I 117th CONGRESS 1st Session H. R. 6149 IN THE HOUSE OF REPRESENTATIVES December 7, 2021 Mr. Cartwright (for himself and Mr. McKinley ) introduced the following bill; which was referred to the Committee on Energy and Commerce A BILL To amend the Public Health Service Act to develop and test an expanded and advanced role for direct-care workers who provide long-term services and supports to older adults and people with disabilities in efforts to coordinate care and improve the efficiency of service delivery, and for other purposes.

1. Short title This Act may be cited as the Improving Care for Vulnerable Older Citizens and People with Disabilities through Workforce Advancement Act of 2021 . 2. Findings Congress finds the following: (1) As of 2019, more than 54,000,000 Americans were age 65 or older. By 2030, the Census Bureau projects that one in five Americans will be 65 or older. More than 80 percent of older Americans 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 (GAO) found that 34 percent of Americans who are age 60 or older reported needing assistance performing activities of daily living. According to a 2015 GAO report, between 67 and 78 percent of older adults who likely need home-based care receive limited or no help with their difficulties. (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 range of other daily tasks. They are a lifeline for those they serve, as well as for families and friends struggling to provide high-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 nearly 4,600,000 jobs and is expected to add nearly 1,300,000 new positions within the next decade. (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. In 2019, DCWs providing home-based care already outnumbered DCWs in nursing homes by more than 4 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 2016, 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 has required developing new models of care for those receiving long-term services and supports. 3. Demonstration program on care coordination and service delivery Title III of the Public Health Service Act is amended by inserting after section 330N of such Act ( 42 U.S.C. 254c–20 ) the following: 330O. Demonstration program on care coordination and service delivery (a) Establishment of demonstration program (1) In general The Secretary, acting through the Administrator of the Health Resources and Services Administration, shall carry out a demonstration program in accordance with this section. Under such program, the Secretary shall award grants to eligible entities to carry out demonstration projects that focus on care coordination and service delivery redesign for older adults and people with disabilities who have chronic illness or are at risk of institutional placement by— (A) designing and testing new models of care coordination and service delivery that thoughtfully and effectively deploy direct-care workers in advanced roles to improve efficiency and quality of care for older adults and people with disabilities; 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 under this section shall be composed of 4 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 or on training direct-care workers to take on greater responsibilities related to specific diseases, including Alzheimer’s disease and dementia, congestive heart failure, and diabetes. Under these projects, direct-care workers shall assist in monitoring health status, ensuring compliance with prescribed care, and educating and coaching the older adults and people with disabilities involved, as well as any family caregivers and other members of the care team. (c) Eligible entity In this section, the term eligible entity means a consortium that consists of— (1) at least 1— (A) skilled nursing facility or other residential long-term care provider; or (B) home health and 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 and disability services 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 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 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, encompassing workforce outcomes, care outcomes, and cost outcomes. (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 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 adults and people with disabilities. (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; 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, and 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 under this section 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. .