ADDRESSING THE SHORTAGE OF DEMENTIA CAPABLE WORKERS: INSIGHTS AND
STRATEGIES FROM THE ALZHEIMER'S DISEASE DEMONSTRATION GRANT TO STATES
PROGRAM

Rhonda J. V. Montgomery

University of Wisconsin-Milwaukee

Karl Kosloski

University of Nebraska at Omaha

Lyn Holley

University of Nebraska at Omaha

Jerome Deichert

University of Nebraska at Omaha

A Report from the Helen Bader School of Social Welfare at the University
of Wisconsin-Milwaukee to the Administration on Aging

March 2004

Authors

Rhonda J.V. Montgomery, Ph.D.

Helen Bader Endowed Professor in Applied Gerontology

Helen Bader School of Social Welfare

University of Wisconsin-Milwaukee

Karl Kosloski, Ph.D.

Professor

Department of Gerontology

University of Nebraska at Omaha

Lyn Holley, Ph.D.

Visiting Assistant Professor

Department of Gerontology

University of Nebraska at Omaha

Jerome Deichert, Ph.D.

Director

Center for Public Affairs Research

University of Nebraska at Omaha

Contents

[Introduction i](#introduction)

[Prevalence of Worker Shortage 4](#prevalence-of-worker-shortage)

[*Background* 4](#background)

[*Analysis of Census Data* 6](#analysis-of-census-data)

[Limitations of Previous Studies 7](#limitations-of-previous-studies)

[Generation of Profile Using 2000 Census Data
10](#generation-of-profile-using-2000-census-data)

[Comparisons of Samples Generated Using Different Selection Criteria
14](#comparisons-of-samples-generated-using-different-selection-criteria)

[Comparison of Worker Profiles Generated from Two Samples Using PUMS
19](#comparison-of-worker-profiles-generated-from-two-samples-using-pums)

[Comparison of CPS and Census 2000 Estimates
23](#comparison-of-cps-and-census-2000-estimates)

[Conclusions and Implications 24](#conclusions-and-implications)

[Factors Linked to Workforce Retention & Recruitment
27](#factors-linked-to-workforce-retention-recruitment)

[*Rewards* 29](#rewards)

[*The Influence of Job Characteristics*
34](#the-influence-of-job-characteristics)

[*Management Practices and Communication.*
36](#management-practices-and-communication.)

[Opportunity for Worker Participation in Decisions
36](#opportunity-for-worker-participation-in-decisions)

[Supervisor Communication 37](#supervisor-communication)

[*Employee Training and Other Supports*
38](#employee-training-and-other-supports)

[*Peer Relations* 41](#peer-relations)

[*Worker Characteristics and Recruitment*
42](#worker-characteristics-and-recruitment)

[Efforts of ADDGS Projects to Solve Workforce Issues
45](#efforts-of-addgs-projects-to-solve-workforce-issues)

[*ADDGS: An Opportunity for Innovation*
45](#addgs-an-opportunity-for-innovation)

[*Efforts to Increase Worker Rewards*
46](#efforts-to-increase-worker-rewards)

[Opportunities for Advancement 47](#opportunities-for-advancement)

[Stabilize Organizations by Assuring a Client Base
49](#stabilize-organizations-by-assuring-a-client-base)

[Creating New Provider Organizations
51](#creating-new-provider-organizations)

[Training to Expand Service Capacity
53](#training-to-expand-service-capacity)

[*Expand Sources of Workers* 60](#expand-sources-of-workers)

[Volunteers as a Source of Direct Care Workers
60](#volunteers-as-a-source-of-direct-care-workers)

[Helping Families Become Employers
66](#helping-families-become-employers)

[*Using technology to expand the workforce*
70](#using-technology-to-expand-the-workforce)

[*Summary* 72](#summary)

[Conclusion 74](#conclusion)

Tables

**Table 1.** Current Population Survey (CPS) Occupation and Industry
Codes

Mapped Against Comparable Census Codes 9

**Table 2.** Composition of Samples Using Alternate Selection Criteria
15

**Table 3.** Employment by Class of Worker 19

**Table 4.** Descriptive Characteristics Comparing Two Definitions of
Aides (2000 Census Data) 21

# Introduction

As families struggle to care for their members with Alzheimer's Disease,
their most frequent request is for some sort of respite care (e.g. group
settings or home-based) (Montgomery & Kosloski, 1994). Th . Thie
Alzheimer's Disease Demonstration Grants to States (ADDGS) program was
created by Congress in 1990 to address this central need. The provision
of respite care, however, is not a simple matter of providing funds to
needy families. While many families do need financial assistance to pay
for services, there is an equally pressing need in most communities for
respite programs that are adequately staffed with qualified workers.
Direct care workers provide eight of every ten hours of paid care
received by long-term care clients (Paraprofessional Healthcare
Institute, 2001). These workers are paraprofessionals employed in
institutional settings, assisted living facilities, adult day care
centers, and clients' homes. Unfortunately, demand for direct care
workers is steadily increasing at a time when recruitment and retention
of these workers are widely reported to be increasingly difficult.
Experts agree there is a shortage of direct workers throughout the
country (Institute of Medicine, 2000) and results of national surveys of
state officials indicate a growing concern over the shortage (Harmuth &
Dyson, 2002; Paraprofessional Healthcare Institute, 2001; U.S. General
Accounting Office, 2001)

This shortage of direct care workers has proven to be one of the most
difficult challenges for the grantees of the ADDGS program, which not
only need a workforce of sufficient size, but also a workforce that is
adequately prepared to deal with the special needs of Alzheimer's
patients. As ADDGS projects have worked to develop viable respite
services in their communities, many have devised creative strategies for
enhancing the direct care work force in their communities. In some
cases, the goal of enhancing the workforce has been specifically
articulated; in other cases, enhancement of the workforce has been a
by-product of a larger focus. In all cases, the flexibility of the ADDGS
program has facilitated the creation of programs that are worthy of
examination because they may serve as exemplars for replication.

The purpose of this report is to: (1) describe some of the most
innovative ADDGS programs that have been designed and implemented to
enhance the pool of qualified direct care workers available to assist
families caring for persons with Alzheimer's disease in community
settings; and (2) examine these innovations within the context of the
current state of knowledge about the characteristics of the direct care
workforce and factors affecting the recruitment and retention of direct
care workers.

The report is divided into three sections. The first section critically
examines the present scope of knowledge concerning the characteristics
of the present workforce, including its size and demographic
composition. In particular, published estimates are compared to
estimates obtained from the 2000 Census, and alternative workforce
definitions are evaluated. The second section of the report provides an
overview of the current state-of-knowledge about job and workplace
characteristics that are related to worker job satisfaction and
retention of in-home care workers. An overview of this research provides
a useful background for better understanding of the workforce-related
innovations contained in the ADDGS programs. The final section of the
report describes the primary strategies that ADDGS projects have
undertaken to address the workforce shortage and provides detailed
descriptions of many of the programs. Descriptions of the ADDGS projects
are based on written proposals and reports, and information gathered
during on-site interviews with project participants in the 33 states
that began during the period from 2000 through 2002.

An overarching goal of this report is to establish a context within
which to understand more fully the ADDGS demonstration programs. These
programs are being implemented in an environment characterized by a
severe shortage of dementia-capable workers. As a result, many of the
ADDGS innovations contain programmatic elements that address this
shortage either directly or indirectly. In addition, this report is
intended to provide a solid foundation for designing and implementing
future scientific studies to evaluate some of the more promising
innovations developed by ADDGS grantees designed to address the current
and future shortage of direct care workers available to care for persons
with Alzheimer's disease.

#  PrevAlEnce of Worker Shortage

## Background

Concerns over the current labor shortage are underscored by projections
of even greater shortages in the foreseeable future. The number of
elders who need long-term care will increase dramatically as the
population aged 65 and older virtually doubles from 2000 to 2030 (U.S.
General Accounting Office, 2001). The number of individuals receiving
care in nursing homes, group residences, or using home care services is
expected to increase from 15 million in 2000 to 27 million in 2050 (U.S.
Department of Health and Human Services Office of Long-Term Care, 2003).

Technologic advances, coupled with increased funding for in-home
services especially form Medicare and Medicaid, make it possible for
increasing numbers of people with significant care needs to live at home
(U.S. General Accounting Office, 2001). The need for direct service
workers can also be expected to increase due to the increase in the
proportion of long-term care clients cared for outside of hospitals,
especially in dispersed settings where direct service workers are more
central to the provision of care (Institute of Medicine, 2000).

The increase in demand for direct service workers, which is estimated to
be 1.2 million additional workers by 2010, will outpace increases in the
size of the labor pool that supplies direct services workers. The
traditional source of recruits for direct service jobs, women in the
civilian workforce aged 25 to 44, will increase by only 400,000 during
the years from 2000 to 2010 (U.S. Department of Health and Human
Services Office of Long-Term Care, 2003). Even if all the working women
aged 25 to 44 in this decade were to became direct service workers,
estimates are that hundreds of thousands more workers still would be
needed (Harmuth & Dyson, 2002).

The supply of direct services workers that is actually available is
further constrained by features of the work that impede recruitment and
retention. Low wages, lack of benefits, onerous physical demands, and
lack of organizational support are typical. Since the government is the
dominant payer for these services, flexibility to adjust wages or
benefits or to invest resources in other improvements for workers is
constrained by rates of government reimbursement (Close, Estes, Linkins,
& Binney, 1994; Feldman, 1993; Paraprofessional Healthcare Institute,
2001; Stone & Wiener, 2001; U.S. Department of Health and Human Services
Office of Long-Term Care, 2003; Wilner, 2000)

Turnover of direct service workers is pronounced and available data
indicate annual turnover rates in nursing homes and in-home health care
agencies to be substantially higher than the 13 to 18 percent reported
for the labor force overall and for the 20 percent annual turnover rate
reported for all services (U.S. General Accounting Office, 2001). A
review of studies of turnover in nursing homes estimates that turnover
of aides ranged from 37 to 93% (Cohen-Mansfield, 1997). A national
survey of home health care agencies placed turnover among direct
services workers at 28% (U.S. General Accounting Office, 2001). Reports
of turnover in excess of 100 percent annually are not rare for nursing
homes (U.S. General Accounting Office, 2001) or in-home agencies
(Feldman, 1993; Harmuth & Dyson, 2002). It has been argued that these
high rates of worker turnover increase provider costs and may lead to
quality of care problems (U.S. General Accounting Office, 2001)
Consequently, state initiatives directed specifically toward improving
recruitment and retention of direct service workers are widespread
(Harmuth & Dyson, 2002), but little evidence is available to guide them
(U.S. General Accounting Office, 2001).

##  Analysis of Census Data

In order for planners and policy makers to identify and effectively
implement strategies to increase the recruitment and retention of direct
care workers, such as home care aides, it is important to establish a
clear understanding of the size and characteristics of the current
workforce. Such information is essential for targeting variables for
possible intervention. For example, knowledge of the demographic
characteristics of workers may help define the target population for
future recruitment efforts. Similarly, knowledge of job characteristics,
such as types of employers and differential pay scales, may provide
clues to strategies potentially useful to attract and retain workers.

To date, the most complete information available about the long-term
care workforce has been provided by two studies that have used the
Current Population Survey (CPS) to estimate the size and demographic
characteristics of the workforce that is engaged in this direct care
work (Crown, Ahlburg, & McAdam, 1995; Yamada, 2002). From these studies
we have learned that the typical paraprofessional or frontline worker in
the long-term care industry is a middle-aged, white, single mother, with
low educational attainment, and very low income (Stone, 2001). Also,
from comparisons made between the profiles generated by the two studies,
which used data collected ten years apart, we have learned that the
demographic characteristics of hospital and nursing home aides have
changed little over the course of the last decade. In contrast, home
care aides of the late 1990\'s appear to be younger, better educated,
more likely to hold a full-time position, and receive job-related
benefits such as health insurance than their predecessors in the
previous decade (Yamada, 2002).

### Limitations of Previous Studies

Although valuable, the profiles of the direct care workforce provided by
Crown and his colleagues (1995), and again ten years later in the
replication by Yamada, have two limitations that could potentially limit
the accuracy and utility of the descriptive findings for guiding policy
and practice today. First, in both studies, the sample size is small, a
fact that greatly increases the variability of the population estimates
and does not allow for sub-national analysis. Second, as noted by the
authors themselves, the industry and occupational codes available in the
CPS data set preclude precise identification of many of the workers.
Consequently, the sample of workers included in the two studies under
represents workers in some occupations and over represents workers in
others.

Data for the CPS are collected annually from a nationally representative
sample of the noninstitutionalized U.S. population. Interviews are
conducted with upwards of 100,000 individuals aged 15 and over,
providing estimates of respondents' economic activities and status,
along with demographic information. The CPS sample for any given year,
however, is inadequate to represent all home care workers because they
represent such a small proportion of the total working population.
Therefore, for both the study by Crown et al., and the replication study
by Yamada, three years of CPS data were merged in order to overcome the
potential instability of small-sample estimates. In the former study,
data from 1987-1989 were used. In the latter study, data from 1997-1999
were examined. In spite of these efforts, only 301 cases for home care
aides were available for analysis by Crown and his colleagues. That
number fell to 216 in the subsequent analysis by Yamada. Thus, in both
cases, work force descriptions of home care aides were based on a
relatively small sample of workers. The likely outcome is less precise
population estimates (i.e., larger standard errors), along with even
less reliable estimates of change over time (Lord, 1963).

A potentially more serious problem of the CPS data is the difficulty
associated with accurately identifying home care aides in the data set.
The samples of workers included in the analyses conducted by the Crown
and his colleagues (1995), and by Yamada (2002), were selected using a
process of cross-classification of industry codes with occupational
codes. Specifically the investigators identified seven industry codes
and three occupational codes to identify direct care workers in the CPS
data set. As shown in Table 1, the occupations and occupation codes used
for sample selection were health aides except nursing (446), nursing
aides, orderlies, and attendants (447) and welfare aides (465). The
seven industries and their codes included private households (761),
hospitals (831), nursing and personal care facilities (832), health
services not elsewhere classified (840), job training, vocational
rehabilitation (861), social services not elsewhere classified, and
religious

**Table 1. Current Population Survey (CPS) Occupation and Industry
Codes**

**Mapped Against Comparable Census Codes**

+----+-------------------------+---+----------------------------------+
| C  |                         | C |                                  |
| ur |                         | e |                                  |
| re |                         | n |                                  |
| nt |                         | s |                                  |
| Po |                         | u |                                  |
| pu |                         | s |                                  |
| la |                         | 2 |                                  |
| ti |                         | 0 |                                  |
| on |                         | 0 |                                  |
| Su |                         | 0 |                                  |
| rv |                         | ( |                                  |
| ey |                         | P |                                  |
| (  |                         | U |                                  |
| CP |                         | M |                                  |
| S) |                         | S |                                  |
|    |                         | ) |                                  |
+----+-------------------------+---+----------------------------------+
| Cr |                         | C |                                  |
| ow |                         | r |                                  |
| n, |                         | o |                                  |
| Ah |                         | w |                                  |
| lb |                         | n |                                  |
| ur |                         | , |                                  |
| g, |                         | A |                                  |
| a  |                         | h |                                  |
| nd |                         | l |                                  |
| M  |                         | b |                                  |
| ac |                         | u |                                  |
| Ad |                         | r |                                  |
| am |                         | g |                                  |
| d  |                         | , |                                  |
| ef |                         | a |                                  |
| in |                         | n |                                  |
| it |                         | d |                                  |
| io |                         | M |                                  |
| ns |                         | a |                                  |
|    |                         | c |                                  |
|    |                         | A |                                  |
|    |                         | d |                                  |
|    |                         | a |                                  |
|    |                         | m |                                  |
|    |                         | d |                                  |
|    |                         | e |                                  |
|    |                         | f |                                  |
|    |                         | i |                                  |
|    |                         | n |                                  |
|    |                         | i |                                  |
|    |                         | t |                                  |
|    |                         | i |                                  |
|    |                         | o |                                  |
|    |                         | n |                                  |
|    |                         | s |                                  |
+----+-------------------------+---+----------------------------------+
| OC |                         | O |                                  |
| CU |                         | C |                                  |
| PA |                         | C |                                  |
| TI |                         | U |                                  |
| ON |                         | P |                                  |
|    |                         | A |                                  |
|    |                         | T |                                  |
|    |                         | I |                                  |
|    |                         | O |                                  |
|    |                         | N |                                  |
+----+-------------------------+---+----------------------------------+
| Co | Description             | C | Description                      |
| de |                         | o |                                  |
|    |                         | d |                                  |
|    |                         | e |                                  |
+----+-------------------------+---+----------------------------------+
| 4  | Health Aides, Except    | 3 | Occupational therapist           |
| 46 | Nursing                 | 6 | assistants and aides             |
|    |                         | 1 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 3 | Physical therapist assistants    |
|    |                         | 6 | and aides                        |
|    |                         | 2 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 3 | Medical assistants and other     |
|    |                         | 6 | healthcare \\                    |
|    |                         | 5 |                                  |
|    |                         |   | support occupations              |
+----+-------------------------+---+----------------------------------+
|    |                         | 9 | Ambulance drivers and            |
|    |                         | 1 | attendants, except               |
|    |                         | 1 |                                  |
|    |                         |   | emergency medical technicians    |
+----+-------------------------+---+----------------------------------+
| 4  | Nursing Aides,          | 3 | Nursing, psychiatric, and home   |
| 47 | Orderlies, and          | 6 | health aides                     |
|    | Attendants              | 0 |                                  |
+----+-------------------------+---+----------------------------------+
| 4  | Welfare Service Aides   | 4 | Personal and home care aides     |
| 65 |                         | 6 |                                  |
|    |                         | 1 |                                  |
+----+-------------------------+---+----------------------------------+
| IN |                         | I |                                  |
| DU |                         | N |                                  |
| ST |                         | D |                                  |
| RY |                         | U |                                  |
|    |                         | S |                                  |
|    |                         | T |                                  |
|    |                         | R |                                  |
|    |                         | Y |                                  |
+----+-------------------------+---+----------------------------------+
| Co | Description             | C | Description                      |
| de |                         | o |                                  |
|    |                         | d |                                  |
|    |                         | e |                                  |
+----+-------------------------+---+----------------------------------+
| 7  | Private households      | 9 | Private households               |
| 61 |                         | 2 |                                  |
|    |                         | 9 |                                  |
+----+-------------------------+---+----------------------------------+
| 8  | Hospitals               | 8 | Hospitals                        |
| 31 |                         | 1 |                                  |
|    |                         | 9 |                                  |
+----+-------------------------+---+----------------------------------+
| 8  | Nursing and personal    | 8 | Nursing care facilities          |
| 32 | care facilities         | 2 |                                  |
|    |                         | 7 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 8 | Residential care facilities,     |
|    |                         | 2 | without                          |
|    |                         | 8 |                                  |
|    |                         |   | nursing                          |
+----+-------------------------+---+----------------------------------+
| 8  | Health service not      | 3 | Medical equipment and            |
| 40 | elsewhere classified    | 9 |                                  |
|    | (n.e.c.)                | 6 | supplies manufacturing           |
+----+-------------------------+---+----------------------------------+
|    |                         | 7 | Specialized design services      |
|    |                         | 3 |                                  |
|    |                         | 7 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 8 | Outpatient care centers          |
|    |                         | 0 |                                  |
|    |                         | 9 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 8 | Home health care services        |
|    |                         | 1 |                                  |
|    |                         | 7 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 8 | Other health care services       |
|    |                         | 1 |                                  |
|    |                         | 8 |                                  |
+----+-------------------------+---+----------------------------------+
| 8  | Job training,           | 8 | Vocational rehabilitation        |
| 61 | vocational              | 3 | services                         |
|    | rehabilitation          | 9 |                                  |
+----+-------------------------+---+----------------------------------+
| 8  | Social service n.e.c.   | 8 | Individual and family services   |
| 71 |                         | 3 |                                  |
|    |                         | 7 |                                  |
+----+-------------------------+---+----------------------------------+
|    |                         | 8 | Community food and housing, and  |
|    |                         | 3 | emergency                        |
|    |                         | 8 |                                  |
|    |                         |   | services                         |
+----+-------------------------+---+----------------------------------+
|    |                         | 9 | Civic, social, advocacy,         |
|    |                         | 1 | organizations, and               |
|    |                         | 7 |                                  |
|    |                         |   | grant making and giving services |
+----+-------------------------+---+----------------------------------+
|    |                         | 9 | Justice, public order, and       |
|    |                         | 4 | safety activities                |
|    |                         | 7 |                                  |
+----+-------------------------+---+----------------------------------+
| 8  | Religious organizations | 9 | Religious organizations          |
| 80 |                         | 1 |                                  |
|    |                         | 6 |                                  |
+----+-------------------------+---+----------------------------------+

organizations (880). While these categories for industries and
occupations enabled the investigators to select a study sample that
reasonably represents the direct care workforce, they are not as precise
as those available in the Census data. Consequently, as Crown and his
colleagues note, application of their criteria for sample selection,
which relied on the cross-classification of these industry and
occupation codes, was very likely to result in a sample that included
individuals who were not home care aides. It is also the case that the
criteria used likely resulted in the omission of a number of workers who
should have been included in the sample.

###  Generation of Profile Using 2000 Census Data

Our goal for this report was to generate a profile of the direct care
workforce using the 5% Public Use Micro Sample (PUMS) data from the 2000
Census. The PUMS data allow for the creation of a profile that is based
on the more recent national data and one that is not subject to many of
the limitations of the CPS data. Using this data set, we were able to
generate a study sample that more accurately includes the full range of
direct care workers and excludes several groups of workers that had
inappropriately been included in previous analyses. When the profiles of
the direct care workforce generated using these data are examined and
compared with compared with those of Yamada (2002), some interesting
differences in the characteristics of the direct care workforce can be
observed that may have important implications for policy and program
development.

#### Analysis Strategy {#analysis-strategy .unnumbered}

Our analysis proceeded in four steps. First, to assure the accuracy of
our understanding of the criteria used by the investigators of the
previous studies, we replicated the procedure used by Yamada for sample
selection on the same data set (i.e., CPS data from 1997-1999). This
procedure produced the same sample sizes reported by Yamada: 216 home
care aides, 761 hospital aides, and 1,238 nursing home aides. The second
step was to replicate the procedure used by Crown et al. and Yamada,
using the 5% PUMS data from the 2000 Census data. Third, using the more
precise categories for occupation type that are available for the census
data in the PUMS,we developed a new set of criteria for selecting home
care workers. Fourth, we compared demographic profiles using both sets
of criteria for sample selection and then compared these profiles with
those generated by Yamada (200) using CPS data from (1997-9999).

#### Differences in Sample Selection Criteria {#differences-in-sample-selection-criteria .unnumbered}

The primary difference between the new selection criteria used to
identify the sample for our analysis and the criteria used by Crown et
al. and Yamada (2002) is the use of industries and occupations from the
census that identify more precisely the segments of the population that
are appropriate for inclusion in the sample. The specific differences in
the coding schemes are shown in Table 1 where the CPS codes are mapped
to corresponding Census codes.

Crown and his colleagues identified individuals as home care workers if
they were classified in CPS occupational codes 446 (health aides except
nursing), 447 (nursing aides, orderlies, and attendants), or 465
(welfare service aides) ***and*** worked in industries coded as 840
(health services not elsewhere classified), 861 (job training and
vocational rehabilitation services), 871 (social services not elsewhere
classified), or 880 (religious organizations). They were also identified
as home care aides if they were classified in CPS occupational codes 446
(health aides except nursing) or 447 (nursing aides, orderlies, and
attendants) and worked in industry 761 (private households).

There are three specific problems with the sample selection criteria
used by Crown and Yamada. The first issue centers on the group of
workers identified by the CPS code 446. As shown in Table 1, this group
of workers includes four discrete groups of workers that have unique
codes in the Census data. These are occupational therapists and
assistants (361) , physical therapists assistants and aides (362)
medical and other health care support occupations (365) and ambulance
drivers and attendants (911) . Individuals in these occupations are
relatively highly paid and typically work in hospitals and nursing
homes. Regardless of whether they work in hospitals, nursing homes, or
private homes, however, individuals in these occupations would rarely be
subsumed under the heading "frontline" home care worker. As Crown and
his colleagues note, their cross-classification was very likely to
include individuals who are not home care aides.

The second problem with previous selection criteria is the omission of
groups of workers that should have been included in the sample. Welfare
service aides (occupation code 465) working in private households
(industry 761) were omitted from previous study samples, presumably
because home care aides could not be disaggregated from case workers who
determine program eligibility (see Yamada, 2002, Table 1, p. 200). The
likely consequence, however, is the under representation of home care
aides. We were able to include this group because the census data
allowed us to disaggregate them from case managers.

Also omitted from previous samples were health aides and nursing aides
from occupations 446 and 447 that were working in industry 840 (health
service not elsewhere classified), an industry that includes home health
agencies. The reason for this exclusion is that home health agencies
were combined with several other industries in code 840 and
disaggregating them was impossible. The likely result, however, is the
under-representation of health aides working in home health agencies.
For the analyses presented here, we were able to overcome this
limitation because the industry codes for the census data are more
precise in their identification of different industries. In particular,
we included nursing aides from occupations with CPS codes 447 and 465
(i.e. census codes 360 and 461) who were employed in home health
agencies (census code 817). Similarly we were able to select into our
sample nursing aides, orderlies and attendants (census code 360) who
were employed in individual and family services (837).

The identification of hospital aides and nursing home aides by Crown and
his colleagues, and subsequently by Yamada, was more straightforward
than their selection of home care workers. Using this same
cross-classification procedure, individuals were classified as hospital
aides if they worked in CPS occupations 465 (welfare aides), 446 (health
aides except nurses) or 447 (nursing aides, orderlies, and attendants)
**and** worked in industry 831 (hospitals). Similarly, workers in those
occupations were classified as nursing home aides if they worked in CPS
occupations 465, 446 or 447 **and** in industry 832 (nursing and
personal care facilities). Again, the inclusion of workers in category
446 (health aides, except nurses) working in either of these industries
is questionable given that they are assistants to occupational
therapists, psychiatrists, or other medical professional or they are
ambulance drivers and attendants. This group of workers was omitted from
our second sample, using the more precise codes available with the
census data.

### Comparisons of Samples Generated Using Different Selection Criteria

The differences in the composition of the samples that are drawn from
the Census 2000 data using the two different selection criteria are
shown in Table 2. The first two columns show the CPS and Census industry
codes associated with each industry from which subjects were drawn.
Occupational categories and the codes used for sample selection are
shown in the third column. The CPS codes and occupational categories are
presented in bold with corresponding census codes in italics. When a CPS
occupational code subsumes several categories, the Census categories are
listed below the CPS category along with Census codes.

The last two columns give the number of workers selected from the each
industry-by-occupation category using the two different selection
criteria. The composition of the sample generated using the criteria
established by Crown et al., (1995) are shown in column four. The
numbers shown in the last column of Table 2 depict the composition of
the sample that is generated from the PUMS data when the more precise
Census codes are used.

A comparison between the numbers in the last two columns of Table 2
provides a clear picture of the differences in the composition of the
two samples. Application of the more precise criteria for sample section
results in a sample of home care workers that differs substantially in
composition and size from the one described by Crown et al. (1995) and
replicated by Yamada (2002). Application of Crown's criteria for sample
selection identifies 10,903 home care aides which

TABLE 2 (page one)

TABLE 2 (page two)

TABLE 2 (page 3)

translates to a population estimate of 208,312 nationwide. Using the
alternate criteria for sample selection, 42,624 home care aides are
identified, which translates to a population estimate of 789,149. This
fourfold increase in the estimate of the total number of home care
workers is the direct consequence of the more finely graded industry and
occupational classifications available for the census data, groupings
that are not attainable in the smaller CPS survey.

Equally important is the fact that the majority of these newly
identified care aides are working in private homes. This finding means
that, in the past, in-home workers have been substantially
underrepresented in the profiles generated from national data sets.
Moreover, about one-fifth of these newly identified workers are employed
in private households.

Another interesting characteristic of home care aides, available from
the Census 2000, and not reported by either Crown et al. or Yamada, is
the high proportion of self-employed home health aides. Using the Crown
criteria for sampling home care aides, approximately 10% of the aides
can be classified as self-employed. Using the more precise occupation
occupational codes available in the PUMS our analysis indicate that
fully 18% of home care aides are self-employed, compared to less than 1%
of nursing home aides, and virtually no hospital aides. This difference
is clearly illustrated in Table 3.

In contrast to the sizable differences between the two study samples in
the composition of in-home workers, the composition of direct care
workers employed in hospital and nursing home settings is not
dramatically different. It is the case, however. that the estimates of
the number of hospital aides and nursing home aides are somewhat smaller
when the more precise census codes are used to identify workers for
inclusion in the sample.

**Table 3. Employment by Class of Worker**

+-----------------------+-----+-------+-------+---+-----+-------+-------+
|                       | Cr  |       |       |   | Alt |       |       |
|                       | own |       |       |   | ern |       |       |
|                       | D   |       |       |   | ate |       |       |
|                       | efi |       |       |   | D   |       |       |
|                       | nit |       |       |   | efi |       |       |
|                       | ion |       |       |   | nit |       |       |
|                       |     |       |       |   | ion |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
|                       |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
|                       | Ho  | Nu    | Home  |   | Ho  | Nu    | Home  |
|                       | spi | rsing |       |   | spi | rsing |       |
|                       | tal | Home  | Care  |   | tal |       | Care  |
|                       | A   | Aide  | Aide  |   | A   | Home  | Aide  |
|                       | ide |       |       |   | ide | Aide  |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
|                       |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Employee private for  | 6   | 76.8  | 56.2  |   | 6   | 76.8  | 60.6  |
| profit                | 2.2 |       |       |   | 3.6 |       |       |
|                       |     |       |       |   |     |       |       |
| Company               |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Employee private not  | 2   | 13.0  | 15.1  |   | 1   | 12.9  | 7.9   |
| for profit company    | 0.9 |       |       |   | 8.1 |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Employee of local     | 5.4 | 4.8   | 8.2   |   | 5.7 | 4.8   | 6.1   |
| government            |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Employee of state     | 8.5 | 4.5   | 8.9   |   | 9.7 | 4.7   | 5.5   |
| government            |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Employee of federal   | 2.6 | 0.3   | 0.6   |   | 2.6 | 0.3   | 0.4   |
| government            |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Self-employed in      | 0.1 | 0.3   | 8.7   |   | 0.0 | 0.3   | 16.7  |
| unincorporated        |     |       |       |   |     |       |       |
| business              |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Self-employed in      | 0.0 | 0.1   | 0.9   |   | 0.0 | 0.1   | 1.4   |
| incorporated business |     |       |       |   |     |       |       |
+-----------------------+-----+-------+-------+---+-----+-------+-------+
| Unpaid family worker  | 0.2 | 0.1   | 1.3   |   | 0.2 | 0.1   | 1.4   |
+-----------------------+-----+-------+-------+---+-----+-------+-------+

### Comparison of Worker Profiles Generated from Two Samples Using PUMS 

Given the dramatic differences in the population sizes estimated using
the two different sample selection criteria, the issue arises as to
whether the two samples will reveal different profiles for direct care
workers. Table 4 shows the population characteristics of hospital aides,
nursing home aides, and home care aides using the two different samples
drawn from 2000 PUMS data. The first three columns in Table 4 depict the
sample characteristics for the smaller sample that was drawn by
replicating the criteria used by Crown et al., (1995). The last three
columns depict the findings for the larger sample that results when the
more precise sample selection, using industry and occupation codes
included with the census data are employed.

In spite of the substantial differences in the number of workers
included who were identified by the two methods, Table 4 reveals very
few differences in demographic characteristics for the two samples. The
only major discrepancies occur in the estimates of income. Using the
definition of hospital aide put forth by Crown and his colleagues, the
median hourly wage for hospital aides is \$10.00. In the alternative
definition presented here, the hourly wage drops to \$9.64. This likely
occurs because the more highly paid workers in CPS occupational code 446
are not included in the new definition of "aide." These workers included
occupational therapy assistants, physical therapy assistants, medical
assistants, and ambulance drivers and attendants. In contrast, the
hourly wage for home care aides goes from \$7.05/hour, using the Crown
definition, to \$7.50/hour using the alternative definition. This
substantial increase is likely due to the addition of the large number
of aides employed by home care agencies. These shifts in income are
reflected, to a lesser extent, in the categories of total annual
earnings and total personal income as well (Table 4). Interestingly, the
income of nursing home aides is unaffected by changing the definition
used.

**Table 4. Descriptive Characteristics Comparing Two Definitions of
Aides**

**(2000 Census Data)**

+-----------------------+-----+------+------+---+------+------+------+
|                       | Cr  |      |      |   | A    |      |      |
|                       | own |      |      |   | lter |      |      |
|                       | D   |      |      |   | nate |      |      |
|                       | efi |      |      |   | De   |      |      |
|                       | nit |      |      |   | fini |      |      |
|                       | ion |      |      |   | tion |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       | Ho  | Nur  | Home |   | Hosp | Nur  | Home |
|                       | spi | sing |      |   | ital | sing |      |
|                       | tal | Home | Care |   | Aide | Home | Care |
|                       | A   | Aide | Aide |   |      | Aide | Aide |
|                       | ide |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Age                   |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Under 25              | 1   | 21.7 | 8.4  |   | 14.7 | 20.8 | 7.4  |
|                       | 5.0 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| 25-34                 | 2   | 23.5 | 15.4 |   | 22.7 | 24.0 | 16.0 |
|                       | 3.3 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| 35-44                 | 2   | 22.7 | 21.8 |   | 24.1 | 23.0 | 22.8 |
|                       | 4.6 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| 45-54                 | 1   | 16.8 | 21.8 |   | 19.3 | 17.0 | 22.3 |
|                       | 9.3 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| 55-64                 | 1   | 10.6 | 18.7 |   | 12.8 | 10.6 | 18.6 |
|                       | 2.1 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| 65 or older           | 5.9 | 4.7  | 13.8 |   | 6.5  | 4.7  | 12.9 |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Median Age            | 3   | 37.0 | 46.0 |   | 40.0 | 37.0 | 46.0 |
|                       | 9.0 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Mean Age              | 4   | 38.2 | 46.8 |   | 41.0 | 38.4 | 46.7 |
|                       | 0.6 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Gender                |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Male                  | 1   | 8.7  | 9.7  |   | 17.2 | 8.1  | 7.4  |
|                       | 6.8 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Female                | 8   | 91.3 | 90.3 |   | 82.8 | 91.9 | 92.6 |
|                       | 3.2 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Race                  |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| White alone           | 5   | 64.6 | 64.8 |   | 56.2 | 64.1 | 62.0 |
|                       | 9.7 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| African American      | 2   | 25.7 | 20.0 |   | 30.9 | 26.1 | 23.9 |
| alone                 | 7.8 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Other                 | 1   | 9.7  | 15.2 |   | 12.9 | 9.8  | 14.1 |
|                       | 2.5 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Hispanic/Latino       | 1   | 7.2  | 14.6 |   | 10.6 | 7.3  | 14.6 |
|                       | 0.4 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Marital Status        |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Married               | 4   | 44.4 | 45.1 |   | 47.8 | 44.7 | 45.7 |
|                       | 9.1 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Widow                 | 2   | 24.9 | 34.6 |   | 25.2 | 25.5 | 35.0 |
| ed/Divorced/Separated | 4.1 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Never Married         | 2   | 30.7 | 20.3 |   | 27.0 | 29.7 | 19.2 |
|                       | 6.8 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Education             |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Not high school grad  | 1   | 28.2 | 33.9 |   | 20.2 | 27.6 | 32.4 |
|                       | 7.8 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| High school grad      | 3   | 41.5 | 34.5 |   | 36.5 | 42.0 | 35.6 |
|                       | 4.4 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Some college          | 3   | 27.0 | 25.6 |   | 35.8 | 27.1 | 26.0 |
|                       | 9.6 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| 4+ Years of College   | 8.2 | 3.4  | 6.1  |   | 7.5  | 3.3  | 5.9  |
+-----------------------+-----+------+------+---+------+------+------+
|                       |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Citizenship           |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Native-born US        | 8   | 88.1 | 81.7 |   | 82.8 | 87.9 | 78.9 |
|                       | 4.2 |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Native-born US        | 0.8 | 0.6  | 0.7  |   | 0.9  | 0.6  | 1.1  |
| Outlying Area         |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Native-born Abroad US | 0.6 | 0.5  | 0.4  |   | 0.5  | 0.5  | 0.4  |
| Parent                |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Foreign Born          | 8.0 | 5.0  | 7.7  |   | 8.6  | 5.0  | 9.1  |
| (naturalized)         |     |      |      |   |      |      |      |
+-----------------------+-----+------+------+---+------+------+------+
| Not a US Citizen      | 6.4 | 5.9  | 9.5  |   | 7.1  | 6.0  | 10.5 |
+-----------------------+-----+------+------+---+------+------+------+

<table style="width:100%;">
<colgroup>
<col style="width: 29%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 10%" />
<col style="width: 0%" />
<col style="width: 1%" />
<col style="width: 2%" />
<col style="width: 8%" />
<col style="width: 2%" />
<col style="width: 10%" />
<col style="width: 10%" />
</colgroup>
<tbody>
<tr class="odd">
<td colspan="14"><strong>Table 4. (Continued)</strong></td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td></td>
<td colspan="3"></td>
<td></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="6">Crown Definition</td>
<td></td>
<td colspan="5">Alternate Definition</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="6"></td>
<td></td>
<td colspan="5"></td>
</tr>
<tr class="odd">
<td colspan="2"></td>
<td colspan="2">Hospital Aide</td>
<td colspan="2">Nursing Home Aide</td>
<td colspan="2"><p>Home</p>
<p>Care Aide</p></td>
<td></td>
<td colspan="2">Hospital Aide</td>
<td colspan="2">Nursing Home Aide</td>
<td><p>Home</p>
<p>Care Aide</p></td>
</tr>
<tr class="even">
<td colspan="2">Labor Force Participation</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Nonworker</td>
<td colspan="2">13.2</td>
<td colspan="2">13.9</td>
<td colspan="2">19.8</td>
<td></td>
<td colspan="2">14.4</td>
<td colspan="2">14.1</td>
<td>20.3</td>
</tr>
<tr class="even">
<td colspan="2">Year-round, fulltime</td>
<td colspan="2">46.7</td>
<td colspan="2">41.0</td>
<td colspan="2">27.0</td>
<td></td>
<td colspan="2">44.9</td>
<td colspan="2">41.6</td>
<td>27.3</td>
</tr>
<tr class="odd">
<td colspan="2">Year-round, parttime</td>
<td colspan="2">18.7</td>
<td colspan="2">21.0</td>
<td colspan="2">17.6</td>
<td></td>
<td colspan="2">19.6</td>
<td colspan="2">21.5</td>
<td>17.7</td>
</tr>
<tr class="even">
<td colspan="2">Part-year, fulltime</td>
<td colspan="2">10.2</td>
<td colspan="2">10.5</td>
<td colspan="2">15.8</td>
<td></td>
<td colspan="2">9.8</td>
<td colspan="2">10.0</td>
<td>15.3</td>
</tr>
<tr class="odd">
<td colspan="2">Part-year, parttime</td>
<td colspan="2">11.2</td>
<td colspan="2">13.5</td>
<td colspan="2">19.7</td>
<td></td>
<td colspan="2">11.3</td>
<td colspan="2">12.8</td>
<td>19.4</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Weeks Worked Per Year*</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Median</td>
<td colspan="2">52.0</td>
<td colspan="2">52.0</td>
<td colspan="2">50.0</td>
<td></td>
<td colspan="2">52.0</td>
<td colspan="2">52.0</td>
<td>50.0</td>
</tr>
<tr class="odd">
<td colspan="2">Mean</td>
<td colspan="2">44.4</td>
<td colspan="2">42.4</td>
<td colspan="2">40.6</td>
<td></td>
<td colspan="2">43.9</td>
<td colspan="2">42.5</td>
<td>40.8</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Hours Worked Per Week*</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Median</td>
<td colspan="2">40.0</td>
<td colspan="2">40.0</td>
<td colspan="2">36.0</td>
<td></td>
<td colspan="2">40.0</td>
<td colspan="2">40.0</td>
<td>37.0</td>
</tr>
<tr class="odd">
<td colspan="2">Mean</td>
<td colspan="2">36.9</td>
<td colspan="2">36.6</td>
<td colspan="2">34.5</td>
<td></td>
<td colspan="2">37.0</td>
<td colspan="2">37.0</td>
<td>34.7</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Hourly Earnings*</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Median</td>
<td colspan="2">10.00</td>
<td colspan="2">8.01</td>
<td colspan="2">7.05</td>
<td></td>
<td colspan="2">9.64</td>
<td colspan="2">8.03</td>
<td>7.50</td>
</tr>
<tr class="odd">
<td colspan="2">Mean</td>
<td colspan="2">14.33</td>
<td colspan="2">11.06</td>
<td colspan="2">12.36</td>
<td></td>
<td colspan="2">14.37</td>
<td colspan="2">11.07</td>
<td>13.04</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Total Annual Earnings*</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Median</td>
<td colspan="2">17,300</td>
<td colspan="2">13,000</td>
<td colspan="2">9,600</td>
<td></td>
<td colspan="2">16,800</td>
<td colspan="2">13,200</td>
<td>10,000</td>
</tr>
<tr class="odd">
<td colspan="2">Mean</td>
<td colspan="2">19,842</td>
<td colspan="2">15,213</td>
<td colspan="2">13,541</td>
<td></td>
<td colspan="2">19,564</td>
<td colspan="2">15,337</td>
<td>14,319</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Total Personal Income</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Median</td>
<td colspan="2">16,800</td>
<td colspan="2">12,700</td>
<td colspan="2">10,000</td>
<td></td>
<td colspan="2">16,000</td>
<td colspan="2">12,900</td>
<td>10,000</td>
</tr>
<tr class="odd">
<td colspan="2">Mean</td>
<td colspan="2">19,196</td>
<td colspan="2">14,736</td>
<td colspan="2">13,874</td>
<td></td>
<td colspan="2">18,842</td>
<td colspan="2">14,835</td>
<td>14,325</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="2">Poverty Ratio</td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="even">
<td colspan="2">Less than 1.00</td>
<td colspan="2">13.4</td>
<td colspan="2">19.5</td>
<td colspan="2">23.8</td>
<td></td>
<td colspan="2">14.7</td>
<td colspan="2">19.7</td>
<td>23.0</td>
</tr>
<tr class="odd">
<td colspan="2">1.00-1.49</td>
<td colspan="2">9.7</td>
<td colspan="2">13.8</td>
<td colspan="2">15.0</td>
<td></td>
<td colspan="2">10.7</td>
<td colspan="2">14.1</td>
<td>14.3</td>
</tr>
<tr class="even">
<td colspan="2">1.50-1.99</td>
<td colspan="2">11.1</td>
<td colspan="2">13.7</td>
<td colspan="2">14.1</td>
<td></td>
<td colspan="2">11.7</td>
<td colspan="2">13.8</td>
<td>13.2</td>
</tr>
<tr class="odd">
<td colspan="2">2.00-2.49</td>
<td colspan="2">11.8</td>
<td colspan="2">12.2</td>
<td colspan="2">10.5</td>
<td></td>
<td colspan="2">12.1</td>
<td colspan="2">12.3</td>
<td>11.0</td>
</tr>
<tr class="even">
<td colspan="2">2.50-2.99</td>
<td colspan="2">10.4</td>
<td colspan="2">10.0</td>
<td colspan="2">8.3</td>
<td></td>
<td colspan="2">10.4</td>
<td colspan="2">9.9</td>
<td>9.0</td>
</tr>
<tr class="odd">
<td colspan="2">3.00 or More</td>
<td colspan="2">43.6</td>
<td colspan="2">30.8</td>
<td colspan="2">28.3</td>
<td></td>
<td colspan="2">40.4</td>
<td colspan="2">30.1</td>
<td>29.5</td>
</tr>
<tr class="even">
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td></td>
</tr>
<tr class="odd">
<td colspan="14"><p>*These items were calculated only for workers. The
other items included both workers and non-workers</p>
<p>(i.e., individuals who did not report any income the previous
year).</p></td>
</tr>
<tr class="even">
<td></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="2"></td>
<td colspan="3"></td>
<td colspan="2"></td>
<td></td>
<td></td>
</tr>
</tbody>
</table>

### Comparison of CPS and Census 2000 Estimates

The second set of comparisons that we made was between the findings
reported by Yamada (2002), based on a sample drawn from the CPS (1997-
1999), and the findings that emerged from the two samples drawn from the
census data. For the most part our analysis revealed few differences in
the demographic profile of the direct care workers studied by Yamada and
those included in our two study samples. However, for two
characteristics, demographic estimates of the long-term aide workforce
based on the CPS data differ notably from estimates based on the Census
2000 data. These differences can be observed by comparing the
demographic characteristics in Table 4 to those reported by Yamada
(2002). First, the profile generated from the Census data reveals a much
larger proportion of minority workers employed as aides than was
reported by Yamada based upon her use of the 1997-1999 CPS data. She
estimated that 3.7% of the direct care workers are minorities classified
as "other" (i.e., neither Caucasian nor African-American). The estimate
from the Census data is 15.2% using the CPS codes for selection and
14.1% using the Census codes and alternative selection criteria.
Similarly, Yamada's estimates identify a much lower proportion of
"others" among nursing home aides and hospital aides.

A second notable difference pertains to the mean age of workers. After
comparing the average age of home care aides reported by Crown using CPS
data from 1987-189 with her findings using the CPS data from 1997-1999,
Yamada concluded that home care aides are now younger than they were ten
years ago (mean age of 42.8 in her study vs. 46.7 in the Crown et al.
study 10 years prior). However, the estimates for average age shown in
Table 2 (for the sample selected to replicate the selection criteria of
and Crown et al. and Yamada), average age is estimated to be 46.8 \-- a
figure that is virtually unchanged from Crown's original estimate of
46.7. Thus, what has been construed to be the changing demographic
make-up of home care aides may simply be due to sampling variability and
the vagaries of small samples associated with the small sample size in
the CPS data.

### Conclusions and Implications 

In sum, the foregoing analyses suggest several conclusions. First, the
coding restrictions associated with the occupational and industry codes
used in the CPS lead to an under estimate of the number of home care
workers. In spite of this apparent bias, however, descriptions of the
population of home care workers obtained by Crown and his colleagues
(1995), and later by Yamada (2002), generally agree quite well with
those obtained from the Census 2000 (PUMS) data -- with the exceptions
of income and ethnicity. With respect to income, Yamada estimates the
median income of home care workers to be \$6.00/hour. Applying her
definition of home care aide to the Census data, a median wage of \$7.05
is obtained. If the alternative definition (afforded by the 2000 Census)
of what constitutes a home care aide is used, median income increases
further to \$7.50/hour. Thus, one conclusion is that home care aides are
somewhat better off financially than previously thought, although the
overall pay is still quite low.

In the case of ethnicity, Yamada's estimate of 3.7% home care aides
classified as "other" (i.e., non-Caucasian, non-African-American) is
much lower than the Census estimate of 15.2%, using the same definition
of home care aide. Using the alternate definition, the estimate of
"others" using the Census data is 14.6%. Moreover, the Census data
suggest a dramatically different picture of home care aides with
Hispanic/Latinos comprising a significant proportion of home care
workers (approximately 15%).

An obvious conclusion is that the estimates of parameters of interest,
such as income, generated from the Census 2000 PUMS have much smaller
standard errors than similar estimates from the CPS due to the larger
sample size of the PUMS. This greater stability in parameter estimates
provides a more accurate basis for drawing conclusions about the changes
in the direct care workforce. The relevance of this difference can be
seen from an examination of estimates of age. Specifically, in comparing
her estimate of the mean age of home care aides with those obtained a
decade earlier by Crown and his associates, Yamada concludes that, on
average, home care aides are younger. Given the Census estimate of that
same parameter, which essentially replicates the Crown estimate, an
alternative explanation is that the apparent age change observed by
Yamada could be due to sampling error.

The foregoing analyses also have implications for possible intervention
programs to recruit and/or retain home care workers. With respect to
recruitment, the sizeable proportion of home care aides who are
self-employed suggests that one viable avenue for recruitment might be
to assist home care workers to establish their own micro-enterprises.
Since self-employment is a viable vehicle for home care aides and offers
the potential for greater monetary reward, it might be useful in
attracting future home care workers, especially single mothers who may
need flexible schedules.

In addition, the findings on ethnicity suggest that home care may
represent an entry level position for new immigrants. On the one hand,
the finding makes salient a population from which willing recruits into
the long-term care workforce may be identified. On the other hand, the
finding raises important issues of cultural competency and training as
well.

# Factors Linked to Workforce Retention & Recruitment

Concern over the growing shortage of a qualified workforce willing and
able to care for a rapidly expanding elderly population has motivated
both policy makers and leaders in the long-term care industry to take a
keen interest in learning more about factors linked to the recruitment
and retention of qualified direct care workers. The largest bodies of
literature related to worker retention have been generated by scholars
in the fields of Occupational Psychology and Organizational Behavior who
have studied worker turnover in a wide range of industries. A large
proportion of early studies of worker satisfaction and retention were
conducted in manufacturing industries. Later, the work was extended to
service industries including health care settings (Cranny, Smith, &
Stone, 1992). Much of this work has been synthesized in a series of
meta-analyses (Cotton & Tuttle, 1986; Griffeth, Hom, & Gaertner, 2000;
Hom & Griffieth, 1995) that have identified overall job satisfaction and
employees' comparisons of their current job with alternatives available
in the job market[^1] as the two factors most directly linked to worker
turnover. More distal predictors of job satisfaction found in this
literature include core characteristics of the job and of the work place
including pay, benefits, role clarity, role conflict, promotional
chances, job scope, job skills, supervisor style and competence,
instrumental communication, and work group cohesion (Griffeth et al.,
2000). An important finding that has emerged from these meta-analyses is
that the predictors of job satisfaction and worker retention, and the
relative strength of these predictors differ across occupations and
employment settings. The strength of the relationship between turnover
and pay structures or perceived economic alternatives varies across
industries (Cotton & Tuttle, 1986; Griffeth et al., 2000; McEvoy &
Cascio, 1985). Consequently, an adequate understanding of the factors
that influence the retention of direct care workers in specific long
term care settings will depend upon studies conducted in that particular
long-term care setting.

In a useful overview of research on long-term care workers in
institutional and non-institutional settings, both social policy issues
and elements of the workplace were identified as factors that influence
worker retention (Stone & Wiener, 2001). Elements within the work place
are generally of greatest interest because they are factors that are
most amenable to influence and change. It is noteworthy that studies of
direct care workers have identified a set of factors that largely mirror
those identified in other industries. In particular, worker retention
and recruitment have been linked to wages, benefits, bonus programs,
career development or promotion opportunity, management styles, job and
role design, availability of clinical protocols, training, tenor of
employee interactions and informal communications, and individual
attributes. These factors are also consistent with factors identified in
a recent report to the US Congress on the supply of long-term care
in-home direct service workers (U.S. Department of Health and Human
Services Office of Long-Term Care, 2003).

Unfortunately, the number of studies of direct care workers employed in
in-home settings has been limited. Even so, the findings from earlier
research focused on manufacturing and service industries, and more
recent research conducted in health care settings provide valuable
guidance for the development of polices, programs, and practices that
could potentially enhance the size and quality of the direct care work
force. Essentially, past research has linked worker retention to five
broad sets of factors: (1) rewards in the form of wages, benefits and
promotion opportunities; (2) job characteristics including job scope,
job clarity, job design and autonomy; (3) management practices and
styles including organizational philosophy and values, management style,
and communication and interaction with employees; (4) employee supports
including training , technology and structured protocols, and (5) peer
relations including worker cohesion, co-worker communication and
support. In addition to job characteristics, attention has also been
given to identifying personal characteristics of workers that are
associated with longevity of employment in a particular industry or job.

## Rewards 

Competitive pay and benefits have been uniformly regarded by scholars
and human resource professionals as essential to recruitment and
retention. Based on their meta-analyses covering more than 170 studies,
Griffith and his colleagues (Griffeth et al., 2000) reported the
correlation coefficient between pay rate and worker retention to be only
.11. The authors caution, however, that this coefficient is probably an
underestimate due to the exclusion of fringe benefits and other forms of
compensation from the studies, and due to restriction of the variance in
pay within industries. In a market economy, employers must offer
competitive rewards, or be disadvantaged relative to other employers
seeking to tap the same labor pool. (Griffeth & Hom, 2001).
Consequently, pay variance is restricted as employers seek to offer
wages high enough to attract the labor pool but low enough to avoid
increased prices and reduced market share or profits.

For the most part, studies of worker compensation have focused on
overall compensation levels. Very few studies have examined the
effectiveness of particular compensation practices (Griffeth & Hom,
2001). There is, however, some evidence that fringe benefits can lower
turnover, but the effectiveness of various benefits may be specific to
particular employers and occupations (Griffeth & Hom, 2001). Employers
of high turnover workforces comprised of unskilled workers at low pay,
such as McDonald's and Marriott, are attempting to enhance recruitment
and retention by pioneering a variety of benefits. For example,
McDonald's has offered 50% food discounts for workers' families, and
Marriott provides a hotline to social workers who help with child care
and transportation problems (Griffeth & Hom, 2001). The majority of
evidence supporting these types of approaches is anecdotal or stems from
case studies, but a few quantitative studies have been undertaken.
Results of a survey of 209 fast food chain restaurants in Indiana show
that, for every type of fringe benefit studied, annual rates of turnover
were lower in restaurants that offered the benefit (Lalopa, Felli, &
Kavanaugh, 1999) In a related study conducted by LaLopa and his
colleagues (Lalopa et al., 1999), restaurants providing Christmas
bonuses were found to have a turnover rate of 137% compared with 191% in
restaurants that did not provide bonuses. Similarly, the authors
reported a turnover rate of 156% in restaurants providing life insurance
and 191% in those that did not provide life insurance and a turnover
rate 174% in restaurants providing health insurance compared to 209% in
restaurants not providing health insurance.

The central importance of wages and benefits for recruitment and
retention of direct care workers in the long-term care industry has also
been documented by recent surveys of in-home workers (Donovan, 1989;
Feldman, 1993; Gilbert, 1991; Harmuth & Dyson, 2002) and of employees in
nursing home settings (Salmon et al., 1999; Stone & Wiener, 2001; Weber,
1990). In a study of direct services workers conducted in 74 nursing
homes in Washington, the concern most frequently reported by workers to
be related to their decision to quit was their salary (Caudill &
Patrick, 1991). More than a decade later, focus groups of direct service
workers from ten long-term care agencies in Milwaukee echoed that
response, identifying pay as the one aspect of their job that they would
most like to change (Milwaukee Aging Consortium, 2002). Similarly,
administrators of 209 home care agencies located throughout the nation
identified pay as the foremost reason in-home direct service workers
would leave their jobs. Of these administrators, 90% identified "not
enough work hours" and 70% identified "low pay" as reasons direct
service workers quit, while the next most frequently chosen reason,
transportation, was identified by only about 20% (Cushman, Barnette, &
Williams, 2001)**.**

The pay and benefits for direct service workers are influenced by
special factors that affect the adjustment of the market prices for
services. Prior to limitations imposed by the 1996 Personal
Responsibility and Work Opportunity Reconciliation which require welfare
mothers to work, public assistance compensated somewhat for low wages
and inadequate or lacking benefits. Before the enactment of this
"welfare to work" program, direct service workers could stop working and
be supported by welfare when they needed sick leave and then return to
the direct services work force. Moreover, this cycle could be repeated
indefinitely (Dawson & Surpin, 2001a). Presently, 13% of nursing home
aides and nearly 15 % of home health care aides receive food stamps.
(Dawson, 2003). It is important to note, however, that changes in
government welfare policy that reduce hidden subsidies are beyond the
control of individual employers or communities.

The opportunity for promotion or the existence of an acknowledged career
ladder is the third factor related to worker retention that can be
considered a form of reward. Results of the meta-analysis conducted by
Griffeth and his colleagues (Griffeth et al., 2000) revealed a
correlation coefficient of .16 between promotional opportunities and
worker retention. Results of a follow-up study to the most comprehensive
study of in-home workers to date indicate that interventions that
created the potential for career advancement reduced turnover (Feldman,
1993)

Although results of research on turnover suggest that improving rewards
for employees in the form of wages, benefits, bonuses or chances for
promotion can improve recruitment and retention, these types of
interventions are beyond the reach of most employers of long-term care
direct service workers. Fiscal constraints on governments and the strong
government influence on the market for long-term care direct services
constrain wages and prices. Public funds account for almost 60% of the
money spent in the US on long-term care (Stone & Wiener, 2001); In 1998,
53% of home health care expenditures and 60% of nursing home
expenditures were paid through public funds (Health Care Financing
Administration, 2000). Medicaid alone funds 45% of long-term care
(Dawson, 2003; Stone & Wiener, 2001). As a result, government rates of
reimbursement leave individual employers and communities little
flexibility in respect to wages, benefits, or prices for direct care
services.

Recently state governments have begun to take action to improve wages or
benefits. Thirty-six states have enacted legislation that explicitly
increases wages or benefits for direct care workers. State initiatives
to enhance worker benefits include legislated rate increases, shift
differentials, living wage initiatives, health insurance for direct care
workers, access to existing state health insurance, bonuses, and
childcare or transportation assistance (Harmuth & Dyson, 2002).

The most popular type of state initiative is the "wage pass through".
This mechanism entails a requirement that increases in reimbursement
rates be directly linked to increases in workers wages or benefits
during a particular budget period. The following twenty states have
enacted wage pass through legislation: Arkansas, Arizona, California,
Colorado, Florida, Illinois, Kansas, Massachusetts, Maine, Michigan,
Minnesota, Missouri, Montana, Oklahoma, Rhode Island, South Carolina,
Virginia, Washington, Wisconsin, Wyoming. In the state of Michigan,
during implementation of wage pass through from 1990 through 1998,
certified nurse assistant turnover decreased from 75% to 68%; in Kansas,
after one year of implementation of the wage pass through, turnover
rates for targeted positions had decreased from 111% to 101%. Although
these results from studies of state interventions to improve the rewards
of work seem promising, the findings are not definitive because the
number of studies has been limited and the study designs have been weak.
In addition, turnover data are unavailable for most states. As a further
complication in the states that have been studied, many other influences
are likely to affect turnover during the years covered by the studies.
Indeed, only eight states have reported that they use a uniform
methodology statewide to collect turnover data on direct care workers,
and most of the eight have not yet accumulated trend data. (Harmuth &
Dyson, 2002)

## The Influence of Job Characteristics 

In addition to wages and benefits, a wide range of job characteristics
have been identified as possible predictors of job satisfaction and
worker retention. The meta-analysis of data from studies of worker
turnover in a variety of occupations conducted by Griffeth and his
colleagues (2000) has linked the following factors with retention:
leader-member exchange, role clarity, role conflict, met expectations,
job scope or routinization, instrumental communication, satisfaction
with supervisor. Other job characteristics that have been hypothesized
to affect retention include: the scope of the job, routinization of the
job, the variety of skills required, level of autonomy, the level of
task significance (i.e. the extent to which work affects others), role
ambiguity and role stress.

A number of studies have examined the link between job characteristics
and job satisfaction by evaluating job enrichment programs that have
been grounded in the popular Job Characteristic Model (Griffeth, 1985;
McEvoy & Cascio, 1985). The Job Characteristics Model focuses on five
specific job characteristics that are purported to shape the
meaningfulness of work to the worker, the worker's felt degree of
responsibility for work, and the worker's knowledge of how well they are
doing the work. These psychological states, in turn, are hypothesized to
influence a worker's job satisfaction, retention, and work performance.
The five core job characteristics are: skill variety (variety of skills
required by the work), task identity (doing a whole, or identifiable
piece of work), task significance (doing work that affects others),
autonomy (freedom to schedule work or work procedures) and feedback
(receiving direct, clear information about job performance

In most respects, the job characteristics of direct care workers are
similar to those of other types of hourly jobs with comparable pay and
benefits (Brannon, Cohn, & Smyer, 1990). Nonetheless, there is some
evidence from the limited number of studies focused on direct service
workers that some aspects of job design may influence retention. For
example, findings from a study conducted in 21 Pennsylvania nursing
homes indicate that there is a potential for reducing turnover through
job redesign strategies that expand the variety of skills used in the
job and improve feedback to workers about their performance. In a
related vein, Caudill and Patrick (1991) identified social relationships
established between workers and clients as a second aspect of the job
that may enhance retention (Caudill & Patrick, 1991). Reporting findings
from their study of 74 nursing homes in Washington, these authors noted
that "personal feelings for the patient" was the reason most frequently
given by direct care workers for their intentions to remain in their
job.

Role conflict and role stress also are job characteristics that have
been linked to the decision to leave a job. It has been suggested that
direct care workers may experience role conflict because they are often
cast in the role of providing social support for clients, but this
function is not recognized by employers nor rewarded as an important
part of their jobs (Henderson, 1994; Weber, 1990). Role stress can be
induced by incompatible demands from others, or a lack of clarity about
work role expectations (Griffeth & Hom, 2001)

## Management practices and Communication. 

### Opportunity for Worker Participation in Decisions

Another source of role stress for direct care workers was identified by
Banaszak-Holl and Hines when they studied workers in 254 nursing homes
(1996). Findings from the study indicated direct service workers
experienced role stress when they were excluded from the care planning
process. As the closest observers of the residents and the persons
actually delivering care, nurses' aides were often frustrated that they
were not consulted. Nursing homes that operated with protocols that
included the discussion of care plans with direct care workers and that
accepted the suggestions of the direct care workers had turnover rates
one-third lower than those that did not include such protocols. The
turnover rates in facilities that involved direct service workers in
care plan meetings were 50% lower than turnover rates in nursing homes
that excluded direct care workers from the care plan process.

This pattern of findings is consistent with findings from a survey of
direct care workers which indicate that the workers viewed limited
autonomy as inconsistent with the significance of their work (Brannon et
al., 1990). Direct service workers view lack of opportunity for input
regarding care planning as disrespect for their work, and a sufficient
reason to leave an employer (National Association of Geriatric Nursing
Assistants, 2002). A recent case study illustrates the importance of
participatory management. The study compared a high performance self
managed work team with a low performance team in one nursing home. Both
work teams were comprised of several direct service workers and a nurse.
In contrast to the low performance team, management of the high
performance team was characterized by participation, trust,
communication and increased job satisfaction of direct care workers
(Yeatts & Seward, 2000).

### Supervisor Communication

The importance of effective communication by supervisors has been widely
documented in studies of organizational behavior. Effective
communication about work expectations and performance can reduce role
conflict and ambiguity and has been linked with retention in several
studies (Johnston, Parasuranam, Futrell, & Black, 1990; Jones, Kantak,
Futrell, & Johnston, 1996). Several studies have also affirmed that a
sustained display of hostile verbal and nonverbal supervisory behaviors
can prompt job exit (Aquino, Griffeth, Allen, & Horn, 1997; Dittrch &
Carrell, 1979; Donovan, Drasgow, & Munson, 1998; Tepper, 2000)

Although past research offers little guidance for retention-inducing
supervision, a small number of studies suggest that organizations can
design evidence-based interventions to shape supervisor behaviors in
ways that reduce turnover. (Griffeth & Hom, 2001) For example, one bank
reported success with introducing counseling meetings between
supervisors and their subordinates. During the three-month experiment,
turnover was significantly lower in the experimental branches of the
bank than in the matched group of control branches (Krackhardt, McKenna,
Portar, & Steers, 1981). Research relevant to managing direct service
workers in nursing homes has reinforced the link of worker participation
in care planning or worker autonomy with job satisfaction and turnover
(Stone & Wiener, 2001). Few studies, however, focus on supervisor
behavior (Salmon et al., 1999).

In-home service providers may not be able to implement improvements in
management or supervision as readily as service providers in
institutional settings. Managerial resources in many in-home agencies
are stretched, and implementation of improvements in several agencies
requires either the enlistment of outside help or diversion of staff
from normal operations (Feldman, 1993).

## Employee Training and Other Supports

Worker training is the dominant focus of interventions to make jobs less
demanding and to improve workforce quality (Brannon, Zinn, Mor, & Davis,
2002). Training interventions vary widely and include instruction
delivered in a classroom and other specialized settings, on-the-job
training, and provision of instructional materials. Advocacy for
training is, generally, grounded in the assumption that improving
technical and/or social job skills and knowledge will improve both
recruitment and retention. With respect to recruitment, training will
provide a larger pool of qualified workers from which to draw. With
respect to retention, it is widely believed that training programs will
better prepare workers for their job tasks and thereby make their work
easier.

The effects of training typically are measured in terms of the number of
individuals that completed or attended training, employee satisfaction
with training they received or, less frequently, with the results of
tests that assess comprehension or acquisition of training content
(Salmon et al., 1999). The majority of studies that have examined the
effects of training have focused on training and education as individual
attributes. Interestingly, however, a meta-analysis of results from such
studies conducted in a wide range of industries does not reveal a
meaningful link between education and training of individuals and
turnover (Griffeth et al., 2000).

To some extent, the failure to document a link between training and
retention of direct care workers may be due to a ceiling effect created
by minimum training requirements established by law or regulation.
Medicare-certified agencies require 75 hours of training for home health
aides. Federal regulations require a minimum of 75 hours of initial
nurse aide training, and require that nursing homes pay for the training
required for certification of all nurse aide employees (U.S. Department
of Education, 1965). The Omnibus Budget Reconciliation Act (OBRA) of
1987 mandates 12 hours of in-service training for long-term care direct
service workers in nursing homes based on individual competency
evaluations.

A second factor that may account for the failure of previous studies to
unambiguously document a link between training and retention is the
failure of many studies to use a design that will allow the assessment
of the impact of training apart from other practices or interventions
that may be influencing job retention. For example, an evaluation of a
newly established Geriatric Nursing Assistant career ladder that
included a training program that leads to qualification for promotion
did not address the effects of the training program separate from the
effects of creating the new positions (McDonald, 1992).

Current knowledge about the link between training and retention also has
been limited by the fact that little attention has been given to
differences in the types of training programs that have been evaluated.
When Banazak-Holl and Hines (1996) failed to find the expected negative
association between training and turnover, they interpreted the results
to be an indication that different types of training may have different
impacts on turnover. Training related to increased worker autonomy or
better career opportunity might increase retention, while other types of
training may not. For example, training mandated for workers by a new
government regulations may not lead to greater retention. In fact, a
recent study revealed a higher rate of turnover in facilities that
offered a certified nursing assistant (CNA) training program than in
facilities without the training program (Brannon et al., 2002). The
facilities with training programs presumably were serving as entry
points for direct service workers to the occupation. After attaining
certification, direct service workers could find better employment in
other facilities

Findings from studies that have examined the impact of specific types of
training on turnover have been more encouraging. For example, studies of
service workers in other industries such as bank tellers indicate that
orientation training can be an effective tool for retention (Wanous &
Roland, 1992). They note that the use of the "realistic job preview
techniques" boosts job retention rates in a wide range of jobs, by an
average of 8%. Techniques used to provide job previews include
videotaped role models, and small group discussion with current
employees (Wanous & Roland, 1992).

It has also been speculated that the positive effects of some training
programs may result from an increase in peer support rather than from an
increase in skills *per se.* One possibility is that gathering together
for training sessions relieves the isolation so typical of in-home
direct services work (Feldman, 1993). In at least one experimental
study, training targeted to improve quality of care did not increase
knowledge, but was associated with reduced turnover of assistants in a
nursing home (McCallion, Toseland, Lacey, & Banks, 1999).

To the extent that training programs increase the number of persons who
are qualified to do the work, such programs potentially can expand the
size of the qualified labor pool. Beyond that connection, however,
research findings indicate that the link between training and improved
recruitment and retention is weak. Nonetheless, training interventions
are almost universally popular, and training is consistently among
interventions recommended for dealing with the shortage of direct
service workers (Paraprofessional Healthcare Institute, 2001; Stone &
Wiener, 2001; U.S. Department of Health and Human Services Office of
Long-Term Care, 2003). Importantly, it is also something over which
employees have considerable control.

## Peer Relations 

Organizational behavior research over the years has indicated that
workgroup cohesion is negatively related to turnover. Meta-analysis
covering more than 173 studies found a relationship between turnover and
work group cohesion. This relationship suggests that interventions to
facilitate communication with coworkers or workgroup cohesion could be
effective. Results of at least one study of intensive care nurses showed
that conducting support groups for nurses resulted in reductions in
turnover (Weiner & Caldwell, 1983).

A second study analyzed effects of providing hour long support groups
biweekly for direct service workers in 16 nursing homes. The
experimental nursing homes that offered support groups showed modest
improvements in turnover compared with turnover in the 14 nursing homes
that served as a comparison group. Observers reported benefits in
addition to reduced turnover such as improved communication and
increased tolerance among workers with language differences (about a
third of the participants spoke one of 23 languages other than English),
and an exchange of "tips" about how to communicate with supervisors or
difficult clients (Wilner, 1994)

## Worker Characteristics and Recruitment

While a significant portion of previous research on worker retention has
examined the influence of job and workplace characteristics on worker
turnover, there is also a large body of literature that has focused on
individual characteristics. In particular, efforts have been made to
identify specific demographic and personal characteristics of workers
that are associated with a greater likelihood of retention. Such
information can be used to guide the hiring process by selecting
applicants with a greater likelihood of staying on the job. The
"weighted application blank" is a widely used procedure for assessing
the "fit" of an individual with a particular type of job or particular
employer. The procedure uses an application blank with questions and a
scoring scheme that have been developed to give weight to individual
traits that previously been found to predict worker longevity in a
particular job or company. When Griffeth and his colleagues (2000)
conducted their meta-analysis of studies on worker turnover, they noted
that the use of a weighted application blank in the selection process is
among the stronger predictors of retention with a correlation
coefficient of .31 for the studies included in the analysis. The
meta-analysis identified several Individual attributes that found to
have statistically significant correlations with retention including
tenure with the current employer (+.23), number of children (-.16) and
age (+.11). Notably a number of other individual attributes that were
studied were not related to turnover including: cognitive ability,
education, training, marital status, kinship responsibilities, race,
gender, and age.

The relatively powerful link between retention and utilization of the
weighted application blank is an indication of the importance of
"fitting" attributes of individuals with the job. Use of the weighted
application blank procedure is, however, constrained by legal issues. If
the procedure results in screening outcomes that are not balanced in
respect to race or gender, employers using the procedure may be liable
to charges of discrimination. Defense against such charges requires that
the employer demonstrate that no other comparably valid and less
discriminatory procedure was available (Griffeth & Hom, 2001)

An example of the successful use of this type of screening and hiring
procedure is provided by a study conducted in a small nursing home
chain, (Kettlitz, Zbib, & Motwani, 1997). The study of 175 applications
of direct service workers used this type of screening procedure to
compare retrospectively the answers given by the workers who left their
employment with the nursing home after three months or less to those
employed for at least six months. Application of the procedure resulted
in correct classification of 78% of the sample and was more accurate
than existing selection procedures.

The importance of a good fit of direct service workers with their job is
underscored in a report of an ambitious study undertaken to investigate,
among other things, the effects of personal and job related stress on
job satisfaction and retention of new nursing assistants in skilled
nursing facilities (Stone, 2001). The study was impeded by inability to
recruit a large enough sample of new nursing assistants from training
programs. After completing training programs, the nursing assistants
either did not become employed, did not remain on the job for at least
one month, or relocated. This outcome suggests that many individuals
recruited do not "fit" well with the work or work situation.

In addition, results of quantitative studies seeking to develop profiles
of individual attributes associated with retention indicate,
consistently, that individuals who are likely to stay longer in direct
service jobs in nursing homes ("stayers") are older and more likely to
be female. Findings regarding other personal attributes, including race
and ethnicity, have not been consistent. At least one study suggested
that "stayers" are likely to be African-American, while an ethnographic
study suggests that aides in rural areas who tend to stay are white
(Garland, Oyabu, & Gipson, 1988; Tellis-Nayak & Tellis-Nayak, 1989)
[]{.mark} The limited, two-item profile shown to characterize stayers,
however, parallels the demographics reported for the long-term care
workforce in general, and is probably not particularly useful for
recruitment purposes. Moreover, its use for hiring purpose could
potentially lead to illegal hiring practices.

# Efforts of ADDGS PROJECTS TO Solve Workforce Issues 

## ADDGS: An Opportunity for Innovation

The purpose of the ADDGS program is to facilitate development of
statewide systems of support services for persons with Alzheimer's
disease and their caregivers, with emphasis on inclusion of rural and
minority populations. The structure of the program encourages local
communities and public and private stakeholders to set priorities, and
devise and implement projects. This structure gives states and local
communities flexibility to select the issues their projects will address
from a very broad spectrum of challenges relevant to the overall goal.
This flexibility is highly valued by the grantees and has given
communities and organizations opportunities to develop innovative
projects that address the workforce issues embedded in expansion and
development of services.

Projects in several states are exemplars of innovations that enhance
workforce capacity. In some cases the goal to enhance the size or
quality of the available workforce has been explicit and central to the
state's demonstration, in other cases enhancement of the workforce
available to provide care for persons with dementia has been a secondary
or implicit goal. Regardless of the centrality of the workforce
initiative to a state's project, the efforts and experiences of these
demonstrations have the potential to provide information valuable for
further development of successful strategies to enhance the workforce
available to serve families caring for persons with Alzheimer's disease
in other regions as well.

Within the context to the ADDGS program, states have attempted to expand
and enhance the capacity of the direct care workforce in three ways. To
increase rewards for workers, a number of projects have attempted to
create stable career ladders and employment opportunities. Training
programs that focus on dementia care and cultural competency have been
created to expand the capability of the current workforce to serve a
more diverse client population. The third, and probably most innovative,
yet controversial, strategy used by the ADDGS projects to expand the
workforce is to identify and hire from new pools of workers including
volunteers, family members and individuals who traditionally work
outside of formal employer organizations. Each of these approaches to
expanding the workforce is described in greater detail here along with
innovative programs that illustrate each approach.

##  Efforts to Increase Worker Rewards

A number of the ADDGS sites have designed and implemented programs that
enhance rewards or reward structures for direct care workers. Two of
these projects have been implemented with the stated goal of increasing
pay and workers' opportunities for promotion. In Tulsa, Oklahoma,
partner organizations have attempted to create a career ladder for
direct care workers. In Maryland, individuals who work independently as
in-home caregivers have been helped to become small businesses or
"micro" enterprises. This process helps workers obtain greater autonomy,
higher status and higher wages. The majority of the ADDGS projects that
are concerned with increased rewards have found ways to by-pass the
seemingly intractable barriers to implementation of more conventional
improvements in rewards for work such as increasing wages or providing
benefits. These programs have focused on organizational changes that
will lead to greater opportunities for workers to obtain full and steady
employment.

### 1. Opportunities for Advancement {#opportunities-for-advancement .unnumbered}

#### Career Ladder for Direct Service Workers in Tulsa  {#career-ladder-for-direct-service-workers-in-tulsa .unnumbered}

A goal of the Oklahoma project in Tulsa was to create a career ladder
for frontline workers that would provide an opportunity for advancement
and pay increases based upon increased skill. The career ladder was
created by adding a dementia competency requirement to a Geriatric
Technician certificate program offered by Tulsa Community College. The
Geriatric Technician Certificate is recognized by provider organizations
as a valued credential for CNAs that can be rewarded with higher pay
rates. Persons who obtain the Geriatric Technician Certificate are also
well positioned to continue their training to advance to the next level
of Licensed Practical Nurse.

The curriculum for the Geriatric Technician certificate program at Tulsa
Community College has been changed to require class room training and
clinical experience in dementia care. The eight week program includes 8
hours of classroom instruction per week and 12 hours of clinical
experience caring for persons with Alzheimer's disease. Students
enrolled in the program must be CNAs. Although completion of a high
school level of education is desirable, a diploma or GED is not
required. The Technician Certificate is equivalent to six hours of
college credit. In 2003, tuition was \$360.

The Geriatric Technician program has been established in close
consultation with representatives of provider organizations and has an
advisory board comprised of representatives of long term care providers.
The clinical components of the first two training programs were
conducted in the facilities of organizations represented on the advisory
board. Provider organizations, particularly those with representation on
the advisory board, often allow staff to attend class during paid
working hours, and may offer some support for tuition, or venues for the
students' clinical experience. Although there is no legal requirement to
increase hourly wages of certificate holders, providers have been
willing to pay higher wages to graduates of the Geriatric Technician
program and most of the graduates have received a wage increment of 50
cents per hour. At least three Geriatric Technicians have continued
their education beyond attainment of the certificate to become Licensed
Practical Nurses.

Informal feedback from the employers of graduates of the Geriatric
Technician Program indicates that the program has contributed to
improved staff communication and better working relations among staff,
and between staff and supervisors. Graduates report that training has
improved their job satisfaction, increased their confidence in their
skills, helped them to better understand the the tasks they perform, and
feel more a part of a professional care team. While these interventions
have face validity, and anecdotal reports are positive, further research
is needed to document the impact, if any, of the new career ladder on
real and perceived rewards for the worker and, ultimately, on
recruitment and retention of workers.

#### Transforming Workers into "Micro-enterprises"  {#transforming-workers-into-micro-enterprises .unnumbered}

In Maryland, individuals who work as in-home caregivers or use their own
homes to provide day care for two or three elders can, with small
business training and technical assistance, become small business or
"micro" enterprises. The fostering of micro-enterprises is expected to
improve the skills, image, and financial circumstances of these direct
workers. Such improved rewards are, in turn, expected to attract more
workers to direct services and in this way address the special
challenges of building respite capacity in rural, low-income areas.
Micro-enterprises also have the potential to improve the economic
environment of these rural areas.

For each of the three demonstration sites in Maryland, the Alzheimer's
Association Chapter contracts with an organization that has expertise in
development of micro-enterprises to provide business training and
technical assistance to informal providers seeking to become
micro-enterprises. The Alzheimer's Association Chapter identifies
potential micro-entrepreneurs and refers them to the micro enterprise
developer. The AA chapter also provides dementia training to enable
self-employed providers meet minimum federal requirements for Medicaid
Waiver care.

### 2. Stabilize Organizations by Assuring a Client Base {#stabilize-organizations-by-assuring-a-client-base .unnumbered}

It is widely acknowledged that improved stability of paid employment can
be expected to improve recruitment and retention of long-term care
direct service workers (Dawson & Surpin, 2001b; Feldman, 1994; Stone &
Wiener, 2001). ADDGS projects in nine states attempted to create
opportunities for direct care workers to have steady employment. In
several states, the projects have taken measures to insure a steady
client base. In other communities, new organizations have been created
to foster employment of direct care workers. The third strategy used by
ADDGS programs has been to offer training programs to expand the skills
of direct care workers to serve a wider range of clients and make them
more employable.

Many organizations that provide in-home or adult day care services are
struggling for economic survival, especially in the rural and ethnic
communities targeted by ADDGS. Although families need the services,
maintaining the number of clients necessary for the economic viability
of provider organizations can be a problem. Providers experience a
natural attrition of clients through nursing home placement or death
which means that there is a continuous need to enroll new clients. Yet,
there are significant barriers to attracting clients to either in-home
or adult day services. These barriers include the client's lack of
knowledge of the services, and cultural and service delivery barriers.
The sheer effort and time that families must take to prepare clients to
attend a day care center and to transport them to a facility can serve
as a significant barrier to use. Additionally, many providers are unable
to serve clients with dementia. All of these barriers work to limit the
client base for provider organizations which, in turn, limits employment
opportunities for direct service workers to part-time or contingent
employment.

Several of the ADDGS projects have been able to expand their client base
by offering a "package" of support services that facilitate client
patronage. In rural **Indiana**, AAAs in Vincennes (Area 13), and
Richmond (Area 9), offer clients vouchers to pay for adult day care
services and a package of support services to help them to use the day
care centers. Families are eligible for transportation to the center,
assistance of a home health aide or attendants to help with dressing and
bathing clients to prepare them to attend the center, and case
management services that facilitate use of services by clients and their
caregivers. The amount of the voucher varies with the functional
impairment of the clients. This allows day care centers to have a
multi-level fee structure to assure adequate staffing without economic
risk to the organization.

The Otsego County Commission on Aging in **Michigan** is providing
similar support services to families though an in-home service called
"Up and Go. The "Up and Go" program provides aides to help clients get
ready to attend adult day care center and provides in-home respite after
adult day care programming. The after-hours in-home program makes the
day care center a viable option for l working caregivers. Fees for the
support services are assessed on a sliding scale basis. The Michigan
program is also working to increase the client base of existing day care
center by enhancing the capability of the program to serve dementia
clients. The ADDGS project provides training for staff development and
an enhanced activity program. The Adult Day Care Program center will add
special activities targeted to clients with dementia, including the
employment to artists, musicians, storytellers and gardeners to engage
clients in creative expression and communication.

### Creating New Provider Organizations

In communities with few or no formal organizations that employ direct
service workers, most in-home care workers are free-lance workers
employed directly by families. A large proportion of these workers do
not receive training, social security, or other benefits of employment.
Moreover, to be fully employed they must work for multiple families and
manage complex schedules. In these communities the development of new
organizations has been a strategy used to foster full employment and
better benefits for direct care workers.

The **Virginia** ADDGS project has provided technical assistance and
funded key staff positions for two start-up organizations. As part of
the ADDGS Program, Our Lady of Mt. Carmel Church Outreach Ministry is
developing a new in-home service in two cities that have substantial
minority representation - Hampton Roads and Newport News. The Outreach
Ministry conducts outreach and education, recruits potential clients and
carries out education and outreach, and provides in-home services by
contracting with a private provider, the Personal Touch Home Care
agency. The Personal Touch Home Care Agency conducts a client assessment
and provides direct services. The Ministry and the home care agency
collaborate closely with the Peninsula Agency on Aging AAA.

An explicit goal of the Tappahannock initiative is to ease pressure from
a shortage of in-home workers by establishing a new adult day care
center*.* The Tappahannock Presbyterian Chapel of the Milden
Presbyterian Church will establish an adult day care facility in Essex
County, a rural area with 60 families wait listed for respite services
at the time the grant proposal was drafted. The Chapel has contracted
with Bay Aging, Inc., AAA to move an existing facility into a more
accessible location, expand the facility, add dementia capability, and
initiate transportation service for the facility.

Clients enrolled in the program must be nursing-home eligible. The grant
funds the salary of an adult day care administrator and two aides, as
well as the occasional services of an assistant administrator and a
nurse. The grant also funds the salary of a quarter-time driver. The
Chapel contributes matching funds in the form of facilities, counseling
and volunteer services, and cash contributions from the Milden Church.
Other contributions will come from project revenues.

###  Training to Expand Service Capacity 

A number of the state ADDGS projects have devised training programs to
expand the capacity of workers and agencies to serve a wider range of
clients and a larger number of clients. These programs have included
state-wide efforts to increase the number of direct care workers capable
of caring for dementia clients, more focused training programs aimed at
expanding the capacity of provider organizations, and training programs
to increase cultural competency. When staff members are trained to
effectively serve dementia clients and clients from multiple cultures,
the employing organization can serve larger numbers of clients, and the
trained workers may have more opportunities for steady work. Trained
workers also may have a broader choice of employers, improved
opportunities for advancement and more opportunities for steady
employment. ADDGS projects in 21 states provide dementia training.
Additionally, projects in Arizona and California leverage the capacity
of the existing workforce by hiring persons who are bi-lingual and
bi-cultural to provide technical assistance to workers and providers,
supplying the cultural competence necessary to serve specific ethnic
populations

#### State-wide efforts to Expand Dementia Capability  {#state-wide-efforts-to-expand-dementia-capability .unnumbered}

Incentives for provider organizations to train direct care staff in
dementia care are offered by ADDGS projects in fourteen states. In a
number of states, dementia care training is advertised and offered to
providers free of charge (Alaska, Arizona, California, Illinois,
Massachusetts, Maine, Michigan/Otsego Rhode Island, Minnesota/Elder
Circle, Nebraska, and Nevada/Reno). In other states the offer of
training is underscored by making specific dementia care training for
staff prerequisite to provider eligibility to supply services funded by
the project (Arkansas, Mississippi, Tennessee, and Texas).

Statewide curricula required for certification are being modified or
developed in projects in Alaska, Arkansas, Rhode Island, Virginia and
West Virginia. A goal of the ADDGS project in West Virginia is to modify
the technical-vocational high school Certified Nurses Assistant
curriculum and statewide certification examination to encompass dementia
care. The AA Chapter in West Virginia is leading curriculum change and
will conduct regional train-the-trainer programs for instructors. A
project to develop a culturally sensitive protocol for dementia care
training is part of the ADDGS program in Rhode Island. The ADDGS project
in Arkansas is an exemplar of the use of dementia care training as the
centerpiece for a statewide strategy to enhance the capacity of the
existing workforce to care for persons with dementia.

In **Arkansas**, respite services funded through the demonstration are
provided by adult day care or adult day health center. These centers are
also responsible for screening and enrolling clients in the
demonstration program. Participating centers benefit from the program as
they are able to increase their client census, extend hours of service
provided and increase revenues. Simultaneously, the adult day care
centers expand the opportunities for employment of direct care service
workers. To be eligible to participate in the program, a center must
have at least 50% of its staff certified in dementia care. This
requirement provides a strong incentive for adult day care centers to
employ workers with dementia training and to seek dementia care training
for their employees.

The Arkansas Division of Aging and Adult Services has partnered with the
Pennebaker Center, one of only two dementia-specific adult day centers
in Arkansas, to develop and deliver dementia training programs. The
project administrator or the director of the Pennebaker Center conducts
two-day dementia training sessions for center directors and supervisors
in each of the participating areas. Proficiency testing is carried out
pre- and post-training, and a satisfactory test score is requisite for
certification as a dementia specialist. Subsequently, center directors
and supervisors train direct care workers in their respective
facilities, and incorporate training into the facility orientation
program for new direct care workers.

#### Training to Expand Provider Capacity {#training-to-expand-provider-capacity .unnumbered}

In five states, training programs fostered by the ADDGS program have
been initiated to enhance the capacity of existing provider
organizations to serve a new group of clients. In New York, the focus
has been on preparing organizations serving persons with developmental
disabilities to care for their clients with dementia. In Wisconsin the
focus is on assisted living facilities. The goal of the Vermont ADDGS
project is to adapt adult day care facilities statewide so that the
environment can support, and management and staff of each facility can
provide, dementia care. Finally, the goal of the Michigan project has
been to train staff to meet the changing needs of persons with dementia
and thereby enable a wider range of clients to be served in a single
setting.

The goal of the **New York** ADDGS project is to connect the network of
government agencies and organizations that provides services appropriate
for persons with Alzheimer's disease or related dementia with the
network that serves persons with developmental disabilities. The
mechanism for achieving this goal is to engage both networks in
providing grant-funded services to developmentally disabled persons who
also have Alzheimer's disease. By providing dementia care training and
funding direct services, the project will create a model for
coordination of the efforts of providers in the two separate systems.
The project involves a collaboration of two Area Agencies on Aging
(AAAs) with two Alzheimer's Association (AA) Chapters. The AA Chapters
handle the day-to-day operation of the demonstration and are responsible
for the education and the direct service components of the grant.
Technical assistance for the project is provided by the state unit on
aging in collaboration with the State University of New York, Albany
Center for Excellence in Aging Services.

In **Wisconsin**, a training module called "Changing our Minds from
Parent to Caregiver" was developed to enable small group living
facilities or Adult Family Homes to accept clients with dementia. A
state-wide survey of these homes, which typically serve only one or two
clients indicated that providers were willing to accept persons with
dementia, if appropriate support was available. The training emphasizes
differences between parenting, which is helping people who are growing,
and learning, versus caring for persons with dementia. The focus is on
explaining how particular behaviors are processed by a child's brain
versus the brain processes of a person with dementia.

In **Vermont,** training programs for staff have been included as one
element of a more comprehensive package of services given to Adult Day
Care Centers to improve and expand their dementia capability. The
Vermont/New Hampshire Alzheimer's Association Chapter and the Division
of Advocacy and Independent Living, within the Department of Aging and
Disabilities jointly conducted assessments of the sixteen
state-subsidized and two independent ADCs. The ADCs received training,
guidance and small grants (\$3500.00) to improve the environments of
care for persons with dementia based on the assessments.

The goal of the **Michigan** project in Midland County is to embed a
consistent philosophy of care for clients at all stages of the disease
process. A training program serves as the centerpiece of the strategy
for accomplishing this goal. Arrangements for the training are made by
Senior Services and agency under the Midland County Council on Aging, an
umbrella organization that oversees all types of county elder services.
Case managers and care staff of organizations that provide services
needed at each stage of the disease process in the Gentlecare ™
philosophy that underpins written service protocols.

#### **Leveraging Cultural Competence***.*  {#leveraging-cultural-competence. .unnumbered}

To expand the capacity of existing service workers to serve clients from
multiple cultures, projects in Arizona and California have created new
staff positions that have been filled by bilingual and bi-cultural
individuals. These persons serve as liaisons between clients and service
providers.

The **Arizona** *Camino de Amistad* project was developed to address the
specific needs of rural Hispanic communities in Maricopa County and is
modeled on earlier ADDGS projects in Los Angeles (*El Portal*) and
Seattle (SeaMar). Although Arizona has a significant Spanish speaking
population, prior to the demonstration few service providers employed
Spanish-speaking staff or conducted culturally relevant and appropriate
activities and services. To address this barrier, the AA Chapter created
the Rec Tech position for a bi-cultural and bi-lingual person. The Rec
Techs work to bridge the cultural gaps between clients and some provider
agencies. They add their cultural knowledge and awareness to the agency
setting, and make this dimension available to agency staff at all levels
and thereby improve the cultural appropriateness of care provided. The
Rec Tech also works with the client and family caregivers to facilitate
understanding and acceptance of formal care

To implement this project, the Desert Southwest AA Chapter first
conducted a needs assessment of the target area that developed a staging
and resource guide for local case managers, and a training guide for
dementia awareness. The AA Chapter provides dementia training and
additional cultural competence presentations to service providers. Rec
Techs are paid through the demonstration project, and supervised
directly by the provider agency directors with oversight from the
project Care Consultant. The project Care Consultant, like the Rec Tech,
is bi-cultural and bi-lingual. The project care consultant visits new
client families and develops a care plan.

**In California**, bi-cultural, bilingual Care Advocates work with
service providers to improve appropriateness of care and with clients
and caregiving families to facilitate understanding and acceptance of
formal care. The current California project, which serves Asian
families, is modeled after an earlier ADDGS project that served Latino
families. The program in Santa Clara targets Vietnamese and Chinese
populations, and the Los Angeles site targets the Japanese and Chinese
communities in that area.

The Northern California and Northern Nevada Alzheimer's Association
Chapter (Northern California AA Chapter) has been the key partner
responsible for developing a culturally sensitive and appropriate
service model for Vietnamese and Chinese families with dementia needs in
Santa Clara County. The Northern Area Agency on Aging of Santa Clara
County (AAA) also is a partner in the project. To provide direct
services, the Northern California AA Chapter has partnered with a local
agency, John XXIII Multi-Service Center, in San Jose. The Multi-Service
Center has hired and trained two part-time bicultural and bilingual care
advocates from the target communities. The two Care Advocates work
closely with other staff of the Multi-Service Center and are active and
visible in the local community. When families are identified, Care
Advocates initiate a home visit during which they build a relationship
with the family, offer information and support, and suggest options for
meeting identified care needs. A licensed family social worker is
available as a resource for the Care Advocates if clinical concerns
arise.

Through a voucher system, families are offered reimbursement of up to
\$1600 per year for respite services. Families may personally hire
individuals to provide care or they may use formal service providers.
The AA chapter in each demonstration site handles all the paperwork and
fiscal management for the respite reimbursements in that site.

In the southern site, Los Angeles County, the Los Angeles AA Chapter has
partnered with two agencies - Little Tokyo Service Center to reach the
Japanese community, and Chinatown Service Center to connect with the
Chinese population. Both agencies have been active in serving their
respective communities for over two decades, and are well known and well
respected. Each agency has hired a full time bicultural and bilingual
Care Advocate. The Care Advocates are integrated into the staff of the
service agencies. They also work actively in the community and serve as
point persons for the demonstration. Their work with families and
provider organizations parallels the process of the northern site.

## Expand Sources of Workers

Despite a large and growing need for direct service workers, efforts to
increase the size of the workforce are constrained by fiscal and
demographic factors beyond the reach of individual employers. Government
reimbursement policies limit prices paid for direct services that, in
turn, limit the wages paid to direct service workers. Constraints on
wages limit the segment of the labor force that can be recruited. The
total number of people in the age group that typifies the direct service
workforce is shrinking dramatically in relation to the number of elderly
persons needing direct services. In the face of these constraints,
several of the ADDGS projects addressed the worker shortage by
recruiting workers from non-traditional sources - volunteers, family
members and informal caregivers identified and recruited by families.

###  Volunteers as a Source of Direct Care Workers

The scarcity of direct care workers has prompted both government and
private agencies to recruit volunteers to supplement their workforces.
In the past, many social service programs have not been able to use
volunteers as a reliable source of workers because volunteers'
contributions tend to be sporadic or unpredictable. A number of
management issues must be addressed to transform volunteers into a
reliable source of care and include their efforts as a predictable part
of a care plan. These issues include recruitment, training, supervision,
and retention of volunteers. Additionally, an effective mechanism for
matching volunteers with assignments is required.

ADDGS projects, located in eleven states, have designed programs that
effectively incorporated volunteers into the direct care workforce. The
majority of these programs have been created by expanding volunteer
efforts of established organizations to include volunteer respite
services. Projects in Tennessee and Virginia provide support for
increased participation in the federal Senior Companion volunteer
program and offer specialized dementia care training to Senior
Companions. In Virginia and Oklahoma, volunteer service hours have been
incorporated into an ongoing academic curriculum. The project in Florida
has added dementia volunteer services to the outreach ministries of
faith-based organizations; and the project in West Virginia includes a
plan for programs such as the Boy Scouts or 4-H Clubs to add merit
badges for dementia services to their programs.

A second approach to effectively incorporate volunteers has been used by
the ADDGS projects in Kansas, Maryland, and Mississippi. In each of
these locations, demonstration funds have been used to create an ongoing
community project which serves as the focal point for eliciting and
organizing volunteers. The project in Kansas involves volunteers in
planning, establishing and operating a community Arts and Inspiration
Center for persons with dementia that will serve as a model for
replication at other rural locations. A project in Maryland depends on
volunteers to help operate and expand a Brookdale-style adult day care
center serving persons with dementia that will be replicated at rural
locations in the region. The project in Mississippi is designed to
recruit and support the individuals who will establish and operate
all-volunteer "First Friends" adult day centers at rural locations
across the state.

The third approach for use by ADDGS programs to capitalize on volunteer
efforts is to organize individual volunteer efforts at the neighborhood
level. In Minnesota, projects at two different locations fund part of
the costs of organizations or individuals that help match volunteers
with assignments. In Alabama, a nationally recognized program developed
originally to help care for persons with HIV has been expanded and
targeted to help care for persons with dementia. The essence of the
Alabama program is a process for organization and coaching of frontline
volunteers and leader volunteers, supported nationally by fewer than a
half dozen experts with a web site and telephones. Three of the ADDGS
projects that utilize volunteers are described here to provide examples
of each of the three approaches that have been used to expand the
workforce by regularizing the contributions of volunteers.

#### Service learning at James Madison University {#service-learning-at-james-madison-university .unnumbered}

As part of the Virginia ADDGS project, the Holistic Health Resource
Center of the Department of Nursing at James Madison University received
funds to establish a new program to recruit students from the Schools of
Social Work and Nursing to serve as volunteer providers of in-home
companion respite service. The program integrates volunteer service into
the students' academic programs. The project was designed in close
partnership with the Piedmont-Valley Chapter of the Alzheimer's
Association and developed in consultation with a Community Respite Task
Group specifically convened for that purpose. The Task Group continues
to play an advisory role. Two faculty members direct the demonstration
program -- one from the School of Nursing and one from the School of
Social Work. The project also employs a fulltime program coordinator and
a part-time outreach coordinator. University faculty from both the
Social Work and Nursing programs recruit, train, and oversee the work of
the student volunteers.

To be eligible to provide respite as part of their university service
learning curriculum, students must be enrolled in an appropriate
academic program and meet other standards established for participation
in the demonstration program. Student volunteers receive special
training pertaining to caregiver needs, respite care, and Alzheimer's
disease. The volunteers are monitored and supported during their respite
assignments.

Clients served by the program are referred by the AAA. With approval of
the potential client, the AAA faxes to the university the results of the
Uniform Assessment Instrument. The Program Coordinator then visits the
potential client at home, informs the client about the demonstration,
and enrolls appropriate clients. An outreach coordinator matches
enrolled clients with student volunteers, and accompanies each student
on their first respite service visit. The university provides in-kind
contributions of office space, web site development, some personnel
hours, and support for staff travel to conferences.

#### Building a New Volunteer Program in Kansas {#building-a-new-volunteer-program-in-kansas .unnumbered}

In the rural community of Parsons, Kansas, a new adult day care center
has been built around an "Arts and Inspiration" program. The Center
serves as the nexus for recruiting volunteers to work with persons who
have Alzheimer's disease. Development and operation of Arts and
Inspiration adult day care program provides the community with an
opportunity to synchronize efforts to remove barriers to use of
supportive services at the same time as it increases the capacity and
quality of services available in the community.

The Adult Day Center at Parsons is housed in a church and operates under
supervision of a part-time director who is employed by the Alzheimer's
Association (AA) and paid through grant funds. The program has an active
project advisory body and a reserve force of volunteers that includes
individuals who lead the arts activities and nurses who come to the
Center to administer medications. During a day at the Arts and
Inspiration Center, volunteers lead drama, music, poetry, and watercolor
activities for the participants. Through the arts activities, the AA
staff member and the volunteers help participants express and affirm
their own, and each other's, humanity and worth. The Center is not
licensed as a day health program, but medications are available to
participants through the services of two nurse volunteers from another
community facility that come at midday to administer them. The AA
Chapter trains all volunteers and Center staff in dementia care.

The program was developed by engaging a wide range community groups,
including faith based organizations, in assessing community respite
needs and developing and operating the model adult day care programs.
For more than a year, the AA Chapter worked to develop relationships
with potential client families and other community members who were
interested in meeting the needs of families caring for a person with
Alzheimer's disease. The AA chapter facilitated formation of a Coalition
for Aging, which has provided the impetus and structure for the
development of the center.

The Heart of American AA Chapter provides information and technical
assistance to other organizations interested in starting similar centers
for families caring for a person with Alzheimer's disease or a related
dementia. Staff of the chapter is seeking other appropriate venues in
six rural counties of eastern Kansas for replication of the community
process that produced the Center in Parsons.

#### CARE in Alabama: Organizing neighborhood volunteers {#care-in-alabama-organizing-neighborhood-volunteers .unnumbered}

In **Alabama**, a model volunteer program originally designed to assist
HIV patients, is being adapted to serve families caring for a person
with Alzheimer's disease. The CARE program provides leadership,
infrastructure and technical assistance to five or six-person teams of
volunteers. Each CARE Team works together to provide respite for one
family. The CARE program trains leaders who recruit, train and monitor
teams in their respective areas, and the program provides materials and
expert consultation via web site, email and telephone.

Two care teams are being developed by Area Agencies on Aging -- the
Tombigbee Regional Commission and the South Alabama Regional Planning
Commission. Care team members are frequently drawn from faith-based and
community organizations. The Southern Alabama Regional Planning
Commission AAA will partner with the Care Team Network organization to
conduct leadership conferences at which individuals from across the
state are trained to recruit and develop care teams.

The Care Team model originated at the Medical School of the University
of Alabama and is now used in 30 states. The Care Team Network, a
nonprofit organization affiliated with the Medical School of the
University of Alabama, Birmingham, supports use and promulgation of the
model. The Care Team Network organization provides training for the
demonstration. Continuing technical assistance to the team is provided
through an infrastructure that includes the originator and the Care Team
Network organization. The Care Team Network maintains a web page, and
can be consulted by telephone and email.

### ***Helping Families Become Employers*** 

Several ADDGS projects address the shortage of direct services workers
by helping families become qualified and informed employers. The effect
of these strategies is to attract persons into the direct care workforce
who otherwise are unlikely to be available. In addition to recruiting a
new group of workers into he direct care workforce, these programs have
the potential to make direct service jobs more attractive and retain
these workers in the labor pool. The strategy of supporting families as
employers is particularly useful for addressing challenges associated
with remoteness and inaccessibility in locations such as Alaska.

It is widely acknowledged that many families hire direct service workers
on an informal basis (e.g., (Harmuth & Dyson, 2002; U.S. General
Accounting Office, 2001). Families often can find persons to recruit and
hire as direct service workers that would not be reached by other types
of potential employers. Many times these direct care workers are members
of the extended family or are family friends. In other cases, families
learn of available workers through informal word-of-mouth channels.
Families acting as employers, however, face many daunting challenges as
they recruit, hire, supervise and pay workers who are not employed by
formal agencies. At a minimum, they must have access to funds to pay for
services. To ensure appropriate and safe care for their love ones,
families must determine whether or not potential workers can be trusted
and whether they have adequate training and skills. In many cases they
must teach workers to care for their loved ones and know how to
supervise those workers. To fully comply with state and federal laws,
families also must deal with paperwork and comply with reporting
procedures associated with Social Security, and local and state
requirements for background checks for direct care workers. Given the
many challenges it is not uncommon for families to circumvent state and
federal regulations by hiring local individuals who may be willing to
work on an informal basis. Such a practice, however, potentially has
serious ramifications for both the care receiver whose safety and health
may be placed in jeopardy, and for the direct care worker, who may be
subjected to poor working conditions and prevented from obtaining fair
wages and future benefits Social Security benefits.

Projects in Alabama, Maryland, Missouri, and Rhode Island exemplify
innovative programs designed to help families function as competent
employers. These programs provide reimbursement to families for
purchased services, and a variety of other services to support the
family in the role of employer including: (1) help with background
checks and completion of tax forms, (2) training programs for family
members that include communication skills and protocols for hiring and
supervision (3) coaching or counseling in support of the family as
employer, and (4) dementia training for workers recruited by the family.

In ***Alabama*** the Tombigbee AAA demonstration project serves a region
characterized by poverty and rural isolation with an elderly population
that is 41.5% Black/African American. Families participating in the
demonstration are initially visited by a case manger that completes
financial, social, and functional assessments during the visit. Families
deemed appropriate for the demonstration program are then given
information about dementia and about the project. A program of care for
the person with dementia is developed in consultation with family
members and the family is given vouchers to cover six months of
demonstration services.

In addition to working with the family members to design care programs,
the project manager also conducts basic dementia training for direct
care workers who are recruited and hired by the family. In an effort to
retain these trained workers in the labor pool, the project manager
encourages existing provider organizations to hire the trained care
workers to be to be sitters or companions for other persons with
dementia.

In ***Charles County, Maryland*** the AAA has contracted with Episcopal
Senior Ministries Care (ESM Care), a faith-based program for case
management. The Care Team Network organization receives demonstration
funds to cover materials and training to implement an innovative model
of case management that is focused on coaching family members to be
employers. The Ministry hired a full time social worker to visit with
and assesses potential project clients. The social worker develops a
one-on-one relationship with each client family and trains and counsels
families to communicate with and supervise the caregivers they employ.
Training covers topics such as how to hire, how to assign work tasks and
supervise workers, and how to complete Social Security and other
required government forms.

In **Missouri**, independent workers employed by families deliver
respite services for clients participating in the demonstration program.
The demonstration program offers these families a number of supports to
help them assume the role employer. Families identify potential aides,
and negotiate the rate of pay and contract directly with the individual
they have identified. AA chapter staff assists families with these
tasks. AA chapter staff also helps families comply with the state law
that mandates a background check for all in-home respite workers by
submitting required paperwork to the state on behalf of the family.
Project funds are made available to cover the \$15 charge for the
background check.

The individuals hired to provide respite through this program are given
a "Basic Care Guidelines" booklet that contains information about care
practices, a list of resources, a workbook with a quiz for
individualized learning section, and other materials that are made
available by the national Alzheimer's Association. Families are
reimbursed for respite costs based on monthly statements submitted to
the AA chapter. The annual limit for reimbursement is set by each
chapter.

In **Rhode Island**, families may directly hire individuals to provide
direct care and be reimbursed through the demonstration for wages paid
to these workers. Families may employ any individual who does not reside
in the home of the individual with Alzheimer's disease and is not the
spouse. The individuals hired receive training for dementia care from
the AA Chapter. Additionally, with the help of a certified public
account, the Diocese of Providence Office of Community Services and
Advocacy has developed a protocol that relieves families of the
bookkeeping and tax payments required of employers. Families may sign a
limited durable power of attorney that allows the Diocese to act as a
fiscal agent for the family. The Diocese then assists the family in
obtaining a Federal Tax Identification number, and attends to the
bookkeeping and tax payments on behalf of the family.

The Rhode Island AA Chapter has hired two part-time workers to perform
intakes into the demonstration. During the initial visit, the AA staff
member assesses the safety of the home and helps the family identify
care needs and understand the available options for care. Individuals
hired by the family to provide respite are required to attend an AA
Chapter training program to increase their understanding of dementia,
and require skills for meeting the care needs of their family employers.
Staff members of the AA Chapter maintain close contact with the families
until service provision has begun. After services are in place, the
families are contacted at regular, but less frequent, intervals.

## Using technology to expand the workforce 

In Indiana, an innovative technology has been used to reconfigure work
in a way that may reduce the number of workers need to supervise a
person with dementia and provide family caregivers with respite. The
video respite system uses a novel blend of technology adapted from
residential security and telecommunications applications. Specifically,
persons with Alzheimer's disease are monitored for safety by offsite
observers using cameras installed in clients' homes. Remote observers
alert family caregivers or care staff when intervention is necessary.

This remote monitoring capability permits one paid respite worker to
monitor more than one person with dementia. It is also a mechanism that
will allow friends, neighbors, or paid workers, who are not able to be
physically present in client homes, to help with care and thereby expand
the workforce. If effective, this approach has implications for
contending with current shortages in the workforce as well as the high
costs of long-term care.

The Area 16 AAA, the Southwestern Indiana Regional Council on Aging in
Evansville, is implementing the video respite component of the
demonstration in partnership with a private company, Guardian Medical
Monitoring. The AAA will build on the existing working relationship with
local adult care providers to implement the video-monitoring project.
Local providers may refer potential video-monitoring participants to the
AAA. Local adult day care providers eventually may participate in the
program as monitors.

The AAA, in collaboration with providers and its private partner
organization, has developed the assessment protocols for the video
respite project. Nurses assess prospective clients. Video monitoring is
expected to be most useful during the early stages of the disease
process. Once a client is identified, the protocol calls for an AAA
staff member and an agent of Guardian Video Monitoring to jointly visit
potential clients. The AAA assesses the eligibility of the client and
the appropriateness of the client and family for participation in video
monitoring. The agent from Guardian Video Monitoring assesses the
feasibility of using electronic monitoring equipment to monitor the
potential client in his or her home, and the feasibility of installing
the equipment in the home.

If a client is deemed appropriate, up to four cameras can be installed
in the home. Equipment can also include alarm modes for hazards such as
falls or wandering. Once installed, video-monitoring cameras are used to
observe the person with Alzheimer's disease by using special software to
transmit an image over a separate telephone line to a screen in a remote
location. The image can be monitored from an adult day care facility by
paid staff, by a neighbor or relative from their own home, or by a home
health agency. The designated observer is responsible for alerting the
caregiver when the person with Alzheimer's disease is in danger or need
of assistance.

## Summary

As communities and organizations participating in the ADDGS work to
design and implement programs to support families caring for persons
with AD, they have faced a shortage well-trained direct care workers.
For many of the programs the issue is not simply one of quantity, but
also an issue of capability of workers to serve dementia clients and
clients from multiple ethnic groups. Although previous research on
worker retention would suggest several avenues to recruit and retain
workers, efforts of the ADDGS projects have primarily been restricted to
three strategies. Two projects, one in Oklahoma and one in Maryland,
have specifically designed programs to increase the wages of workers.
For the most part, efforts of ADDGS grantees intended to increase
rewards for workers have focused on the expansion of opportunities for
stable employment. Many of the programs have attempted to create stable
employment by supporting employee organizations and expanding the client
base for adult day care settings.

A large number of the ADDGS projects have included training programs to
help workers to expand their knowledge and skills. These training
programs, which have focused on cultural competency and dementia care,
have enhanced the workforce in two ways. From the perspective of the
individual workers, training expands their skills and their opportunity
for choice of steady employment. From the perspective of the employers,
training programs allow organizations to serve a wider client base
including multiple ethnic groups and persons with dementia.

Probably the most creative means used by ADDGS project to expand their
workforce has been to identify and include new groups of persons in the
workforce. These new workers are volunteers, family members and
self-employed individuals identified and hired by family members. A wide
range of strategies have been used to capitalize on these new sources of
workers. In some cases model programs previously used for other
populations have been adapted to serve dementia clients and their
families. In other cases, a range of supports services have been put in
place to help families become effective employers.

Clearly, the flexibility of the ADDGS program has afforded many of the
grantees sufficient latitude to creatively address their need for
workers. Many of these efforts are worthy of note and might well serve
as prototypes in the future for "best practices". However, at this time
little evidence has been gathered about the outcomes of the various
strategies with regard to enhancing and retaining a direct care
workforce. To benefit fully from these demonstrations programs, it will
be important to assess the success of each strategy and project as
measured by increased recruitment and/or retention of workers. In
particular, it will be important to track the impact on individual
workers, as well as, on the long term care workforce within a community
or state. With adequate assessment, it will be possible to translate the
best aspects of each prototype into a "best practice".

# Conclusion

The shortage of direct care workers, especially those serving clients in
their homes, is a growing problem throughout the country. This worker
shortage has been especially problematic for states participating in the
ADDGS program, which have focused on developing systems of support
services to provide dementia care to hard-to-reach populations. For
these grantees the issue has been one of adequacy of numbers and
competency of care. Fortunately, many of the states have been
exceptionally creative in their efforts to overcome the problem of a
worker shortage. The goal of this report has been to describe these
innovative programs and provide a context for this description. To do
so, we have provided a critical analysis of what is currently known
about the home care worker shortage, along with a description of factors
related to worker recruitment and retention as gleaned from the extant
literature.

A number of conclusions can be extracted from this report. First, the
state of knowledge about the long term care workforce, particularly the
home care workforce, is still inadequate. Much of what is known about
the home care workforce has been taken from two studies, both based on
data from the Current Population Survey (CPS). Comparisons of these
estimates to estimates based on data from the Census 2000 Public Use
(5%) Micro data Sample (PUMS) clearly indicate the limitations of using
the CPS. In particular, the small samples sizes associated with the CPS
make identification of home care workers tenuous which, in turn, make
population estimates unreliable. While our analysis provided a profile
of workers that is similar to previous descriptions for most demographic
characteristics, it also revealed some aspects of the workforce that may
have serious implications for future practice and policy. Specifically,
our analyses suggest that *more* home care workers are employed in the
industry than previously reported, and close to one-fifth of these
workers are self-employed. Moreover, almost 40% of direct care workers
are from minority groups with approximately 15% being Latino or
Hispanic. It is also the case that the income of these home care workers
is somewhat higher than previously reported, albeit still very low.
These findings are of interest because they underscore the potential
utility of the ADDGS projects that have focused on improving the care
delivered to multiple ethnic groups and the programs that have focused
on enhancing the skills, supervision and wages of self-employed home
care workers.

Second, our review of the literature suggests that too little is known
about the factors that influence recruitment and retention of direct
service workers, particularly home care workers. Although numerous
factors that impact employee recruitment and retention have been
identified from previous research, the effects of each factor are
generally modest and the exact manner in which these factors operate
appears to be largely industry-specific or unspecified. Overall, very
little research has actually addressed recruitment and retention of the
long term care workforce. Consequently, there is very little guidance in
the scientific literature on how to proceed.

Third, and perhaps not surprisingly, there is a remarkable range of
innovations within the ADDGS programs that are intended, either directly
or indirectly, to enhance recruitment and retention of home care
workers. In part, this diversity of approaches is due to the lack of
direction from empirical studies. It is also due, however, to the
inescapable realization that recruitment is not a unitary notion; that
is, it does not refer to a single processes. Specific needs vary by
location and program type. For example, where competition for workers is
high, "recruitment" may refer to recruiting any willing worker. In other
locales, recruitment may refer to recruitment of dementia-trained
workers. Clearly, the specific strategy employed by any given
demonstration participant is likely to be tailored to its specific needs
within a highly circumscribed context. As such, the ADDGS programs serve
as exemplars of the range of options open to communities with similar
needs and constraints.

Fourth, the large majority of ADDGS innovations are not receiving
adequate evaluation to establish their efficacy. As a result, while the
details of program implementation are well established, potential
outcomes remain unstudied or anecdotal, at best. To fully benefit from
demonstration programs, it will be important to rigorously document and
evaluate the efforts that communities and organizations make to overcome
the seemingly intractable problems of recruitment and retention of
direct care workers. In the absence of such evaluation, there is no
evidence to identify the "best practices" that are emerging under the
auspices of the demonstration. Consequently, some of the most innovative
and successful efforts may go unheralded and unheeded. This outcome
would indeed be a significant loss as organizations, communities,
states, and the federal government struggle to develop an adequate and
capable workforce to provide long term care for the rapidly growing
population of older adults.

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[^1]: In addition to job components relevant to improving retention, the
    2000 meta-analysis shows that turnover can be predicted by measures
    of an employee's intention to leave the job or by behaviors that
    withdraw the employee from the job such as absenteeism or tardiness.
    Measures of organization commitment, while strongly linked with
    turnover, contain items indicating intention to quit and the link
    with turnover might not exist without those items. Although studies
    that include many occupations do not show individual attributes to
    be related to turnover (with the exceptions of age, tenure in the
    job, and number of children), the authors note that implementation
    of selection procedures guided by attributes linked with success in
    particular jobs with particular employers have resulted in reduced
    turnover.