, and direct care workers,

30,270,271

for

whom professional growth opportunities often are not available. In the proceedings of a 2011

workshop at the National Academies titled Allied Health Workforce and Services, a university

administrator concluded that “career ladders in the allied health professions tend not to be

available.”

For these and other entry-level health care jobs, there is no opportunity for

promotion without leaving work because more-skilled, higher-paying jobs require advanced

training and skill sets. Even where formal training might not be required, there might not be

opportunities to informally learn new skills that are required by a higher-level job.

272

For employees, career ladders can lead to improved job satisfaction, fewer challenges when

trying to advance to a new occupation, and higher pay and job security.

195

For employers, career

ladders can address high turnover, maintain institutional knowledge, decrease the likelihood of

dealing with issues of worker shortages or the inability to find workers with the appropriate

skills, and build a diverse and culturally competent workforce,

209

although it is not clear for all

jobs what the specific career ladder can or should look like. Given the low pay, frequently poor

working conditions, and absence of opportunities to advance within their careers that entry-level

health care workers experience, employers, and particularly LTC employers, often find

themselves competing with jobs in other service industries, which might offer higher pay and

better work environments.

110

Where career ladders do exist, they are not clearly defined for

certain occupations

195

and can be complicated by overly broad options for advancement—thus,

sometimes the preferred term is a lattice rather than a ladder because of the many options and

complexities facing these workers at each step.

209,273

Researchers looking at organizational expectations versus employee expectations found that

many existing career development programs offer little in the way of long-term gain for workers,

despite being framed by employers as opportunities for upward mobility.

274

For example, career

programs that “consistently helped workers to gain upward social mobility were nursing

credential programs, which enabled low-level workers to move into licensed nursing positions,”

as opposed to departmental career ladders, which were limited in scope and lead to very small

wage increases.

274

The concept of a career lattice evokes not a singular path upward but instead a

multifaceted set of skills and advancements that allows people to move across occupations and

work settings as well as up, giving employees increased flexibility (although decreasing concrete

direction).

Opportunities for advancement and movement are limited among the EHCW,

30,270,271

although we found several promising examples of programs addressing this deficit. Unite Here

Health Center in New York created a career ladder for MAs, developing a training with didactic

and clinical curriculum for them to take on expanded patient education roles and creating the

opportunity for advancement as health coaches and floor coordinators.

275

As MAs progress

within the career ladder, they are given pay raises at each step.

275

Other efforts to promote career

ladders include the provision of stackable credentials, a concept highlighted in the H2P

Consortium program. Stackable credentials are a sequence of achievements—e.g., certificates,

degrees, or licenses—that can be accumulated over time and applied toward future certificates or

degree programs across different roles. The consortium, which facilitated partnerships among

health care organizations, educational institutions, and community-based organizations, sought to

transform health care education within community colleges across five states. A 2015 evaluation

of the consortium found that “nearly one out of every ten students who earned a credential

earned more than one, supporting the assumption that the stackable credential strategy improved

credential attainment rates for H2P participants.”

276

Some health care organizations have developed specific tracks to allow their employees to

advance in their careers and gain skills as they progress, such as CHAP (see Appendix A), which

serves Native and American Indian populations in Alaska. This program, which trains selected

community members to become CHAs in rural communities, provides five levels of progressive

certification that range from CHA Level I to CHP, with each level requiring 120 to 160 hours of

training. It is recommended that CHAs wait at least six months between levels to practice and

solidify new skills. CHAs not only receive further training and acquire more responsibilities as

they advance through the track but they also are better compensated. The entire process of basic

training can be completed in about two years, although for some it takes longer.

277

Similarly, UPMC has developed its own advanced positions, which it calls lead roles—e.g., a

lead MA. This allows individuals to advance to a quasi-supervisory role with more

responsibility, allowing them to gain managerial experience but not hire-and-fire capabilities.

According to correspondence with a key informant in December 2019, the leadership at this

large health care system has found that this intermediate position is successful at helping people

move into management and especially increases opportunities for people of color.

Another example from an integrated health care system is Geisinger’s School at Work

program.

278

At Geisinger, the program is coordinated by the Human Resources Organizational

Development and Training Department “to assist employees in taking the next step in their

career,” according to a November 29, 2019, email from a Geisinger executive. “Program topics

include communication skills; grammar, reading, [and] writing; patient safety and satisfaction;

medical terminology; and tactics for success and career advancement.” This staff education

program is not unique to Geisinger; other health care organizations have similar models to

position employees for further training.

279

BACH, which we discussed in Chapter 5, is a nonprofit organization that was established in

2005 in Baltimore, Maryland, with the goal of ending specific EHCW shortages in the region.

213

BACH has partnered with more than 80 educational institutions, health care employers, federal

agencies, foundations, and other community-based agencies to train MAs and CNAs in Maryland

and connect them with employers with a focus on “introducing programs that advance incumbent

employees through career ladders and custom-designed, work-based education.”

280

Health care organizations, nonprofit organizations, and educational institutions can work

together to create career ladders that include education, training, and job mobility within the

health care workforce. Both the gray literature and key informant discussions supported

partnerships as a key method of establishing career ladders for the EHCW. For example,

registered apprenticeships are one method of expanding career ladders because registered

apprenticeship programs promote both upward mobility and career advancement.

172

Joint Labor

Management Partnerships similarly encourage long-term collaboration between employers and

local unions in a manner that is mutually beneficial.

281-283

Community colleges are potential

partners in efforts to create sustainable career pathways and workforce development programs

for the EHCW.

284,285

Evaluations of career ladder programs have been rare, but some organizations have

incorporated an evaluation component into their programs. For example, the Extended Care

Career Ladder Initiative (ECCLI) was a grant program that funded 11 nursing homes and home

health agencies in Massachusetts to create career ladders for CNAs and HHAs. A qualitative

evaluation involving 102 interviews, 40 focus groups, and 19 site visits found that “the

opportunity for education and career advancement improves frontline workers’ feelings of self-

confidence and respect.”

271

Although our academic literature search returned very few rigorous

evaluations of the outcomes of career ladder programs, gray literature that documents the need

for such programs is abundant and often advocates for widespread implementation of career

ladders. A recent examination of a New Orleans Career Pathways program looked at

implementation and effectiveness in addition to cost-benefit outcomes and found very positive

outcomes including wage growth, job satisfaction, and return on investment for the 25 percent of

the study group in the health care pathway.

286

Key informants varied in their perspectives about the availability of career ladders for

EHCW members. Although several individuals acknowledged a lack of career ladders, some key

stakeholders cited examples of career ladder programs within their own organizations. Multiple

key informants noted the utility of establishing partnerships with universities and NGOs to

provide education as part of career ladder programs. For instance, one key informant, Rebecca

Hanson, executive director of the SEIU-UHW Joint Employer Education Fund, discussed her

organization’s approach to career advancement and the need for partnerships as follows:

[The objective] was to really address career advancement and create actual job

ladders beyond continuing education and skills development. We have validated

this by working with employers, workers, and unions to understand what their

specific needs are and how they align with job ladders. We validate this through

focus groups and surveys of membership and understand their interests and needs

and how they want to receive their training (e.g., online, hybrid). And thinking

about what kinds of partnerships it takes with education, labor, and management

to build sustainable career path programs.

In a July 31, 2019, phone discussion, another key informant echoed the findings of the

ECCLI evaluation, noting that the adoption of career ladders is essential for recognizing the

value of workers, which can also play a role in worker retention. They said that

There are very few rungs in the career ladders available, particularly for HCWs,

and moving up to an LPN or other nursing profession is not realistic for the

majority of people in this workforce, but we know that entry-level workers can

do more than they’re currently doing and they deserve more value than the

system affords them. . . . We actually have to build that rung in that career ladder

and create an advanced role with different sets of responsibilities and pay scale to

prove that those are valuable positions and other payers should be investing in

those types of roles.

One innovative effort from an integrated health system used the large amount of data

available to them to explore the career paths of their employees. In 2019, a key informant from

this organization described a new human resources system that will allow them to use

automation and machine learning “to highlight for our employees what the different career

pathways are. . . . We have close to 2,000 people who transfer between jobs on an annual basis,

and the system will learn about those transfers. We will be able to highlight how folks are able to

envision their career path and what their career could potentially be.”

These insights from key informants highlight the generally positive effects that career ladder

programs can have on both employees who want to advance and the employer.

Support for Ongoing Training for Skill Development

In health care organizations that provide employees with financial support for ongoing skill

development, employees’ perceptions that upward mobility is possible can improve retention and

job satisfaction.

274

For example, Dill and colleagues found that an employee’s perceived mobility

within an organization is positively associated with overall job satisfaction and intentions to stay

with a current employer.

287

Tuition assistance and other financial benefits offered by an employer can be catalysts for

skill development and career advancement. For low-wage EHCW members, tuition can be a

barrier,

288

and taking time off from work for further training might be an even greater one.

Programs that allow training while an employee is working or even those that provide payment

for training attempt to address this challenge. For example, in the program described in the

Kaiser Permanente case study (see Appendix A), the employer pays a trainee holding the

position of sterile processing aide until 1,000 hours of training have been achieved and the

individual is certified as a sterile processing technician (at a higher salary).

When workers advance, attrition might be a concern to employers—given that employees

can take their newly acquired skills elsewhere for new opportunities

289

—but it is also possible

that, with thoughtful planning, the employee’s current health care organization can internally

promote individuals, especially if training is coordinated with advancement opportunities.

287,290

Alternatively, organizations can modify their training assistance programs by including

stipulations that require workers to stay at the organization for a certain amount of time, as the

VA does.

There is a modest amount of evidence that tuition assistance and other financial support

programs promote worker retention in health care in general, with experts repeatedly citing

tuition assistance and loan reimbursement as ideal methods for strengthening retention.

24,291

For

example, the IOM’s 2008 report on building the health care workforce specifies scholarships and

loans for education as a key retention tool, with loan repayment and financial incentives being

the most successful at retaining physicians in rural areas of need. However, no such research is

available regarding the EHCW.

110

In a phone discussion on May 8, 2019, various experts alluded

to the need for this type of assistance, including one key informant who noted the high

educational cost:

How much tuition [is] being paid for people to go to technical schools,

community colleges, let alone four-year colleges? We don’t have a very good

handle on the debt piece of it and so when people are faced with a training

program for one year that’s for a medical assistant job that may be $10,000—that

is a huge debt load that one might be taking on. To think about how one might

complete a four-year degree that can be quite burdensome. Ultimately you have

to step out of workforce in order to do that.

Role Expansion Through Skill Development

Role expansion can be achieved through skill development.

Skill development programs

can expand the scope and competencies of existing roles by teaching skills necessary to perform

at a higher level within one’s role, which is sometimes referred to as upskilling.

292

These types of

programs can also prepare individuals to transition from one job category to another.

Many health care organizations have created internal programs for skill development and

paths for EHCW members to transition into new roles. For example, Project LVN LEAD, based

in California, developed leadership and management skills among LVNs to support their growth

as supervisors in nursing homes.

293

For HHAs, PHI’s Care Connections project in New York

created a higher-paid advanced HHA role in home health care agencies, through which aides

underwent three months of classroom and on-the-job training.

294,295

This role, called the senior

aide role, did not extend HHAs’ scope of practice, but it was designed to give aides further

responsibility in the form of taking observations and feeding this information back to the care

team. In another example, a day-long program, known as Advanced Training on Nursing Home

Resident Needs, builds skills among nursing assistants to identify a problem specific to their

facilities, design an intervention to address that problem, and propose outcome measures to

assess the success of the intervention.

296

In a final example, a physician group in Illinois tied the

completion of clinical projects—in such areas as process improvement—to pay increases for

MAs.

297

The idea behind this is to reward MAs for each rung they climb on their career ladder.

There have been a limited number of formal evaluations of skill development programs for

EHCW members, but emerging evidence suggests that expanding roles can reduce turnover. One

example of a multifaceted program that successfully addressed nursing assistant turnover is the

Win a Step Up program in North Carolina nursing homes. This ongoing workforce development

intervention seeks to address issues of retention and job satisfaction. During the operational

phase, nursing assistants had the opportunity to complete a 33-hour curriculum “focusing on

clinical and interpersonal topics, such as infection control, being part of a team, and dementia

care.”

The program required a formal commitment by the workers, including a contract stating

that they would stay in the job for three months. In return, the employer committed to provide a

retention bonus and/or a wage increase of at least $0.25 per hour to the direct care workers who

completed the program.

An evaluation of this program found that “nursing facilities that

participated in the Win a Step Up intervention were significantly more likely to have below-

average turnover—that is, a turnover rate below the mean yearly rate of 107 percent

—in the

year that they participated in the intervention.”

Such programs expand EHCW roles and

position employees for further advancement in the field without requiring them to forego an

income.

Turnover can exceed 100 percent in the event that the typical position is turned over more than once during the

period of analysis.

Key informants noted that EHCW members within their own health care organizations have

expressed interest in expanding their skills. For example, Shana Welch of Mercy Health and

Saint Joseph Mercy Health System remarked that

A few years ago, all medical assistants needed to become registered or certified

in order to access health records. At that time, we started to see a shift in the

importance they play on the team, and we started to see a shift in broadening

their scope. In cases where the MAs are then stretched to work “at the top of their

certification,” that is when they start to get the appetite for more. They say,

“Wow, I really want to go on to nursing,” or “I think I want to become a

[physician assistant].”

There are also programs that create new roles for existing workforce members. For example,

Geisinger Health recently created a community health assistant role, which is similar to a

community health worker but focuses on visiting people in their homes, akin to an HHA. The

role requires a high school diploma and an eight-week training program. Although there is no

specific career ladder for these employees, the new role allows other staff to focus on a more

narrow set of tasks, including allowing case managers to spend more time engaged in their

clinical work.

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One example of legislation around new roles is in New York, where the state

legislature ratified the Nurse Practice Act in 2016, recognizing the category of advanced home

health aide, such that those certified are permitted to perform such tasks as administering

medications and injecting insulin.

201,299

This was enacted, in part, to respond to an increasing

need to support older adults and those with disabilities to live independently in their homes.

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Policy Opportunities

Career pathways for entry-level health care workers ensure that talented individuals have the

opportunity for promotion, greater responsibility, and improved wages over time. Mechanisms to

achieve this goal include programs that lead to a career ladder and subsidies for educational

opportunities outside employment that lead to career progression. The programs and literature

outlined in this chapter demonstrate the diverse ways in which employers can facilitate the

adoption of these elements in their own organizations. We identified the following approaches

for expanding these types of efforts:

• Creating career pathways that facilitate job security and upward mobility.

Employers can work with educational and training institutions to accomplish this. Health

care employers can support EHCW members by removing financial barriers to

continuing education through tuition assistance, loan reimbursement, and scholarships.

This can improve retention.

Federal and state governments could provide incentives,

either financial or resource-based, to various stakeholders to encourage the creation of

career ladders. Federal and state governments could also update and further disseminate

toolkits, such as the Career Pathways Toolkit from the U.S. Department of Labor.

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• Expanding research on career ladders and stackable credentials. More analysis is

needed to determine what constitutes successful career ladders—i.e., pathways that

provide opportunities for retention and advancement. Part of this work relates to

considering credentials that can be accumulated for advancement over time and across

fields—a lattice approach rather than a linear ladder model.

• Using training to support career mobility. Time off from work or tuition support to

develop new skills allow for career advancement with the same employer.

• Expanding roles for current workers. Roles for workers can be expanded by

reassessing the scope of responsibilities for EHCW members. Employers can provide

career advancement opportunities for their workers, allowing them to gain skills while in

their current positions that translate into increased wages and greater recognition.

9. Objective VI: Improve Work Environment

Employee retention goes beyond financial and nonfinancial incentives, career ladders, and

skill development. To create a sustainable workforce, workers need a caring and supportive

environment that encourages employees to remain with an employer. This aspect of workforce

sustainability can be bolstered by several different actions, including performance recognition,

work flexibility, work predictability, safeguards against burnout, and adequate compensation and

benefits. Given the historically low levels of retention and recognition among entry-level health

care workers in general, efforts in this area might have particular impacts on this workforce, for

example in direct care,

302,303

in nursing,

304

and in community health workers,

305

for whom job

satisfaction and support at work has been closely linked to retention.

Performance Recognition

Performance recognition can take the form of employer recognition and reward programs,

programs to encourage peer-to-peer recognition, and informal communication by managers that

workers are performing well. Promotions and pay increases or bonuses commensurate with

performance also provide a critical means of recognition. Employer recognition of worker

performance can build trust.

306

Workers who feel valued and appreciated may be more likely to

remain with their employer. This also might improve patient care and increase the likelihood of

advancement along the career pathways discussed in Chapter 8. The more self-confident workers

are, the more likely they are to perform well at work.

306-308

Increased satisfaction associated with

performance recognition might indirectly aid future recruitment efforts. Many workers learn

about jobs through word of mouth, and satisfied employees could help recruit high-quality

candidates.

Several programs feature recognition of worker performance as an activity designed to

increase retention and improve job satisfaction. The retention specialist program for CNAs in

New York and Connecticut was designed to reduce turnover among direct-care workers by

employing a staff development model in recognition of performance. The program, which was

implemented by Cornell University as part of Better Jobs Better Care, trained one staff member

in each participating nursing home to serve as a retention specialist with the expertise and

support to address low job satisfaction and resulting turnover. The retention specialists were

charged with evaluating needs and resources, customizing a CNA retention strategy, and

evaluating outcomes for CNAs. Average CNA turnover decreased by 10 percent, CNAs rated the

quality of their workplace as higher, and CNAs reported that their workplace attempted to “keep

good employees.”

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Although the program was successful, it is unclear which aspects of the

program were responsible for improved retention.

Some programs use patient recognition of worker performance. The Care to Share program

for entry-level and other health professionals in Maine enables patients to directly record positive

messages about their experience onto a hospital server. The messages are later shared at staff

meetings.

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Another program at Vident Medical Center in North Carolina employs a storytelling

strategy that involves sharing patient and provider stories through annual “Experience in Care”

videos. Vidant also published “Connections,” an anthology of 66 caregiver stories demonstrating

the power of patient and family-centered care.

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One key informant pointed out that an absence of performance-based pay raises can

negatively affect workplace morale. This person, who is in talent acquisition at a large health

system, shared in a May 20, 2019, phone discussion that some hiring managers perceive

automatic annual pay raises to be problematic for workers who might feel less motivated to

improve performance without a financial incentive to do so. However, another key informant

with knowledge of training programs for CHWs and CHRs told us in a phone discussion on

April 18, 2019, that payment-based incentives are only part of the equation and that perceptions

among colleagues regarding the value that these individuals bring to their organizations also

affects retention.

Despite the promising anecdotal reports of performance recognition, we did not find

conclusive evidence of a positive effect of performance recognition activities on EHCW

retention in the literature. However, there is circumstantial evidence to suggest that performance

recognition and employee retention are connected in other sectors.

312,313

More research is needed

in this space to empirically identify return on investment for recognition programs for EHCW

contributions.

Positive Work Environment and Supportive Supervision

The literature suggests that a positive work environment is characterized by trust, worker

engagement, and worker productivity.

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A healthy workplace is one in which employees are

empowered to work productively and treat one another with respect.

315

Positive work

environments might be just as easily characterized by what they are not. Several key informants

spoke with us about threats to positive work environments for peer specialists in health care

settings. According to phone conversations with key informants on May 3, 2019, May 17, 2019,

June 7, 2019, and May 13, 2019, a lack of regular supervision, inappropriate delegation of work

to peer workers, and lack of respect from colleagues, can all contribute to a negative work

environment.

As one key informant told us over the phone on May 3, 2019, supervision of peer specialists

tends to be provided more closely when the person is first hired, but it diminishes over time as

clinics become busy and supervision hours are supplanted by other pressing needs. Another key

informant with expertise on peer specialists told us in a phone conversation on May 13, 2019,

that where peer support is inadequately implemented, peer specialists might be treated poorly by

some members of the care team who do not understand the role, and this makes supervision and

workplace supports particularly critical to the creation of a healthy work environment for them.

A key informant with knowledge of CHAs told us in a phone conversation on June 20, 2019,

that CHPs who have received more education and training are better equipped to handle the

clinical challenges they encounter, and this makes for a more positive and satisfying work

experience. Another person with expertise in CHWs and CHRs pointed out over the phone on

April 18, 2019, that the recognition of CHRs by providers who understand the CHR role on the

care team can help create a more positive work environment. According to this person, as peers,

CHRs “feel collectively stronger as a team” when their colleagues know and appreciate what

they do to provide patient care.

Several key informants emphasized the importance of championing certain types of workers.

One key informant told us in a phone conversation on June 25, 2019, that many physicians and

other clinicians do not understand or accept the CHW role, and it is the job of the supervisor or

manager to communicate the importance of CHWs to the care team and to ensure that members

know how to function productively in care teams with CHWs.

The use of professional coaches to help workers navigate workplace roles and relationships

can also facilitate a more positive work environment. As one key informant told us in a June 11,

2019, phone discussion, professional coaches can help employees address such issues as

transportation to work to ensure that workers are well positioned for success. One expert

remarked in a phone conversation on June 25, 2019, that supervisors of CHWs need to provide

support and guidance on documentation, delineation of roles and responsibilities, and ways to

stay safe while working in the field.

According to our literature review, activities to improve the work environment for the

EHCW appear to have a positive impact on retention; however, the creation of a more positive

work environment is difficult to systematically and quantitatively document, particularly given

variation in occupations and work settings. In some cases, familiarity with the roles and

competencies of the EHCW is lacking.

Programs that encourage other health care workers to

respect and collaborate with entry-level workers appear promising and should be explored

through more-rigorous evaluation.

Burnout

Burnout appears to be a growing problem in health care, not only among physicians and

those with advanced training in health care but also among the EHCW. For example, burnout has

been demonstrated as an issue for nurse care managers, MAs, LPNs, and administrative clerks.

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Clinical responsibilities can be emotionally taxing, and the experience of compassion fatigue or

vicarious trauma can make work difficult. As one key informant with experience as a peer

specialist told us in a phone discussion on June 7, 2019, weathering challenges associated with

client grief, loss, and illness is challenging. Workers in helping professions must practice self-

care and professional resiliency to ensure that they are able to manage stress, process loss, and

remain healthy through their ongoing work with clients.

The LTC workforce is particularly vulnerable to burnout, although it has not been studied as

much as other fields, such as nursing.

317

Sources of burnout can include documentation burdens

for credentialing and for clinical work in some EHCW settings, long hours, high risk of injury in

some positions, difficulty with control over jobs and clients, poor communication and workflow,

and patient morbidity and mortality.

318-320

Stakeholders identified administrative burdens as a

key contributor to low morale and high turnover.

165

Addressing burnout can improve retention. Burnout is a predictor of turnover or intent to

leave,

317

and reduced turnover can improve the work environment for all workers. Finding

meaning in one’s work is both a means of mitigating burnout and an outcome that can improve

overall workplace morale.

321

Stakeholders identified administrative and paperwork burdens in

particular as a key contributor to low morale and high turnover.

165

Several key informants spoke about antidotes to burnout. One key point is the need to

provide entry-level health care workers with ongoing support. As one key informant with

expertise on CHWs and CHRs told us in a phone conversation on April 18, 2019, it is important

to support CHWs as frontline providers, particularly their mental health and well-being.

Supervision and thoughtful management can be a means of preventing burnout. As another key

informant with knowledge of CHW programs told us in a phone conversation on June 25, 2019,

supervisors can help CHWs manage patient caseloads and keep work responsibilities within a

predictable and reasonable range. Managers can meet regularly with CHWs to discuss patient

cases and challenges, working with them to make adjustments as needed to anticipate and

address worker needs. Supervision was also cited by a key informant in a phone conversation on

May 17, 2019, as critical to the support of peer specialists.

Numerous programs centered on enhancing job satisfaction and reducing inadequate

supervision, which contributes to burnout. One program that was particularly innovative was the

community-based cosupervisory CHW Model of Mayo Employee and Community Health (ECH)

primary care practice.

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Because burnout and stress are often associated with inadequate

support, CHWs were cosupervised by community-based nonprofit organizations and the ECH

clinic, which contributed to smoother workflows (supporting the idea that supervision can help

with burnout). Another program that stood out was the previously discussed retention specialist

program, which created a specialized position for a staff member with dedicated time and

resources to address factors leading to turnover among CNAs in nursing homes, such as work

environment (e.g., communication, career ladders, mentoring) and overall resources and training

(e.g., financial well-being, healthy lifestyles, parenting, transportation).

309

According to a June 7, 2019, phone conversation with one key informant with expertise as a

peer specialist, professional resiliency issues are a common reason for turnover among peers.

This person suggested that better training for professional resiliency self-care and strategies for

processing grief and loss, partnered with attention to initial screening for personality type, could

encourage better professional resilience. According to this key informant, seeing clients make

progress in healing and recovery is a deeply rewarding aspect of the job for many peer workers,

and developing skills to manage the challenges associated with this clinical work can help

sustain peers in their work. More generally, finding meaning in one’s work is both a means of

mitigating burnout and an outcome that can improve overall workplace morale.

321

By sharing

strategies and resources for processing loss and practicing self-care in professional settings, as

well as by finding meaning in one’s work, peer supervisors and managers can help prevent

burnout among workers.

Technology, although it has the potential to lead to efficiencies, has made paperwork more

burdensome in some settings, where what used to be an oral order has become multiple clicks in

the electronic health record (EHR).

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The solution might be auto-filling known fields, using

templates and macros, linking similar orders under a single order set, and finding other

efficiencies. Telemedicine or remote consultation to prevent unnecessary office visits, e-consults

to allow providers to get advice from experts without referring a patient elsewhere, and home

monitors to track chronic conditions (which decreases the need for home visits) all have the

potential to increase efficiency. Well-designed tools and systems, including those with

interoperability and well-functioning communication systems, can reduce burnout, according to a

2019 National Academies report on clinicians.

324

For office staff specifically, simplifying and

unifying communication systems and using secure text messaging instead of phone calls to

reduce no-shows are additional examples of how technology can reduce burden.

325

Despite the promising elements of programs designed to prevent and address worker burnout,

we did not identify evidence that these efforts were definitively associated with improved

retention of entry-level health care workers.

Work Flexibility and Predictability

Work flexibility refers to the ability to take time off, receive coverage for illness or childcare,

and generally be able to choose a schedule that works with personal commitments. Direct care

workers often face nonstandard work schedules, such as shift work outside of normal workday

hours or on weekends, that are associated with lower job retention rates.

326

Workers who are

assigned to non-daytime shift work and weekends have lower retention rates in their jobs.

326

Among nurses in public health agencies, the promise of a flexible work schedule is a strong

recruitment factor,

although schedules significantly depend on the occupation and population

being served: Many entry-level workers have erratic and unpredictable schedules where they do

not know how many hours they will be able to work a given week.

Workplace flexibility has been less frequently targeted by workforce programs for entry-

level health care workers, although it was a component of at least one of the innovative programs

we identified. The Open Door, Inc. program for human immunodeficiency virus– (HIV-)

positive peer navigators in Pittsburgh, Pennsylvania, offers them paid time-off incentives to

attend medical and social support appointments to manage their disease and learn positive coping

skills.

327

In the peer-reviewed literature, we found limited evidence that flexibility is important to the

retention of entry-level workers. One study of RNs, LPNs, and nursing aides found that

organizational culture affected retention for all classes: More-flexible organizational culture

specifically was associated with the satisfaction and retention of LPNs in this study.

328

Several key informants spoke with us about workplace predictability and flexibility during

our discussions. In a phone conversation on May 3, 2019, we heard that unpredictable schedules

are a particular challenge for HCWs, who have their work hours—and therefore, their wages—

reduced unpredictably, making it difficult to manage monthly expenses for transportation and

basic needs. We heard that this lack of scheduling certainty and lack of guaranteed hours has

implications for retention. HCWs will choose to work in other industries with more-regular hours

if they cannot afford the unpredictability of shortened work hours.

Another key informant with knowledge of CHAs told us in a phone conversation on June 20,

2019, that work flexibility is also a challenge for upward mobility in an entry-level role. For

CHAs looking to progress from the entry-level positions into more-advanced CHA roles, the

training can be difficult to complete if it conflicts with family commitments. If training is a

prerequisite to advancement for workers, then the scheduling of such training programs is an

important consideration for retention and upward mobility. Although it makes intuitive sense that

work flexibility facilitates retention, and although there is some research to that effect,

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research specifically with the EHCW is needed to determine the nature of the relationship among

several factor; specifically, workers’ control over their work schedule, turnover, performance,

and satisfaction.

Policy Opportunities

There are several policy opportunities to scale successes associated with retention activities,

including with respect to improved workplace support and experience, along with performance

recognition and work flexibility. Specific opportunities include the following:

• Promoting positive work environments and supporting research on impact and best

practices around care settings. Some programs might improve the EHCW work

environment, but effectiveness has not been well documented. Further study is needed to

determine which aspects of these programs are key to enhancing EHCW retention. Low-

wage and frontline workers are underrepresented in industrial-organizational research,

which tends to focus on white-collar and managerial workers.

330

EHCW-specific research

would be helpful to determine which established workforce findings are generalizable to

EHCW occupations.

• Increasing the flexibility and predictability of EHCW occupations. It is important for

workers to know how much they will be able to work in a given time frame for planning

and budgeting, and it is stressful and potentially infeasible to accommodate last-minute

shifts, in light of childcare and other obligations. Increasing the predictability of hours

and income, as well as flexibility when needed, can contribute to job satisfaction, and, as

a result, can improve retention.

• Maximizing staffing expertise. Staff should be engaged and challenged to fully use the

training they have received. Functioning at the top of one’s license or certification allows

individuals to feel stretched, which is beneficial in supportive environments. Tracking

whether staff feel challenged and motivated to use their skills through surveys or during

performance reviews is one way to generate an internal feedback loop that leads to

reformed practices.

Part 5. Health System Strengthening

(Chapters 10–14)

10. Objective VII: Improve Workforce Distribution

Improved distribution of the EHCW refers to efforts, such as legislation, programs,

partnerships, and forms of regulation, that aim to address the existing maldistribution of the

EHCW—for example, the low numbers of entry-level health care workers in rural, low-income,

and minority communities. Ways to improve distribution include targeted training, recruitment,

and compensation. Telehealth, which can also be used to increase access and address

maldistribution, is considered in Chapter 13, where we discuss technology more broadly.

Target Training and Recruitment to Areas of Need

One way to address maldistribution is to focus training and recruitment efforts in locations

and for populations where the mismatch between supply and demand is particularly pronounced,

especially for specific job categories. Policymakers and program managers can leverage labor

market data to identify shortages and provide appropriate motivation and incentives to steer job

seekers toward underserved communities and populations. For example, in a phone discussion on

June 20, 2019, one key informant told us that “We use labor market data to identify where

shortages are, which allows us to do career counseling with workers who are interested. We help

them steer toward occupations where they are likely to get hired where there is a shortage in the

field.”

Research on training availability can also be used to guide targeted training and recruitment

efforts. In a presentation to the IOM at a workshop titled Allied Health Workforce and Services, a

group of researchers mapped community colleges to find areas that lacked access to one of 18

“rural-relevant allied health occupations.”

These were positions that can be filled by candidates

with training at a community college.

iii

The researchers found that large areas of the United

States, especially in the Midwest and West, had no community college programs for these

occupations. They also found that only 78 percent of rural populations in the country are within a

60-minute drive of a community college with an allied health occupation training program.

When sorting programs by occupation, they found that more rural populations (55 percent) were

within a 60-minute drive of a program for MAs, but only 35 percent were within that distance of

a DH program.

Identifying these kinds of gaps is essential for education program planning.

iii

Specifically, these occupations are DA, DH, health information and medical records technician, MA, occupational

therapist assistant, pharmacy technician or assistant, physical therapist assistant, veterinary technician or assistant,

cardiovascular technologist, electrocardiograph technician, emergency medical technician or paramedic, nuclear

medical technologist, radiation therapist, respiratory care therapist, surgical technologist, diagnostic sonographer or

ultrasound technician, radiographer, and clinical or medical laboratory technician.

According to the lead researcher on this project, “We need data to begin getting the right people

at the right places at the right times.”

States have created programs to focus training opportunities for entry-level health care

workers in rural areas. The MRAHPTP, for example, enables rural training opportunities for

EHCW students in the state. Housing and transportation costs are covered during the students’

clinical rotations if the rotations are done at a rural training site. The program’s overall goal is to

provide these students with rural, community-based clinical training rotations and eventual

employment with a rural health care provider.

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The Workforce Investment Program for LTC

workers in New York was authorized by the Medicaid Redesign Team Waiver Amendment

under New York’s 1115 Demonstration Program and allocates $245 million to initiatives that

recruit and retain health care workers in Long Term Care Workforce Investment Organizations

in the state. The program has a broad goal of supporting the critical long-term health care

workforce infrastructure but will also undertake other initiatives, such as developing plans to

place LTC workers in medically underserved areas.

331

There is evidence that such programs work. For example, the HRSA-funded Behavioral

Health Workforce Education and Training Program (BHWET) aims to expand direct mental

health service access in underserved areas. This program improves behavioral health outcomes in

underserved communities by supporting the expansion of internship and field placement training

experiences for behavioral health workers and peer paraprofessionals. Results so far demonstrate

success: One year after program completion, 47 percent of graduates were working in a

medically underserved community or rural area and roughly 60 percent were working with

children or transitional-aged youth—a vulnerable population at risk of developing behavioral

health problems that the program aims to address.

332

Other policies can support better distribution. For example, the 2014 Workforce Innovation

and Opportunity Act authorized funds for federal grants to states for public employment service

programs to expand access to worker training, education, and support services. It also aims to

help employers find workers.

333

This work is mostly done through state and local organizations

and is very relevant for the EHCW.

334

When the funding is used in mismatched areas, it can help

address the challenges this workforce faces.

Use Compensation to Improve Distribution

A commonly tested approach to improving geographic distribution is loan repayment or other

kinds of financial compensation. Financial incentive programs have placed significant numbers

of health workers in underserved areas.

335

A 2017 report by the National Conference of State

Legislatures on improving access to care in rural and underserved communities identified several

compensation strategies to address maldistribution at the state level, including pathway

programs, scholarships, and loan repayment programs.

334

However, the majority of these loan

repayment programs support only physicians and others with advanced training.

Housing is a benefit that was suggested both by some key informants (noting in a phone

conversation on , that workers at many agencies often lack stable housing) as well as some

research studies, including a 2017 report that found that “among the 203 metro areas studied,

home health aides [were] able to afford to rent only a modest two-bedroom apartment in one

metro area: Mansfield, Ohio.”

336

Although in an ideal world, market forces would lead employers to pay employees a living

wage, this is not always the case—including for members of the EHCW.

For example, despite

the lower cost of living in rural parts of the United States, many individuals become wedded to

their local communities, making the financial pull insufficient to overcome maldistribution.

Policy Opportunities

Despite many examples of programs addressing maldistribution, there is a shortage of

research on what kinds of interventions work. The following actions could be considered:

• Leveraging market data to steer job seekers toward high-need settings. Better data

are needed for employers to maximize the use of targeted training and hiring, including

data that track whether individuals trained and hired in rural settings ultimately stay in

these communities or move elsewhere. Conversely, economic data from job postings

could be used to determine the threshold difference in market salary at which job seekers

are sufficiently enticed to relocate to underserved settings. Likewise, techniques in

advertising, such as A-B testing, could help determine the type of messaging that is

effective in appealing to job seekers who might consider this sort of career.

• Increasing financial incentives. Financial incentives show promise for distributing

primary care health care providers, including some nonphysician roles, such as DHs, to

rural areas and retaining them there. Expanding the application of these financial

incentives could be one strategy for enticing providers into underserved communities.

• Exploring nonfinancial incentives. Nonfinancial incentives have also been shown to

affect distribution, although with limited evidence specifically for the EHCW. Access to

affordable housing might be a key element in recruiting entry-level workers, particularly

direct care workers.

11. Objective VIII: Empower the Workforce

Empowerment is a fuzzy term. However, it is an important concept when considering

mechanisms to strengthen and expand the EHCW. In the EHCW context, we are referring to the

degree of power EHCW members have to represent their own interests.

337

Empowerment in this

sense, particularly in the form of unions, can improve wages and working conditions, provide

greater workforce protections, and provide EHCW members with a say in their roles and

responsibilities—ultimately leading to more-fulfilling experiences. We discuss empowerment

from three vantage points: unions, cooperatives, and coalitions.

Role of Unions

The U.S. health sector, particularly with regard to the EHCW, is one of the most unionized

industries in the country. For example, National Nurses United (NNU) has 185,000 nurse

members across all 50 states,

338

while the SEIU represents more than 1.9 million members,

including HHAs, nursing assistants, and lab technicians.

339

The role of unions can be seen in a variety of recent examples. In July 2019, an SEIU chapter

in Oregon settled a multiyear contract dispute for 24,000 state employees—including HCWs—

that generated a 10 to 15 percent annual wage increase and no rise in health insurance costs.

340

Similar increases have occurred in states like Washington.

341

In another example, the NNU

ratified a five-year contract in 2018 that prevented KP from reducing the wages of 19,000 nurses

and that increased nurse staffing hires as KP transitioned to a new EHR system.

342

A third

example comes from the National Union of Healthcare Workers, which won a case in 2017 to

rehire and provide backpay for five nursing home care workers who were illegally fired after the

individuals planned to assemble in opposition to workforce and patient safety conditions.

343

examples such as these, the collective assembly of the EHCW to represent their interests through

unions has led to financial and health benefits and workplace protections.

The role of unions is less clear in increasing workplace satisfaction. For example, a 2011

study found that unionized RNs reported less job satisfaction compared with nonunionized

RNs.

344

However, it is possible that dissatisfaction was the reason employees joined unions in the

first place.

345

Evidence indicates that union members are less likely to quit their jobs compared

with non-members, which might be partially attributable to financial and other benefits secured

by unions.

345

However, more research is needed that is specific to individual EHCW

occupations.

Discussions with EHCW experts highlighted the role of unions in informing practical

decisions. For example, in a phone conversation on June 11, 2019, one key informant at a large

health system remarked about engaging unions: “We are always assessing what patients are

100

expecting . . . changes in the marketplace, having conversations with unions’ underlying staff.”

In a phone discussion on July 9, 2019, another key informant, in discussing recruitment efforts,

said, “The union is our third partner in this,” noting that the union works with the employer to

identify and recruit workers to go into programs: “If the union takes shared responsibility for

skill enhancement, the employer and union will work together.”

Role of Cooperatives

A cooperative is a firm that is owned, controlled, and operated by its employees.

346

In a

cooperative, individuals function as an autonomous collective with mutually shared economic

and vocational goals. Compared with a top-down management structure, in a cooperative model,

a large share of the decisionmaking is democratic. The cooperative model is relatively rare in the

United States compared with European countries, such as the United Kingdom. However,

approximately 1 billion people worldwide are members of cooperatives,

347

and cooperatives have

several potential benefits for participating members. First, by shaping the direction and

organization of the company, members might have a stronger sense of ownership and self-

efficacy, which promotes job satisfaction.

348

Second, and relatedly, pay might be more evenly

distributed among members of the workforce, leading to higher wages among entry-level

workers.

349

Third, compared with other business models, cooperatives tend to be more resilient

and therefore promote job stability. For example, a 2007 study found that the five-year survival

rate of cooperatives in the United States is 90 percent, compared with 3–5 percent for traditional

businesses.

348

There are few cooperatives in the U.S. health sector. However, home care represents an area

in which the cooperative model has recently grown. For example, Cooperative Home Care

Associates (CHCA) is a nationally recognized, worker-owned home care agency of more than

2,000 individuals that offers a free, four-week HHA training program in English and Spanish,

with graduates receiving certification as HHAs and personal care assistants and guaranteed

employment at CHCA.

350

CHCA successfully trains more than 600 low-income and unemployed

women each year, primarily in the Bronx.

351

In another example, a partnership launched in 2017

between the American Association of Retired Persons (AARP) and Capital Impact Partners has

sponsored a national effort to scale worker-owned home care cooperatives throughout the United

States, with the aim of using this model to empower women aged 50 and older who have

experienced economic inequality and job insecurity, a population that represents a majority of

the home care workforce.

352

The partnership extends opportunities for training, competitive

wages, and career advancement for participants. One beneficiary of the program, Peninsula

Homecare Cooperative, has been in operation for three years; we discuss it in depth in Appendix

A. A national steering committee set several targets for the AARP and Capital Impact project,

including: (1) to reach 10 percent of unemployed women aged 50 and over with caregiving skills

and (2) to ensure that 75 percent of business revenues return to worker owners.

353

101

Cooperative models among EHCW occupations apart from the home care sector are less

common but extend into the areas of nursing, peer support, and mental health counseling.

354,355

Cooperative models also exist—on a much larger scale—on the consumer side in the form of

cooperative health organizations.

356

However, cooperatives face barriers to entry, such as lack of

access to capital

357

and difficulties developing and maintaining an organization that uses a

decentralized management framework.

358

The cooperative model was raised in two qualitative

discussions with experts. The first discussion, with Kippi Waters, founding member of the

Peninsula Homecare Cooperative in Washington state, illustrated the benefits of cooperative

membership. Waters stated that “We had about 24 percent turnover in 2018, but I think the

national average is 70–80 percent.”

Offering additional perspective on the benefits to cooperative

members, she remarked that “Sometimes people just don’t show up. But when you’re an owner,

you show up . . . they take this seriously.” The other key informant with knowledge of home care

cooperatives had a similarly positive outlook, noting in a phone conversation on July 17, 2019,

that there are roughly a dozen home care cooperatives operating in the United States, and that

there is critical mass on the ground that includes support from the USDA.

Role of Coalitions

Coalitions, much like unions and cooperatives, are tools of empowerment for entry-level

health care workers. Coalitions are temporary partnerships to achieve a common goal.

359

contrast with other forms of partnership, in which organizations align with a shared mission and

purpose, coalitions represent entities with divergent missions and purposes that assemble

temporarily based on a specific, mutually held objective.

359

In the context of the EHCW,

coalitions tend to be public-private partnerships that bring together entry-level health care

workers, insurance companies, providers, government agencies, and political representatives that

might—at times—have asymmetric priorities but agree on the urgency of a particular policy

matter. In this environment, EHCW members have a unique degree of leverage in that they have

equal footing alongside other actors with strong decisionmaking authority.

A prime example of an effective coalition is the Florida Community Health Worker Coalition

(FCHWC).

360

This coalition has sought to advance the development of the CHW profession in

Florida across multiple domains—including training and career development—by convening

presidents of educational institutions, directors of state government agencies, executives at health

organizations, and more than 500 members of the CHW workforce around shared objectives.

360

To ensure alignment of stakeholders and assess progress, FCHWC has hosted a Florida CHW

Summit each fall and spring for nine years. There are subgroup committees and a board of

directors. Deliverables include a CHW census, a certification process and standard state

curriculum, a workforce strategies plan and mentorship project, and a compendium of practice-

based research.

361

A second example is the Washington Healthcare Worker Training Coalition,

which was an alliance between Washington state’s Workforce Training and Education

102

Coordinating Board, local union chapters comprising EHCW members, community colleges,

workforce councils, and health systems to train 550 low-wage EHCW members into higher-

paying, high-demand professions.

362

It was completed in 2013. In this instance, the objective of

the coalition was to support acute care needs in hospital settings. As articulated by a key

informant with knowledge of the coalition in a phone conversation on July 9, 2019, the grant

allowed them “to connect long-term care workers and tie it to a career path that leads to even

higher pay in an acute care hospital setting.”

Formal evaluations of coalitions are infrequent, in part because the broad scope and scale of

activities are not amenable to evaluation. However, there are instances of tracking progress

toward coalition objectives. In the FCHWC example, objectives have been updated and tracked

on an annual basis in alignment with a broader mission. In the Washington example, the

coalition ended after 550 trainees completed participation and job placement. More broadly

speaking, there is some evidence from the literature that the success and sustainability of

coalitions depend on the degree of local buy-in, as measured, for example, by the number of

engaged entities and the degree of leadership exhibited.

363

For instance, an analysis of the Health

Communities Access Program, which strengthened local safety nets through financial support of

260 coalitions across 45 states, found that more than two-thirds of coalitions were sustained after

federal funding concluded, and that those most likely to succeed had a larger and more-diverse

body of members and strong leadership, as exhibited by the formation of a board of directors or

executive committee.

202

Policy Opportunities

Mechanisms that promote EHCW empowerment—such as unions, cooperatives, and

coalitions—might offer strategies to address worker vulnerabilities to job pressures created by

such factors as low wages and lack of job security. We offer the following policy considerations:

• Bringing unions to the table in efforts to empower the EHCW. Unions are tightly

woven into the fabric of the U.S. health care system. As a direct advocate for the needs

and concerns of EHCW members, unions can be crucial members of coalitions and

partnerships seeking to address EHCW challenges.

• Replicating cooperative models. There is evidence from other sectors that cooperative

models have greater long-term stability than other models of practice. The few examples

of cooperatives for the ECHW support replicating these models in the home health care

sector. Evaluating whether cooperatives lead to improved retention, wages, and job

satisfaction among members, in addition to positive patient outcomes, can determine

whether broader scale-up is well advised. Barriers, such as limited access to capital for

starting cooperatives, could be overcome through federal subsidies or reduced loan rates.

• Creating coalitions to address EHCW challenges. Coalitions, especially at the state

and community levels, might level the playing field such that all stakeholders have a

voice in shaping coalition objectives and mission.

103

12. Objective IX: Recognize the Financial Value of the EHCW

In earlier chapters, we discussed incentives that affect individual decisions to enter the

EHCW and work environment issues that affect retention. In this chapter, we discuss broader

issues that transcend each of these topics and address issues regarding how the health care

system values the EHCW and how individual providers incorporate these employees into their

workplaces. We focus on policies that shape the development of the EHCW and recognize their

value. These policies include wages, reimbursement, research on cost savings and return on

investment, and challenges with unpaid work.

Wages

Entry-level health care workers typically receive low wages,

364

particularly in long-term and

home-based care, where, according to a phone conversation with a key informant on June 20,

2019, many jobs pay minimum wage and workers cannot secure full-time work. Access to health

insurance is also limited because of part-time status, informal arrangements, and contract status,

although Medicaid expansion has increased coverage rates for hundreds of thousands in this

workforce.

365,366

According to a phone conversation with a key informant on May 17, 2019,

entry-level workers in community-based clinics and nonprofit organizations also receive lower

wages because community agencies have fewer resources for worker salaries and benefits.

According to phone conversations with several key informants on May 3, 2019, May 16, 2019,

and May 13, 2019, the degree to which certain occupations are valued by health care institutions

can also shape salaries: A lower perception of workforce contribution can translate into lower

wages.

It is difficult to track EHCW wages, particularly in home-based care, where individuals

might be paid out of pocket in cash for services, according to a April 23, 2019 phone

conversation with a key informant. Moreover, public databases on employment and income, such

as the American Community Survey and Current Population Survey, do not successfully capture

wages from multiple employers. Individual wages are reported either in aggregate or for an

individual’s primary occupation. Against this backdrop, determining trends in wages and wage

growth can be challenging. However, the available evidence points to relatively stagnant wages.

For instance, wages in the home care sector have barely changed during the past decade,

increasing less than fifty cents per hour, from $10.66 in 2007 to $11.03 in 2017,

which is

consistent with low-wage worker roles in other sectors.

367

Low wages have a dual impact: First,

they suppress level of entry into a profession,

368

and second, they contribute to turnover by

pushing workers to search for jobs with higher levels of compensation.

369

Low wages also have

other harmful effects on health and family.

370,371

104

More broadly, low wages for EHCW members are associated with costs to federal benefit

programs such as SNAP (i.e., food stamps), Temporary Assistance for Needy Families (TANF),

housing assistance, and Medicaid. At least 25 percent of PCAs and nursing aides, psychiatric

aides, and HHAs are estimated to receive SNAP benefits, based on 2015 American Community

Survey data,

372

and more than one-third of HCWs have Medicaid, Medicare, or another public

health insurance option, according to 2016 American Community Survey data.

Two programs that reported committing operating budget funds to improve EHCW wages

are the Christus Spohn Health System CHW program and the San Francisco Department of

Public Health CHW employment track. At Christus Spohn Health System in Corpus Christi,

Texas, the employer reported paying CHWs full-time salaries to staff the emergency department

and inpatient units using resources especially committed as part of the operating budget, with

support from leadership for this earmark.

373,374

In the city of San Francisco, California, the CHW

employment track is a career ladder program through which CHWs can advance to supervisory

and specialized positions and receive salaries according to an increasing pay scale.

373,374

The city

budget has been permanently modified to allow CHW positions to range from I to IV, with each

successive level associated with higher pay.

375

We spoke with several key informants about wages among peer specialists at the VA.

According to a phone conversation with one key informant on May 13, 2019, peer specialists at

the VA have upward mobility through advancement within the General Schedule (GS) pay scale

for federal workers. According to one knowledgeable key informant, peer specialists receive pay

at levels GS-6 (ranging from $33,567 to 43,638 in 2020, not including locality pay adjustments)

through GS-9 (ranging from $45,627 to $59,316 in 2020, not including locality pay adjustments),

with GS-6 being the most common level. Another expert on the peer specialist role in the VA

system reported in a phone discussion on June 7, 2019, that the VA is the largest and highest-

paying employer of peer specialists in the United States. They mentioned that receiving a

comparably high wage as a peer specialist is far more difficult in community-based agencies.

Moreover, they noted that community-based peer specialists often need to pay for their own

training and continuing education.

Wage Policy

We identified policies in various stages of consideration or enactment that would increase

wages among certain occupations, often for home health workers. One example is Illinois’s

Community Care Homemaker Wages Bill of 2018, which raised wages for home care workers

by increasing the overall rate paid to the social service agencies.

376,377

Another initiative, the

Universal Home Care Program, was on the ballot in November 2018 in Maine but did not pass.

This policy aimed to increase the salaries and improve the training of home care workers with

funding from a proposed payroll and nonwage income tax.

378,379

At the federal level, the U.S.

Department of Labor mandated that, beginning in 2015, home care workers are eligible for

105

overtime and minimum wage protections in accordance with the Fair Labor Standards Act.

380,381

There have been reports that enforcement has been ineffective, and some advocates have pushed

against capping work hours.

365

In general, efforts to influence wage policies and related labor

laws for members of the EHCW have been hard-fought, incremental, and fragmented.

365,382-386

Some sources in the literature raised the issues of financial sustainability in connection with

equitable delivery of health care, and some of our key informants echoed this.

387

For example, in

a phone discussion on July 31, 2019, one key informant remarked, “How do we use change to

impact quality of care and jobs and equity in the delivery of care and access to livable wages? I

think there’s opportunity to think about how programs serve that focus.” Another, discussing the

peer specialist position in a phone discussion on May 13, 2019, stated, “If it’s a job that you want

people to stay in, you do have to create a good living wage and a career ladder.”

Focusing on mechanisms to make the labor market for EHCW members more competitive

might provide a productive pathway to results. One team of researchers identified policy levers

to support this objective with regard to LTC, but their recommendations are applicable to all

EHCW occupations:

(1) raising wages such that worker compensation is in line with wages

paid to workers in other settings, and (2) expanding Medicaid wage pass-throughs, which are

state-level allocations of funds provided through Medicaid reimbursement for the express

purpose of increasing compensation for direct care workers.

Reimbursement Policy

Reimbursement for health care services is at a transition point. Organizations that provide

health care services traditionally have received most payments on a fee-for-service basis, which

incentivizes organizations to prioritize volume over the value of care.

388

Reimbursement is

increasingly shifting to a value-based model, which rewards the health care organizations based

on the value of the care delivered rather than the quantity of services provided.

389

Currently, members of the EHCW are paid in different ways. For example, HHAs are paid

via a fragmented system, sometimes directly and sometimes through an agency. Medicaid

benefits vary from state to state, with wages set by the state’s Medicaid program.

404

Medicare’s

fee-for-service payments are organized around episodes of care rather than direct payments,

390

and in other cases, aides are paid by families directly. CHWs, peer specialists, and MAs are

commonly salaried and paid through health centers, but the health centers in which they work are

usually paid on a fee-for-service basis, meaning that entry-level health care workers can only

indirectly enhance health center revenues by making higher-level workers more productive for

billable services. This payment scheme makes it hard to assess the effectiveness of increased

payments for this cohort. However, as payment shifts to value-based models, the role of the

EHCW in reducing costs becomes clearer. For example, with risk-adjusted capitation,

organizations are paid a fixed amount to care for an individual with a health condition over a set

time interval.

391

In this value-based model, the organization is incentivized to provide high-

106

quality community-based care that relies on competent and well-equipped entry-level health care

workers because this is a less expensive alternative to complex, facility-based care that might be

required if health conditions are allowed to worsen.

CMMI is a division of CMS that tests innovative health care payment and service delivery

models. CMMI funds demonstration programs to explore how to achieve high-quality care at

lower cost because CMS oversees two of the largest health insurance systems in the United

States and is responsible for two sets of high utilizers: the disabled and the elderly. For example,

Comprehensive Primary Care Plus, a demonstration model funded by CMMI, is a national,

advanced primary care medical home model through which roughly 2,900 primary care practices

track performance and receive payments based on access and continuity of care, care

management, comprehensiveness and coordination, patient and caregiver engagement, and

population health. Compensation is risk-adjusted for each practice to account for intensity of care

management services required, based on treatment population.

392

Comprehensive Primary Care

Plus includes a standard set of reimbursements for a variety of health services provided by the

EHCW, including home health care, transitional care management, and skilled nursing facility

care.

393

However, evidence from the first annual evaluation in 2019 indicated no uptick in the

volume of EHCW-related services.

394

ACOs that leverage provider networks to coordinate care of Medicare patients—and

theoretically achieve cost savings—have an incentive to rely on EHCW roles, such as MAs, to

perform such activities as patient visit reminders and referral coordination, but the impact of

ACOs on EHCW members has not been examined in significant detail. Collectively, these

payment policies and pilot programs have had only modest implications for the EHCW.

However, a fuller transition to a value-based model of health care delivery could have a more

sizable and transformative impact on the EHCW.

Key informants alluded to federal legislation that has shifted the landscape for EHCW

members. According to our literature review, broadened reimbursement policies reflected in the

ACA could lead to greater utilization of EHCW members.

395

A key informant from the VA

explained in a phone discussion on June 13, 2019, that changes in provider classification for peer

support staff have allowed providers—first at the VA, but then in the private sector—to bill for

peer support: “National Uniform Codes define which careers exist which define roles and

[Centers for Medicare and Medicaid Services (CMS)] services, and there was no code for peer

specialists. . . . In turn, this helped the private sector because now they had a provider

classification so that CMS could pay for peer support.”

There is also movement toward a policy change in the way CMS reimburses some types of

in-home care. CMS offered direct reimbursement for nonmedical in-home care as a supplemental

benefit for Medicare Advantage plans for the first time in 2019, but only 3 percent of plans

offered such a service in 2019 because of little time to plan.

396

107

Demonstrating Cost Savings

Another way in which entry-level health care workers can demonstrate value is by pointing

to cost savings—relative to the cost of higher-paid health care providers—as the result of their

involvement in care. Several studies have detailed the potential for cost savings. In an FQHC in

Colorado, for example, MAs were trained to assume the roles of health coach, patient navigator,

and CHW. This increased MA productivity by 50 percent, generating an additional $500,000 per

year in revenue.

102

Researchers at Cornell University designed a 20-percent full-time equivalent

retention specialist role to address CNA turnover at nursing homes. The result was an average

reduction in turnover of 10 percent,

309

which should theoretically result in significant cost

savings, although the extent of such savings was not quantified in the study.

397

A systematic review of the potential cost savings of using CHWs reviewed 34 primary

research studies, including 16 randomized controlled trials (RCTs).

398

CHW interventions had

variable effects but resulted in average cost savings on the order of thousands of dollars per

patient. For example, a study that used CHWs to facilitate asthma management of African

American children in Chicago resulted in cost savings of more than $2,500 per participant, with

an average program return on investment of $5.58 per dollar spent.

399

Better information about which interventions with which job roles are cost-effective, and in

what contexts, might persuade health systems and providers to scale the use of the EHCW and

prompt insurance companies to reimburse for these services. A key informant noted in a phone

conversation on June 13, 2019, that as more studies are published regarding the benefits of peer

specialists, more discussion about reimbursement has followed.

Unpaid Roles

Although we have focused on the paid workforce, there are many uncompensated caregivers,

often family members, who provide direct support to elderly or sick relatives. According to the

Family Caregiver Alliance, these caregivers also coordinate care within the medical system, play

an active role in condition monitoring, and often serve as advocates for high-quality care.

400

Family caregivers and other informal care providers are essentially part-time workers. The cost

of this unpaid work was estimated at $470 billion in 2013; it exceeded the value of paid home

care and total Medicaid spending, and “nearly matched the value of the sales of the world’s

largest company, Wal-Mart ($477 billion)” that year.

400

As important as this informal caregiver workforce is, we lack a clear understanding of its size

and the extent of its labor efforts; size estimates, for instance, range from 3.5 to 65.7

million.

400,401

Recent policies have aimed to support this unseen workforce, such as the

Recognize, Assist, Include, Support, and Engage Family Caregivers Act.

402

This law provided a

mandate for the Secretary of the U.S. Department of Health and Human Services to develop,

maintain, and update a strategy to recognize and support family caregivers, although to date no

funds have been authorized for this activity.

108

Policy Opportunities

There are several ways to better recognize the value of the EHCW, including remunerating

them and better demonstrating their value. We identified the following policy opportunities in

this area:

• Increasing wages for the EHCW. More than half of paid HCWs rely on a form of

public support, and average wages for many EHCW members are close to federal poverty

levels. Higher wages would draw more individuals to EHCW professions.

• Piloting cost-savings evaluations. Pilot programs to strengthen the EHCW, sponsored

by HRSA and others, routinely contain an evaluation component. Requiring these

evaluations to include cost-benefit and cost-effectiveness analyses could provide

evidence of the financial case for such programs in both the public and private sectors.

• Considering ways to leverage the EHCW to support transitions toward value-based

payments. The role of the EHCW is circumscribed in settings where there is a financial

incentive to provide complex, physician-based services within health facilities. CMMI

and other entities are continuing to transition to value-based care through alternative

payment models, but further experimentation and evaluation are needed. As organizations

shift to value-based payment models, there might be new opportunities for the EHCW to

demonstrate the value that this workforce adds.

109

13. Objective X: Use Technology to Support the EHCW

Across the key objectives detailed in the past nine chapters, technology has been a recurring

theme. It supports many of the activities detailed earlier, such as training, which we discussed in

Chapter 4. In this regard, the CHAP model in Alaska—which we discuss further in Appendix

A—represents a paradigm success case: Trainees in remote communities are able to

electronically engage with learning materials in real time and asynchronously, and this is

bolstered by in-person meetings and practicum experiences that occur intermittently.

In this chapter, we describe some of the new technologies that, if they are effectively used to

support and enhance the EHCW role, could improve patient health. The ways technology can

contribute in the health care setting are extremely diverse, including improved quality, increased

access to care and information, better and more accurate record storage and access, and use of

online jobs boards.

206

LTC settings lag in the use of technology compared with other settings and

therefore are especially ripe for new digital interventions.

403,404

Telehealth and Teleconsultation

Telehealth can improve access in underserved and rural communities

405

by reducing wait

times, decreasing transportation requirements, and improving access to specialty care.

334

Specifically, live video is a way for health care providers to provide access to people in rural or

otherwise underserved areas using technology. However, telehealth often requires a trained

person to be onsite with the patient to set up the technology and sometimes to do more-clinical

work, such as assessing the patient on behalf of the remote provider. This technology can also

enable remote consults or advice from more-expert clinicians, whether the local person is an

entry-level health care worker or another kind of provider. For example, as of 2014, the chain

pharmacy CVS is using LVNs to staff its MinuteClinics in rural locations; those LVNs are

connected to NPs at a distant MinuteClinic who are responsible for the diagnosis and treatment

plan. The LVN enables the remote NP to see the patient’s ears and throat and listen to the

patient’s heartbeat via devices that transmit live video and images.

406

Use of telehealth for behavioral health has been increasing and has been shown to be as

effective as in-person treatment in some cases.

407-409

Behavioral health poses a particular

opportunity for telehealth because so much of it is based on conversation and prescribing rather

than a physical examination. At the same time, there are sometimes downsides to not having

face-to-face interaction. As one key informant told us in a phone discussion on June 13, 2019,

“There’s always continuing discussions about how to do telehealth well for behavioral health in

particular.” Current barriers to telehealth include cost, infrastructure, and reimbursement;

addressing these barriers will increase access in general but could make it easier for EHCW

110

members, such as peer specialists, to address behavioral health services gaps in particular, given

the fact that most behavioral health care does not require direct physical interaction. Currently,

where billing codes do exist to support telehealth, members of the EHCW generally are not

eligible to use them because of the type of service offered or their occupational classification.

410

Devices

Researchers have identified several ways in which technology can help the home care

workforce;

411

specifically, with training and skills development, communication and

coordination, and workforce management. A fourth category is augmenting direct assistance

using technology. This is an emerging field and is limited by client knowledge and

understanding of technology, issues of privacy and reliability, and lack of evidence of impact,

but there is potential for home monitoring, remote tracking, and new devices that can help reduce

the need for some in-person services. Devices often are used by patients or their caregivers, but

they need trained personnel to set them up and interpret the results. This can be a role for

members of the EHCW; for example, by training patients on device use, monitoring results, and

downloading and submitting data from the devices for interpretation by other experts.

Payment models are newly supportive, and several billing codes have emerged to support

remote monitoring. Easier access to reimbursement likely will also drive increased use.

412

There

are many benefits to home monitoring, such as allowing health care workers to monitor more

patients or save trips solely conducted to collect measurements, enabling more-frequent

monitoring, and empowering patients by allowing them to better track and report their own

symptoms. However, not everyone has access to these tools.

413-416

As one analysis in Health

Affairs concluded, “In sum, the availability of assistive technologies to help home care workers

support their clients is limited by inadequate investment in research and development (with

translational research in home care settings especially needed, to identify the conditions and

competencies that are required for their safe implementation), and access is unevenly distributed

by population, region, and other factors.”

411

EHCW members are also using increasingly complex technology as part of their jobs,

including radiology technicians, who use complex imaging machines, and MAs, who routinely

use digital blood pressure cuffs, thermometers, and scales. However, they are far removed from

the device makers. As noted at a workshop at the National Academy of Medicine, “Many if not

most of the allied health professions are driven and defined by technology,”

which suggests

that these professionals could get involved with manufacturers in the design of the tool they use

(although this report includes health professionals with bachelor’s or master’s degrees as well).

One workforce expert noted the promising potential for technology to have an impact in

direct care, but this enthusiasm came with a caveat. Technology can improve communication and

enable documentation of observations, such as taking a picture of a bedsore, for example, and

sending the picture to a clinician for immediate assessment. This expert noted in a phone

111

conversation on May 28, 2019, that “We do believe there’s opportunity for technology to have a

positive impact. It’s a matter of finding the sweet spot that would be sustainable for the system.

The challenge with the technology piece is cost.” Other experts, in a report on behavioral health

in Nebraska, note that the major cost issue is reimbursement to cover not just the technology but

the startup costs and time, suggesting that even small grants could help adoption of telemental

health services.

417

Coordination and Communication

Across the United States, health care organizations are working to modernize their

technological systems, including by improving their EHR systems and the interoperability

between (and often within) institutions. These tools, however, are not always designed with the

EHCW in mind, meaning that there are not ways for workers to log in or enter information that

would be helpful to the team. To promote coordination of care, the EHCW could be trained and

contribute to the interspecialty communication that takes place via the EHR system. In a 2012

survey conducted by researchers at the University of Washington, two-thirds of respondents at

clinical practices stated that they were seeking further EHR or health information technology

(HIT) training for their staff, with nearly one-third noting that access to baccalaureate or higher-

level training was a barrier to EHR and HIT use.

Many LTC settings do not have EHR systems, and there are few ways to connect with

services in the social assistance sector electronically, which is one of the roles of EHCW

members. Where there are electronic tools, they do not usually integrate well or effectively share

client information, including the integration of behavioral health records with primary care

records.

Limits to Technology: Access and Training

There are also limits to technology. Sufficient internet access is essential but is lacking in

many rural parts of the United States, where one-quarter of the population says access to the

internet is a major issue for their community.

As noted in a report from the University of

Washington on the HIT needs of rural primary care practices, “Accessing the Web/Internet

challenged nearly a quarter of practices in isolated rural areas, and nearly a fifth in small rural

areas. Finding relevant vendors/consultants and qualified staff were greater barriers in small and

isolated rural areas than in large rural areas.”

Even where there is internet access, a portion of the population lacks the devices or the

education to use it, and these barriers are also related to socioeconomic status. For example, in a

study as part of the IMPaCT efforts (see the full case study in Appendix A), organizers wanted to

use a smartphone-based glucometer to track blood sugar for a diabetic population. It did not

work, according to the coauthor and founder of IMPaCT, because of the digital divide

experienced by the population that comes from high-poverty zip codes: According to a 2019

112

article, “We act like everybody has the same tools. They don’t. . . . People don’t have

smartphones. And even if they have the device they may not have the data.”

418

Addressing these

inequalities is much more challenging than simply providing the devices or tools.

Another report out of Montana noted a similar challenge. When workers do not have

information technology skills, it not only poses issues related to doing one’s job; it can even

make it hard to get one. According to the report, “Lack of adequate [information technology]

skills also presents a challenge to employers. One employer stated that prospective employees

can’t complete an online job application.”

208

Some employers address this problem for

employees. KP has a program to promote “digital fluency” through free online courses for staff

to learn to use computers, mobile devices, and data, and it even lends employees computers to

take the courses if they do not have them (see the case study in Appendix A).

419

Other employers

feature technology prominently as part of training.

Policy Opportunities

We identified the following policy opportunity for this objective:

• Encouraging technology adoption and standards for interoperability. As members of

the EHCW expand their roles, their engagement in communication and documentation

becomes increasingly important. Workers should be trained in technology, and

particularly in the use of EHRs. Telemedicine from remote practitioners is unlikely to

address the shortage of rural providers, but telemedicine tools can be used to fill gaps in

care coordination, especially in cases where EHCW members are visiting patients at

home, in the community, and in underserved areas. Ongoing work to standardize

interoperability and data transfer into post-acute care settings—through such coalitions as

the Post-Acute Care Interoperability (PACIO) Project

420

—will enable greater

participation of the EHCW in reviewing and exchanging patient information. More

research is also needed on how monitoring and tracking devices can support better patient

outcomes.

113

14. Research Needs

There is extensive research on entry-level workers in health care, some of which is funded by

HRSA’s Health Workforce Research Centers.

70,421

However, many key informants and our

review of the literature identified areas where there is a critical need for more data and evaluation

work.

More Data, More Coordination

Several key informants noted that national data on EHCW supply and demand from the

Bureau of Labor Statistics have limitations. They also pointed to the problem that states are not

gathering important EHCW-related data. (Multiple key informants noted this in phone

conversations in spring 2019.) According to a phone conversation with a key informant on June

24, 2019, “CHWs, coaches, [and] navigators are completely invisible or impossible to

distinguish in data because there are no codes in the data.” They continued, “Even in states that

certify professions (e.g., peer providers for behavioral health or HHAs), there rarely is any

additional data associated with that.” Another key informant identified data as a problem for

analysis or projections for this workforce in a phone conversation on April 23, 2019: “From my

vantage point, one of the biggest gaps is data. . . . If there’s no data to power the study, there’s no

way to get those projections out.” The National Academies had come to this conclusion in 2011

after a workshop titled Allied Health Workforce and Services, citing experts: “Despite all these

sources of data, the information available is not sufficient to meet many policy

objectives. . . . Differences in data collection hamper comparisons across professions, area, and

time.”

Key informants reported on the need for the modernization of various forms of

documentation associated with EHCW career paths, including the modernization of licensing

bureaus to better connect across bureaus and allow better tracking for workforce planning.

Part of the reason for the lack of data is that there are no certifying agencies at national or

state levels for certain professions—in part because these professions do not require certification.

However, as noted earlier in this report, challenges with identifying job classifications stem from

inconsistencies in understanding about the base competencies associated with different types of

EHCW positions, which in turn causes challenges in establishing the standardization of training

and certification. Where there is certification, states sometimes have information about

recertification, age, and gender, but, according to a phone conversation with a key informant on

June 24, 2019, they rarely have information about race or ethnicity, the kinds of settings in which

individuals are working, or even if they are still actively at work because certifications can lapse.

A few states were noted for short but robust surveys that are linked to licensure: North Carolina

and Indiana, for example, collect information about demographics, language proficiency, work

114

setting, and degree of work commitment through surveys administered at the time of licensing or

license renewal. However, despite recommendations from HRSA on minimum data set elements

with relatively standardized terminology, the data are not available because there is no way to

enforce these standards. The complexity of the system contributes to this: One key informant

noted in a phone conversation on June 24, 2019, that California alone has multiple different

agencies involved in home care licensing, including home health agency licensing, HHA

certification, CNA certification, and PCA optional registration. Other data sources include

establishment surveys and funding sources, such as the Perkins Data Explorer,

422

but each has

limited purview. Key informants noted that, when data are available, the quality is often limited.

According to a phone discussion with a key informant on May 8, 2019, another challenge is

nomenclature around job titles, which varies, making it hard even when there is information to

compare between states. As noted earlier, another gap in knowledge relates to the unpaid

workforce. Behavioral health is particularly lacking in information because it is often siloed from

other medical care and because there is a wide variety of providers, including social services,

that are beyond the purview of health care. In a phone conversation on June 13, 2019, one key

informant said that “Some sort of ‘registry’ or a regular national data collection on the behavioral

health workforce would be helpful in doing all the subsequent work,” noting that the information

needed goes beyond single roles:

The idea that we continue to limit ourselves to provider-population ratios to

decide how many people we need for really complex problems is not going to get

us very far in the long run. Some type of model that looks at teams, the issues

that you are trying to solve, who . . . the providers [are] that are educated, skilled

and trained to address those problems and what’s the mix of teams that you need

to be effective there.

Federal agencies are required to use the Standard Occupational Classification System, but if

there is not a code for an occupation, positions might be merged under a single term, with entry-

level health care occupations grouped into the same codes. The opposite challenge also exists:

Making changes to BLS is a public process, and some titles are introduced because of public

demand, even though they are very similar to existing entries, according to a phone discussion

with one key informant on April 23, 2019. Revision and standardization of occupation codes

could improve tracking.

Improvements at the state level would help: A recent report called for significant updates to

California’s health workforce data system “to understand and address growing care gaps.”

423

The

report called for a more centralized point of data collection and more-comprehensive data sets

for all health occupations. The Health Workforce Technical Assistance Center at the State

University of New York at Albany inventories the information that states are collecting on the

health workforce.

424,425

Better data at the state level would lead to better federal data.

All of this, however, would be only a first step in improving data collection. As one key

informant noted in a phone conversation on June 13, 2019, many factors need to be considered

115

beyond the number of providers. As new delivery and payment methods are considered, more

details about capacity and resources will be needed. Specific research questions are identified in

Chapter 15.

Addressing Gaps in Research

Many key informants noted the need for more research in specific areas, such as scope-of-

practice laws, new roles, and new team configurations. Some organizations have cataloged

scope-of-practice laws, such as at the Scope of Practice Policy website,

426

but research on the

impact of these laws is surely needed. Ideal team configuration is also an urgent research issue;

one key informant called this topic a “wild west” in a phone conversation on June 24, 2019,

observing rapid changes in team configuration but noting that “there is not a lot of research on

what those models are, what they do, [or] what their impacts are.” This key informant also noted

a need for more information about regulations on scope of practice and the potential impact on

patient safety of using new roles to provide certain kinds of care. Others noted the lack of

research around CHWs and peer support staff and what practices have the best evidence, along

with a lack of information about what training will actually improve health outcomes.

Many

reports also identified gaps in knowledge and identified areas of highest need, but priorities

varied by location and author.

84,427-429

Policy Opportunities

Better information systems would be required to collect better data. These data, in turn, could

provide critical insights into existing and anticipated health workforce needs, allowing policies

and programs to respond to this information. We identified the following policy opportunities:

• Collecting more and better data. Several recommendations from the University of

California, San Francisco, report, Envisioning an Ideal Health Workforce Data System

for California, can be applied more broadly, such as improving data collection on

workforce supply and demand and on the education pipeline; expanding data collection to

include jobs, wages, turnover rates, race or ethnicity, and languages spoken; and

conducting surveys for all health profession education programs.

430

There also should be

a way for the public to access this information, whether through email requests or direct

online queries.

• Developing a research agenda to strengthen the field. Data are lacking on patient

outcomes related to the EHCW, and what data do exist are predominantly self-reported.

According to a phone conversation with a key informant on May 28, 2019, patient

outcome data are needed to demonstrate the impact of investment on this workforce.

More information is also needed on cost, scope-of-practice laws, and the impact of team-

based models. Some of this work is already being done, but additional funding would

enable research to examine these issues more broadly.

116

Part 6. Conclusions

(Chapter 15)

117

15. Conclusions

In this report, we have sought to achieve three objectives, the first two of which are (1)

describing what is known about gaps in the health care workforce, the supply and demand

mismatch of service provision, and the challenges facing the EHCW; and (2) identifying and

cataloging innovative strategies that have been tested to strengthen the EHCW. We now turn to

the third objective: outlining potential policy opportunities to address identified challenges. At

the end of each of the previous chapters, we presented potential policy opportunities by

objective, and we now synthesize these into five overarching policy approaches, presented in

Table 15.1. We also offer detailed reflections on each opportunity.

Table 15.1. Policy Options, by Category

Opportunity

Approach

Potential Activities and Outcomes

I. Scale innovative efforts

Researchers could

dentify pathways to

diffuse and scale

promising models

• Supported innovation and scale-up of most-promising models

• Accelerated timeline for implementation of evidence-based

models of care

• Sharing lessons in a learning collaborative model

II. Evaluate new models of

are

Research could

attempt to evaluate the

specific contribution

s of

EHCW members to

strengthen

performa

nce in new

delivery system

models.

• Researchers and implementers could identify methodologies

to specifically evaluate the contribution of EHCW members for

improved value in care delivery

• Opportunities to test expanded or new roles for the EHCW

• Greater evidence to demonstrate what types of integration

work

III. Convene stakeholders

foster learning

An agency or institution

with convening

authority could

assemble stakeholders

at national, regional,

and state levels as

resource for state

coordinating groups.

• Ongoing coordination among employers, training programs,

researchers, and others to better identify and support health

care delivery needs with a workforce that is prepared to meet

these needs

• Information-sharing for problem-solving and efficient

dissemination of new ideas

• Cross-agency, cross-disciplinary, public-private coordination

IV. Address gaps in

esearch

Research can be

supported by a wide

variety of entities

• Identify important gaps in research and opportunities to fill

research gaps

• Support pilot studies with rigorous research methodologies

that address specific gaps in research

• Develop a knowledge base on the effectiveness and cost

savings of potential programs and policies

V. Expand the use of

echnology

Public and private

efforts can

educate,

standardize, and

promote

technology

• Access to patient clinical information and resources

• Improved communication, tracking, and standardization

• Broadened dissemination of best practices

• Expanded access to training on, and adoption of, technology

to strengthen the capacity of EHCW members to address a

broader array of tasks

118

I. Scale Innovative Efforts

Financial support for programs and their evaluations varied considerably across the programs

we identified. In some cases, projects were funded internally by employers to solve their own

workforce needs. In other instances, external funders provided investments that varied

significantly in terms of size, scope, and duration. The most successful models we identified

drew from a source of funding that allowed implementers to establish a model, demonstrate

impact, and (in the best scenarios) scale across domains or locations.

However, investments with a long view toward demonstrated impact and scalability were

uncommon, as outlined in Chapters 4–14 and as indexed in the workforce data website.

Thus, it

seems particularly useful to outline a short list of models that have been found to be successful

on various metrics to bring attention to what appears to be working, in the event that other

stakeholders want to consider opportunities for replication. To that end, we briefly note five

programs in Table 15.2, three of which we discuss in more detail in Appendix A, for their unique

approaches that might be generalizable elsewhere.

119

Table 15.2. Successful Innovative Programs

Program Name

Key Features

Measures of Success

Alaska’s CHAP

Location: Alaska

• Comprehensive program for

recruiting, training, and retaining

health providers in remote

communities

• Culturally competent and community-

based

• Training is highly flexible to

accommodate trainee schedules, and

participation is subsidized at a local

level

• Longevity

• Expansion (model exported to Ohio)

• Review of more than 250,000 patient

encounters published

SEIU Multi-Employer

Training Funds

Location:

national

• Partnerships between employers and

union

• Systematic approach to career

advancement, including addressing

skills, wage support, counseling, and

health care

• Evaluations show the impact of training

programs on retention and grade point

averages

281

PHCAST Training

Program

Location:

six states

• Competency-based training model to

develop certification for personal and

home care aides

• Federal support (ACA) through 2014

• Focused recruitment on unemployed

individuals in low-income

communities

• Evaluation found that “Training programs

and certification for [personal and home

care aides] appear to enhance workers’

job satisfaction and career stability.”

115

Peninsula Homecare

Cooperative

Location: Washington

• A cooperative business model for

home health care

• Cooperative models have the

potential to increase workers’ sense

of autonomy, improve wages, and

offer more job resiliency

• Evaluations of the cooperative model

in home health care are lacking

• Business model has proved to be

successful and sustainable

431

BHWET program

Location: national

• Funded by HRSA to expand direct

mental health services in

underserved areas

• Requirement for reporting outcomes

• Large spread; high rates of intention

to work in rural areas

• Evaluation so far suggests success in

terms of those working in the field

332

NOTE: Three of these examples are covered in more detail in Appendix A. PHCAST is described in Chapter 4,

Chapter 5, and Chapter 7.

115,143

BHWET is described in Chapter 10; more information can be found from HRSA and

the American Psychological Association.

432,433

Multisectoral Innovation Funding

Some of the innovative programs we identified came about because of local creativity, not

because the mechanism that funded it was intended to address EHCW needs. For example,

funding for the Peninsula Homecare Cooperative (see Appendix A) came from a loan from the

Northwest Cooperative Development Center and from support from the USDA. Prior to

Peninsula’s request for funds, these funders would not necessarily have had reason to anticipate

that their resources would be used for a home care cooperative. However, this model has proved

to be successful. Another example of a broad funding mechanism that gave flexibility to grantees

120

to develop creative, on-the-ground solutions is the Robert Wood Johnson Foundation’s Aligning

Forces for Quality program, which aimed to improve “the quality, equality and value of regional

health care markets.” Implementation strategies differed at the local level.

434

A federal funder

also could provide targeted funding through a broad request for proposal to encourage creative

research or efforts to strengthen the EHCW.

When money is invested in communities, they can use those funds to address their specific

needs. With appropriate support and oversight, communities often have the competencies to

identify and solve difficult problems. Funding vehicles, such as grants, can be designed to target

larger goals, such as the promotion of members of the EHCW to more-advanced jobs, but the

institutions that receive funding could be granted more flexibility in choosing their strategic

approach and theory of change. This is a framework that comports with results-based financing.

In addition, funders could provide support to help local efforts, such as technical support and

coordination with relevant community-based organizations. Ideally, funders also award projects

based on their design for sustainability. We identified numerous programs that appeared to be

successful, but implementation ended when grant funding ceased. Funders therefore might want

to consider building sustainability goals into their funding mechanisms.

Matching funds, where federal funds are matched to state and local government investments

or private-sector investments, encourage greater stakeholder buy-in as a way to promote

accountability and success.

This is particularly relevant in the context of LTC, where Medicaid

plays a large funding role. For instance, the Balancing Incentive Program provides financial

incentives to states to increase access to noninstitutional long-term services and supports, which

could bolster the workforce in this space.

Replication of early successes can prove very challenging. With a few notable exceptions,

139

we did not encounter models that were widely replicated. As noted earlier, one way to support

replication would be to establish formalized venues where workforce experts share their

successes with funders, and funders in turn offer bridge funds to test replication of the model

elsewhere. Innovative financing frameworks, such as social impact bonds, might be a way to

motivate private-sector engagement in this space.

II. Evaluate New Models of Care

Entry-level health care workers in fee-for-service models are occasionally employed as a

cost-saving mechanism, substituting for more-expensive individuals that have more training and

specialization. Often, EHCW members are poorly integrated into existing models of care, either

because reimbursement for their services does not exist or because cost savings have not been

demonstrated. As models of care delivery become more team-based and as financial incentives

continue to shift toward rewarding outcomes rather than service volume, cost management and

care coordination dynamics might change. In this context, the role of EHCW members could

121

become more central, as EHCW members are trained in and tasked with coordination of care and

patient education.

Experts expressed the idea that new models and configurations of care should be evaluated,

including how EHCW members can be leveraged more effectively.

For workforce planning

purposes, employers, training programs, and policymakers might benefit from a clearer

understanding of the roles and responsibilities of EHCW members within different care

configurations and how to maximize their potential.

CMMI has been a leader in this space,

funding pilots programs that evaluate alternative care delivery models and payment structures

with an eye toward workforce composition, efficiency, and cost savings.

One principal question in evaluating new models of care is whether and to what extent

members of the EHCW should serve in certain types of direct clinical roles. In several case

studies, such as Alaska’s CHAP model, EHCW members are trained to engage in clinical

activities, such as measuring vital signs, assisting in medication management, and providing

patient clinical education, and these responsibilities can grow with experience. There is also

room for individuals to assume greater clinical roles over time. However, phone discussions with

several key informants on June 24, 2019 and May 28, 2019, indicated that other EHCW

members are restricted from performing even the most rudimentary clinical functions, such as

assisting the elderly and disabled with the administration of medicines or eyedrops. This is

because of state-level scope-of-practice laws and institutional guidelines that attempt to mitigate

liabilities or that might be based on institutional perceptions of the level of training required to

perform a given clinical responsibility.

435

Variations in scope-of-practice laws for EHCW

members involved in behavioral health have been organized and documented by the Behavioral

Health Workforce Research Center at the University of Michigan.

436

Additional research could

inform how the responsibilities of EHCW members could be assessed and broadened once they

are found to be safe, effective, and cost-saving in specific settings.

III. Convene Stakeholders to Foster Learning

Although we identified programs and policies to expand and strengthen the EHCW at the

local, state, and federal levels, these efforts were often fragmented and uncoordinated. This

reflects the array of interests among diverse stakeholders: workers, employers, academics,

unions, and other groups. As noted earlier, coalition-building has been critical in making various

efforts in this space successful. Convening EHCW stakeholders to focus on action-oriented

objectives could provide a concrete and low-cost way of soliciting input on major issues in need

of traction.

There have been efforts to establish national convening bodies on this topic, such as the

National Health Care Workforce Commission, which was authorized as part of the ACA and

charged to develop a national health care workforce strategy. However, the commission was

never funded and therefore has been unable to proceed.

437

Similarly, an Interagency Working

122

Group on career pathways was established after coordination efforts began on the topic between

the U.S. Departments of Education, Health and Human Services, and Labor. The group aimed to

“promote the use of career pathways to assist youth and adults in acquiring valuable skills and

industry-recognized credentials through better alignment with employers of education, training

and employment, and human and social services.”

438

In 2016, 13 U.S. government agencies

wrote a letter of commitment “affirming the importance of aligning workforce and education

systems to support career pathways.”

439,440

The U.S. Department of Labor also funded a career

pathways toolkit in 2016, spearheaded by the working group.

438

However, according to

correspondence with a key informant on August 30, 2019, the group is neither mandated nor

funded.

Convening health care organizations, training programs, members of the EHCW, researchers,

and public policy officials to discuss opportunities to strengthen the EHCW could help identify

how best to support regional and local efforts to address needs related to this segment of the

health care workforce. This type of activity could address the following topics:

• identifying current and anticipated skill sets needed by employers and relevant job

classifications, along with approaches to effectively train future employees in various job

classifications in these skill sets

• documenting cross-state certification and licensing challenges and possibilities for greater

standardization

• identifying opportunities to develop career pathways

• clarifying where there are gaps in evidence that could be addressed to inform EHCW

training and utilization

• coordinating with states, providing technical assistance, toolkits, and support as they

work to spread innovative practices.

IV. Address Gaps in Research

There is a lack of information about patient health benefits and the institutional cost savings

associated with the employment of different types of EHCW members. Overly broad and

inconsistent job titles, inconsistent data sources, poor evaluation designs, and inadequate cost

data make it challenging for researchers and policymakers to accurately identify the utility of

EHCW members in different contexts.

Higher-quality, publicly available data are necessary at national, state, and regional levels

because they could characterize the current capacity of the EHCW and forecast ongoing supply

and demand. This information would be helpful to guide planning decisions, establish a baseline,

and monitor the success of future workforce initiatives.

243

Legislative action—at the national and

state levels—represents one potential means of standardizing occupational categories and

training requirements to make data collection easier, more reliable, and more useful for

workforce planning.

123

More data are likewise relevant for measuring the impact of EHCW engagement on patient

outcomes and spending. According to a phone conversation with a key informant on May 28,

2019, without patient outcome and spending data, it is difficult to demonstrate the impact of

investments on this workforce. An entity within the government or a third-party contractor could

be assigned to study the effects of EHCW occupations on patient outcomes after appropriate

metrics are agreed on and codified (see Appendix C). Some of the effort for this work could

draw on existing health workforce centers across the country and their expertise in forecasting,

microsimulation, and other relevant analytic techniques,

421

and through the National Center for

Health Workforce Analysis.

441

In Table 15.3, we present key research questions that could inform a future research agenda.

These questions are based on challenges identified over the course of our review, as outlined in

Chapters 4–14. For each research question, we describe how the findings could lead to specific

activities that would shape the EHCW. Specific measures for these research questions can be

found in Appendix C.

124

Table 15.3. Research Needed and Implications

Research Question

What Is Needed to Answer the

Question

Potential Activities in Light of

Findings

1. What is the current and projected

supply and demand for EHCW

groups

by role, by geographic

location

, and worksite location?

Standardized data assessment by

states and better national data

collection

Revisions to occupation categories in

Bureau of Labor Statistics

, American

Community Survey

, Centers for

Disease Control and Prevention

edical Expenditure Panel Survey,

and other data

-collecting

organizations

; better research on

maldistribution;

activities to address

unmet need

2. What are the skill sets needed, by

worker type?

Survey information from health care

employers and prospective clients at

the local and state levels

More investment in resources and

curricula

development to expand

needed skill sets

3. What are the costs or cost savings

associated with training and

employing more

entry-level health

care workers?

Evaluation of the cost savings

associated with task shifting and

expanded roles

Business model restructuring for

practices; reimbursement changes

insurance companies

4. What are the effects of scope-of-

practice laws?

What is the impact of

certification for those positions that

do no

t require licensure?

Catalog of scope-of-practice laws

and certification throughout the

United States, according to

profession; exploration of the

relationship between scope, pay,

quality, and costs (building on

existing work)

Ways in which to optimize scope-of-

practice laws

and certification to

model after states that have the

most

-effective policies

5. How can innovative team-based

models

be adopted, and what is their

impact? What

factors contribute to

effective

configurations of employees

in these models?

Pilot models of team-based care that

leverage the EHCW and catalog such

efforts; effects on the delivery system

with rigorous evaluations

Best practices for the use of the

EHCW in practices, hospitals, and

community

-based settings throughout

the U

nited States

6. What are evidence-based and

reproducible methods to improve

recruitment and reduce turnover?

Process and impact evaluations of

efforts to improve recruitment and

retention

An evidence base for which

techniques are most effective for

mainta

ining a vibrant workforce;

incentives to adopt these approaches

V. Expand the Use of Technology

It appears that entry-level jobs will increasingly depend on technological systems as they

support the provision of high-quality care. Our findings identified several possible activities

regarding technology that would support the EHCW, but any technological solutions to support

this workforce would require training for workers to use new technology and, of course, access

to the technology in the first place. These are challenges in their own right.

Opportunities for engagement with technology for the EHCW can be divided into three

categories: (1) those that support the system overall, (2) those that support the job of the provider

or EHCW, and (3) those that support the patient or client.

125

System Solutions

• Supporting broadband. To allow technology to be used, broadband access must be

available. When we consider home care services as part of this effort, internet to the

home represents a considerable barrier, with less than 60 percent of rural Americans

having broadband internet at home (compared with 70 percent of suburban dwellers).

• Digitizing certification. Supporting efforts to digitize certification, whether through a

national system or by supporting states that do so, would enable easier national

information-gathering, interstate licensure compacts, and reduced burden on workers.

• Adopting standards and making data interoperable. Efforts should continue to be

made toward standards adoption and data-sharing beyond the acute care settings to LTC

and home health, which was started by CMS through the PACIO Project, a new effort to

coordinate post-acute care transitions.

420

Provider-Facing Solutions

• Supporting telemedicine infrastructure. Telemedicine sometimes relies on a trained

person onsite to enable the remote provider to assess a patient or provide treatment.

Telemedicine infrastructure could also enable EHCW members, in some cases, to work

remotely themselves. All of this relies on a physical infrastructure for remote

communication and video, along with a means to pay for acquiring and maintaining

systems.

• Supporting remote training. The internet and associated technologies can allow for

remote training of the EHCW. In-person training has its advantages, but a mixed or

blended approach using some remote education can address time, travel, and costs

associated with training or continuing education. This relies on broadband access and

curricula designed for this approach.

• Supporting training in technology and use of EHRs. A specific focus of training for

members of the EHCW could include technology training, which some employers and

training programs have embraced. This education, even if it is not directly related to their

patient-facing duties, will enable members of the EHCW to communicate with other

members of the health care workforce, access more information and training, and share

their important contributions in a formally documented way.

Patient-Facing Solutions

• Overseeing medical monitoring and communication devices. Devices can help

patients monitor their own needs, help them assess when they need to see a doctor, and

gather data to share with providers. However, these devices need oversight for quality

and evaluation for efficacy and they rely on trained personnel to support and interpret the

data. EHCW members could play a key role in training patients on use, monitoring

measurements, and collecting data from devices.

• Ensuring EHR interoperability and patient portals. Patients’ engagement with EHRs

and their own medical histories could promote education and provider-patient

communication. This includes EHCW members in communication with patients through

such platforms; for example, in the context of home health.

126

Other Considerations

Standardization and Certification

Most certification and licensure of EHCW positions occurs at the state level. At the same

time, there are models of standardization of national credentials when boards represent third-

party certifiers, as in the case for physicians or dentists. As noted earlier, the ACA’s Title V

(Subtitle D, Sec. 5302)

153

was intended to support demonstration projects to expand certification

programs for personal and home care aides throughout the United States, potentially supporting a

step toward national certification. However, no funds have been appropriated for this purpose.

This could be a potential model for future efforts to standardize certification as the federal

government looks for ways to simplify the complicated network of existing credentials.

Wages

As we described in Chapter 13, wages are a recurring challenge for the EHCW. Increased

wages have the potential to reduce turnover and stimulate workforce growth and recruitment.

Additional research on the relationship between worker pay and patient health outcomes might

be warranted to inform the relative value that better-paid entry-level health care workers bring to

employers. According to a phone conversation with a key informant on May 16, 2019, if

evidence shows that increased salaries are associated with improved care and better patient

outcomes, there might be greater impetus for increased pay. Moreover, if a greater share of

reimbursement were tied to patient outcomes, there might be stronger incentives to employ

members of the EHCW, and competition for these individuals’ services could also have the net

effect of raising wages.

Concluding Thoughts

There are several activities that could be pursued in the public and private sectors to

strengthen the EHCW. One message we heard from key informants was the importance of

convening and coordinating a variety of key stakeholders. This was perceived to be a means to

promote innovation through sharing insights and perspectives on employer, employee, and

training program needs; identifying research priorities; and encouraging the adoption of new

technologies. In Table 15.4, we outline several of these potential policy opportunities and map

these to the objectives described in earlier chapters.

127

Table 15.4. Matrix of Objectives and Policy Opportunities

Policy Opportunities

Convene

Stakeholders

Evaluate New

Models

Fund and Scale

Successful

Models

Improve

Data and

Research

Deploy

Technology

I. Strengthen

training

quality

Yes

II. Expand

training

opportunities

Yes

III. Expand

recruitment

strategies

Yes

IV. Match the

best-fit

candidates to

jobs

Yes

V. Create career

pathways

Yes

VI. Improve work

environment

Yes

VII. Improve

workforce

distribution

Yes

VIII. Empower the

workforce

Yes

IX. Recognize

the financial

value of the

EHCW

Yes

X. Use

technology to

support the

EHCW

Yes

As reflected on our workforce data website,

there is no shortage of innovations taking place

around the country—particularly among employers and in the context of public-private

partnerships and coalitions that have formed at the local and state levels. What appears to be

lacking is alignment on a focused set of short- and long-term objectives, including the

development of an evidence base from which employers, insurers, and educators can draw to

understand the benefits, costs, and trade-offs of investing in the EHCW. Whether this alignment

can and should take place nationally might need to be assessed on a case-by-case basis for

particular occupations and issues, but the evidence we have reviewed points to several actionable

starting points.

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Appendix A. Case Studies

Case studies were intended to give a closer look at the history of innovative programs

supporting the entry-level health care workforce (EHCW), including the motivations for

founding the programs, the challenges the programs encountered, and lessons learned. The

programs listed in this appendix were selected in coordination with the Office of the Assistant

Secretary for Planning and Evaluation and were informed by the broad view of the landscape we

gained through our environmental scan. We gathered the information for these case studies, as

described in Chapter 2, from published literature, other publicly available data, and discussions

with people involved in the programs. As with other key informant discussions, participants are

named with their permission.

Alaska’s Community Health Aide Program

With geographic isolation in Alaska, it’s easy to understand why we do

this. . . . But there are just-as-isolated communities in Seattle or any other major

metropolitan area. Health care providers are much better if they’re community-

based and culturally appropriate.

–Dr. Robert Onders, medical director, Alaska Native Tribal Health Consortium

Background

Ninety-six percent of Alaska’s land area—representing 39 percent of the state’s population—

is designated a federal Health Professional Shortage Area by the Health Resources and Services

Administration (HRSA).

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Because rural communities often are inaccessible by road, people in

Alaska Native communities have relied on an innovative model of health care training and

delivery: the Community Health Aide Program (CHAP).

We focus on CHAP because it represents a unique and comprehensive framework for

training, recruiting, and expanding the scope of practice among members of the EHCW in a way

that responds to community needs in rural and remote settings. CHAP is managed by the 30

tribal health organizations in the Alaska Area Native Health Service and represents a health

service delivery network of more than 550 community health aides (CHAs) and community

health practitioners (CHPs), more than 50 dental health aides (DHAs) and dental health aide

therapists (DHATs), and more than 50 behavioral health aides (BHAs) and behavioral health

practitioners (BHPs) across more than 170 rural Alaska villages.

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As a model of delivery, CHAP emphasizes culturally competent, community-based care in a

team-based approach. CHAs—the medical providers—are selected by members of their

communities to receive training on clinical competencies that respond to local needs. Following

completion of their training, CHAs at CHA level I are equipped to engage in problem-specific

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medical history taking, assess vital signs and symptoms, and interpret basic laboratory test

results under medical supervision. CHAs can progress through additional levels of certification

and associated competencies (CHA I to CHA IV) and ultimately become CHPs, who execute a

variety of primary care clinical tasks without direct supervision. A retrospective analysis found

that these providers provide care to those in remote Alaskan communities “whose residents

would otherwise be without consistent medical care” and also found that it “could serve as a

health-care delivery model for other remote communities with health care access challenges.”

In recent years, the Indian Health Service (IHS) announced plans to explore an expansion of the

CHAP model beyond Alaska to establish a national CHAP and CHA certification board within

IHS.

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To understand the evolution of this program and highlight key features of CHAP that might

be applied beyond Alaska, we spoke with the medical director of community and health systems

improvement at the Alaska Native Tribal Health Consortium (ANTHC). We also reviewed all

relevant literature on CHAP and offshoots of the program. ANTHC provides training for CHAs

and ensures that the curriculum for training and the steps for career progression evolve to meet

population health needs.

Brief History of the Program

CHAP began in Alaska in the 1950s as a response to tuberculosis, high infant mortality rates,

and other health concerns confronting rural Alaskans. In 1968, CHAP was formally recognized

and funded by Congress.

442

Since then, this small group of trainees that began providing a

targeted scope of services to community members in rural parts of the state has expanded

dramatically.

By the 1990s, CHAP was providing health services from preventive to emergency care to

more than 45,000 Alaskans (see Figure A.1).

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As of 2019, this model reached more than

175,000 Alaska Native and American Indian people and offered an even wider array of services

than it did in the 1990s through several tiers of certification with expanded roles and

responsibilities. In the past decade, there have been several notable outgrowths of CHAP,

including the development of DHA/DHAT

444

and BHA/BHP programs.

445

All of these programs

replicate the overarching CHAP model of training and stress the delivery of culturally

competent, community-based care. Evidence indicates that DHATs, the most advanced of the

DHA roles, achieve a standard of care—within their limited scope of activities—that is

commensurate with dental school graduates in other parts of the United States

446,447

and that

BHAs serve critical roles in a variety of contexts, including caring for Alaska Native cancer

survivors.

448

On June 1, 2016, IHS released a policy statement regarding the creation of a national CHAP,

stating that it supports the expansion of CHAP throughout Indian country, including the creation

of a national certification board.

449

As of 2019, IHS has taken several decisive steps in this

direction, including issuing for comment a draft policy that would lead to the formalization and

130

scale-up of CHAP.

139

Adoption and adaptation of CHAP in the broader IHS context has been a

focal point of the CHAP Tribal Advisory Committee and is reflected in the redesign and

rebudget of Title I and Title V of the Indian Self-Determination and Education Assistance Act of

1975. Meanwhile, more-generalized formulations of CHAP for underrepresented groups have

been adapted for several additional settings, including central Ohio,

450

which we highlight later

in this case study.

Figure A.1. Alaska Village Clinics and Training Centers Participating in CHAP, 2016

SOURCE: Alaska Division of Public Health, Alaska 2015–2016 Primary Care Needs Assessment, p. I-14.

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Updated

as of 2016. Used with permission.

Unique Features of the Program

Several features of CHAP have contributed to its success and plans for expanded adoption

throughout the United States. We highlight a few of these features in this section.

Community-based. At its core, CHAP represents a model of care in which CHAs are

members of the community, are selected by members of the community, and serve the

community. The selection process is overseen by a village tribal council or local tribal health

organization, which identifies candidates with positive community rapport who are interested

and capable (based on their education and background experience). This ensures that participants

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not only reflect the communities from which they come but also return to those communities to

provide culturally competent care. Often, those selected have an interest in health care but have

not received formalized postsecondary education. In discussing the CHAP model, a physician

with whom we spoke on June 20, 2019, reflected that “the current [U.S.] health care model

values technical competency and education over community connectedness and cultural

appropriateness, whereas I think the technical skills are much easier to train.”

According to the physician, the fact that individuals are nominated from within their

communities and selected by local tribal health organizations helps safeguard against the

possibility of a significant time gap between one CHA retiring and another beginning because

communities are active participants in the recruitment process. The same physician also noted

that trainees are from a diverse array of Alaska Native communities and have the ability to shape

the curriculum by conveying the community’s needs and requesting that those needs be

integrated into trainings. Formal mechanisms for ensuring that these needs are integrated include

surveys and examinations of billing codes to inspect what CHAs are encountering in their

communities.

Flexible training. The delivery of the CHA/CHP training curriculum is designed to account

for the life experiences of prospective CHAs. For example, many live in remote and rural areas

and have difficulty receiving training for extended periods. One curriculum option allows for an

abbreviated (four-week) in-person training made up of a two-week didactic and a two-week

clinical component so that CHAs do not have to be away from their families for a long period.

Travel and housing are subsidized over those four weeks. Alternatively, trainees can select a

longer (eight weeks or more) asynchronous distance-training option using Moodle, an open-

source learning content-management system that trainees access in their village clinics. Moodle

allows users to take the training at their own pace and connect with a clinical trainer who can

help answer questions and review trainee performance on assignments. Once this phase is

completed, individuals engage in a two-week in-person clinical program.

Recently, program administrators have created a more intensive, blended curriculum for

CHA I and CHA II that covers emergency care and primary care. This represents a single

distance learning module made up of five courses conducted over 16 weeks, with a week-long

clinical component between each course that can take place where trainees are located.

According to the physician with whom we spoke over the phone on June 20, 2019, in all

instances, the curriculum has responded to feedback from participants and has relied on the

increasing availability of broadband.

Career progression. CHAs have the ability to advance through five levels of certification,

from CHA I to CHA IV and then, ultimately, they can become CHPs. Participation in this

progression is fully subsidized by the state and aligns with a salary progression from $15 to $35

per hour. According to our phone discussion on June 20, 2019, CHAs at level I are required to

communicate directly with a supervising physician during all activities; they can perform patient

assessments but cannot conduct exams. Compared with community health workers (CHWs) in

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other parts of the country, CHAs execute a broader array of clinical responsibilities, from clinic-

management activities to direct patient care following specific patient care plans. Over the course

of additional training, CHAs are given a field placement in which their performance is monitored

by a licensed physician using clinical evaluation forms. With each additional level of

certification completed, CHAs can execute new clinical protocols independent of medical

supervision. At the highest level—CHP—they can function with a status akin to that of a primary

care provider, including by providing emergency, acute, chronic, and preventative care through

patient consultations. However, these individuals cannot prescribe medications. An overview of

all authorized CHA and CHP clinical protocols can be found in CHAP’s Standards and

Procedures document.

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This model of advancement provides a clear pathway for CHAs to receive further education,

achieve increasing levels of autonomy, and obtain higher income levels. According to our June

20, 2019, phone discussion with a physician, over the long run, this model has the potential to

link to accredited graduate degrees that translate into supervision roles. Career progression helps

safeguard against burnout and turnover by providing new opportunities for professional

development.

Program Challenges and How They Were Addressed

• According to a June 20, 2019, phone conversation with a physician involved in CHAP,

there is a higher degree of turnover (roughly 25 percent) among CHA level I and CHA

level II positions relative to those at higher levels. This individual noted that CHA

trainees have the opportunity to care for patients at the earliest stage of training and

therefore quickly recognize that the job might not be a good fit prior to further training.

In this sense, early drop-outs can conserve resources. Among those who do not drop out,

a nontrivial portion of CHA I and CHA II providers remain at these levels for a long time

rather than advancing to higher levels. One way to minimize this, as highlighted by the

key informant, is to create an expectation that individuals will progress, so long as it fits

with individuals’ preferences and schedules—an expectation that has been more-firmly

established among BHAs and DHAs. This expectation has been supplemented with

remote teletraining and online training options that reduce the need for individuals to

travel.

• A second challenge has been logistical difficulties with training and accreditation,

specifically in terms of coordinating training with the awarding of an associate’s degree,

and—through additional training—a bachelor’s and/or master’s degree. For newer

programs, such as the BHA and DHA programs, training is aligned more closely with a

contiguous two-year associate’s degree curriculum. For CHAP, this is an area that needs

further development; the training organization (ANTHC) aims to develop pathways in the

next several years.

• Lastly, although roughly 95 percent of CHAs are Alaska Natives, only 5 percent of CHA

supervisors are Alaska Natives, according to our June 20, 2019, key informant

discussion. This speaks to the need for a link between the CHA progression model and

accreditation by universities, which would allow CHAs to transition more fluidly to other

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medical roles, such as nurse practitioners (NPs) and medical doctors (MDs), that

supervise CHAs.

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Box 1: The Community Health Access Project Pathways Community HUB in Ohio

Formation. The Community Health Access Project Pathways Community HUB (PCH) in

Richland County, Ohio, was founded in 1999 by two physicians who had worked in Alaska in

conjunction with CHAP. Building on CHAP’s principles of community-based and culturally

competent care, Ohio’s PCH is nationally certified

451

—i.e., it is a networking center for local

agencies to deploy culturally connected community care coordinators, such as CHWs and social

workers—and serves communities throughout central Ohio.

Implementation. The Community Health Access Project PCH coordinates care among local

agencies to support the needs of individuals most at risk for adverse outcomes by training CHWs

and others to identify and screen for more than140 risk factors that are mapped onto evidence-

based care pathways, including pathways that support individuals’ behavioral health, housing

security, nutritional, and sustainable employment needs. According to a phone discussion with

key informants on July 2, 2019, CHWs and other providers affiliated with local service agencies

under the Community Health Access Project PCH umbrella are provided with additional

financial compensation based on their clients’ completion of activities and steps within the

established evidence-based care pathways. The training model, akin to its Alaska counterpart,

focuses heavily on cultural competency and community rootedness.

Compared with the CHAP Alaska model, service providers in the Ohio Community Health

Access Project PCH model are less medically focused; instead, they provide and document a

holistic assessment of social, behavioral, and medical risks. The broader model of PCHs extends

across counties in Ohio and is intended to address social determinants that could be root causes

of medical conditions. The level of care provided in the Ohio model is also comparatively

limited. However, both models rely on community-based health workers to execute a

standardized set of protocols under a well-organized supervision structure. Therefore, the

Community Health Access Project PCH is evidence that Alaska’s CHAP has provided an

adaptable model for success in other settings, such as Ohio.

Successes. Over the past several years, the Community Health Access Project PCH has

developed a risk-reduction research initiative framework through which health providers and

administrators can refine an inventory of medical, social, and behavioral risk factors for

identifying adverse outcomes; determine their relative weights; and specify whether these

weights are additive or multiplicative.

452

In the context of high-risk pregnancy, for instance,

focusing on minimizing risk factors through the Community Health Access Project PCH has led

to a reduction of more than 50 percent in low-birth-weight babies among Community Health

Access Project clients compared with non–Community Health Access Project clients.

453

Next Steps. According to our discussion with key informants on July 2, 2019, one of the

challenges for the Community Health Access Project PCH in Ohio is reflected in the research

framework outlined earlier: specifically, establishing the evidence base necessary to identify the

relative risks for adverse outcomes associated with the risk factors for which CHWs are

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intervening. In the coming years, the Community Health Access Project PCH aims to use the

data aggregated through its electronic health record (EHR) system to begin answering these

questions and informing priorities for various pathways over time.

Takeaways from Key Informants

• Program success is connected to community foundation. According to a June 20,

2019, phone conversation with a physician involved in CHAP, the model has thrived for

more than 50 years in large part because it is rooted in the community. From this

individual’s view, if the model is going to succeed in the lower 48 states—and in IHS-

served regions in particular—it needs to maintain its emphasis on being rooted in and

empowering the community.

• Programs should consider community needs and practical logistics. As noted by one

key informant in a phone conversation on June 20, 2019, training flexibility and

curricular adaptations are incorporated not only to address local community needs but

also to ensure that a wide variety of individuals have the opportunity to enter the health

care workforce. CHAP has designed its training to accommodate numerous logistical

challenges—offering remote training, abbreviated training sessions, modular training

components, and subsidized housing and transportation. According to the same key

informant, this flexibility is not merely a bonus feature; it enables local community

members to participate fully.

• New roles are needed to allow for progression and differentiate expertise. This

program created levels of CHAs and made it possible for them to advance to CHP roles,

creating structure, possibility for advancement, and clearer roles.

Peer Specialists in the Veterans Health Administration

I understand how trauma can affect people and often lead to mental illness, and

my passion is helping those who have been down similar paths as myself. That

was my main driving force [for becoming a peer specialist].

–Frederick G. Nardei, Jr., certified forensic peer specialist, Veterans Affairs

Pittsburgh Health System

Background

Peer specialists are one category of the peer support workforce.

iv,454

In the Veterans Health

Administration (VHA), peer specialists are employees in recovery from mental illnesses and

substance use disorders who work with other veterans to engage them in treatment. Combat

veterans sometimes report that they feel most comfortable receiving support services from a peer

specialist who also has experienced combat.

454

As recovery role models, peer specialists provide

The Substance Abuse and Mental Health Services Administration divides the types of support provided by peers

into four categories: (1) emotional (e.g., peer-led support groups or mentoring), (2) informational (e.g., classes in

parenting or job readiness), (3) instrumental or concrete (e.g., childcare or transportation), and (4) affiliational (e.g.,

facilitating contacts and building community through sports league participation and other substance-free

socialization opportunities).

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support services to peers with similar behavioral health challenges by “sharing their own

recovery stories, providing encouragement, instilling a sense of hope, and teaching skills to

veterans.”

455

With appropriate training, peer specialists can facilitate wellness recovery action

plan groups and/or illness management and recovery groups, which aim to help veterans with

serious mental illnesses develop and achieve their goals and manage their conditions more

effectively. Although the definition of peer can mean different things in different contexts,

across various types of peer support programs, peers must have lived experience with a

psychiatric disorder and/or substance use disorder, but this does not necessarily mean that they

have received behavioral health treatment. Furthermore, they cannot work in the same program

in which they are receiving services.

Outside the VHA system, many variations on the theme of peer support providers exist; in

Table A.1, we provide an illustrative list of different position titles and role definitions.

Table A.1. Selected Peer Support Job Titles and Definitions, Both Inside and Outside the VHA

Position Title

Description

Peer specialist

Peer specialists are peers who have completed training and

have met the certification standards of their states to provide

peer support services.

Certified mental health peer

wellness coach or whole health

and resiliency peer specialist

Similar to certified peer specialists, who work in a whole health

environment, peer wellness coaches support people to identify

and meet their individualized wellness and healthy lifestyle

goals.

Addiction recovery coach or mentor

Personal guides, mentors, and role models help individuals

seeking to achieve or sustain long-term recovery from

addiction, regardless of their pathways to recovery. Recovery

coaches serve as connectors to recovery support services,

such as housing, employment, and other professional and

nonprofessional services. Recovery coaches are not sponsors

or counselors.

Peer bridger

Peer bridgers help individuals with long and/or recurrent

involvement in a variety of institutional settings (such as

psychiatric hospitals, detox centers, adult and nursing homes,

and jails and prisons) make successful transitions to

community living and reduce recidivism in those settings.

Peer navigator

Peer navigators advocate for and link individuals to services

and supports.

Peer crisis support worker

Peer crisis support is provided as timely support to people in

psychiatric crisis in a variety of settings, including phone-

based peer support lines, peer crisis respite centers (i.e.,

residential alternatives to emergency rooms), and as home

peer companions.

Peer advocate

Trained peer advocates help ensure a practice of reasonable

accommodation; support consumer self-determination in

shared decisionmaking processes with providers; and assist

individuals in accessing services and enforcing their human,

civil, and legal rights in the mental health system.

Recovery ally

Recovery allies provide case management, resource

brokering, and coaching to help individuals develop and attain

their recovery goals.

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Position Title

Description

Recovery and/or wellness center

staff

These staff facilitate community or site-based programs in

which people develop networks of natural supports, pursue

and protect their rights, and set and attain personal goals.

Peer-run employment support or

coaching services

Peer coaches support individuals to find the resources to get

out of poverty and participate in their communities through

successful transitions to meaningful work.

Self-directed care broker or coach

These individuals assist people in becoming aware of the

broad variety of goods and services that can aid them in their

recovery.

Forensic peer specialist

Forensic peer specialists are individuals living with psychiatric

and/or addiction-related conditions who have histories of

incarceration. They receive special training to work in jails,

prisons, and jail diversion programs to assist people in

avoiding future incarceration and in connecting to their

communities.

Certified family support specialist

Family peer supporters help build resiliency in caregivers and

youth.

Veteran peer specialist and peer

support technician

Veteran peer specialists support other veterans with

psychiatric disorders or addictions to successfully engage in

their treatment. These specialists are the focus of this case

study.

U.S. Department of Veterans

Affairs (VA) community integration

specialist

These specialists are veterans who support homeless

veterans with psychiatric disorders or addictions.

Firestarters

Firestarters are Native American peer leaders who are

responsible for building local recovery communities.

Promotoras, or bilingual peer

specialists

This peer-to-peer support method offers a culturally competent

and cost-effective way to reduce mental health stress in

Spanish -speaking communities.

SOURCE: Adapted from the Peer Services Toolkit: A Guide to Advancing and Implementing Peer-Run Behavioral

Health Services, p. 16.

454

Within the VHA system, peer specialists can serve in a variety of roles. They facilitate

education and support groups; work as peer bridgers for individuals transitioning from hospitals

or jails into the community; work one-on-one with clients as role models, mentors, coaches, and

advocates; and can help clients with goal-setting or action plans and developing documents, such

as psychiatric advance directives and wellness recovery action plans. Finally, they help peers

connect (or reconnect) with their communities and facilitate access to formal and informal

resources for continued recovery support. Peer specialist providers work with clients in many

different settings, such as in general mental health clinics, Psychosocial Residential

Rehabilitation Treatment Program day centers; inpatient settings; the U.S. Department of

Housing and Urban Development–Veterans Affairs Supportive Housing program, which is for

veterans who do not have stable housing; Mental Health Intensive Case Management community

treatment settings; and, most recently, primary care settings on Patient-Aligned Care Teams

(PACTs).

138

It is helpful to define what is in or out of scope for VHA peer specialist providers. The

delineation of roles and boundaries is particularly important for this entry-level role, which

serves as a liaison between clinical staff and veterans using health care services from the VHA.

The VHA Peer Specialist Toolkit describes what is in and out of scope for their peer specialists.

For example, peer specialists do

• facilitate peer support groups

• share their own recovery stories

• advocate for veteran consumers

• act as role models of recovery

• provide crisis support

• communicate with clinical staff

• act as a liaison between staff and veterans

• work on a variety of clinical teams

• provide outreach and education to VA facility staff and veterans about peer support

services.

Peer specialists do not

• provide psychotherapy

• do other people’s jobs or fulfill other people’s roles in the facility

• collude with veteran consumers against clinical staff

• cross boundaries

• support veteran consumers in their self-destructive or illegal behaviors

• criticize clinical staff in front of veteran consumers.

455

Research on the effectiveness of peer support in general has shown numerous benefits, which

contributed to peer support being recognized by the Centers for Medicare and Medicaid Services

as an evidence-based practice in 2007. Over time, the number of states that allow Medicaid

reimbursement for peer support services has grown, from eight in 2008 to 39 in 2018.

456

Clients

consistently report high levels of satisfaction with receiving peer support, and the literature in

non-VHA settings shows that peer support is associated with less inpatient use,

457

more time and

engagement with the community, better treatment engagement, greater satisfaction with life and

quality of life, more hope, improved social functioning, and fewer health care–related problems

or needs.

455,458-464

VHA-specific research is still in an early stage, but current findings are similar

to those for non-VHA settings. Peer support activated veterans’ involvement with their care;

supplemented other treatments; increased access to care; and helped veterans consider

meaningful life roles, realize their purpose, and reintegrate into their communities.

465

One key

informant noted in a phone conversation on May 3, 2019, that it is the relationship between the

supporter and the receiver of support that is the key. There must be a trusting and safe

relationship, and although there are many benefits

454

to having a peer specialist engage with a

client to help them participate in other services, there also is an observed benefit to having an

ongoing relationship with the same client.

139

Brief History of the Program

The development of this program is part of a larger peer support movement. This role grew

out of a recognition that the health care system could be doing a better job of treating individuals

with behavioral health conditions, including by conveying the hope and expectation that people

can transition successfully to recovery and have fulfilling jobs and healthy relationships. In

addition, this role gave both peer specialists and patients a sense of empowerment,

acknowledging that it takes support to help get to a better place in life. In short, “peers

demonstrate on a daily basis that recovery is achievable.”

466

Prior to the establishment of the formalized peer specialist position in the VHA, peer support

groups existed throughout the organization. These groups were aimed at sharing lessons learned

about how to survive, take medications, have healthy relationships, and more. However, a key

informant commented in a phone conversation on May 3, 2019, that attendance in these groups

was lower than expected. Individuals would attend at first but would quickly drop out, or people

would think that it was not worth the effort to travel long distances to attend. To address these

problems, the VHA created a different kind of peer support that was more proactive and brought

the support to the patients rather than having the patients seek it out.

This program also grew out of a broader policy context.

466

In 2003, under the George W.

Bush administration, the President’s New Freedom Commission on Mental Health called for the

transformation of mental health services to create a patient-centered, recovery-oriented system of

care. VHA Mental Health developed a strategic plan to implement the objectives of this

commission and formed the Psychosocial Rehabilitation and Recovery Services section to lead

the transformation. VHA funded peer specialist staff positions nationally in 2005, and the first

cohort was hired in 2006. New classification standards were released in 2012, and the positions

of peer specialist apprentices (General Schedule [GS] level 5) and peer specialists (GS levels 6–

9) were finalized. In 2012, an Executive order by then-President Barack Obama directed the

VHA to hire 800 peer specialists (as they are now known) for mental health care, a target that

was exceeded by the following year.

467

One key informant estimated that, prior to this Executive

order, there were approximately 250 individuals in this role. In 2015, another Executive order

directed the creation of 25 pilot sites to provide peer support in primary care.

468

As of 2019, there

are more than 1,000 peer specialists throughout the VA system. The VHA now requires the

availability of peer specialist providers within mental health treatment.

469-471

Unique Features of the Program

Because it is operated by the VHA, the peer specialist program has several unique features.

One feature is that there are official peer specialist position descriptions that are tied to particular

GS levels (5–9)

472

and geographic locations, with wage rates available online, similar to any

other federal government career staff position. GS 5 providers serve as apprentices until they

complete certification training, which is paid for by the VA (the VA accepts state certifications if

140

the peer support provider has completed those requirements instead). Once certified, they can

work at GS levels 6–9. Another unique feature is that the need for peer specialist services must

be documented in the veteran’s plan of care; the plan must specify how such services are to be

delivered, in what context, for how long, and with what goals. Finally, there is a requirement for

a minimum number of peer support providers per VA medical facility, and there have been

efforts to match staffing levels with the degree of need in a Veterans Integrated Service

Network’s particular catchment area.

Local recovery coordinators—psychologists and social workers who work in VA medical

centers—are primarily responsible for hiring, training, and supervising peer specialists. The job

application and interview process for peer support positions has been shown to have some

complexities.

473

A key informant noted on June 13, 2019, that there is sometimes hesitance

within human resources departments to hire someone with a mental illness, and that there are

legal requirements that prohibit prospective employers from inquiring directly about a history of

physical or mental illness, although this is inferred, given that the individual is applying for a job

that clearly requires lived experience. Great care must be taken with announcing recruitment;

publishing the necessary knowledge, skills, and abilities for the role; and asking particular

interview questions that adhere to general hiring policies. For all of these reasons, job

descriptions must be worded carefully and appropriately, and the VHA and organizations outside

the VHA have found it useful to create and share with one another sample job descriptions for

peer support positions.

454

According to key informants we consulted on May 13, 2019, a lack of

clarity around the job description has been a major barrier to implementation and retention of

these providers. In response, there have been concerted efforts to define a set of expected

competencies. The VHA’s Psychosocial Rehabilitation and Recovery Services: Peer Support

handbook

474

lists ten domains of competency that must be demonstrated by the end of the first

year of employment, either by passing the VHA peer support technician competency test or by

obtaining certification as a peer provider from a state or agency.

The training and certification process often aims to cover this array of competencies in a

short period (perhaps 40 hours over one or two weeks) and can feel quite compressed. Key

informants commented on June 7, 2019, that this training might not be sufficient to completely

prepare the peer specialist provider for the role, particularly around the area of professional

resiliency (i.e., reducing the risk of burnout), but it is intended to provide a framework on which

the trainee can layer their own experience. Furthermore, peer specialist providers must

participate in a certain number of hours of continuing education per year (recently, 12 to 15

hours, although this requirement has changed over time) within these domains.

These competencies are (1) recovery principles, (2) peer support principles, (3) cultural competence, (4)

communication skills, (5) group facilitation skills, (6) managing stigma, (7) comprehending the illness, (8) recovery

tools, (9) professional development and workplace skills, and (10) managing crisis and emergency situations.

141

Successfully integrating peer specialist providers into the care of clients with behavioral

health diagnoses is quite complex.

475,476

The VA Peer Specialist Toolkit recommends employing

the four steps of the Simpson Transfer Model:

477

the first step is to introduce the idea and prepare

clinical teams to adopt peer support in their settings; the second is to identify a facility champion

or coordinator for peer support with dedicated time to devote to managing the program; third is

to obtain stakeholder input on, and document ideas around, the potential contribution of peer

specialist providers; and the final critical step is to plan for how many peer specialist providers

are needed. This final step also involves planning for how the peer specialist providers will be

trained and supervised; how challenges with personal disclosures, confidentiality, boundaries,

and dual roles will be handled;

what their context-specific goals and job duties will be; and how

to integrate them into care teams.

The guidelines for the supervision of peer specialist providers are clear: New hires are

closely supervised, with one hour of face-to-face supervision by nonpeers on a weekly basis

during a probation period and monthly supervision thereafter. In reality, the key informants

acknowledged in a phone conversation on May 3, 2019, that regular supervision is a real

challenge, given how busy clinic staff are. Thus, supervision occurs to varying degrees in

different locations. All peer specialist documentation in the medical record and all patient care–

related documentation must be cosigned

474

by a licensed independent practitioner until the peer

specialist reaches GS 8 or above. Peer specialists do not have primary administrative

responsibility for any patients and are not the clinician of record; instead, their services

supplement the professional behavioral health services the client receives.

Key informants noted in May 2019 that the rate of turnover is thought to be comparable with

the moderate turnover found in similar entry-level health care positions. Possible contributors to

turnover include low morale, low job satisfaction, a perception of lack of respect, low pay, vague

job descriptions, lack of supervision, and impractical evaluation methods.

455

According to the

key informants, as with other health technician and case management positions, there is a

somewhat bimodal distribution to the characteristics of peers who left and the reasons why peers

left their positions. Some leave fairly early because the job was not a good fit, their symptoms

worsened and prevented them from performing their role, or they were not adequately prepared

for the professional environment. In contrast, however, others thrived and went back to school to

become social workers or to take on other advanced roles. The same key informants commented

that, for the most part, peer specialists tend to remain in their positions, which the informants

viewed as a relatively stable and permanent job.

These key informants provided several examples of how career advancement could occur,

478

such as by pursuing additional training to become a certified psychiatric rehab practitioner,

wellness recovery action plan facilitator, or wellness coach; attending and presenting at

The concept of dual roles refers to a situation in which a peer specialist has a relationship with a client outside the

peer-to-peer interaction in the health care setting, which can create challenges with confidentiality and boundaries.

142

conferences or workshops, which can help the individual become better known in the peer

support community and support the case for promotion; attending trainings for particular group

facilitation techniques; serving on medical center committees or local or national task forces;

supervising and managing other peer providers; providing training to others; and being involved

in special projects or quality improvement initiatives. However, although a multitude of

professional development opportunities exist in theory, it can be difficult for peer specialist

providers to take advantage of them. This is because some sites—and some supervisors—are

more invested than others in encouraging peer specialist providers to pursue these opportunities,

making the scheduling adjustments required, and providing the financial support that is

necessary for participation. As a result, according to our phone conversation with a key

informant on May 3, 2019, it is estimated that the majority of peer specialist providers tend to

remain at GS 6 and GS 7.

Program Challenges and How They Were Addressed

The VHA behavioral health program has made progress in addressing several of the

challenges it faced during the early years of implementation. These challenges include:

473,475

• an ongoing lack of clarity about peer specialist providers’ duties and role confusion (The

experts we spoke with noted that a lack of role clarity is the single biggest

implementation challenge to overcome for peer support to succeed.)

• inadequate supervision and support, including administrative support

• potential exclusion from treatment team meetings

• the perception that this is a volunteer rather than paid position

• perceived lack of a career path

• a lack of funding for program implementation

• negative attitudes about peer specialists among their colleagues.

Another challenge that merits discussion, and that is not specific to the VHA, is the tension

between professionalizing peer support positions and preserving the essence of being a true peer.

As Salzer and colleagues note,

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the standards that define a peer support position will continue

to be debated because standardization raises such dilemmas as whether these individuals are

professionals or laypersons, the value of academic versus experiential knowledge, and the

tension between traditional mental health service delivery approaches and approaches based on

the ethos of self-help and mutual aid. As one peer support toolkit puts it, “Peers encompass the

full range of professional skills and still bring something completely unique to the table, the

essence of lived experience.”

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Key informants noted that there has been the need to overcome negative attitudes and

misconceptions toward peer specialists by nonpeer staff and other stakeholders. These

misconceptions include that peer specialist providers cannot fulfill valuable roles, will relapse,

will not be able to handle the administrative demands of the job or document correctly, or will

cause harm to clients that is difficult to undo. Overall, key informants felt that, with time and

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through experience, the program has made significant progress in demonstrating the benefits of

peer support in behavioral health care in the VHA, changing attitudes toward integrating these

providers into care teams, and addressing the stigma and resulting hesitation around employing

individuals with mental health and/or substance use disorders. Exposure to peer support

providers and the unique roles they play in behavioral health has been a powerful force to shift

attitudes and destigmatize mental illness and substance use disorders.

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As this role begins to be

implemented in primary care settings on PACTs, the positive experiences in behavioral health

are serving as a foundation on which to build and a source of lessons learned.

Key informants described successful implementation strategies that helped overcome many

of the challenges described in the literature and that they have observed. Approaching the idea of

training as designed for both the peer support provider (who is preparing to join a team) and the

other members of the care team has proven effective in the settings in which professional service

providers have been receptive and able to attend. In addition, paying careful attention to the

planning stages of the Simpson Model has facilitated implementation, so that individuals are

hired with a well-documented plan for training, supervision, career advancement, integration into

the clinical workflow, and job scope. Finally, local champions and leadership support for the

program play a role in how well the program functions.

Potential future directions for the peer specialists in the VHA are promising.

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Key

informants described creating pilot programs that integrate peer specialists into primary care;

expanding their role to include more community outreach activities; integrating peer specialists

into other sites of care where behavioral health services are needed, such as emergency

departments; and increasing research, program evaluation, and quality improvement efforts.

Furthermore, an increased emphasis on population health care management by peer specialists

could include organizing and delivering community interventions that reduce trauma and

promote good health.

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Takeaways from Key Informants

• First and foremost, the structure of the VHA peer specialist program is unique.

There are significant structural differences between VHA and non-VHA peer support

programs; specifically, wages are higher in the VHA, there is a standardized career

ladder, and there is more built-in support for career advancement and opportunities for

skill development. These features might be related to the fact that the VHA is a large

national system with highly standardized job descriptions, pay structures, career

advancement criteria, and centralized support for the peer specialist role. Key informants

universally noted the uniqueness of the VHA system, but also articulated several lessons

that can be applied elsewhere, regardless of the setting.

• Implementation is key. It is important to lay the groundwork for the successful

implementation of peer support programs, both broadly and specifically, to prepare local

settings and care teams for the arrival and smooth integration of the peer specialists

themselves. The Simpson Transfer Model discussed earlier provides steps for introducing

this innovation into the clinical setting. Offering training and clear education to the team

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that is receiving the peer specialist provider should be done in parallel with training the

provider to fulfill the role. An example was given of a peer specialist arriving on Monday

and the team being alerted on the previous Friday, which did not allow for adequate

preparation for integrating the individual into the team.

• Role clarification is important. The peer role can be nebulous, so it is important to

clarify the role as much as possible, both in advance and on an ongoing basis if scope

creep begins to occur (e.g., peer specialist providers being asked to perform tasks that are

not appropriate for their positions).

• Programs have been tailored to local contexts. As with any large initiative, it is more

accurate to say that, instead of a single VHA peer support program, there are really more

than 130 different peer support programs operating within a variety of local contexts and

that have their own strengths and challenges. This can make program management

challenging, but it also highlights the need for both uniform standards and built-in

flexibility to address local needs.

• Support for professional development is needed. For peer specialists to thrive, they

require explicit support in their professional development and a champion, both for their

well-being and professional growth and for the program as a whole.

Advancing Peer Support in Integrated Care Settings: The Hogg Foundation

for Mental Health’s Work in Three Community Health Centers in Texas

We needed to embed a planning period to be defined for any new project we

were launching, particularly multi-year, because the things we do are really

paradigm shifts. Not a one-year thing and you’re out. You don’t change systems

and organizational cultures in one year.

–Rick Ybarra, senior program officer, the Hogg Foundation for Mental Health

Background

The mission of the Hogg Foundation for Mental Health, which is based at the University of

Texas at Austin, is to “transform how communities promote mental health in everyday life.”

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The foundation has a long history of working in peer support. In 2010, it funded the original

program, Via Hope, in Texas to train and certify peer specialists.

vii

In 2015, it awarded $300,000

over a four-year period (2016–2019) to three Texas community health centers (two of which are

federally qualified health canters [FQHCs]; one is an FQHC look-alike

viii

) to advance peer

support in the delivery of integrated health care to populations that were predominantly

Hispanic.

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In this context, integrated health care refers to the systematic coordination of

primary care, mental health services, and substance use treatment: in other words, integrated

vii

At the time of this writing, Via Hope was responsible only for training; a different body was in charge of peer

specialist certification.

viii

FQHC look-alikes are community-based health centers that meet the requirements of the HRSA Health Center

Program but do not receive Health Center program funding. They provide primary care in underserved areas, offer a

sliding fee scale for services, and have a governing board that includes users of their services.

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physical and behavioral health care. The funding supported the hiring of certified peer specialists

to address the behavioral health needs of the patients at these health centers. In addition, given

the high prevalence of co-occurring mental and physical health conditions, peer specialists

received some basic health education as part of their onboarding process to be able to provide

support around co-occurring physical health conditions, such as diabetes and hypertension.

The three grantees were the Gulf Coast Health Center, based in Port Arthur; Hope Family

Health Center, in McAllen; and Project Vida Health Center. Project Vida Health Center has two

sites in El Paso: Casa Vida Recovery Alliance, which is focused on substance use disorders, and

Family Services, which is focused on mental health. Following a substantial planning period at

each site, each health center grantee hired two certified peer specialists to help deliver team-

based care guided by recovery-oriented principles.

Brief History of the Program

Recognizing that safety-net providers do not typically provide peer support services, the

Hogg Foundation supported the 2015 pilot program that was designed to answer the questions of

whether peer support could be imported successfully into safety-net health centers and whether it

could be truly integrated into team-based care. Peer support was already accepted and, in many

instances, was embraced among mental health provider organizations. The Hogg Foundation

wanted to bring peer specialists into the primary care context.

Unique Features of the Program

One of the grantees, in collaboration with the Hogg Foundation, developed a list of guiding

principles for peer support.

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These principles are

• solidarity

• synergy

• sharing with safety and trust

• companionship

• hopefulness

• focus on strengths and potential

• being yourself

• respect.

During the project, Via Hope served as the certifying body for Texas peer specialists and was

responsible for establishing role descriptions, job criteria, and core competencies. The Hogg

Foundation’s ongoing relationship with this organization facilitated recruitment for the peer

specialist positions supported by the foundation grant. Individuals who wanted to become

certified peer specialists in Texas had to be trained through Via Hope, which kept a database of

all certified peer specialists who had completed the training. This meant that recruitment for the

two positions per health center was very centralized. The grant program worked with Via Hope

to identify potential peer specialists who were located in geographic proximity to the three

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grantee health centers and reached out to the health centers to identify people who would be a

good fit for the roles. These dual strategies generated a lot of interest and enthusiasm. In July

2019 phone conversations, staff at the Hogg Foundation commented that it was an amazing

experience for them and for people with mental health diagnoses, who were used to having doors

shut when seeking employment, to see, for the first time, an advertisement for an organization

that was looking to hire someone specifically because of their experience with mental illness or

substance abuse.

Other facilitators of successful recruitment and hiring included the attention that was paid to

making these positions desirable, such as by providing professional development funding so that

employees could attend conferences and build skills. In addition, the leadership (all the way up

to the chief executive officers of each site) was supportive of the initiative. According to a July

18, 2019, phone discussion with one key informant, leaders spoke to medical staff in meetings

prior to the program launch about their beliefs that the peer specialist program would be a “game

changer.”

Another core component of the program was an extensive planning phase. The grantees spent

the first year of the project preparing to launch the new program. It required an organizational

culture shift because working with peer specialists was not something with which the health

centers had prior experience. According to a May 2019 discussion with a key informant, there

was initial uncertainty about the value peer specialists would provide and confusion about what

their role would be. One key element of the planning phase was helping the health centers

embrace a recovery mindset rather than simply one of symptom management for patients with

behavioral health diagnoses. The organizations needed to understand that recovery is about

wellness and well-being rather than the absence of symptoms and they needed to act on that

understanding. Consultants with expertise in peer support and recovery were hired to provide

technical assistance (TA) to each of the three sites about the role of peer specialists—e.g., what

they are and are not, the criteria for becoming a peer specialist, how they work, what their

limitations are (i.e., they are not care providers). This TA was critical for the organizations to

understand before integrating the peer specialists into their cultures and workflows. After this

year-long planning phase, peer specialists were hired and remained in their positions for years 2,

3, and 4 of the program. Anecdotally, there was minimal turnover among participating peer

specialists, and most of the turnover that did occur was related to external circumstances (e.g.,

displacement resulting from the severe hurricanes that affected Texas).

One key feature of the program is the cultural context and setting within which it operates.

As mentioned earlier, the patient population is primarily Hispanic, and these health centers

operate in very resource-limited communities where there are few opportunities for stable

employment, such as that provided by the peer specialist position.

Another feature of the program is that it has undergone a comprehensive, rigorous, and

objective third-party evaluation run by researchers in the Department of Sociology at Texas State

University. The evaluators sought input from multiple perspectives, including from peer

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specialists and other staff, which provided an opportunity for these entry-level workers to

contribute their important viewpoints on what worked well and what worked less well. It also

provided the staff and peer specialists the opportunity to contribute to generalizable knowledge

in the field of peer support. In addition, peer specialists provided patient case studies to garner a

more in-depth understanding of how peer support was conducted and what its impact on patients

was. Although results from that evaluation are in the process of being disseminated more widely

through the peer-reviewed literature, preliminary findings include the following:

• Peer specialists responded quickly to clients in need, mitigating the effects of month-long

wait times for mental health care by providing immediate support.

• Peer specialists filled gaps in care teams by providing services to clients that they might

otherwise not have received, helping coordinate and manage patient care.

• Peer specialists demonstrated an ability to support clients in unique ways, leveraging

their lived experience with mental and behavioral health conditions and demonstrating

recovery in ways in which other clinicians are unable.

• Peer specialists learned to collect and manage outcome data, including the Patient Health

Questionnaire-9 (PHQ-9) (a depression screening tool) and Recovery Assessment Scale

(RAS) scores. In many cases, peer specialists adopted measurement-based care

principles, using the PHQ-9 and RAS scores to inform the nature and frequency of

supports they provided to clients. Several peer specialists reported that the scores could

be used to help predict client relapse.

• Although the health centers in this project started in different places with respect to their

familiarity with and attitudes toward peer support services, the peer specialists

demonstrated their value such that all health centers found ways to continue funding the

positions after the end of the grant.

• Peer specialists seemed to enjoy professional credibility and staff trust from the outset of

the project, particularly in the behavioral health treatment setting; by the end of the

project, the credibility and staff trust of peer specialists increased in other settings as well.

• Among clients with high RAS scores at baseline, scores remained high. For clients with

low RAS scores at the start of the study, there were statistically significant improvements

over time.

Overall, the evaluation showed that peer specialists served critical roles in integrated

treatment settings, responding quickly and flexibly to meet client needs and facilitating improved

care coordination and continuity. According to a July 26, 2019, phone discussion with a key

informant, these findings also demonstrate that peer specialists are qualified to support clients by

giving them hope, modeling recovery, and standing in solidarity with clients as advocates and

champions. Additional research is required to determine the efficacy of peer specialist

interventions in other treatment settings.

These findings are not yet published. They were kindly provided by Toni Terling Watt, a professor at Texas State

University.

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Program Challenges and How They Were Addressed

Similar to the VA peer support program, the rollout of the program did not go completely

smoothly. There was resistance among some staff members at the health centers who had to

adjust and learn how to work with peer specialists. Part of the challenge was the perception by

some psychologists and social workers that peer specialists were a threat to their professional

identities. Some existing staff were unfamiliar with the concept of recovery, which emphasizes

that clients are active agents of change in transforming the limitations associated with illness or

trauma into new opportunities.

483,484

Hope is critical to this transformation, and peer specialists

give clients hope by demonstrating their own experience of living a satisfying, meaningful life

with mental illness.

485,486

Another challenge was sustainability. Because this was a grant-funded, time-limited pilot

program, the issue of sustainability was a salient one as the program drew to a successful close.

There was a decrease in the percentage of grant-supported salary in the final year of the program,

with the health centers expected to make up the rest. The leadership of all three health centers

committed to funding these positions by restructuring different positions within their

organizations and reallocating resources. According to a July 26, 2019, phone discussion with a

key informant, the evaluation confirmed that all three health centers have located a funding

source to sustain the positions in the period immediately following the conclusion of the

program.

Going forward, the Hogg Foundation, in collaboration with the three grantee entities, intends

to share lessons learned from the implementation of the peer specialist program in the

community health center setting, particularly by drawing on the results of the evaluation. The

foundation also intends to build on the program’s successes so that it responds to the specific

evolving needs of the health centers and continues to offer opportunities for professional growth

for the peer specialists themselves. The Hogg Foundation envisions disseminating the findings

through peer-reviewed publications, conference presentations, and the foundation’s website and

press releases.

Takeaways from Key Informants

• Planning is critical. Extensive planning and preparation are necessary to smoothly

integrate peer specialists into clinical workflows and fully realize their potential. Much

was learned from the initial rollout.

• Centralization at the state level facilitates efficient recruitment and hiring of peer

specialists. With all training and certification going through a single organization, it was

easy to track trainees and positions.

• Training and support are important. With appropriate training and support, the scope

of the peer support position can be broadened to include not only behavioral health but

also physical health and how these positions interact.

• Team members need to be prepared to work with peer specialists. Preparing the other

team members who will be interacting with peer specialists to fully understand their role

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and the value they bring to the team is important in introducing this position to team-

based care.

• Evaluation can support sustainability. An evaluation of this pilot program helped it

become a model that was sustained by the safety-net clinics themselves after the grant

funding ended. The evidence is building for peer specialists as an important role in

recovery and treatment.

Kaiser Permanente’s Training and Recruitment Efforts in Southern

California

My team really focuses on creating a career pathway for people into health care

and clinical support roles.

–Donald Bradburn, director of workforce planning and development at Kaiser

Permanente Southern California

Background

Kaiser Permanente (KP) is among the largest nonprofit integrated health care systems and

nonprofit health plans in the United States. Based in California, KP has more than 12.3 million

health plan members nationally.

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It is made up of a health plan (Kaiser Foundation Health Plan,

Inc., with eight regional subunits), a hospital system (Kaiser Foundation Hospitals and its

subsidiaries), and medical groups of physicians (the Permanente Medical Groups). The Kaiser

Foundation has roughly 23,000 physicians and clinicians and more than 217,000 employees (see

Table A.2).

488

This integrated and high-tech system and its highly unionized workforce strive to

develop and incorporate entry-level workers to support their goals. KP was founded as an

insurance program for workers for Henry J. Kaiser’s building projects in the 1930s and 1940s. In

1945, after World War II, the Permanente Health Plan officially opened to the public; by 1955,

enrollment surpassed 300,000 members in Northern California. (In 1953, its name changed from

“Permanente” to “Kaiser” for the health plan and hospitals, while the medical group kept the

“Permanente.”

489

)

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Table A.2. Kaiser Foundation Overview

Foundation Element

Membership

Kaiser Foundation Health Plan membership, by region

—

Northern California

4,389,705

Southern California

4,613,881

Colorado

647,602

Georgia

319,999

Hawaii

254,039

Midatlantic states (Virginia; Maryland;

Washington, D.C.)

760,962

Northwest (Oregon, parts of Washington state)

624,708

Washington

704,027

Medical facilities and physicians

—

Hospitals

Medical offices

697

Physicians (as of December 31, 2018)

22,914

Nurses (as of December 31, 2018)

59,127

Employees (technical, administrative, and clerical)

217,712

SOURCE: Adapted from KP, “Fast Facts,” webpage.

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NOTE: Estimates are approximate. Data are from March 2019.

KP is one of the largest unionized health care workforces in the United States and one of the

largest models of integrated care.

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To understand how an integrated system addresses the

challenges around workforce retention and support, we focus this case study on KP Southern

California. According to phone conversations with key informants in May and June 2019, given

its large size ($79.7 billion operating revenue in 2018)

487

and extensive geographic reach, KP

does only some things at a national scale; many efforts are more regional. The focus of this case

study is on novel efforts in Southern California around recruitment and training, and especially

how the Southern California Workforce Planning and Development staff work to create career

pathways for the many entry-level workers in this region.

KP Southern California’s Efforts

KP has a large number of employees and is therefore constantly training, hiring, and

supporting its workforce. There are several relationships between KP and other organizations,

including local and national contracts with internship programs and pharmacy schools. For

example, KP has relationships with specific nursing schools and community colleges. Most of

these are local efforts through specific medical centers. As one KP talent acquisition manager

told us in a phone discussion on May 20, 2019, “We do a lot with community outreach. We like

to do business and cultivate relationships with the community where that medical center

functions.”

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KP has been moving to formalize and expand many of these relationships. Donald Bradburn,

the director of workforce planning and development at KP Southern California, described the

three-pronged approach undertaken by KP to develop this workforce as (1) developing

relationships with training programs; (2) including communities in recruitment, which also can

address retention because individuals are committed to their own communities; and (3) creating

formal career pathways. These themes have appeared in other case studies.

Part of the motivation for supporting its workforce is KP’s size. It is often easier to train and

hire from within because people already know the system. According to a phone conversation

with KP staff on May 20, 2019, “40 percent of the thousands of our new hires every year are

external; the majority—over 60 percent—are internal.” Entry-level clinical positions are first

listed internally and are opened to the general public only after it proves impossible to fill them

internally.

Unique Features of the Program

Within the three-pronged approach undertaken by KP Southern California are several

specific programmatic efforts. For the first prong, developing relationships with training

programs, there are both formal and informal pieces. As Bradburn explained,

The work we do is engaging with local schools, universities, colleges, going over

their curricul[a], giving feedback to them on things that might be gaps that we

would like to see addressed, informing them about future trends and shifts in

[the] workplace of certain activities [with a focus on clinical support roles].

In this way, workers can be better equipped for jobs, and employers, such as KP, do not have

to conduct extra training for new hires.

The second effort involves including communities in recruitment by establishing partnerships

with workforce centers, regional occupational centers, and nonprofits that are working on

workforce placement to connect to both training institutions and to people in the community. For

example, according to a phone conversation with a key informant on June 11, 2019, one KP site

in Riverside had a turnover rate of 67 percent per year for housekeeping staff. Because this role

includes more requirements than typical housekeeping, such as sanitizing rooms and frontline

infection control, it requires training; therefore, the turnover was very costly to the organization.

To address this issue, KP developed a partnership with Goodwill, which had been working in

underserved communities and with those with barriers to employment. Goodwill sends qualified

candidates to KP for jobs in environmental services, food and nutrition services, and now the

turnover is exceptionally low. A licensed vocational nurse role was recently added to this

workforce pipeline by the Riverside Medical Center.

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According to a Goodwill director, the

higher retention that has resulted can be attributed to employment readiness workshops, soft-

skills training, connections to services for housing and transportation, and efforts to match

candidates with the skills KP needs when recruiting.

491

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The third approach, creating career pathways for professional development, is novel in its

expanse and impact. KP and its unionized staff participate in two Taft-Hartley Act educational

trust funds: (1) the Ben Hudnall Memorial Trust

492

and (2) the Service Employees International

Union–United Healthcare Workers (SEIU-UHW) West and Joint Employer Education Fund.

493

Both have the same objective: to help the workforce remain competitive and provide skills for

advancement.

494

The money is stored in a joint trustee labor-management fund overseen by KP

and the unions and is used to create training and career advising programs.

492

One training

program, which is set to launch soon, will identify environmental service workers and food

service workers and enable them to go to school, maintain employment, and progress from a

nonclinical career to a clinical pathway. As an example, according to a phone discussion with a

key informant on June 11, 2019, if an individual wants to become a sterile processing technician,

they receive new specialized training in cleaning, sanitation, and waste disposal through a formal

apprenticeship (a program for which KP has received formal recognition by the U.S. Department

of Labor [DOL] and the California Department of Apprenticeship Standards). According to this

key informant, once participants complete a didactic portion of the training, they are promoted to

sterile processing aides and continue to receive 1,000 hours of on-the-job training with a

preceptor. After that, they receive certification as sterile processing technicians. There is a

substantive wage difference ($5 more per hour, on average) from their previous environmental

service jobs, and they receive pay during training. As a sterile processing trainee, a worker must

complete 400 hours of on-the-job training and would receive approximately $1 more per hour,

on average, on the pathway to becoming a sterile processing technician (Level 1). Individuals

can become surgical technicians as a next step in this technical career path. The trust funds are

limited to staff who currently work at KP and, thus, have contributed, but these staff members

can use the trust funds as often as they want as long as they are working for KP. However,

according to the key informant, the SEIU-UHW West and Joint Employer Education Fund is

actively pursuing grant funding to expand these programs to nonincumbent workers.

KP has a related program to train certified anesthesia technologists in collaboration with

Pasadena City College.

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The program is paid for by Kaiser Community Benefit dollars, which

are grants dedicated to supporting local organizations (rather than paid for through the trust

funds, which focus on workers). The program targets anyone, not just current employees.

Despite these differences, according to a phone conversation with a key informant on June 11,

2019, the program is similarly tuition-free and enables movement toward a new job level. The

anesthesia program came directly from a need: Doctors in the KP anesthesiology department

required staff with this skill set, and the training provides a direct pipeline to employment. This

funding is a kind of community benefit grant,

496

serving the community and creating employees

that KP wants to hire. According to the same key informant, KP also is working on an

advancement program for certified nursing assistants, with a goal of moving them into a home

health aide role. The development of home health aides to fill vacancies throughout Southern

California is among KP’s highest priorities from an employment standpoint.

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KP Southern California has worked with various community partners to develop

relationships to support its workforce. One partner is the Center for a Competitive Workforce, a

“data-driven research collaboration between business and education leaders in the Los Angeles

Basin,” which provides regional economic outlook reports that give KP information about labor

market supply and demand.

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The center also aims to support education and workforce

development programs across the Los Angeles region. Another partner is the California Future

Health Workforce Commission, a statewide group of senior leaders across multiple sectors,

including health, education, employment, labor, and government. The commission is funded by

several California-based health philanthropies, and KP staff members have served on this

comission.

498

KP staff also serve in the Los Angeles County Economic Development

Corporation, which “works with business, education and government to collectively advance

opportunity and prosperity for all the residents of the greater Los Angeles region.”

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Program Challenges and How They Were Addressed

The changing landscape of job needs. KP needs and job descriptions sometimes change

rapidly, and hiring and certifying organizations can have trouble keeping up. For example, more

patients are being sent home earlier or cared for through forms of home health, meaning that the

acuity of hospital patients is higher and they need more-specialized treatment from the existing

workforce; according to a phone conversation with a key informant on June 11, 2019, workers

are not always trained to handle such specialized treatment. This has quality-of-care implications

for patients and poses continuing challenges for workers who do not have access to training for

the new requirements. Although there are no solutions yet, awareness of this challenge leads to

interest in finding ways of addressing it.

National scope but regional innovation. KP is a national organization. Thus, programs that

are successful can theoretically be spread across the country. However, much of the innovation

occurs at a local level, and many of the partnerships formed by KP Southern California are

region-specific. Although there is interest in spreading successful practices and making them

available for those in other regions, what we describe here is specific to the Southern California

region. In a phone discussion on June 11, 2019, our key informant noted that, even when desired,

there are limitations to spreading programs in such a large organization as KP because of various

federal and state guidelines regarding licensing and certifications, meaning that programs might

not be easily exportable to another state.

Regulation and licensing. Staff at KP are limited by external licensing regulations and

internal policy governing minimum hiring requirements and union demands. Externally,

licensing regulations are managed by multiple organizations with no coordination across them.

Therefore, it is not easy to support entry-level staff who are moving from state to state, or from

one technical position to another.

Union considerations. Management-level staff members described KP as pro-union, and KP

employees are members of numerous clinical and nonclinical local unions. Although the wages

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and 3-percent automatic annual raise for union positions are considered vital by many workers,

some hiring managers within KP view union positions as problematic for workers who are not

motivated to improve their performance. Unions also might make it harder for KP management

to fire an ineffective employee. In addition, despite many positive relationships with unions and

joint efforts at recruiting, KP has clashed with its unions at times. Most recently, this occurred

during a threat of a strike by SEIU-UHW, which represents 55,000 KP workers across

California.

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Another structural limitation is that, because of the way the positions are listed and

hired, most entry-level positions are “per diem and on-call” and might or might not come with

benefits, depending on union representation. The process for filling job openings is outlined in

the applicable union contracts, which typically require a time-limited internal posting for union

staff. If no unionized per diem, on-call, or full-time staff apply for an opening, the position is

posted to the general public.

Future Directions

In a phone discussion on June 11, 2019, a key informant noted the following future plans:

• KP has plans for addressing the future needs of its entry-level workforce. One plan is to

cross-train its staff. For example, although training in radiology is highly specific, KP is

working to certify staff in radiology roles for multiple modalities.

• KP also is working to promote digital fluency for all staff, given the increasing role of

technology in health care delivery at every level. For example, KP offers online courses

for staff to learn to use computers, mobile devices, and data through the Ben Hudnall

Memorial Trust program and lends employees computers for the courses if they do not

have them.

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• KP is working on expanding its workforce not just in Southern California, for example,

through partnerships with the state government, including the California Future Health

Workforce Commission. It also is beginning to engage high school career technical

education programs to create a talent pipeline of students that might not be interested in

or cannot afford a four-year university but could benefit from an entry-level health care

career, with a focus on high schools in underserved communities.

Takeaways from Key Informants

• Local efforts are helpful for success, even within big systems. This national health

system has not yet standardized a model to cultivate the community relationships that

lead to a robust workforce. Instead, much of this work continues to occur at a local level

through persistent rapport-building and problem-solving with individual partners.

• Sponsored training supports a workforce that cannot otherwise get training. KP’s

success in its employees’ pathway development comes, in part, from the fact that its staff

can train for higher-level jobs at no cost or while continuing to work. In general, KP’s

utilization of internal candidates (who make up more than 60 percent of all hires) is

remarkable compared with that of other businesses, which generally hire less than 30

percent of employees internally.

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Future work should consider examining its model

in more detail.

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• Partnerships can bring mutual benefit. KP’s partnerships with local organizations

benefit both the workforce community and KP itself. In addition to providing better

training and more jobs, those partnerships decrease turnover within KP, which saves the

organization the cost of training new personnel.

• Modernization of licensing agencies might be helpful. In a phone discussion on June

11, 2019, key informants emphasized the challenge of different licenses and license

authorities for each entry-level position, even where there is overlap, such as for different

kinds of radiology technicians. They also noted that, for many licensing agencies, record-

keeping and renewals are on paper and that there is no way to transfer credentials from

state to state. Multistate health systems, such as KP, face the challenge of navigating

different regulatory systems with limited interstate reciprocity for licensure and

certification. Interstate licensure compacts and other modernization to encourage more-

standardized requirements across states might benefit workers and health care system

employers alike.

Care Connections Project in New York City

The argument for investing in home care workers is structured around

improvements in quality of care and reduced health care spending. At its core is

this idea that speaking to home care workers’ impact on those metrics may be the

most effective way to convince payers to invest in fair wages and better jobs.

–Angelina Del Rio Drake, chief operating officer, PHI

Background

The United States is experiencing a rapidly increasing need for long-term care services, given

a growing elderly population and increasing patient acuity.

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Accordingly, home care workers

(HCWs), who provide personal and basic clinical support to older and disabled individuals,

represent the fastest-growing occupation in health care.

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However, HCWs have poor training

standards, low pay (the median national wage is $11.03 per hour without benefits), and little

room for advancement.

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Accordingly, home care agencies experienced a turnover rate of 82

percent in 2018.

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PHI is an organization aimed at improving long-term care services and the

quality of direct-care jobs through policy, training, and consulting for the purposes of enhancing,

recognizing, and demonstrating the value of HCWs in long-term care and driving investment by

payers in the home care workforce,. In pursuit of this mission, PHI implemented the Care

Connections Project (CCP) in New York City.

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At its core, CCP engaged two strategies.

According to a phone conversation with key informants on July 31, 2019, one strategy involved

upskilling, or providing supplementary training to HCWs to improve their competency in key

skills needed in their existing responsibilities.

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The second strategy involved training

experienced HCWs to advance into an expanded role (but still within the scope of practice for

home health aides) that was salaried and had benefits. This expanded role is called a care

connections senior aide (CCSA). These two strategies are described in greater detail in the

following sections.

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Brief History of the Program

In 2014, the New York State Department of Health issued a request for applications for the

Balancing Incentive Program to fund strategies that reduce barriers in providing community-

based long-term supports and services for Medicaid beneficiaries.

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PHI and its managed care

plan partner, Independence Care System, had conducted a small exploration of an advanced

HCW role and decided to apply for Balancing Incentive Program funding to formalize the role

and to integrate Coleman and colleagues’ Four Pillars model of improving care transitions.

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PHI was notified of the award in late July 2014 and the demonstration began in August 2014,

leaving PHI with only a few weeks to prepare for implementation, which (according to a phone

conversation with key informants on July 31, 2019) would have implications for the initiative, as

we describe in the “Program Challenges” section. The program was implemented across three

home care agencies within the Independence Care System network: Cooperative Homecare

Associates, Jewish Association Serving the Aging, and Sunnyside Community Services.

506

After

the demonstration ended in March 2016, the three home care agencies decided to retain five of

the eight CCSAs in their roles, sustained by reimbursement from the managed care plan.

According to the same key informant, since then, two of the retained CCSAs have left their home

care agencies.

Unique Features of the Program

In CCP, the twin strategies of upskilling and implementing an advanced role for HCWs were

largely interrelated. PHI trained 14 experienced HCWs for more than 200 hours on chronic

diseases, mentorship, and enhanced communication skills (e.g., observe, report, and record

[ORR] skills) to advance them to the role of CCSAs (eight of whom were full-time). PHI also

trained three registered nurses (RNs) as clinical managers to oversee the CCSAs.

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For the

project, the eight full-time CCSAs were deployed to client homes, where they provided support

and upskilling for entry-level HCWs, who were responsible for 1,439 Independence Care System

clients in total.

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According to a phone conversation with a key informant on July 31, 2019,

prior to the CCSAs, the HCWs were supervised directly by RNs.

After clients transitioned from the hospital to the home care environment, CCSAs would

meet with entry-level HCWs and visit with clients and caregivers to train them on symptoms of

deterioration and support the client’s medication and physician visit adherence. According to the

key informant, in addition to general check-ins, CCSAs would mediate interpersonal conflicts

between entry-level HCWs and clients and attend to any persistent complaints that entry-level

HCWs felt they could not address. Although CCSAs were not trained to notice social

determinants of health, PHI found that CCSAs would observe and convey those details as well

(e.g., poor access to food, insect infestations). Although they were still paid a low wage, CCSAs

were salaried and saw, on average, a 60-percent increase in pay: New York City home health

aides and personal care aides earn a base wage of $10 per hour without benefits (averaging 35

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hours per week, or $18,200 per year), and CCSAs make $28,00 per year in addition to

benefits.

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The new arrangement improved communication flow in two ways: (1) by simplifying

communication channels for entry-level HCWs when they had to report changes in a client’s

condition and (2) by integrating CCSAs into interdisciplinary care teams so that they could

provide a more up-to-date and detailed context for care-planning decisions. For the entry-level

HCWs, the CCSAs served as an immediate point of contact. Previously, when a patient

underwent a change in condition, the responsible HCW had to convey that information through a

phone call, which was then transferred through various agencies, and it could take a few days

before the HCW heard back. By that time, the patient’s condition could have worsened and the

HCW might have taken the patient to the emergency room. With this new program, the HCW

could call the CCSA immediately, who, in turn, could provide advice or convey details to the RN

manager if the problem went beyond their ability, thereby preventing delays in triage. The

second way in which communication was improved was that CCSAs were part of

interdisciplinary care teams. Thus, they could share their own observations and those from entry-

level HCWs directly with other caregivers to inform care planning at the point at which decisions

were being made.

292,509

In evaluating the program, PHI found an 8-percent drop in the rate of emergency room (ER)

visits from March 2015 to March 2016 compared with 2014. PHI also found that it reduced

strain among the HCWs.

292,509

However, the evaluation faced challenges: It used self-reported

outcomes and lacked control groups for comparison (see the next section for further discussion ).

Anecdotally, entry-level workers reported feeling more valued, supported, and effective.

509

Additionally, the eight CCSAs were retained postdemonstration because the managed care plan

saw value in paying for them even without grant funding.

509

A small component of the project (which covered 157 high-risk clients of 1,439 total) tested

the use of a tablet-based software program for entry-level HCWs to convey changes in a client’s

condition to clinical supervisors.

509

In this telehealth intervention, HCWs were trained to answer

yes-or-no questions during each regular shift that would generate a color-coded alert based on

the urgency of a change in a client’s condition for the clinical manager to address as needed.

509

According to a phone conversation with a key informant on July 31, 2019, the telehealth

intervention was deemed to be less successful compared with the larger CCP interventions.

Program Challenges and How They Were Addressed

CCP encountered multiple challenges that prevented it from contributing optimally to PHI’s

overarching goal of creating a strong business case for payer investment.

Timeline. One primary challenge was the project timeline: The project began within weeks

of notification of the award, which prevented optimal planning and implementation across

various project components, including the telehealth intervention and evaluation, as we describe

in more detail later.

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Data challenges. RNs collected data on clients using the Universal Assessment System for

New York about every six months. To evaluate CCP, PHI compared relevant outcomes—

specifically, ER visits and hospital readmissions—from the final year of the project with those

from 2014, the most recent calendar year prior to the project.

509

Baseline outcomes were self-

reported and likely of insufficient accuracy. Some of the data challenges were because of the

rapid startup of the program; PHI recognized the need for collecting better data and improved the

data-collection process during the final year of the project by having clinical managers and

CCSAs reach out to clients for more-frequent updates. However, this new process still

complicated comparisons with 2014 data, and the challenge of accessing acute care data—which

were not made available—remained. Additionally, there was no control group: Caregiver strain

was measured among a sample of 194 individuals who were family or informal caregivers of

CCP-participating clients and was compared between December 2015 and March 2015,

demonstrating a 7-percent net increase in satisfaction, but without any non-CCP caregivers for

comparison.

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CCP also did not report on any changes in retention.

Telehealth intervention. Many clients did not accept the telehealth installation because of

concerns about being monitored, even though they were assured that the tablet would be locked

for purposes other than the intervention. Internet access and opportunities to charge tablets were

practical barriers, and devices would stop working during automatic updates. Also, the software

provider did not supply support staff, and the managed care provider’s support staff was not

equipped to provide the tech support needed. This raised the cost of maintaining the telehealth

intervention, and the agencies did not retain it postdemonstration. It might have been preferable

for HCWs to have used smartphones instead of installed tablets because smartphones would

represent less of a daily interference in the homes of concerned clients; however, several

obstacles stood in the way. Some HCWs did not have smartphones or data plans, and there had

been instances of HCWs being assigned phones in the past for other purposes and accidently

losing or forgetting to return them. The short period between award and implementation also

made a smartphone-based intervention difficult to develop and roll out. These difficulties are

reflective of the larger challenge: According to a phone conversation with a key informant on

July 31, 2019, home care lags behind other areas of health services in telehealth development.

Future Directions

PHI is further developing CCP in two ways. First, it is implementing a similar project in

Michigan. Second, it is using the CCP experience to fundraise for more projects to build the

evidence base on HCWs’ advanced roles, with the idea that evidence will entice payers to invest

in the program. With Trinity Health System in Michigan, PHI is creating a transition specialist

role that will be similar to the CCSA role. Transition specialists will focus on clients leaving the

hospital for a nursing home instead of a home care environment. According to a phone

conversation with a key informant on July 31, 2019, PHI is designing the evaluation component

for this project after learning from the challenges faced with CCP.

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PHI also has recently secured a yearlong planning grant to develop another pilot to build the

evidence base for the advanced aide role. Depending on the amount of funding PHI might

receive for implementation, its current plans for this pilot differ from CCP in several ways. PHI

hopes to train six aides for the advanced role, covering about 300 clients. Aides will be formally

trained to observe social determinants of health. As in the planned Michigan project, PHI aims to

implement a stronger evaluation component. Given more time to plan the project, PHI is working

with an expert at New York University Langone’s Department of Population Health to design the

evaluation and it hopes to use a third-party evaluator. PHI aims to implement a more robust data-

collection process for ER visits and avoidable hospital admissions (potentially by accessing acute

care data and/or collecting self-reported data more regularly) and plans to have a control group.

Additionally, PHI aims to capture changes in job satisfaction, retention, and knowledge and

confidence after training more clearly. According to the key informant, PHI also plans to

measure the delay for entering a nursing home.

Takeaways from Key Informants

• Combining upskilling and career ladders can be fruitful. Upskilling and

implementing a career ladder for HCWs are interlocking strategies that can be pursued

together to improve satisfaction among both entry-level and experienced HCWs.

• Communication channels are key to address client needs as they arise. PHI reported

that the most crucial element in the intervention was streamlining and clarifying the

communication channel for HCWs. Where there once was an obscure, multiple-day

process for communicating occurrences in the home, CCP instituted a clear and quick

workflow to triage calls. It is important to underscore that the telehealth intervention was

not required to transform the communication channels. This lesson is particularly relevant

because home care is underresourced.

• HCWs have critical information to share for care-planning purposes. Many of the

HCWs who participated in CCP had never been asked for information on a patient’s

condition prior to the project. Asking HCWs for input—and developing worker skills to

address their observations through CCSA outreach and ORR skill development—

represents a radical change in care delivery and might unearth new information on

symptoms and problems in care, such as unfilled prescriptions, that inform care planning.

The Individualized Management for Patient-Centered Targets Model in

Philadelphia, Pennsylvania

CHWs are a very broad umbrella category for a workforce. . . . There is a lot of

nuance in the details, and specific models need to be evaluated using rigorous

science in the same way that we would evaluate a drug or a medical device.

–Dr. Shreya Kangovi, founding executive director, Penn Center for Community

Health Workers

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Background

Individualized Management for Patient-Centered Targets (IMPaCT) is a scalable CHW care

model designed by and for low-socioeconomic-status patients at high risk of poor health

outcomes.

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The model adheres to a flexible, evidence-based protocol for the recruitment,

hiring, training, and management of CHWs, who are health professionals with a unique

knowledge of the values, needs, strengths, and services of their local communities. Working as a

bridge between communities and the clinical settings in which they work, IMPaCT CHWs use a

standardized disease-agnostic protocol to work with patients to create and pursue patient-

identified goals in collaboration with their clinical providers.

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Although they are based in

health care settings (i.e., hospitals and other outpatient practices), IMPaCT CHWs work

primarily in the field with patients, including attending social services appointments, advocating

for secure housing, and providing companionship by doing such things as going grocery

shopping or playing basketball with a patient in their neighborhood. CHWs help guide patients to

appropriate clinicians and lead weekly patient support groups to establish social networks among

patients who can support each other in the long term. In addition, CHWs use a smartphone-based

app to document their visits with patients while on the go. Through these various components,

the IMPaCT model has demonstrated success in reducing hospitalizations and improving self-

reported mental health for patients.

Interest in implementing CHW programs across the United States has been increasing,

particularly with the move toward value-based payment models and integrated, team-based

approaches to addressing social determinants of health. Over time, CHWs have worked in their

communities as promotoras de salud, lay health advisers, CHAs, and under many other names

and occupational identities to apply their knowledge of patient populations, cultures, and

available community resources. Although the role of CHWs is not new, they are being used in

new ways. For example, CHWs increasingly are brought on to care teams and are included in

decisions about appropriate use of services.

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By employing individuals who might have similar

life experiences to those of patients, health care organizations anticipate that patients will

improve not only their health outcomes but also the social circumstances affecting their quality

of life. This is because CHWs are uniquely positioned to build trust with patients, offer practical

guidance, and provide nonjudgmental support. However, many health care organizations in the

United States have yet to develop successful, sustainable CHW programs that help patients deal

with social issues that occur outside the hospital or clinic.

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Historically, CHW programs have

been largely unstructured or developed without clear standards and role delineation.

Furthermore, the lack of evidence on CHW program implementation has made these types of

programs challenging to scale up because it has been unclear how to do so effectively.

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Originally developed in 2013 at the Penn Center for Community Health Workers in

Philadelphia, Pennsylvania, IMPaCT has been adapted for patients across diseases and settings

by 35 organizations across 18 different states.

418,511

The center has directly served more than

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10,000 patients in Philadelphia to date.

186

IMPaCT has been implemented successfully in a

variety of different treatment settings, including the VA, FQHCs, and inpatient and outpatient

care settings. The Penn Center for Community Health Workers also provides TA to other

organizations to help them launch and sustain CHW programs modeled on IMPaCT.

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According to a phone conversation with a key informant on June 25, 2019, more than 1,000

organizations have accessed the IMPaCT manuals on the center’s website. Support for the center

comes from the University of Pennsylvania Health System in the form of funding and other

resources: The chair of medicine first assisted with securing a $65,000 grant to hire two part-time

CHWs for the pilot study.

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The research team also secured $60,000 in extramural grant funding

for the first randomized controlled trial (RCT).

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Funding also comes from National Institutes of

Health and Patient-Centered Outcomes Research Institute (PCORI) grants (including a three-

year, $1.4 million award in early 2019); additional revenue comes from partners who pay for TA

for their local implementations.

418,516

The Penn Center for Community Health Workers grew from six to 40 full-time employees

from 2013 to 2014, in part because of an investment by the University of Pennsylvania, which

acknowledged the return on investment demonstrated by the center. The University of

Pennsylvania has now embedded CHWs in every general medicine clinic throughout the Penn

Medicine health system.

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It has also recently published evidence that the program saves money:

Every dollar invested in the intervention returned $2.47 within the same fiscal year, meaning that

much in savings for every dollar paid to the program by an average Medicaid payer.

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Brief History of the Program

Recognizing the need to address upstream determinants of health, IMPaCT founder Shreya

Kangovi took a community-based approach to developing the program. Not only does the

IMPaCT model attend to many of the unmet social needs that often affect an individual’s health

and well-being, it also provides a blueprint for the sustainability and replicability of a CHW

program, which has been difficult for others to achieve. Kangovi partnered with community

members and disparities researchers at the University of Pennsylvania to better understand the

needs of patients utilizing Philadelphia’s health care system. Her team conducted interviews with

more than 1,500 low-income patients, asking such questions as “What makes it difficult for you

to stay healthy?” These types of questions ultimately helped shape the delivery of the IMPaCT

model. In addition to engaging the community, Kangovi reviewed relevant literature and carried

out key informant interviews, both domestically and globally, with leaders of CHW programs

and funders who opted out of investing to understand why they were not interested in funding

these types of programs. Funding and political support did not appear to be the main obstacles

for many CHW programs; rather, five implementation-related components were the primary

challenges (which we discuss further below).

IMPaCT was developed after careful study of CHW models and implementation science, and

Kangovi is careful to credit forerunners in the field even as she builds IMPaCT into its own

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unique evidence-based program. IMPaCT uses concepts central to Sarah and Mark Redding’s

Community Health Access Project,

450,518

adapting the model to allow for greater flexibility in

patient goal-setting and planning.

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IMPaCT also builds on work by MacGregor et al.

513,519

IMPaCT was developed using qualitative participatory action research, which engages

stakeholders and people that have firsthand knowledge of an issue (i.e., social determinants of

health) to inform patient- and population-centered program design.

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Using findings from discussions, relevant literature, and prior work, the IMPaCT model aims

to address identified obstacles and change them into the following core guiding principles: (1)

specialized hiring; (2) standardized training, work practice, and supervision; (3) clinical

integration; (4) patient-centered; and (5) scientifically proven.

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For the first principle,

specialized hiring, Kangovi and her team developed hiring algorithms for interviews based on

organizational psychology that are designed to identify natural helpers (i.e., people with

empathy, active listeners, and those who are willing to help others). According to a phone

discussion with a key informant on June 25, 2019, identifying and hiring the right individuals is

critical for addressing the issue of turnover and ensuring quality of care for patients. Using this

strategy, the IMPaCT model in Philadelphia has experienced an annual turnover rate of 1.7

percent compared with other programs, which see rates as high as 77 percent.

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The second key

to success is a standardized infrastructure. According to the key informant, this entails having

work practice manuals and training at all levels for CHWs, as well as training for supervisors and

directors. According to Kangovi, the third principle (clinical integration) involves “striking a

balance between maintaining the grassroots community-based nature of CHWs while also

integrating them with the formal health care system.” The fourth principle highlights the fact that

CHW programs should be flexible and not disease-specific because many patients have multiple

health conditions. An upstream focus allows for this flexibility and prevents CHWs from

becoming overly clinical in nature when they are not trained for that role. CHWs focus on

navigation, support, and other kinds of help rather than having laypeople provide clinical health

education. Because this model is not specific to one disease, it might be more flexible and

scalable. According to a phone discussion with a key informant on June 25, 2019, the fifth

principle acknowledges that studies of other CHW programs often are poorly designed and can

be limiting in terms of providing useful data, in contrast to the IMPaCT model, which has RCTs

that support its approach. These core principles are described in detail on the IMPaCT website

and in its training materials.

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Unique Features of the Program

Standardized recruitment and training. According to a phone discussion with a key

informant on June 25, 2019, IMPaCT is unique in its approach to CHW training and recruitment,

both of which are key to successful program implementation. The CHW recruitment protocol

was developed using the same qualitative participatory action research methodology used to

create the IMPaCT intervention protocols and it emphasizes hiring empathic, active listeners.

510

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Many CHWs who are recruited to participate in IMPaCT initially were not seeking out a CHW

role; they are often part-time employees in other industries, active volunteers in their

communities, and not necessarily perusing online job boards. With this in mind, IMPaCT uses a

community-based recruitment strategy, advertising the program through community groups,

churches, and neighborhood alliances (according to a June 25, 2019, phone discussion with a key

informant). Program-hiring guidelines, which include a series of interview questions, are used to

ensure that IMPaCT CHWs have the traits that were identified by patients as most critical: a

nonjudgmental attitude and good listening skills.

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Once hired, CHWs complete a month-long

college-accredited training course featuring motivational interviewing.

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This program is

followed by a period of on-the-job training with a senior CHW that continues until new trainees

demonstrate competence and adherence to the IMPaCT model.

521

Manualized protocol. IMPaCT is an evidence-based manualized intervention, meaning that

there is a clear set of standard operating procedures for CHWs to use on the job, detailed in a

manual that other organizations can use as well.

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The IMPaCT protocol defines the work to be

conducted with patients over the course of one to six months (depending on patient

characteristics) and there are three stages of the program: (1) goal setting, (2) goal support, and

(3) connection with long-term support.

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Once a patient has been identified as eligible for the

IMPaCT program, they might work with their primary care provider to set a health goal

collaboratively. Providers use program-provided visual decision aids to select a health condition

of focus and identify a specific measurable goal appropriate to that health condition (see Figure

A.2).

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The patient then meets with their CHW, who uses a semistructured interview guide to

get to know the patient’s life story and understand any unmet social or behavioral needs. CHWs

ask each patient about what they think they need to reach their health goal and use this as the

basis for creating individualized action plans or road maps. These road maps summarize a goal,

identify the resources needed, and develop a step-by-step plan to achieve it during the standard

period of intensive support.

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According to a June 25, 2019, phone discussion with a key

informant, patients typically graduate from the program after a prespecified period, but for some

high-needs patients, this period can be extended. Dissemination tools include a website with

illustrative documentary videos, the technical consultation service noted earlier, and the many

publications that have come out of the program.

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Figure A.2. Collaborative IMPaCT Decision Aid

SOURCE: Kangovi et al., 2017, p. 120.

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Used with permission from Penn Center for Community Health Workers.

Supervision and support. A core component of the IMPaCT model—supervision—serves a

variety of purposes. Social workers or masters-level public health professionals, whose

responsibilities include integrating teams in a variety of different settings, supervise CHWs. At

the center, Penn Medicine continues to fund these positions through grants. The supervisor’s role

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involves integrating CHWs into clinical teams in a variety of settings. These settings can range

from a primary care practice to a sickle cell practice, with one or two CHWs working in each.

According to a June 25, 2019, phone discussion with a key informant, among other duties, the

supervisor ensures that the clinical team in those settings understands and accepts the CHW role

so that the CHWs are incorporated appropriately into the care team. Each supervisor manages a

team of three to six CHWs and works with them to support their patients. They conduct chart

audits and work with CHWs to manage caseloads. CHWs and supervisors discuss any problems

that arise and updates on patient goals and then troubleshoot to ensure that patients graduate

from the program in a timely manner.

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CHWs also review patient action plans with their

supervisors, who can provide feedback and input.

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The key informant noted that supervisors

also work with CHWs to determine their professional goals.

According to a June 25, 2019, phone discussion with a key informant, the CHW supervisor is

a full-time role at IMPaCT, in contrast to other programs, which might have an RN supervisor

available to CHWs for only a small portion of the workday; furthermore, the RN supervisor

might not be familiar with the CHW role. According to another key informant (who we also

spoke with on June 25, 2019), supervisors have the opportunity to undertake their own projects,

such as improving the reporting system or working on an element of health system integration.

Although it is difficult to measure, the support provided by supervisors likely affects the

retention of CHWs. According to this key informant, the Penn Center for Community Health

Workers strives to

make sure supervisors are hired because they are passionate about CHWs. [Being

a CHW] can be a difficult job. CHWs can be exposed to traumatic experiences

that their patients are going through and a lot of our CHWs have a lot of things in

their own lives that they’ve overcome or are working through that are difficult.

You need people and a program that are going to support people so that they

show up for their patients and [do] not burn out.

Having an advocate and a resource with whom to help solve problems and discuss challenges

can lessen the heavy burden that often falls on workers who engage directly with patients.

Data tracking. IMPaCT CHWs use electronic messaging in EHR systems to share

information with physicians about patients’ goals and action plans through cloud-based software

called HOMEBASE.

522

This software can also be used in a smartphone app that supports data

collection and reporting for CHWs while in the field. According to a June 25, 2019, phone

discussion with a key informant, although HOMEBASE does have features that integrate with

the EHR, this has not been the app’s focus. The HOMEBASE app is able to pull data from the

EHR at the University of Pennsylvania Health System and has the capability to generate a to-do

list automatically for each of the CHWs’ patients when they document their notes. This allows

CHWs to stay organized and manage their caseloads. In addition, the app automatically

generates dashboards that allow for tracking of CHW performance on key metrics over time for

supervisors. Although this app is currently used by the University of Pennsylvania’s Health

166

System and has been tailored to use in the VA, it had not yet been developed for the first two

RCTs of IMPaCT at the time of this writing.

523

Evaluation. Three RCTs have demonstrated the effectiveness of the IMPaCT intervention.

The first RCT found that patients who participated in IMPaCT during the transition from

inpatient treatment had better posthospital primary care access, improved postdischarge

communication, improved mental health and patient activation, and reduced recurrent

readmission compared with those not in the program.

510

The second RCT was conducted in an

outpatient hospital setting and demonstrated reduced hospitalization, improved self-rated mental

health, and improved quality of care among patients with multiple chronic conditions seen in two

outpatient internal medicine clinics.

511

The most recent RCT was a multicenter trial of IMPaCT

in three primary care facilities—an outpatient VA clinic, an FQHC, and an academic family

practice. Patients with multiple chronic conditions who met with IMPaCT CHWs for six months

in this multicenter RCT reported higher quality of care, spent fewer total days in the hospital at

six and nine months, and had lower odds of repeat hospitalizations.

523

As we discussed earlier,

the program has also demonstrated financial returns on investment.

517

Teaching service program. IMPaCT CHWs are valued for more than just their

contributions to team-based patient care. Since 2013, IMPaCT CHWs have been partnering with

medical students through a rotation program at the Perelman School of Medicine and the Penn

Center for Community Health Workers.

524

The purpose of the program is to train medical

students in social determinants of health and in the importance of practicing medicine with

cultural humility.

524

The rotation is elective and available to third- and fourth-year medical

students to complete as a two-to-four-week rotation, which includes shadowing CHWs in the

field and meeting for weekly group discussions about the implications of disability, cross-

cultural communication, policies that have disparate impacts on individuals from different racial

and ethnic backgrounds, and means-tested social service programs.

524

Dissemination. Stakeholder engagement is the first step in disseminating the IMPaCT model

to other sites, according to Kangovi. According to a June 25, 2019, phone discussion with a key

informant, external organizations will often reach out to the Penn Center for Community Health

Workers for paid consultation about CHW programs because it has established itself as a

national center of excellence. When working with a new site that is interested in developing a

CHW program, the Penn Center for Community Health Workers sends a leadership team,

including a CHW, to meet with a small group of stakeholders to discuss their goals and devise a

plan for what they want to do. This group discusses the types of problems that need to be solved

and how a CHW program could be structured to address these issues. Together, the IMPaCT

team and site representatives consider such questions as, “Which outcome metrics do you want

to see move in your community in the next couple of years?” “What are the areas that are most

affected by these problems?” and “What are some of the underlying ethnographic issues within

the community?” According to a June 25, 2019, phone discussion with a different key informant,

this first stage, which is called the blueprint process, draws on the core components of

167

effectiveness in IMPaCT and allows for flexibility for local influences. The Penn Center for

Community Health Workers team provides the local team with a high-level, 50-page blueprint

for their CHW program that outlines the detailed plan and overall goals. Finally, IMPaCT assists

with the implementation of the actual program. IMPaCT helps hire and train CHWs and launches

and builds the data infrastructure that the site will be using for its program. According to the key

informant, as the program progresses, the Penn Center for Community Health Workers team

remains available to help with troubleshooting, evaluation, and scalability.

Program Challenges and How They Were Addressed

• Clinical integration. CHWs face various challenges when dealing with other providers

or clinical staff within health care organizations, given the lack of standardization and

definition of their roles. There is the potential for CHWs’ roles to be misunderstood or

underappreciated, and clinicians might assign inappropriate tasks to them, such as

scheduling calls. IMPaCT CHWs are meant to be an equal part of the care team rather

than viewed as workers at the bottom of the chain of command. According to a June 25,

2019, phone discussion with a key informant, the IMPaCT model seeks to get to the heart

of this issue by requiring CHW supervisors to advocate for CHWs. According to a

different key informant, in addition to having a clear reporting structure, IMPaCT CHWs

have delineated roles such that other clinicians know that they should not delegate work

to them. RCTs also have helped establish legitimacy for the IMPaCT CHW model, which

could change the way CHWs are perceived by other members of the care team.

• Career advancement. When one of the program’s CHWs observed in 2018 that there

were no opportunities for upward mobility for the staff who had been with the program

for two to five years, the center responded by creating a professional development

initiative called Career Paths. This initiative provides IMPaCT CHWs with a

standardized means of pursuing promotion—and increased pay, based on tenure and

performance—to two new positions: lead CHW and senior CHW. The Career Paths

initiative also established three specialized career tracks within the CHW role: (1)

community, (2) project, and (3) leadership. The leadership track was intended to provide

a mechanism by which CHWs could take on additional responsibility and eventually

supervise other CHWs, although, according to a key informant, this track has not been

popular. Although there has been variable uptake in these career track options, there are

now new opportunities for CHWs to expand their knowledge and skills within the field.

• New recruitment strategies. Before the coronavirus disease 2019 (COVID-19)

pandemic began in the United States in spring 2020, unemployment rates were at record

lows,

525

but with unemployment now significantly increased, the IMPaCT model may

have more interested candidates. With the growth in paraprofessional and entry-level

roles, especially by for-profit home care agencies with larger budgets that provide

benefits, there was some increased competition among potential workers for open

positions. According to a June 25, 2019, key informant discussion, although IMPaCT’s

original hiring algorithms can continue to be used to bring in the right people, the center

recognizes that new approaches to recruitment must be developed.

168

Takeaways from Key Informants

• Scalability should be built into a model from the outset. Scalability has been a high-

priority outcome for the IMPaCT model since its inception. According to a June 25,

2019, key informant discussion, it is imperative to “build in a pivot that will allow for

adaptability.” This strategy allowed the IMPaCT model to identify the aspects that could

be adapted to different settings and for various populations early on, thus allowing for the

widespread adoption of the program in a variety of health care organizations.

• Having the right people is important. Recruitment of the right people is a key piece of

the IMPaCT model for both CHWs and supervisors. CHWs and supervisors alike must be

resilient, given the intense nature of the care they provide to patients. Supervisors also

must be passionate about working with CHWs because they will need to provide constant

support for CHWs and solutions for difficult situations. According to the key informant,

without individuals who are well suited for the CHW and supervisor roles, burnout and

turnover become much more common.

• Evidence can be gathered for interventions around the workforce, and

demonstrated impact can enable a program to get support and spread. The IMPaCT

project has shown that rigorous evaluation can accompany innovative interventions using

entry-level workers, particularly if those interventions are designed with evaluation in

mind.

• Return on investment. Calculating the return on investment of the original IMPaCT

program has been key to the program’s success. Outcomes data from the original RCT on

IMPaCT were used to calculate a return on investment; this calculation found a return of

$1.80 for Penn Medicine health system.

515

This return prompted the Penn Health System

to adopt IMPaCT as a systemwide population health management tool in 2013.

515

From

2013 to 2014, CHWs were integrated into every general medicine hospital service in

Penn Medicine’s two largest hospitals and every academic Penn Medicine primary care

practice in Philadelphia.

515

As of 2016, for each dollar invested in the program, there has

been a return on investment of $2.47.

515,517

• Institutional support. The University of Pennsylvania Health System has been a

consistent supporter of IMPaCT, which it uses systemwide for population health

management. Support from the home institution has been important to IMPaCT, along

with the funding it provided; further funding secured through grants has enabled further

expansion.

Health Professions Pathways Consortium

[Health Professions Pathways colleges] aspired to have more impact. That really

unified them, and I think created a more collaborative kind of environment.

–Dr. Debra Bragg, director, Community College Research Initiatives, University

of Washington (former director, Office of Community College Research and

Leadership)

Background

The Health Professions Pathways (H2P) Consortium was formed in 2011 through a four-

year, $19.6 million grant from the DOL Trade Adjustment Assistance Community College and

169

Career Training (TAACCCT) program. Its goal was to galvanize a national movement to

improve health workforce education and training through curriculum reform, engagement with

industry stakeholders, and the implementation and evaluation of innovative practices.

526

Led by

Cincinnati State Technical and Community College, the consortium comprised nine community

college co-grantees in five states (see Table A.3) and six partner organizations (see Table ).

527

The adoption of a career pathways framework and a competence-based core curriculum were

critical aspects of the collaborative,

527

as was the use of holistic career and employment

advising.

528

Table A.3. Co-Grantee Colleges in the Health Professions Pathways Consortium

Co-Grantee College

System

Location

Anoka-Ramsey Community

College

Minnesota State Colleges and

Universities system

Coon Rapids, Minn.

Ashland Community and

Technical College

Kentucky Community and Technical

College System

Ashland, Ky.

Cincinnati State Technical

and Community College

N/A

Cincinnati, Ohio

El Centro College

Dallas County Community College

District

Dallas, Tex.

Jefferson Community and

Technical College

Kentucky Community and Technical

College System

Louisville, Ky.

Malcolm X College

City Colleges of Chicago

Chicago, Ill.

Owens Community College

N/A

Toledo, Ohio

Pine Technical and

Community College

Minnesota State Colleges and

Universities system

Pine City, Minn.

Texarkana College

N/A

Texarkana, Tex.

Table A.4. Partner Organizations in the Health Professions Pathways Consortium

Partner Organization

Role in H2P

Health Professions Network

Core curriculum implementation

527

iSeek Solutions

Virtual career network implementation

527

National Network of Health Career Programs in Two Year

Colleges

Core curriculum implementation

527

National Association of Workforce Boards

Technical advising on workforce system and training

programs for incumbent workers

527

Office of Community College Research and Leadership

Third-party grant evaluation

529

Teaching Institute for Excellence in STEM

TA on core curriculum

527

TAACCCT funding came at the right time for H2P leaders, who, according to a conversation

with a key informant on April 4, 2019, were deeply committed to curriculum reform. The

purpose of TAACCCT grants was to provide training to workers who had been displaced by

170

international trade,

530

although other workers were included as program beneficiaries.

TAACCCT grants were created to fund the development and replication of evidence-based

programs to support workers in acquiring the necessary skills and credentials for high-wage

employment.

530,531

According to a April 18, 2019, phone conversation with a key informant, with

this goal as its mission statement, H2P colleges agreed to create and update programs of study

that were consistent with one or more of the following strategies:

• online needs assessment and career advising

527

• contextualized developmental education,

532

or math, writing, and comprehension courses

that are tailored to contain content that is specific to a health care program of study

285

• competency-based core curriculum that is aligned with career pathways and informed by

industry requirements

527

• industry-recognized stackable credentials—i.e., educational certificates, industry

certifications, educational degrees, and professional licenses that are valued by employers

and can be attained over time (The goal of stackable credentials is to shorten the time to

completion so that individuals can move back into the workforce more quickly.

528

Earlier

credentials serve as building blocks such that workers can pick up where they left off

once they are able to return to school or training.

533

In the long term, stackable credentials

are meant to facilitate flexibility and upward mobility into higher-paying jobs.

534

)

• holistic student supports, such as career and employment advising

528

• training for incumbent workers—i.e., individuals already working in health care—to

prepare them for more-advanced positions

532

• enhanced use of data across systems.

527,532

Although grantee colleges could implement any combination of these strategies in designing

their programming, they agreed to adopt a core curriculum (which we describe below) and

establish at least one new health profession credential or certificate.

532

The TA on core

curriculum that was provided to H2P colleges allowed for flexibility in implementation to

accommodate the needs and demands of states, regions, employers, and communities.

532

Postsecondary education is becoming a prerequisite to gaining living-wage employment.

284

Enrollment in degree-granting postsecondary educational institutions increased by 37 percent

from 2000 to 2010—with an increase of 29 percent at two-year institutions

—and, despite a

recent decline, enrollment in community colleges is projected to increase again over the next ten

years.

284,535,536

Historically, federal funds in workforce development have been used to create

short-term training programs of six months or less, and these initiatives typically have not

required collaboration among colleges.

284,537

Career pathways in allied health

are not always

clear,

538-540

particularly for new and emerging positions, and the low wages of many allied health

Total fall enrollment in degree-granting postsecondary institutions increased by 42 percent at four-year institutions

from 2000 to 2010.

Allied health is a term that is inconsistently applied to a diverse group of health care workers. Cadres of workers

that often are excluded from allied health include physicians and nurses; dentists and pharmacists; and nurse

practitioners, midwives, physician assistants, social workers, and mental health counselors.

171

positions make the existence of a clear and reliable path to upward mobility more important.

Associate’s degrees and certificates in allied health are associated with higher earnings, which is

one option for advancement for entry-level workers.

195

Students who complete terminal degrees

in allied health at community colleges have among the highest rates of returns in earnings

compared with other investments in education or training.

195

Brief History of the Program

The TAACCCT program was created by the American Recovery and Reinvestment Act of

2009

541

and supported by the Health Care and Education Reconciliation Act of 2010,

530,542

which

allocated additional funds for the program.

543

In many ways, the TAACCCT program was a

continuation of a 2005–2009 DOL program that provided grant funding to community colleges

to train workers in high-demand industries: the Community-Based Job Training Grant

Program.

544,545

TAACCCT grants were designed to fund community colleges and other

institutions of higher education over multiple years, and institutions were encouraged to apply

individually or as consortia of two or more.

531

Two factors motivated and precipitated the creation of H2P. The first was the success of the

Health Careers Collaborative of Greater Cincinnati—a partnership initiative of employers,

training providers, and community-based organizations dedicated to strengthening the Cincinnati

area health care workforce through training and career support for workers and the

unemployed.

546

According to a key informant discussion on April 18, 2019, the second factor

was the health care core curriculum being implemented at H2P co-grantee El Centro College.

The success of the Health Careers Collaborative of Greater Cincinnati captured the attention of

leadership at Kentucky colleges. The idea of a core curriculum for allied health professions was

first recommended by the Pew Health Professions Commission in 1995

547,548

and implemented at

El Centro College beginning in 1998.

549,550

According to our key informant discussion, long-

standing relationships among Cincinnati State Technical and Community College, El Centro

College, and Jefferson Community and Technical College had established the imperative for

information-sharing and increased collaboration; when the TAACCCT program was introduced,

they found a funding source.

Consistent with the early goals of the TAACCCT program, H2P aimed to strengthen and

standardize career pathways for allied health occupations and shorten the amount of time

required to complete training.

532

The H2P Consortium was designed to be scalable, in large part

to achieve the mission of spurring a national movement to reform allied health professions

education and training. Strategies were selected based on available evidence,

551

and H2P

leadership allowed for flexibility of implementation to facilitate the adoption of H2P initiatives

in different settings. Other strategies identified by the TAACCCT funding announcement that

were incorporated into H2P include the redesign of developmental education; the use of online

and technology-enabled learning; and an emphasis on enhanced data collection, analysis, and

data sharing across systems.

527,532

An evaluation found “compelling evidence that the reforms

172

that H2P colleges implemented made a positive impact on the attainment rates of healthcare

students.”

529

Unique Features of the Program

Competency-based core curriculum. The purpose of the H2P core curriculum was to

establish a shared educational foundation for different allied health fields. According to a key

informant discussion on April 18, 2019, it also functioned to help students better understand the

different workforce opportunities in the allied health professions. Co-grantees adopted the DOL

Allied Health Competency Model

552

implemented by El Centro College and committed to

developing one core curriculum course each.

527

The curricula developed at co-grantee colleges

ranged from one or two courses at Texarkana College and Pine Technical and Community

College to six or seven courses at El Centro College and Ashland Community and Technical

College.

529

Several H2P co-grantees planned, but had not yet implemented, competency-based

core curricula by the end of the funding period.

529

Consortium members met in person on a

monthly basis for core curriculum community of practice meetings to track progress and share

successes and challenges.

527

In an effort to ensure the sustainability and scaling of best practices for curriculum reform,

in-person core curriculum summit meetings were held in Minneapolis, Minnesota, as an

opportunity for consortium members to meet with policymakers and other key stakeholders,

including employers, funders, and technical educators.

527

Through their relationships with H2P

partners, H2P leaders were invited to participate in the Community College Transformative

Change Initiative to develop a plan for scaling the core curriculum. In 2013, the H2P Consortium

committed to expanding its health care core curriculum—inclusive of stackable credentials

(which we describe below)—to 100 additional community colleges by 2017 via the Clinton

Global Initiative.

553

At the conclusion of the grant, the Health Professions Network, the National

Network of Health Career Programs in Two Year Colleges, and H2P began working to update

DOL’s National Model for Competency Based Core Curriculum.

527

The core curriculum was approved for statewide adoption at 17 community colleges in the

Kentucky Community and Technical College System.

527

H2P also collaborated with HealthForce

Minnesota and the Minnesota System of State Colleges and Universities to create a core

curriculum for high school or college students that featured a training offered through the Anoka-

Ramsey Community College workforce development scholarships.

551

H2P also helped a round-

three TAACCCT recipient, the Los Angeles Healthcare Competencies to Careers Consortium,

adopt the H2P core curriculum with the support and assistance of H2P leadership.

551

In 2016, the

White House announced a Health Career Pathways Initiative that works with seven communities

and builds on the work of the H2P Consortium.

554

Stackable credentials. These types of credentials are interim credentials embedded in larger

programs of study that can be accumulated over time,

285

allowing students to earn both the

credentials they need for employment and the credits they can apply toward future study if they

173

return to school.

285,526

According to the key informant, many H2P member colleges had

stackable credentials before the start of the consortium, but the credentials varied in terms of how

easily students could move from one program to another for career advancement. Another

important aspect of stackable credentials was the tailoring of developmental education courses,

or courses designed for students with less of a foundation in math, writing, or reading.

Contextualized developmental learning, or the tailoring of adult developmental education

courses to a technical field—such as health care—is meant to prepare students for academic

success through remedial coursework while providing credit for foundational courses in a

program of study. The courses had the additional advantage of giving students an early sense of

their interest in the allied health field to allow for the potential to switch to a different program of

study more efficiently—i.e., before expending too much time or money on a given

preprofessional program.

The flexibility of H2P implementation meant that colleges could pursue further development

of these credentials and courses in whatever manner made most sense in the context of their

existing programs and populations. According to the key informant discussion, many colleges

chose to amend their existing licensed practical nurse (LPN) and licensed vocational nurse

(LVN) programs to make them more user-friendly for individuals approaching the program with

different work experience. For students with backgrounds in nursing, these changes were likely

imperceptible; for individuals with non-nursing work experience, the programs were designed to

be more approachable from different points of entry.

Online assessment and advising. In some cases, through the Virtual Career Network,

555

and

in other cases, through existing tools and resources, the H2P colleges offered enhanced academic

and career advising to students enrolled in H2P programming. These advising services were

designed to improve recruitment and enhance the supports available to students.

532

Student

advising and supports were implemented successfully by all nine of the co-grantee colleges in

the H2P Consortium,

285

and all H2P students met with a success coach or adviser.

527

Prior

learning assessment was another important offering. Students would meet with a counselor to

learn which, if any, of their past courses might be counted toward a future certificate or degree

program. Such arrangements were designed to support student retention

527

and shorten the

amount of time required to complete a certificate or degree program. H2P colleges reported

improved student retention rates for those who participated in H2P career counseling and

academic advising, averaging 88 percent across the consortium compared with 72.7 percent

among students not participating in H2P at one H2P Consortium member institituion.

527

Use of data to inform implementation. Although it was not a requirement of round one

TAACCCT grants, the H2P Consortium elected to hire an outside evaluator to design and

manage data collection.

285

H2P used the Pathways to Results model of continuous improvement

developed by the external evaluator, the Office of Community College Research and Leadership.

The purpose of Pathways to Results was to inform implementation by monitoring outcomes data

for various programs and initiatives with an emphasis on equity.

529

H2P leaders consulted with

174

evaluators throughout the grant to make decisions about curriculum changes and retention

strategies in an attempt to ameliorate disparities in student outcomes.

285

Program Challenges and How They Were Addressed

• Variation in state-level requirements. The development and adoption of a common

health care core curriculum was both the catalyst for H2P and a major implementation

challenge. The H2P Consortium spanned multiple states and, according to a key

informant discussion on April 18, 2019, the team quickly realized that there were

different governing systems and requirements that would necessitate flexibility in

implementation in Kentucky as compared with in Texas. According to the key informant,

to address the differences, H2P adapted the Texas curriculum developed at El Centro

College—which involved preprogram work and additional courses—into a freestanding

credential that was understood as a “first step in a health care career” for Kentucky. At

the time, the foundational program had three courses that were designed to help students

understand their career options and basic terminology and to provide a means of

exploring career interests and job prospects. In this way, the consortium interacted with

incumbent workers in area health care facilities in Texas and Kentucky, with the shared

outcome of creating exposure and a broad first step for anyone in the community who

was interested in moving into a health care career.

• The interdisciplinary nature of curriculum reform. According to a phone discussion

with a key informant on April 4, 2019, several of the H2P strategies that pertained to the

development of a core curriculum, such as the use of contextualized developmental

education courses, required the approval of other decisionmakers (e.g., employers,

community partners, licensing bodies) who were outside the H2P Consortium.

Competency-based models for developing curricula that support career pathways are

complex and affect many different stakeholders and decisionmakers (e.g., faculty,

administration) in an educational institution.

285

Foundational courses, such as math and

science, are applicable to students in many different disciplines, and the process of

contextualizing these courses to allied health care requires coordination with faculty and

administrators in the various departments that host allied health training programs in H2P

co-grantee colleges, making this strategy difficult to implement.

529

• Availability of funding. Students enrolled in H2P programming had a higher-than-usual

retention rate (88 percent) at H2P co-grantee colleges, which evaluators attributed to the

supports that students received through their relationships with career success coaches.

527

H2P co-grantee college leadership expressed the belief that TAACCCT dollars were well

spent on this holistic advising (i.e., the use of academic advisers, career coaches, and

retention specialists). However, the majority of H2P colleges did not elect to retain those

positions after the end of the grant funding.

529

Evaluators hypothesized that community

colleges did not have the funds to support these positions without external support,

observing that, in several cases, the co-grantee colleges were pursuing funding through

other federal programs in an attempt to fund career adviser or retention specialist

positions.

529

When they did secure additional short-term funding through state or federal

grant programs after the conclusion of H2P, several colleges elected to prioritize funding

to reinstate retention specialist positions.

529

The last round of TAACCCT grants ended in

September 2018.

545

Such bills as the Community College to Career Fund Act

556

have

175

been introduced to establish successor programs. No such bills were enacted in the last

Congress, and although the Community College to Career Fund Act has been

reintroduced, it seems unlikely that it will be enacted.

545,557

• Racial disparities. Community colleges have been gateways to four-year colleges and

universities for students who traditionally have been underserved by and

underrepresented at such institutions.

558

Successful matriculation through education and

training programs and into higher-wage employment is facilitated by previous exposure

to opportunities that are not available equally to all students; this can contribute to racial

and ethnic stratification in education and employment outcomes.

558

Students of color

were less likely than White students to complete longer-term programs, even as they

completed short certificates at equal rates: Of those students who participated in H2P,

16.9 percent of Black students and 16.4 percent of Latino students earned a certificate or

associate’s degree, compared with 27.9 percent of White students.

526

Despite an overall

increase in the proportion of students enrolled in associate’s degree programs, Black and

Latino students were still significantly underrepresented in associate’s degree

programs.

543

Many short-term credentials were determined to have limited market

value

526

based on calculations by H2P colleges of trainee gains in earning potential,

suggesting that stackable credentials could reinforce racial stratification unless the racial

disparities in completing longer-term programs are addressed.

Takeaways from Key Informants

• Communities of practice can facilitate learning.

554

Regular, sustained communication

among co-grantee colleges facilitated the sharing of information and best practices. The

learning that took place as a result of participation in the consortium is more transferable

to other community colleges

529

by virtue of having been developed by many institutions

across multiple states. Co-grantee colleges made an effort to understand the values, goals,

and unique implementation of consortium strategies at partner colleges and shared ideas

and information in support of their shared objectives.

554

Materials created through the

H2P Consortium were shared with the public through SkillsCommons.org,

559

an online

library created by the TAACCCT program.

560

• Flexible implementation can help support success. H2P evaluators believed that the

variability of implementation of the H2P Consortium strategies was a strength. According

to a key informant discussion on April 18, 2019, the greater the variation, and the more

ways in which one could implement a successful strategy, the better chances are that

others will be successful in adapting that strategy to their own unique contexts. They also

told us that community colleges are so different that there is no one strategy suited to all

contexts. That said, the need for flexible implementation can make it difficult to build

evidence in support of broader reform.

554

• Systems change requires the commitment of leadership.

285

Thoughtful leadership was

critical to the success of the H2P Consortium. H2P used distributed leadership—the

sharing of leadership practices for efficiency or to encourage a more democratic

process

561

—to implement H2P strategies in different settings. In some cases, leadership

was shared through including numerous stakeholders in the design and implementation

process. In other cases, grants were used to distribute responsibility and decisionmaking

authority to H2P partners, such as health care employers. For example, according to a key

informant discussion on April 18, 2019, the program at Jefferson Community and

176

Technical College featured a partnership with employer Norton Healthcare, and in this

way, the H2P Consortium was a business–community college partner with these two

entities. Jefferson Community and Technical College was lauded for this partnership.

529

Particularly for initiatives that require systems-level change, trusted leaders are critical—

they must articulate the importance of reforms, bring together key stakeholders, and

define a process for adopting new practices.

285

• Trusting relationships are key to a successful collaboration.

285

Trust and reciprocity

are critical to the success of educational consortia, and collaboration is increasingly a

requirement of workforce-development initiatives.

284

According to a phone discussion

with a key informant on April 4, 2019, H2P community colleges had numerous long-

standing relationships with employers, particularly at the local and regional levels, prior

to the start of the consortium. According to our key informant discussion on April 18,

2019, leveraging their existing professional networks, which spanned five states and nine

colleges, helped H2P members build networks in their communities as quickly as they

could, reaching out to leaders in hospitals, nursing homes, health professions, and

education software companies. H2P co-grantee colleges reported a total of 246

relationships with local and regional partners in support of the consortium, of which 60

relationships were newly formed as a result of TAACCCT funding.

554

Students who

participated in H2P gained an estimated $1,400–$1,700

xii

in average quarterly earnings

postschooling.

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Career pathways reform requires input and partnerships from

stakeholders, both internal and external to community colleges.

285

Service Employees International Union Multi-Employer Training Funds

If you’re a medical assistant, there is no reason why you shouldn’t be able to take

some of your learning in anatomy and physiology and other things and apply that

to a degree program. But that is not happening. It does happen in pockets, but it’s

not happening at scale.

–Sandi Vito, executive director, 1199 Service Employees International Union

(SEIU) Training and Education Fund

Background

SEIU is an international labor union representing nearly 2 million workers in North America

in health care, public services, and property services. There are more than 150 local and regional

SEIUs, each with its own governance structure and constituent members.

562

Union members

might be employed by any number of employers in a given region, and where the union has a

presence, the local union negotiates on behalf of its members with their constituent employers to

form collective-bargaining agreements that determine the wages, benefits, and workplace

conditions for its workers.

In addition to advocating on behalf of members, union support for education, certification,

skills training, and career advising is relatively common. One mechanism for this is a jointly

xii

Estimates varied slightly depending on the method of calculation at different H2P Consortium institutions.

177

governed labor-management partnership, or a joint workforce development initiative, between a

union and its partner employers. Established through collective-bargaining agreements and

funded by employer-paid contributions, labor-management training partnerships build training

and education programs to support worker advancement and retention.

282

Several local SEIUs

have labor-management training partnerships.

The advantages of these partnerships are numerous, both for employers and workers. For

employers, joint labor-management training and education partnerships encourage worker

retention and increase the availability of trained workers for open positions.

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Partnership

funding and the processes for determining training priorities based on existing workforce gaps

are decided through collective bargaining such that the shared governance structure is decided by

a contract.

283

Workers benefit from the increased availability of funding and opportunities that

result from the partnership.

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Health care employers in a region are brought together in

partnership by way of their shared relationships with a given health care union.

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This case study focuses on two large SEIU labor-management joint training partnerships: (1)

1199SEIU UHW East’s Training and Employment Fund (TEF) and (2) the SEIU UHW West

and Joint Employer Education Fund (colloquially known as “the Education Fund”). Together,

they are referred to as “The Funds.”

Brief History of the Program

1199SEIU is the largest health care union in the United States. It first organized workers in

some of New York City’s most prominent hospitals. Its joint labor-management partnership,

TEF, constitutes the largest such fund in the United States.

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TEF grew out of the first multi-

employer training partnership in health care, the Training and Upgrading Fund, which was

established in 1969 by a partnership between 1199SEIU and the League of Voluntary Hospitals

and Homes in New York City.

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TEF has since expanded to provide benefits for more than 250,000 health care workers and

450 employers across the East Coast (in New York; Massachusetts; New Jersey; Maryland;

Washington, D.C.; and Florida). Each year, approximately 40,000 health care workers receive

fund benefits.

564

TEF has served as a model for the development of similar partnerships across

the country; one such partnership is the Education Fund.

565

The Education Fund was negotiated

by SEIU UHW West in 2004 and provides benefits to 105,000 health care workers; five other

SEIU local unions across the West Coast; and 17 employers, including KP, its largest employer-

partner.

566-568

To share knowledge and tools and foster collaboration among local SEIUs and employers

involved in joint labor-management partnerships, SEIU and TEF created the Healthcare Career

Advancement Program, which is a national organization that provides health care education and

workforce development tools.

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This coalition has expanded to cover approximately 1,000

employers and 600,000 health care workers across 16 states and Washington, D.C.

564

178

Evaluations of these programs show a positive impact of training programs on retention and

grade point averages.

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Unique Features of the Program

The Funds provide educational and job placement services (see Table A.5) to serve two main

functions: (1) retaining health care workers through career advancement and (2) enabling

employers to recruit the workforce they require. According to phone conversations with key

informants on July 9, 2019, and July 31, 2019, TEF also runs the Labor Management Project,

which facilitates labor and management partnerships to improve patient care quality.

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Several

characteristics enable The Funds to provide these services, including employer contributions and

priority setting.

Employer contributions and grant funding. The Funds are Taft-Hartley 501(c)(9) trusts

that are supported by employer contributions. Typically, employer contributions amount to

between 0.5 percent and 1 percent of wages and are paid to the bargaining units represented. A

study of SEIU joint labor-management partnerships based on key informant discussions

concluded that contributions of this size from multiple employers add up to a well-resourced

workforce-development effort that affords economies of scale, not only in the provision of its

services but also in the pursuit of grant funding.

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Priority setting and resource matching. TEF uses labor market data, surveys of employers,

biannual meetings with employers, ad hoc focus groups with employers, and conversations with

hospital leaders to set priorities for how to spend funds and match existing resources to employer

needs. According to a phone conversation with a key informant on July 9, 2019, the union also

works with employers to recruit workers for relevant TEF programs. We learned from another

key informant discussion on July 31, 2019, that the Education Fund similarly engages with

employers and conducts surveys and focus groups with workers to understand their specific

career goals and preferences for program design.

Career and academic counseling. According to phone conversations with key informants

on July 9, 2019, and July 31, 2019, The Funds provide career and academic counseling to

members up front so that they are well aware of the requirements of career-advancement

programs and can make informed decisions about future career paths.

570

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Table A.5. 1199SEIU TEF and SEIU UHW Joint Employer Education Fund Programs

Initiative Type

1199SEIU TEF

The Education Fund

Career counseling

• Career exploration, skills and interest

assessments, job search preparation,

overviews of financial aid and benefits of

The Funds

• Similar scope to TEF

Courses and

tutorials on career

skills

• Courses on EHRs, computer basics, care

coordination

• Foreign language skills (see, e.g., Bronx

Healthcare Learning Collaborative)

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• Courses on computer basics,

Microsoft Office, communication

skills

• Specific version for KP employees

Preparatory

courses for

college

• City University of New York (CUNY) and

LPN nursing school entrance exam prep,

English and math prep

• Online courses on such subjects as

introductory biology and anatomy

Professional

development

• Certification and licensing exam prep

courses, reimbursement for certification

programs

• Fund-sponsored seminars for continuing

education units (CEUs); reimbursement for

CEU conferences, workshops, and

programs; online courses for CEUs

571

• Reimbursement for licensure and

certification (certification classes

offered for medical assistants [MAs])

• Reimbursement for CEU courses

and certifications at conferences

571

• Employer-arranged classes for

groups of interested employees to

earn certifications

Tuition and

nonfinancial

assistance for

training programs

• Tuition assistance for degree programs

• LPN program: tuition assistance,

counseling, academic support to LPN

students

• Basil Paterson Scholarship: tuition and cash

stipend to HCWs

572

• Advance Your Career:

reimbursement for tuition, fees,

textbooks, and certification exams

Apprenticeships

• Registered apprenticeship programs

• Pre-apprenticeship programs

Adult basic

education

• High school equivalency prep, digital

literacy, English as a second language

(ESL)

• General Education Development

(GED) test preparation, digital

literacy, ESL

Citizenship

preparation

• ESL, civics and history prep, interview and

test prep, legal counseling

• Citizenship exam prep

Assistance during

reduction-in-force

transitions

• Job Security Fund: Short-term skills training

and job search support in case of layoffs (in

addition to supplemental unemployment pay

and health care benefits)

• Job-to-Job Program: training and

support, including reimbursement for

training during reduction-in-force

transitions

Prerequisite

support

• Health Careers College Core Curriculum

Program enables members to take

prerequisites (e.g., biology, chemistry,

English) required for a variety of degrees in

allied health

572

• Financial support, counseling,

tutoring in completing college

readiness, prerequisite, and general

education classes at community

colleges

• Version for KP employees in

Northern California includes health

care training beyond prerequisites

Stipend programs

• Service Payback Education Program: in

addition to tuition assistance, salary stipend

and health care benefits to cover the

release time provided by the employer to

help full-time students

• Only for KP employees: wage

replacement for up to 16 hours per

pay period (and $10,000 total per

student) for students undergoing

training for certain positions (e.g.,

LVN/LPN)

Bronx Healthcare

Learning

Collaborative

• Helps Spanish-speaking health care

workers pass CUNY entrance exam,

provides Spanish classes, courses in

patient-centered care, and cultural

competency

190

• Not applicable (unique to TEF)

SOURCES: 1199SEIU TEF;

190,572,573

1199SEIU Funds Labor Management Project;

574

and SEIU UHW-West and

Joint Employer Education Fund.

567,570,571

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Cohort approach. Several programs that The Funds offer use the cohort approach. The

cohort is a group of worker-students that enter and graduate from a program together. For

example, TEF’s Health Careers College Core Curriculum uses the cohort approach to allow

workers to take prerequisite classes that can count toward the completion of allied health

degrees. According to phone conversations with key informants on July 31, 2019, the Education

Fund runs a cohort-based MA-to-LPN bridge program that has been going on for five years to

provide employers with a steady supply of LPNs. A different key informant told us on July 9,

2019, that this approach enables mutual support among students and also enables the union to

organize more easily and/or provide peer learning groups, tutoring, and counseling. Our key

informants noted that this approach also enables The Funds to contract directly with partners to

provide classes at convenient locations and times, such as in the mornings and evenings.

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This

flexibility and additional support improves the retention of students in educational programs and

placement rates.

Educational partnerships and scale. The Funds maintain partnerships with numerous

educational institutions. According to our key informants, partnerships are formalized through

contracts (for example, The Funds buy seats in training programs and courses) and are

maintained through well-developed and informal relationships between staff and educational

partners. A TEF key informant mentioned in a discussion on July 9, 2019, that, given its close

relationship with employers and its scale, TEF can influence educational partners to change

curricula to align more with industry standards.

Program Challenges and How They Were Addressed

TEF is facing challenges that are not inherent to its program; rather, they are a feature of the

educational and labor environment. Low wages, poor working conditions, and lack of

standardized training are common for home health aides, for example. It also can be difficult for

them to find full-time work. According to discussions with key informants on May 16, 2019, and

July 9, 2019, these factors make it difficult to recruit and retain home health aides, despite joint

labor-management partnership efforts. Another challenge is the lack of focus in higher education

on serving adult learners, working learners, and immigrants. At TEF’s urging, CUNY—TEF’s

largest educational partner—revised its admission policy to omit from consideration scores on

the Regents exam, a high-stakes New York state test taken at the completion of high school.

However, this revision applied only to traditional students—not adult learners, working learners,

or immigrants. 1199SEIU’s workers are less likely to have Regents exam scores, Scholastic

Aptitude Test (SAT) scores, or adequate high school grades, thus inhibiting access to higher

education. According to a key informant with whom we spoke on July 9, 2019, there is no

system in place for accrediting workers’ frontline experience toward degree programs.

Key informants from the Education Fund cited additional challenges in a phone call on July

31, 2019: Specifically, they stated that extensive career ladder programs for entry-level health

care workers are not present at scale and labor-management partnerships like theirs are among

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the first to create such programs. Another challenge is finding high-quality educational

institutions; the Education Fund is still seeking appropriate partners for some initiatives.

Future Directions

In the future, TEF will focus on continuing to innovate on career pathways in partnership

with higher education. One specific initiative would involve working to secure credit for

frontline experience toward degree completion. TEF also will turn toward developing new

training programs and improving care processes focused on addressing social determinants of

health through its Labor Management Project. According to a key informant discussion on July

9, 2019, because of shortages in many health care occupations, the third focus for TEF is using

grant money and sources of funding other than the employer-contributed funds to pay for the

recruitment of the unemployed or part-time employees from other industries.

The Education Fund plans to iterate on its pre-apprenticeship program pilot, which trains

mainly nonclinical workers in prerequisites for apprenticeship programs. In the earlier pilot, the

pre-apprenticeship program was not directly affiliated with a registered apprenticeship program

and was offered on a part-time basis (two days per week and four hours per day, for a total of

128 hours). According to a discussion with key informants on July 31, 2019, in its next version,

the Education Fund plans to implement a full-time model that directly links workers to a

registered apprenticeship program.

Takeaways from Key Informants

• Joint labor-management funds enable targeted, long-term–focused workforce-

development initiatives. Most employers, apart from such large-scale employers as KP,

plan for workforce needs in the relatively near future. According to a key informant we

spoke with on July 12, 2019, unions, on the other hand, are focused on career

advancement for their members. Another key informant told us on July 9, 2019, that the

negotiated partnerships with employers allow for a greater focus on longer-term

workforce goals that could be more mutually beneficial. It is unclear whether workforce-

development efforts that solicit input from labor and management but are not jointly

governed yield a similar focus.

• Capitalizing on scale is crucial to joint labor-management funds’ success. Joint labor-

management funds take advantage of their large-scale funding, influence, and

membership to shape the development of training in partnership with educational service

providers and to provide access to an array of training and support services that would

otherwise be too expensive for individual employers to provide. These funds are able to

group together cohorts of workers with different employers who are interested in

advancing in their careers, allowing for more-economical provision of classes tailored for

adult and working learners, in addition to supportive academic services and flexibly

scheduled classes.

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• A systematic approach facilitates career advancement. The Funds’ education

programs and support services are comprehensive and work in concert: They address

multiple factors that are important to advancing members’ careers, such as language

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skills, wage support, and counseling, in addition to access to health care training

programs. According to phone conversations with key informants on July 9, 2019, and

July 31, 2019, these programs connect members to jobs by providing placement services.

This systematic approach can serve as a model for other types of workforce development

initiatives. However, the extent to which the provision of comprehensive services might

be facilitated by the partnership between labor and management is unclear.

Peninsula Homecare Cooperative for Health Aides

It’s a big project, it really is, but it’s something that has to be looked at because

the caregiver shortage crisis across the country is dire.

–Kippi Waters, cofounder, Peninsula Homecare Cooperative

Background

Peninsula Homecare Cooperative, which was founded in 2016, is a worker-owned home care

agency that focuses on senior and end-of-life care. Peninsula Homecare Cooperative—or the

cooperative—has two missions. The first is to provide quality home care to meet the needs of

private-pay seniors in its service area. The second is to provide seniors with services from

caregivers who feel valued, are well compensated, and have a dedicated stake in the future

progress of the agency. Located in Port Townsend, Washington, the cooperative currently

employs 18 members, each of whom has an equal stake in the company. Cooperative members

are caregivers—also termed personal care aides or HCWs—who provide a variety of services for

older adults, including bathing and grooming, shopping with clients, and providing

companionship. Within the first year of its existence, Peninsula Homecare Cooperative was able

to provide more than 1,000 hours of care and was expected to double that amount in its second

year and beyond.

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There are many cooperatives in the Port Townsend area, so the cooperative model was not

new to residents. However, Peninsula Homecare Cooperative is the first state-licensed and

caregiver-owned home care agency on the Olympic Peninsula.

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As with other cooperatives, the

main tenet of the Peninsula Homecare Cooperative is that it is democratically controlled by its

employees. With a five-member board, Peninsula Homecare Cooperative members “collectively

decide on policy that ensures the highest quality care for [their] clients, and fair and sustainable

employment practices for [their] caregivers.”

577

According to key informants we spoke with over

the phone on July 17, 2019, the growth of Peninsula Homecare Cooperative was aided by the

town’s small size and the ability of word to travel fast about its services. Although the

cooperative has maintained a strong presence in the Port Townsend community since its

inception, its journey has been paved with both successes and challenges.

This case study was selected because of its focus on HCWs and because of the innovative

implementation of the cooperative model to this type of position.

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Brief History of the Program

Port Townsend, with 9,500 residents, is the only city in a 2,000-square-mile area. Port

Townsend is located in Jefferson County, where one in three residents is aged 65 or older—more

than twice the proportion for Washington state or the United States as a whole.

431

Thus, HCWs

are in high demand. Kippi Waters, who founded Peninsula Homecare Cooperative, knew the

challenges faced by these workers because she was a private caregiver. Prior to founding the

cooperative, Waters had been an employee of an agency because she was only able to receive

reimbursement for her services if she worked in an agency. She shared that she feels strongly

about the mission of the cooperative, in part because of her belief that “something falls apart

when the emphasis is on making money rather than the quality of care . . . .” This concept

sparked some of the motivation behind the creation of a home care cooperative in Port

Townsend.

With support from the Northwest Cooperative Development Center (NWCDC)

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—which is

funded by the U.S. Department of Agriculture (USDA), and modeling its efforts after another

home care cooperative in nearby Bellingham—Waters and her colleagues founded Peninsula

Homecare Cooperative. NWCDC helped them develop model bylaws and articles of

incorporation, and assisted with other tasks involved in starting a worker-owned business. After

opening its doors, the fledgling organization needed financing for salaries, office space, and

other costs. This was provided through a start-up loan from a local investment opportunity

network. Their presentation was so well-received that they received funding the same night.

Thus, the pace of the whole project was fast: The decision to open the cooperative was made in

April 2015 and the doors opened nine months later. According to Waters, they were profitable by

their third quarter and paid off the start-up loan in 18 months. There was a convergence of

different factors that allowed for the successful launch of the cooperative, including the needs of

the aging population at the time it began and the community’s identity as a wealthy retirement

community with liberal views. The cooperative continues to receive TA through the USDA

funding that is distributed to local organizations by the Cooperative Development Foundation in

Washington, D.C. Their TA provider is an organization called the ICA Group. They also have

benefited from a joint program funded by the American Association of Retired Persons (AARP)

Foundation and managed by Capital Impact Partners from 2016 to 2018. That program pays the

cost of state certification for program participants older than 50 years who seek to become

certified home care aides, given that the $500 fee is often a barrier to entry for low-wage

workers.

352,579

Although the attributes of the local community raise issues of generalizability,

organizations such as NWCDC and others support the establishment of cooperatives in diverse

settings around the country.

184

Unique Features of the Program

Peninsula Homecare Cooperative is similar to other home care agencies in terms of the

services it provides. Launched in 2015 at an organizing meeting, it opened for business in

February 2016, only ten months later. Like other home care agencies, they provide personal,

home, and respite care to seniors in eastern Jefferson County, Washington. The main difference

is that it is worker-owned, with 18 member-owners. Training for providers is the same as for

other HCWs and is administered through courses and state-regulated tests. In Washington,

caregivers are required to take a 75-hour course and pass a state test to become licensed.

Prospective caregivers have the opportunity to complete a regional online program that provides

55 hours of coursework coupled with two additional days of skills labs. The cooperative does not

pay for training up front, but it does reimburse the cost of training for those who become

members of the cooperative. In its first year of operations, 2017, revenues were $600,000, and

they have grown since. The cooperative is governed by a five-member board elected by the

membership. Only caregivers are eligible for cooperative membership.

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Because of the high demand for caregivers in the Port Townsend area, the caregiver shortage

is still acutely felt. Waters described a large advertising effort for workers, emphasizing that

because of the remote location, efforts have to be focused and local rather than conducted

through big job sites. There has been increased interest in the cooperative since a November

2018 conference brought more attention to the organization. However, Waters also noted that

there have been many applicants who are not qualified or who apply but do not intend or desire

to be HCWs, so despite a large effort on outreach and recruitment, the majority of successful

hires have come from other home health agencies or by word of mouth. A known issue in

caregiving is the aging of the workforce, but Peninsula has begun hiring many more young

people. According to Waters, when the cooperative was first established, almost everyone was in

their forties or fifties, but they have started bringing in a younger generation; there are now four

or five workers in their twenties.

Ownership. Because every caregiver is also an owner, key informants noted that the

approach to work is different. They have observed that owners have more responsibility and are

more committed. The converse is true, too: Those who are not committed to the job do not fit

well as owners. According to Waters, “Sometimes people just don’t show up for their shifts. But

when you’re an owner you show up. You take this seriously.”

Communication and teamwork. Peninsula ensures that multiple people are scheduled to

take care of the same person so that one person is not solely responsible for any given individual,

unlike at other agencies, where a single worker might be responsible for a given client. This

ensures that problems are identified even if one person misses clues. Peninsula uses a combined

system of email, texting, and notes in its scheduling database to share information about clients

and their needs; key informants mentioned that in a regular agency, notification around problems

might go somewhere central and there could be delays in responding.

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Mentorship. The caregivers meet monthly to provide each other with emotional support,

including processing client deaths that might have occurred. They also have formalized

mentoring through shadowing to ensure that new caregivers feel comfortable with their tasks and

that quality of care is high.

Job satisfaction. Some programs focus on career ladders, but Peninsula is particularly

focused instead on job satisfaction. Although it might not have a traditional vertical career

ladder, there is an opportunity for movement horizontally within the organization. Waters

recognized that it is not particularly advantageous for the cooperative to invest in caregivers who

want to go on to become nurses. Although she might consider developing career ladders for

HCWs in the future, Waters is concentrating on ensuring that workers have a lot of variety in

their work and are being challenged in positive ways, thus providing a career that helps workers

remain focused and happy.

Turnover. Turnover at the cooperative was 24 percent in 2018 compared with a national

average of 70 to 80 percent, according to Waters. Some employees retire or move out of the area,

and some have to be fired (which can be done, even for owners). Even so, the overall retention

rate is significantly higher than the norm for this profession.

As noted elsewhere in this report, the national home care workforce is not paid highly (a

median hourly wage of $10, and a median annual wage of $22,000 if working full-time), and

those wages have fallen by 5 percent over the past decade.

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In addition, nationally, most of

these workers are part-time and do not receive benefits.

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HCWs are almost all women and are

mostly minorities, potentially exacerbating inequality. Peninsula Homecare Cooperative, in

contrast, has a starting wage of $15 per hour, which is 46 percent above the national average.

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With profit-sharing each month, this wage rises to $22 per hour. Peninsula has lower turnover

rates, has better scheduling, and provides a better-quality job compared with other home care

agencies—which is sometimes referred to as the “cooperative advantage”—although bigger

agencies sometimes offer better benefits, such as health insurance, than the small cooperative

can, according to a conversation with key informants on July 17, 2019.

Program Challenges and How They Were Addressed

• Recruitment of caregivers. Similar to other home care agencies, Peninsula Homecare

Cooperative continues to face challenges with recruitment. In a town with such a high

proportion of aging adults (one-quarter of the residents are over 65

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), demand for

caregivers is climbing. At the same time, it is becoming increasingly difficult to recruit

enough caregivers to fill the need. Livability for young, low-wage workers in Port

Townsend is a growing challenge because of a lack of affordable housing and a high cost

of living. Although there is no silver bullet to attract people to these positions, the

cooperative is considering different ways to diversify its reimbursement streams and

grow its revenue. Housing concerns are substantial enough that local experts are

considering strategies for affordable housing for caregivers. In addition, branching out

into various fields, such as palliative or respite care, can allow HCWs to receive

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reimbursement from public payers as opposed to relying solely on wages paid by their

agency, which receives reimbursement from private-pay patients. According to a

conversation with key informants on July 17, 2019, given that Medicaid often sets the

standard for reimbursement rates, employing caregivers in these other types of care might

increase the likelihood of being paid a livable wage and, thus, could attract more people

to the profession.

• Trade-offs for wages and benefits. Although the cooperative is able to provide higher-

than-average wages because there is no overhead and it is worker-owned, it is unable to

provide its members with other benefits, such as health insurance, which is a key reason

caregivers might decide to work for other agencies. The undervaluing of HCWs in the

United States is a key concern. As one key informant told us in a phone conversation on

July 17, 2019, “When the wage for a home care worker is the same amount as [for] a

barista at Starbucks, we have a serious problem about our moral imperative.” According

to Waters, “rebranding caregiving” is an essential step in moving the field forward, and

cooperative members have already begun this movement by organizing events, such as a

summit on elder care.

• Limited resources. Although operating in a small, rural town has been a benefit in terms

of allowing the cooperative to thrive, limited resources continue to be an obstacle.

According to a discussion with a key informant on July 16, 2019, compared with small

businesses in urban areas, Peninsula Homecare Cooperative does not have access to

resources, such as seminars, trainings, and other educational opportunities, that could

benefit many of the cooperative members.

Takeaways from Key Informants

• Giving workers a voice is important. Key informants reported that there is often a

hierarchy in an organization’s structure that inhibits employees’ voices from fully being

heard. But members of the cooperative strive to ensure that democracy is maintained

within their organization. They are constantly working toward determining what

democracy actually means, what it should look like, and how it should be operationalized

in their workplace.

• It is important for small cooperatives to build a strong board of directors. In addition

to long-term support from external stakeholders, having a strong board of directors is

critical. In the home care cooperative space, it is possible that someone can be a great

caregiver but might not have the necessary experience to be on the board of directors.

According to a conversation with key informants on July 17, 2019, directors must be able

to not only carry out fiduciary duties and administrative activities but also oversee

managers. Taking on the role of director is more demanding than the typical roles and

responsibilities of the caregiver; it warrants further training as well.

• Sustained external support is essential to this model. Peninsula Homecare Cooperative

has thrived in its first three years, in part because of the financial and technical support it

has received from various organizations, including nontraditional health care sources.

Because of funding from the USDA and Local Investing Opportunity Network, the

cooperative was able to get off the ground. The TA provided by the NWCDC and the

Cooperative Development Foundation has strengthened the cooperative as it has grown.

Representatives who helped launch the cooperative with whom we spoke on July 17,

2019, also have cited having a local champion (Kippi Waters) and enlisting experts (from

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the NWCDC and the Cooperative Development Foundation) as crucial pieces in building

the cooperative.

• The cooperative can have a major impact on its members and on the broader

community. One of the by-products of the establishment of the Peninsula Homecare

Cooperative is the empowerment of its members. As worker-owners, cooperative

members have developed local leadership skills that have propelled them into civic

activism. According to a conversation with key informants on July 17, 2019, they have

become leaders in their own organization and also have taken on more civic

responsibility in their communities. Furthermore, a survey that was administered to

HCWs in 2018 found that being in the cooperative reduced their reliance on public

subsidies.

Mercy Health System in West Michigan

Get your community involved. Don’t do it yourself. Tap the resource that you

have in your community, and do this as a sustainable partnership.

–Shana Welch, executive director of talent acquisition, Mercy Health

Background

Mercy Health is a not-for-profit, integrated managed care organization based in West

Michigan and a constituent member of the Catholic Trinity Health System, the nation’s second-

largest Catholic health system. Mercy Health, as an integrated system, comprises more than 60

physician practices, treatment facilities, and urgent care facilities, as well as five hospital

campuses. Mercy Health employs roughly 1,300 medical staff physicians and 7,200 additional

personnel.

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This case study focuses on Mercy Health’s talent acquisition program because it has modeled

innovative practices in EHCW job creation and career development following the Great

Recession—notably, it has done so in a part of the United States that was hit hardest by the

economic downturn. Based in West Michigan, the communities served by the Mercy Health

system have relied heavily on manufacturing, producing items from boots to aircraft

components. Therefore, these communities have experienced declining economic activity since

the early 2000s.

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In response, Mercy Health has paired with West Michigan Works!

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and

Talent 2025,

233

representing collective partnerships among employers and educators to create

qualified workforce members to address current and future workforce needs in the health sector.

Through such initiatives, Mercy Health’s Talent Acquisition and Workforce Programs

Department has positioned itself to foster a robust EHCW and has been recognized as a national

leader in this space through its Medical Assistant Registered Apprenticeship Program (MARAP)

and its Evidence-Based Selection Process (EBSP). This program was selected because (1) it is

implemented within a large health care system that has many factors to weigh in its hiring and

staff support; (2) it focuses on MAs, a position that is not the main focus of any other case study,

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but is important when considering entry-level workers; and (3) it has an apprenticeship program

that is of interest and is promising for the ECHW.

Brief History of the Program

Mercy Health was formed in 2011 as a merger of Saint Mary’s Health Care of Grand Rapids;

Mercy Health Partners of Muskegon; and, later, Mercy Hospitals in Cadillac and Grayling,

Michigan. According to a key informant, with whom we spoke on July 18, 2019, this

reorganization of the health care landscape required the Talent Acquisition and Workforce

Programs Department to swiftly ramp up operations to more than 50 employees and broaden the

base of its hiring pool accordingly. Over the past eight years, Mercy Health has implemented

several innovative efforts to improve the training and recruitment of prospective EHCW

employees, from apprenticeships and EBSPs to specific workforce diversity, equity, and

inclusion initiatives. This has involved a hands-on workforce board steering committee to drive

such initiatives as the MARAP and the EBSP, which we describe in the following section.

Programs Within Mercy Health

Medical Assistant Registered Apprenticeship Program. MARAP represents a partnership

among four health care employers (Mercy Health, Cherry Health, Spectrum Health, and Hackley

Community Care) and two local community colleges, with the objective of creating well-

equipped MAs through a continuous 12-month training program. Over the course of the year,

students attend tuition-free classes at Grand Rapids or Muskegon Community College, serve as

paid employees of Mercy Health or of another employer, and receive on-the-job training and

incrementally greater responsibilities as they complete their coursework. Following completion

of the program, students receive a Medical Assistant Certificate of Completion and a certificate

of completion of apprenticeship from DOL.

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Coursework takes place two days per week, and tuition is covered. The cost to participating

individuals is typically less than $8,000 for all learning materials across the 12 months.

200

Meanwhile, students are able to work 20–30 hours per week at a starting wage of $11.25 per

hour, which increases with each completed quarter of coursework and includes full health

insurance and retirement savings benefits. Following program enrollment, apprentices commit to

employment at Mercy Health or another employer for at least one year after graduation.

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To date, Mercy Health has trained roughly 60 MAs through MARAP of 100 total graduates

from the program. The organization regards the program as a thorough success. Key informants

reported that MAs trained through the program had higher retention rates than other MAs at

Mercy Health and that Mercy Health has been able to expand the model to other employment

areas, such as scribe processing and clinical documentation. Moreover, Mercy Health has been

able to offer MARAP and related programs to those already in the organization. Executive

director Shana Welch reflected,

I always try to find a win, win, win. How many wins can we get out of one

strategy? With the medical apprenticeship program, not only were we filling the

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need to develop a pipeline of talent because we had a shortage in our region, but

it was also important to us to make sure we were reaching our own colleagues,

giving our entry-level colleagues an opportunity to get on a career track to more

of a middle-wage job.

Because of the success of MARAP, Mercy Health was approached by the Kellogg

Foundation—which focuses on helping vulnerable individuals achieve success in society—to

develop an even more robust hiring and talent-promotion program. According to a phone

conversation with a key informant on July 18, 2019, the new program, dubbed “Rise Up,” aims

to recruit 300 individuals from the local communities that Mercy Health serves into the health

system as employees, plus an additional 150 incumbent workers who will be provided with the

education and training to assume new roles within Mercy Health.

Evidence-Based Selection Process. To ensure that Mercy Health is recruiting the best

candidates for job vacancies, the Talent Acquisition Department has implemented the EBSP,

which includes a suite of materials, such as formal assessment tools, 360-degree references,

structured interviews, and a compensatory rating system. This system is particularly critical for

entry-level health care workers because they represent the majority of the 1,200 employees in the

system. Moreover, EHCW members are the most likely to represent lower-income individuals,

including minorities, who might be subject to implicit racial bias. As such, EBSP training

exercises included educating managers and hospital leadership on the role of implicit racial bias

and conducting refresher awareness sessions. According to a member of the talent acquisition

team at Mercy Health who we spoke with on July 18, 2019, the approach to hiring has led them

to identify the best-qualified individuals, resulting in a doubling of diverse hires in terms of

racial and ethnic background from 18 percent to more than 36 percent.

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The key informant also

noted that since the program’s implementation, the overarching Trinity Health System has

adopted and scaled the effort nationally.

In addition to identifying the best candidates at the stage of screening and interviews, Mercy

Health has engaged in active search efforts to find underrepresented hires in its own community.

This has included the creation of a sourcing team that is dedicated to recruitment efforts in the

communities Mercy Health serves. One feature of these efforts constitutes monthly hiring events

at two service centers in areas that are diverse and underserved. We learned from our discussions

that the sourcing team also has developed a diversity guide to inform its outreach efforts.

Community-sourcing efforts now take place on a statewide level.

Lastly, to provide an evidence-based component for hiring and promotion within Mercy

Health, the organization has built a career development center where current employees can learn

about their strengths, express their interests, and find new opportunities to which they are best

matched. Most positions at Mercy Health come with tuition assistance as a benefit for continuous

education; additional training for novel, in-demand jobs is emphasized strongly. Together, Mercy

Health’s MARAP, EBSP, and other innovations have led to local and national recognition,

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including as Mercy Health being named the 2017 employer of the year by Michigan Works!, the

statewide system of which West Michigan Works! is a part.

Program Challenges and How They Were Addressed

• At an early stage of MARAP, one challenge identified by the executive director of talent

acquisition was that the program was not serving a diverse pool of candidates in terms of

race, ethnicity, or socioeconomic status. Instead, it was serving a narrower demographic

of individuals who learned about the program and had the flexibility to participate. In

years 2 and 3 of MARAP, this was addressed by strengthening local partnerships,

including with West Michigan Works! to draw from a broader base of individuals, and a

nonprofit organization called The Source,

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which helps remove barriers to participation,

such as childcare and transportation needs.

• Because MARAP relies on a partnership among employers, educators, and community-

based organizations, there is a significant degree of coordination that needs to take place

among individuals running the program. This is particularly the case for participants who

might be falling behind by missing sessions or requiring additional time to meet

competency standards at work or in the classroom. To tackle this issue, program

members have developed routine huddle calls between employers and educators—and,

when necessary, with MAs themselves—to talk through ongoing challenges.

• In terms of the EBSP, one of the challenges at an early point in the rollout of materials

was ensuring that leadership was on board with the transition. This was the point at which

the executive director of talent acquisition decided to scale training on implicit racial bias

to more than 1,200 individuals.

Takeaways from Key Informants

• Founders reported that there is a replicable formula for instituting an initiative like

MARAP. Key informants said that the program needs (1) clear leadership, such as

through the assembly of a steering committee or a workforce board; (2) the participation

of a community college; and (3) champion employers who will back up these efforts.

Through the leadership of Shana Welch and others, Mercy Health has been able to extend

its reach within Trinity to develop a National Workforce Development Council that

includes six other states.

• It is critical to engage with community-based organizations in recruitment and

training efforts. Efforts done in isolation will be more likely to fail because the scope

and scale are too significant to be undertaken alone. The involvement of local

organizations extends resources, ensures sustainability, and draws from complementary

sources of expertise.

• It is important to see challenges as opportunities. There will always be new difficulties

that emerge when trying to work in a large health system that supports thousands of

EHCW members. Addressing challenges head-on as opportunities for improvement

allows staff to seek victories rather than focusing on “putting out fires.”

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Appendix B. Key Informant List

In Table B.1, we provide a list of our key informants’ titles, institutions, and sectors.

Table B.1. Overview of Key Informants

Title

Institution

Sector

Senior behavioral scientist;

center director

Nonprofit research organization

Academia

Center director; professor

University-based research center

Academia

Senior deputy director of center

University-based research center

Academia

Center director; professor

University-based research center

Academia

Center director

University-based research center

Academia

Executive director; professor

University-based practice and research

center

Academia

Project manager

University-based practice and research

center

Academia

Director of policy

University-based practice and research

center

Academia

Assistant director

University research office

Academia

Director of research group

University-based research center

Academia

Program officer

University-based practice and research

center

Academia

Professor

State university

Academia

Staff member

Health care labor union

Advocacy

Organization president

Health worker advocacy organization

Advocacy

Chief operating officer

Health worker advocacy organization

Advocacy

Executive director

Health care labor management fund

Advocacy

Advocate

Health worker advocacy organization

Advocacy

Executive director

Health care labor management fund

Advocacy

Department director

Health care labor management fund

Advocacy

Special assistant

Federal government agency

Government

Center director

Federal government agency

Government

Deputy administrator

Major federal department

Government

Division director

Major federal department

Government

Division director

Major federal department

Government

Unit chief

Major federal department

Government

Department director

National health care delivery organization

Governmental: Health care delivery

Fellowship director

National health care delivery organization

Governmental: Health care delivery

Peer specialist

National health care delivery organization

Governmental: Health care delivery

Medical director

Nonprofit health organization

Nonprofit

Executive director

Nonprofit cooperative development

organization

Nonprofit

Specialist

Nonprofit cooperative development

organization

Nonprofit

Program director

Health care labor management organization

Nonprofit

Executive director; professor

Nonprofit health organization

Nonprofit: Health care delivery

Investigator

Regional nonprofit health plan

Nonprofit: Health care delivery

Human resources manager

Regional nonprofit health plan

Nonprofit: Health care delivery

Department director

Regional nonprofit health plan

Nonprofit: Health care delivery

Quality director

National health care delivery program

Nonprofit: Health care delivery

Executive director

National health care delivery program

Nonprofit: Health care delivery

Vice president, human resources

Regional nonprofit health plan

Nonprofit: Health care delivery

Senior researcher

National nonprofit health plan

Nonprofit: Health care delivery

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Title

Institution

Sector

Executive director of behavioral

health

National nonprofit health plan

Nonprofit: Health care delivery

Senior vice president and chief

human resources officer

Regional nonprofit health plan

Nonprofit: Health care delivery

Director of strategic initiatives

Private funding institution

Private entities

Department director

Regional integrated managed health care

organization

Private: Health care delivery

Cooperative director

Home care cooperative

Private: Health care delivery

193

Appendix C. Process and Outcome Indicators for EHCW

Research

In addition to the research identified in the conclusions chapter, we list a series of key

process and outcome performance indicators that could be prioritized by the U.S. Department of

Health and Human Services and the research community for tracking the performance of

programs intended to expand and strengthen the EHCW. Having a standard set of indicators for

research studies could provide a useful compass for implementers, help focus the evidence base

in priority areas, allow for a common language to relate findings, and offer an inventory that

funders could emphasize when reviewing proposals. For the indicators, we used a framework

outlined by the Centers for Disease Control and Prevention (CDC) for the public health

workforce but it is applicable for the EHCW as well. The CDC identifies the following five

priorities to build the capacity of the public health workforce:

586

• Data for decisions: The CDC describes collecting “needed data about workforce gaps

and training needs to inform decisions about public health workforce development.” We

also include provider experience and career path trajectories as types of information

needed.

• Cross-cutting competencies: We include patient outcomes here because those are

measurable outcomes that should have detectable changes. As the CDC notes, there are

cross-cutting skills that should complement discipline-specific skills.

• Quality standards for training: This pertains to the application of established education

and training standards to align investments with high-quality products.

• Training decision tools and access: This includes accessing training and defining

training needs.

• Funding integration: Workforce development should be integrated into funding

requirements; we include cost outcome measures in this category as well.

These priorities are translated into strategies and outcomes. We use this framework to

categorize relevant measures for whether an intervention has been effective at developing the

workforce (see Table C.1). This is not a complete list; we highlight some important measures

that have not been sufficiently collected or reported in the existing literature.

194

Table C.1. Potential Measures for Success of Workforce Development

Measure Type

Domain

Goal That This Measure Could

Support

Health care worker self-reported job satisfaction

Experience

Data for decisions

Health care worker self-reported respect

Experience

Data for decisions

Health care worker self-reported autonomy

Experience

Data for decisions

Health care worker self-reported opportunity for career

growth

Experience

Data for decisions

Health care worker self-reported financial security

Experience

Data for decisions

Health care worker turnover rate

Experience

Data for decisions

Health care worker promotion rate

Experience

Data for decisions

Overall cost of care, with clarification of source of

information and cost to whom (claims data from private

insurance and Medicaid in addition to Medicare, for

example)

Cost

Funding integration

Provider recruitment and training expenditure

Cost

Funding integration

Health system, hospital, or agency payroll data (some

already available for Medicare; private health insurance and

Medicaid)

Cost

Funding integration

Cost savings as a function of new staff and programs

Cost

Funding integration

Patient outcomes (e.g., systolic blood pressure)

Quality

Cross-cutting competencies

Population-level outcomes

Quality

Cross-cutting competencies

Patient-reported communication quality

Quality

Cross-cutting competencies

Patient- reported satisfaction with care

Quality

Cross-cutting competencies

Patient wait time

Quality

Cross-cutting competencies

Patient self-reported access to care, including wait times,

distance to closest care, and co-pay as barrier

Quality

Cross-cutting competencies

Workforce competencies

Capacity

Quality standards for training

Knowledge of workforce

Capacity

Quality standards for training

Standardization of training

Training

Cross-cutting competencies

Rate of training completion

Training

Data for decisions, cross-cutting

competencies

NOTE: This table is based on the CDC framework described above.

586

195

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