I 
113TH CONGRESS 
2D SESSION 
H. R. 4445 
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 im-
prove the efficiency of service delivery. 
IN THE HOUSE OF REPRESENTATIVES 
APRIL 10, 2014 
Mr. CARTWRIGHT (for himself, Mr. GRAYSON, and Ms. JACKSON LEE) intro-
duced the following bill; which was referred to the Committee on Edu-
cation and the Workforce 
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 im-
prove the efficiency of service delivery. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Improving Care for 
Vulnerable Older Citizens through Workforce Advance-
ment Act of 2014’’. 
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SEC. 2. FINDINGS. 
Congress finds the following: 
(1) As of 2012, more than 41,000,000 Ameri-
cans are age 65 or older. More than 75 percent of 
them suffer from chronic conditions which require 
person-centered, coordinated care that helps them to 
live in a home- or community-based setting. In 
2012, the Government Accountability Office found 
that 34 percent of Americans 60 and older reported 
needing assistance performing Activities of Daily 
Living. 
(2) Direct-care workers (referred to in this sec-
tion as ‘‘DCWs’’) provide an estimated 70 to 80 per-
cent of the paid hands-on long-term care and per-
sonal assistance received by elders and people with 
disabilities or other chronic conditions in the United 
States. These workers help their clients bathe, dress, 
and negotiate a host of other daily tasks. They are 
a lifeline for those they serve, as well as for families 
and friends struggling to provide quality care. 
(3) Eldercare and disability services positions 
account for nearly one-third of the 18,000,000 
health care jobs in the United States. The direct- 
care workforce alone accounts for more than 
4,000,000 jobs, expected to add 1,600,000 new posi-
tions by 2020. 
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(4) The majority of DCWs are now employed in 
home- and community-based settings, and not in in-
stitutional settings such as nursing care facilities or 
hospitals. By 2020, home- and community-based 
DCWs are likely to outnumber facility workers by 
more than 2 to 1. 
(5) A 2008 Institute of Medicine report, enti-
tled ‘‘Re-tooling for an Aging America: Building the 
Health Care Workforce’’, called for new models of 
care delivery and coordination, and dedicated a 
chapter to the central importance of the direct-care 
workforce in a ‘‘re-tooled’’ eldercare delivery system. 
(6) An Institute of Medicine report on the fu-
ture of nursing, released in October of 2010, rec-
ommended nurses should practice to the full extent 
of their education and training. The report also 
states that all health care professionals should work 
collaboratively in team-based models, and that the 
goal should be to encourage care models that use 
every member of the team to the full capacity of his 
or her training and skills. 
(7) The Patient Protection and Affordable Care 
Act (Public Law 111–148) emphasizes the need for 
improving care and lowering costs by better coordi-
nation of care and integration of services, particu-
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larly for consumers with multiple chronic conditions. 
This will require developing new models of care for 
those receiving long-term services and supports. 
SEC. 3. DEMONSTRATION PROGRAM ON CARE COORDINA-
TION AND SERVICE DELIVERY. 
Part A of title IV of the Older Americans Act of 1965 
(42 U.S.C. 3032 et seq.) is amended by adding at the end 
the following: 
‘‘SEC. 423. DEMONSTRATION PROGRAM ON CARE COORDI-
NATION AND SERVICE DELIVERY. 
‘‘(a) ESTABLISHMENT
OF DEMONSTRATION PRO-
GRAM.— 
‘‘(1) IN
GENERAL.—The Assistant Secretary 
shall carry out a demonstration program in accord-
ance with this section. Under such program, the As-
sistant Secretary shall award grants to eligible enti-
ties to carry out demonstration projects that focus 
on care coordination and service delivery redesign 
for older individuals with chronic illness or at risk 
of institutional placement by— 
‘‘(A) designing and testing new models of 
care coordination and service delivery that 
thoughtfully and effectively deploy advanced 
aides to improve efficiency and quality of care 
for frail older individuals; and 
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‘‘(B) giving direct-care workers opportuni-
ties for career advancement through additional 
training, an expanded role, and increased com-
pensation. 
‘‘(2) DIRECT-CARE WORKER.—In this section, 
the term ‘direct-care worker’ has the meaning given 
that term in the 2010 Standard Occupational Classi-
fications of the Department of Labor for Home 
Health Aides [31–1011], Psychiatric Aides [31– 
1013], Nursing Assistants [31–1014], and Personal 
Care Aides [39–9021]. 
‘‘(b) DEMONSTRATION PROJECTS.—The demonstra-
tion program shall be composed of 6 demonstration 
projects, as follows: 
‘‘(1) Two demonstration projects shall focus on 
using the abilities of direct-care workers to promote 
smooth transitions in care and help to prevent un-
necessary 
hospital 
readmissions. 
Under 
these 
projects, direct-care workers shall be incorporated as 
essential members of interdisciplinary care coordina-
tion teams. 
‘‘(2) Two demonstration projects shall focus on 
maintaining the health and improving the health sta-
tus of those with multiple chronic conditions and 
long-term care needs. Under these projects, direct- 
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care workers shall assist in monitoring health status, 
ensuring compliance with prescribed care, and edu-
cating and coaching the older individual involved and 
any family caregivers. 
‘‘(3) Two demonstration projects shall focus on 
training direct-care workers to take on deeper clin-
ical responsibilities related to specific diseases, in-
cluding Alzheimer’s and dementia, congestive heart 
failure, and diabetes. 
‘‘(c) ELIGIBLE ENTITY.—In this section, the term 
‘eligible entity’ means a consortium that consists of— 
‘‘(1) at least 1— 
‘‘(A) long-term care and rehabilitation fa-
cility; or 
‘‘(B) home personal care service provider; 
and 
‘‘(2) at least 1— 
‘‘(A) hospital or health system; 
‘‘(B) labor organization or labor-manage-
ment partnership; 
‘‘(C) community-based aging service pro-
vider; 
‘‘(D) patient-centered medical home; 
‘‘(E) federally qualified health center; 
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‘‘(F) managed care entity, including a 
managed health and long-term care program; 
‘‘(G) entity that provides health services 
training; 
‘‘(H) State-based public entity engaged in 
building new roles and related curricula for di-
rect-care workers; or 
‘‘(I) any other entity that the Assistant 
Secretary deems eligible based on integrated 
care criteria. 
‘‘(d) APPLICATION.—To be eligible to receive a grant 
under this section, an eligible entity shall submit to the 
Assistant Secretary an application at such time, in such 
manner, and containing such information as the Secretary 
may require, which shall include— 
‘‘(1) a description of the care coordination and 
service delivery models of the entity, detailed on a 
general, organizational, and staff level; 
‘‘(2) a description of how the demonstration 
project carried out by the entity will improve care 
quality, including specific objectives and anticipated 
outcomes that will be used to measure success; and 
‘‘(3) a description of how the coordinated care 
team approach with an enhanced role for the direct- 
care worker under the demonstration project will in-
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crease efficiency and cost effectiveness compared to 
past practice. 
‘‘(e) PLANNING AWARDS UNDER DEMONSTRATION 
PROGRAM.— 
‘‘(1) IN GENERAL.—Each eligible entity that re-
ceives a grant under this section shall receive a 
grant for planning activities related to the dem-
onstration project to be carried out by the entity, in-
cluding— 
‘‘(A) designing the implementation of the 
project; 
‘‘(B) identifying competencies and devel-
oping curricula for the training of participating 
direct-care workers; 
‘‘(C) developing training materials and 
processes for other members of the interdiscipli-
nary care team; 
‘‘(D) articulating a plan for identifying 
and tracking cost savings gained from imple-
mentation of the project and for achieving long- 
term financial sustainability; and 
‘‘(E) articulating a plan for evaluating the 
project. 
‘‘(2) AMOUNT AND TERM.— 
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‘‘(A) 
TOTAL
AMOUNT.—The 
amount 
awarded under paragraph (1) for all grants 
shall not exceed $600,000. 
‘‘(B) TERM.—Activities carried out under 
a grant awarded under paragraph (1) shall be 
completed not later than 1 year after the grant 
is awarded. 
‘‘(f) IMPLEMENTATION
AWARDS
UNDER
DEM-
ONSTRATION PROGRAM.— 
‘‘(1) IN GENERAL.—Each eligible entity may re-
ceive a grant for implementation activities related to 
the demonstration project to be carried out by the 
entity, if the Assistant Secretary determines the en-
tity— 
‘‘(A) has successfully carried out the ac-
tivities under the grant awarded under sub-
section (e); 
‘‘(B) offers a feasible plan for long-term fi-
nancial sustainability; 
‘‘(C) has constructed a meaningful model 
of advancement for direct-care workers; and 
‘‘(D) aims to provide training to a sizeable 
number of direct-care workers and to serve a 
sizeable number of older individuals. 
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‘‘(2) USE OF FUNDS.—The implementation ac-
tivities described under paragraph (1) shall in-
clude— 
‘‘(A) training of all care team members in 
accordance with the design of the demonstra-
tion project; and 
‘‘(B) evaluating the competency of all staff 
based on project design. 
‘‘(3) EVALUATION AND REPORT.— 
‘‘(A) EVALUATION.—Each recipient of a 
grant under paragraph (1), in consultation with 
an independent evaluation contractor, shall 
evaluate— 
‘‘(i) the impact of training and de-
ployment of direct-care workers in ad-
vanced roles, as described in this section, 
within each participating entity on out-
comes, such as direct-care worker job satis-
faction and turnover, beneficiary and fam-
ily caregiver satisfaction with services, rate 
of hospitalization of beneficiaries, and ad-
ditional measures determined by the Sec-
retary; 
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‘‘(ii) the impact of such training and 
deployment on the long-term services and 
supports delivery system and resources; 
‘‘(iii) statement of the potential of the 
use of direct-care workers in advanced 
roles to lower cost and improve quality of 
care in the Medicaid program; and 
‘‘(iv) long-term financial sustainability 
of the model used under the grant and the 
impact of such model on quality of care. 
‘‘(B) REPORTS.—Not later than 180 days 
after completion of the demonstration program 
under this section, each recipient of a grant 
under paragraph (1) shall submit to the Sec-
retary a report on the implementation of activi-
ties conducted under the demonstration project, 
including— 
‘‘(i) the outcomes, performance bench-
marks, lessons learned from the project; 
‘‘(ii) a statement of cost savings 
gained from implementation of the project 
and how the cost savings have been rein-
vested to improve direct-care job quality 
and quality of care; and 
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