Another approach to improving the quality of care as well as the quality of life for recipients of long-term care involves development of a high-quality and stable workforce. Michigan is focusing on the needs of its direct-care workers (e.g., nursing assistants, home care aides) as part of the foundation for its quality improvement activities. The Michigan Department of Community Health is using resources from two CMS initiatives to assess the volume, stability (in terms of turnover and vacancies), and compensation of the state's long-term care direct service workforce, and to incorporate workforce measures into an evaluation of the state's progress on its long-term care goals.
"The workforce is the foundation for good quality outcomes, and states need to think about the entire workforce, about basic data for every setting and program," said Hollis Turnham, the Midwest director for PHI, a national organization that provides technical assistance and policy analysis focused on the long-term care workforce. "In Michigan, assessing the workforce has also been an opportunity to incorporate consumers' preferences and their experience of care and support."
Michigan was one of 10 states to receive a CMS State Profile grant in 2008 to study its publicly funded long-term care system and help CMS develop national benchmarks for states to measure their progress in increasing access to home- and community-based services and reducing institutionally based care. According to the state profile report that Michigan produced, its functions are to:
- provide a snapshot of the long-term care support system;
- ensure a common knowledge base among policymakers and stakeholders;
- identify opportunities for improved coordination and collaboration;
- acknowledge the success that has occurred;
- identify service gaps;
- provide recommendations for improvement; and
- provide a framework for comparing rebalancing efforts across the states.
Michigan included an assessment of its long-term care workforce in the report, adding an additional dimension to the profile model that CMS had developed. The workforce component was added on the recommendation of the consumer stakeholder advisory group that helped develop the report. "The state profile grant provided an opportunity to look at workforce issues that we already felt were important, issues that we knew to be at the forefront in long-term care, and we were able to use the funding in flexible ways to collect the data we needed," said Jane Church, program specialist at the Michigan Office of Services to the Aging.
The state used a set of standard workforce measures developed by the CMS-funded National Direct Service Workforce Resource Center to target the biggest challenges states face. These included:
- workforce volume: number of full-time and part-time workers;
- workforce stability: turnover and vacancy rates; and
- worker compensation: average hourly wages and benefit packages.
The Resource Center recommends that states capture this information for the full range of institutional and non-institutional long-term care providers in order to get an accurate picture of the often fragmented long-term care sector—including not just nursing facilities and home health or personal care services, but also assisted living, hospice, adult day programs, and rehabilitation and vocational support programs. Michigan's report notes that the state had more than 5,000 providers of various types of long-term care supports and services. It was able to combine a variety of data sources and estimates to create a picture of the workforce, but the challenges of doing so across the many parts of the health care system are evident.
"We found that it was relatively easy to adapt the Resource Center tool to our specific needs in Michigan, to allow us to look at a broader array of data," said Church. The data come from many sources on different schedules, making the process of collecting and synthesizing them more complex and time-consuming, but the state is currently looking at updating the entire profile to reflect conditions in 2009. "This project has also snowballed into a couple of other projects to enhance our workforce data collection beyond institutional settings. So far, these are 'snapshot-in-time' type measurements," said Church. In general, Turnham added, "States should work on workforce measurement issues at two levels, both from a broad, system-wide perspective, but also in what some people would call silos. Look at everything, but don't be afraid to step off into a specific area or program that is particularly challenging—or conversely, where you think data will be easy to gather—to get a better understanding of a workforce issue."
Other states are taking innovative steps to strengthen their direct-care workforces. Kansas Medicaid is using a reimbursement method that boosts payment rates for nursing facilities that show they have low turnover and high continuity of care among direct-care workers, and Oklahoma's Focus on Excellence Program enhances nursing facility reimbursement rates based on a variety of measures that include workforce turnover. Though workforce challenges are significant, state innovation can help generate more—and better—jobs in occupations that are increasingly critical as the population ages. Understanding the characteristics of the current workforce is a critical building block.
For more information, contact: Jane Church at [email protected] or Hollis Turnham at [email protected].