I 113th CONGRESS 2d Session H. R. 4445 IN THE HOUSE OF REPRESENTATIVES April 10, 2014 Mr. Cartwright (for himself, Mr. Grayson , and Ms. Jackson Lee ) introduced the following bill; which was referred to the Committee on Education 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 improve the efficiency of service delivery.

1. Short title This Act may be cited as the Improving Care for Vulnerable Older Citizens through Workforce Advancement Act of 2014 . 2. Findings Congress finds the following: (1) As of 2012, more than 41,000,000 Americans 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 section as DCWs ) provide an estimated 70 to 80 percent of the paid hands-on long-term care and personal 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 positions by 2020. (4) The majority of DCWs are now employed in home- and community-based settings, and not in institutional 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, entitled 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 future of nursing, released in October of 2010, recommended 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 coordination of care and integration of services, particularly for consumers with multiple chronic conditions. This will require developing new models of care for those receiving long-term services and supports. 3. Demonstration program on care coordination 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: 423. Demonstration program on care coordination and service delivery (a) Establishment of demonstration program (1) In general The Assistant Secretary shall carry out a demonstration program in accordance with this section. Under such program, the Assistant Secretary shall award grants to eligible entities 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 (B) giving direct-care workers opportunities for career advancement through additional training, an expanded role, and increased compensation. (2) Direct-care worker In this section, the term direct-care worker has the meaning given that term in the 2010 Standard Occupational Classifications 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 demonstration 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 unnecessary hospital readmissions. Under these projects, direct-care workers shall be incorporated as essential members of interdisciplinary care coordination teams. (2) Two demonstration projects shall focus on maintaining the health and improving the health status of those with multiple chronic conditions and long-term care needs. Under these projects, direct-care workers shall assist in monitoring health status, ensuring compliance with prescribed care, and educating 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 clinical responsibilities related to specific diseases, including 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 facility; or (B) home personal care service provider; and (2) at least 1— (A) hospital or health system; (B) labor organization or labor-management partnership; (C) community-based aging service provider; (D) patient-centered medical home; (E) federally qualified health center; (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 direct-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 increase efficiency and cost effectiveness compared to past practice. (e) Planning awards under demonstration program (1) In general Each eligible entity that receives a grant under this section shall receive a grant for planning activities related to the demonstration project to be carried out by the entity, including— (A) designing the implementation of the project; (B) identifying competencies and developing curricula for the training of participating direct-care workers; (C) developing training materials and processes for other members of the interdisciplinary care team; (D) articulating a plan for identifying and tracking cost savings gained from implementation of the project and for achieving long-term financial sustainability; and (E) articulating a plan for evaluating the project. (2) Amount and term (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 demonstration program (1) In general Each eligible entity may receive a grant for implementation activities related to the demonstration project to be carried out by the entity, if the Assistant Secretary determines the entity— (A) has successfully carried out the activities under the grant awarded under subsection (e); (B) offers a feasible plan for long-term financial 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. (2) Use of funds The implementation activities described under paragraph (1) shall include— (A) training of all care team members in accordance with the design of the demonstration 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 deployment of direct-care workers in advanced roles, as described in this section, within each participating entity on outcomes, such as direct-care worker job satisfaction and turnover, beneficiary and family caregiver satisfaction with services, rate of hospitalization of beneficiaries, and additional measures determined by the Secretary; (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 Secretary a report on the implementation of activities conducted under the demonstration project, including— (i) the outcomes, performance benchmarks, lessons learned from the project; (ii) a statement of cost savings gained from implementation of the project and how the cost savings have been reinvested to improve direct-care job quality and quality of care; and (iii) results of the evaluation conducted under subparagraph (A) with respect to such activities, together with such recommendations for legislation or administrative action for expansion of the demonstration program on a broader scale as the Secretary determines appropriate. (4) Amount and term (A) Total amount The amount awarded under paragraph (1) for all grants shall not exceed $2,900,000. (B) Term Activities carried out under a grant awarded under paragraph (1) shall be completed not later than 3 years after the grant is awarded. .