II 

113TH CONGRESS 

2D SESSION S. 2251 

To amend the Older Americans Act of 1965 to develop and test an expanded 

and advanced role for direct care workers who provide long-term services 

and supports to older individuals in efforts to coordinate care and improve the efficiency of service delivery. 

IN THE SENATE OF THE UNITED STATES 

APRIL 10, 2014 

Mr. CASEY (for himself and Mr. FRANKEN) introduced the following bill; 

which was read twice and referred to the Committee on Health, Education, Labor, and Pensions 

A BILL 

To amend the Older Americans Act of 1965 to develop 

and test an expanded and advanced role for direct care 

workers who provide long-term services and supports to 

older individuals in efforts to coordinate care and improve the efficiency of service delivery. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Improving Care for 

5 Vulnerable Older Citizens through Workforce Advance6 ment Act of 2014’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) As of 2012, more than 41,000,000 Ameri4 cans are age 65 or older. More than 75 percent of 

5 them suffer from chronic conditions which require 

6 person-centered, coordinated care that helps them to 

7 live in a home- or community-based setting. In 

8 2012, the Government Accountability Office found 

9 that 34 percent of Americans 60 and older reported 

10 needing assistance performing Activities of Daily 

11 Living. 

12 (2) Direct-care workers (referred to in this sec13 tion as ‘‘DCWs’’) provide an estimated 70 to 80 per14 cent of the paid hands-on long-term care and per15 sonal assistance received by elders and people with 

16 disabilities or other chronic conditions in the United 

17 States. These workers help their clients bathe, dress, 

18 and negotiate a host of other daily tasks. They are 

19 a lifeline for those they serve, as well as for families 

20 and friends struggling to provide quality care. 

21 (3) Eldercare and disability services positions 

22 account for nearly one-third of the 18,000,000 

23 health care jobs in the United States. The direct24 care workforce alone accounts for more than 

25 4,000,000 jobs, expected to add 1,600,000 new posi26 tions by 2020. 


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1 (4) The majority of DCWs are now employed in 

2 home- and community-based settings, and not in in3 stitutional settings such as nursing care facilities or 

4 hospitals. By 2020, home- and community-based 

5 DCWs are likely to outnumber facility workers by 

6 more than 2 to 1. 

7 (5) A 2008 Institute of Medicine report, enti8 tled ‘‘Re-tooling for an Aging America: Building the 

9 Health Care Workforce’’, called for new models of 

10 care delivery and coordination, and dedicated a 

11 chapter to the central importance of the direct-care 

12 workforce in a ‘‘re-tooled’’ eldercare delivery system. 

13 (6) An Institute of Medicine report on the fu14 ture of nursing, released in October of 2010, rec15 ommended nurses should practice to the full extent 

16 of their education and training. The report also 

17 states that all health care professionals should work 

18 collaboratively in team-based models, and that the 

19 goal should be to encourage care models that use 

20 every member of the team to the full capacity of his 

21 or her training and skills. 

22 (7) The Patient Protection and Affordable Care 

23 Act (Public Law 111–148) emphasizes the need for 

24 improving care and lowering costs by better coordi25 nation of care and integration of services, particuVerDate Mar 15 2010 22:57 Apr 17, 2014 Jkt 039200 PO 00000 Frm 00003 Fmt 6652 Sfmt 6201 E:\BILLS\S2251.IS S2251

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1 larly for consumers with multiple chronic conditions. 

2 This will require developing new models of care for 

3 those receiving long-term services and supports. 

4 SEC. 3. DEMONSTRATION PROGRAM ON CARE COORDINA5 TION AND SERVICE DELIVERY. 

6 Part A of title IV of the Older Americans Act of 1965 

7 (42 U.S.C. 3032 et seq.) is amended by adding at the end 

8 the following: 

9 ‘‘SEC. 423. DEMONSTRATION PROGRAM ON CARE COORDI10 NATION AND SERVICE DELIVERY. 

11 ‘‘(a) ESTABLISHMENT OF DEMONSTRATION PRO12 GRAM.— 

13 ‘‘(1) IN GENERAL.—The Assistant Secretary 

14 shall carry out a demonstration program in accord15 ance with this section. Under such program, the As16 sistant Secretary shall award grants to eligible enti17 ties to carry out demonstration projects that focus 

18 on care coordination and service delivery redesign 

19 for older individuals with chronic illness or at risk 

20 of institutional placement by— 

21 ‘‘(A) designing and testing new models of 

22 care coordination and service delivery that 

23 thoughtfully and effectively deploy advanced 

24 aides to improve efficiency and quality of care 

25 for frail older individuals; and 


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1 ‘‘(B) giving direct-care workers opportuni2 ties for career advancement through additional 

3 training, an expanded role, and increased com4 pensation. 

5 ‘‘(2) DIRECT-CARE WORKER.—In this section, 

6 the term ‘direct-care worker’ has the meaning given 

7 that term in the 2010 Standard Occupational Classi8 fications of the Department of Labor for Home 

9 Health Aides [31–1011], Psychiatric Aides [31– 

10 1013], Nursing Assistants [31–1014], and Personal 

11 Care Aides [39–9021]. 

12 ‘‘(b) DEMONSTRATION PROJECTS.—The demonstra13 tion program shall be composed of 6 demonstration 

14 projects, as follows: 

15 ‘‘(1) Two demonstration projects shall focus on 

16 using the abilities of direct-care workers to promote 

17 smooth transitions in care and help to prevent un18 necessary hospital readmissions. Under these 

19 projects, direct-care workers shall be incorporated as 

20 essential members of interdisciplinary care coordina21 tion teams. 

22 ‘‘(2) Two demonstration projects shall focus on 

23 maintaining the health and improving the health sta24 tus of those with multiple chronic conditions and 

25 long-term care needs. Under these projects, directVerDate Mar 15 2010 22:57 Apr 17, 2014 Jkt 039200 PO 00000 Frm 00005 Fmt 6652 Sfmt 6201 E:\BILLS\S2251.IS S2251

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1 care workers shall assist in monitoring health status, 

2 ensuring compliance with prescribed care, and edu3 cating and coaching the older individual involved and 

4 any family caregivers. 

5 ‘‘(3) Two demonstration projects shall focus on 

6 training direct-care workers to take on deeper clin7 ical responsibilities related to specific diseases, in8 cluding Alzheimer’s and dementia, congestive heart 

9 failure, and diabetes. 

10 ‘‘(c) ELIGIBLE ENTITY.—In this section, the term 

11 ‘eligible entity’ means a consortium that consists of— 

12 ‘‘(1) at least 1— 

13 ‘‘(A) long-term care and rehabilitation fa14 cility; or 

15 ‘‘(B) home personal care service provider; 

16 and 

17 ‘‘(2) at least 1— 

18 ‘‘(A) hospital or health system; 

19 ‘‘(B) labor organization or labor-manage20 ment partnership; 

21 ‘‘(C) community-based aging service pro22 vider; 

23 ‘‘(D) patient-centered medical home; 

24 ‘‘(E) federally qualified health center; 


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1 ‘‘(F) managed care entity, including a 

2 managed health and long-term care program; 

3 ‘‘(G) entity that provides health services 

4 training; 

5 ‘‘(H) State-based public entity engaged in 

6 building new roles and related curricula for di7 rect-care workers; or 

8 ‘‘(I) any other entity that the Assistant 

9 Secretary deems eligible based on integrated 

10 care criteria. 

11 ‘‘(d) APPLICATION.—To be eligible to receive a grant 

12 under this section, an eligible entity shall submit to the 

13 Assistant Secretary an application at such time, in such 

14 manner, and containing such information as the Secretary 

15 may require, which shall include— 

16 ‘‘(1) a description of the care coordination and 

17 service delivery models of the entity, detailed on a 

18 general, organizational, and staff level; 

19 ‘‘(2) a description of how the demonstration 

20 project carried out by the entity will improve care 

21 quality, including specific objectives and anticipated 

22 outcomes that will be used to measure success; and 

23 ‘‘(3) a description of how the coordinated care 

24 team approach with an enhanced role for the direct25 care worker under the demonstration project will inVerDate Mar 15 2010 22:57 Apr 17, 2014 Jkt 039200 PO 00000 Frm 00007 Fmt 6652 Sfmt 6201 E:\BILLS\S2251.IS S2251

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1 crease efficiency and cost effectiveness compared to 

2 past practice. 

3 ‘‘(e) PLANNING AWARDS UNDER DEMONSTRATION

4 PROGRAM.— 

5 ‘‘(1) IN GENERAL.—Each eligible entity that re6 ceives a grant under this section shall receive a 

7 grant for planning activities related to the dem8 onstration project to be carried out by the entity, in9 cluding— 

10 ‘‘(A) designing the implementation of the 

11 project; 

12 ‘‘(B) identifying competencies and devel13 oping curricula for the training of participating 

14 direct-care workers; 

15 ‘‘(C) developing training materials and 

16 processes for other members of the interdiscipli17 nary care team; 

18 ‘‘(D) articulating a plan for identifying 

19 and tracking cost savings gained from imple20 mentation of the project and for achieving long21 term financial sustainability; and 

22 ‘‘(E) articulating a plan for evaluating the 

23 project. 

24 ‘‘(2) AMOUNT AND TERM.— 


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1 ‘‘(A) TOTAL AMOUNT.—The amount 

2 awarded under paragraph (1) for all grants 

3 shall not exceed $600,000. 

4 ‘‘(B) TERM.—Activities carried out under 

5 a grant awarded under paragraph (1) shall be 

6 completed not later than 1 year after the grant 

7 is awarded. 

8 ‘‘(f) IMPLEMENTATION AWARDS UNDER DEM9 ONSTRATION PROGRAM.— 

10 ‘‘(1) IN GENERAL.—Each eligible entity may re11 ceive a grant for implementation activities related to 

12 the demonstration project to be carried out by the 

13 entity, if the Assistant Secretary determines the en14 tity— 

15 ‘‘(A) has successfully carried out the ac16 tivities under the grant awarded under sub17 section (e); 

18 ‘‘(B) offers a feasible plan for long-term fi19 nancial sustainability; 

20 ‘‘(C) has constructed a meaningful model 

21 of advancement for direct-care workers; and 

22 ‘‘(D) aims to provide training to a sizeable 

23 number of direct-care workers and to serve a 

24 sizeable number of older individuals. 


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1 ‘‘(2) USE OF FUNDS.—The implementation ac2 tivities described under paragraph (1) shall in3 clude— 

4 ‘‘(A) training of all care team members in 

5 accordance with the design of the demonstra6 tion project; and 

7 ‘‘(B) evaluating the competency of all staff 

8 based on project design. 

9 ‘‘(3) EVALUATION AND REPORT.— 

10 ‘‘(A) EVALUATION.—Each recipient of a 

11 grant under paragraph (1), in consultation with 

12 an independent evaluation contractor, shall 

13 evaluate— 

14 ‘‘(i) the impact of training and de15 ployment of direct-care workers in ad16 vanced roles, as described in this section, 

17 within each participating entity on out18 comes, such as direct-care worker job satis19 faction and turnover, beneficiary and fam20 ily caregiver satisfaction with services, rate 

21 of hospitalization of beneficiaries, and ad22 ditional measures determined by the Sec23 retary; 


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1 ‘‘(ii) the impact of such training and 

2 deployment on the long-term services and 

3 supports delivery system and resources; 

4 ‘‘(iii) statement of the potential of the 

5 use of direct-care workers in advanced 

6 roles to lower cost and improve quality of 

7 care in the Medicaid program; and 

8 ‘‘(iv) long-term financial sustainability 

9 of the model used under the grant and the 

10 impact of such model on quality of care. 

11 ‘‘(B) REPORTS.—Not later than 180 days 

12 after completion of the demonstration program 

13 under this section, each recipient of a grant 

14 under paragraph (1) shall submit to the Sec15 retary a report on the implementation of activi16 ties conducted under the demonstration project, 

17 including— 

18 ‘‘(i) the outcomes, performance bench19 marks, lessons learned from the project; 

20 ‘‘(ii) a statement of cost savings 

21 gained from implementation of the project 

22 and how the cost savings have been rein23 vested to improve direct-care job quality 

24 and quality of care; and 


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1 ‘‘(iii) results of the evaluation con2 ducted under subparagraph (A) with re3 spect to such activities, together with such 

4 recommendations for legislation or admin5 istrative action for expansion of the dem6 onstration program on a broader scale as 

7 the Secretary determines appropriate. 

8 ‘‘(4) AMOUNT AND TERM.— 

9 ‘‘(A) TOTAL AMOUNT.—The amount 

10 awarded under paragraph (1) for all grants 

11 shall not exceed $2,900,000. 

12 ‘‘(B) TERM.—Activities carried out under 

13 a grant awarded under paragraph (1) shall be 

14 completed not later than 3 years after the grant 

15 is awarded.’’. 

Æ 


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