The Gerontologist 48:14-16 (2008)
© 2008 The Gerontological Society of America
Better Jobs Better Care: A Foundation Initiative Focusing on Direct Care Workers
Wendy Yallowitz, MSW and
Brian F. Hofland, PhD
Correspondence: Address correspondence to Wendy Yallowitz, MSW, Robert Wood Johnson Foundation, Route 1 & College Road East, Princeton, NJ 08543. E-mail: wyallowitz{at}rwjf.org
The Atlantic Philanthropies (Atlantic) and the Robert Wood Johnson Foundation (RWJF) are both committed to improving the lives of the most vulnerable people, including those within the aging population. Those aged 65 and older are projected to represent at least 20% of the total U.S. population by 2030, with the 85-and-older population increasing the most (Institute of Medicine, 2001). The growth of the oldest old will have a major effect on the demand for and supply of long-term care services.
Direct care workers, who are essential to the care of frail older adults, assist with activities of daily living when older persons can no longer perform all of those duties themselves. They help vulnerable older adults maintain independence as long as possible in their own homes and help older adults living in institutions have a higher quality of life.
Recognizing the current and projected shortage in the frontline workforce for long-term care, Atlantic and RWJF jointly developed and funded the $15.5 million 5-year national initiative Better Jobs Better Care (BJBC) to bring about changes in policy and practice that would lead to improved recruitment and retention of high-quality direct care workers in nursing homes as well as in home- and community-based settings. The initiative was designed to use two types of grant programs—demonstration programs and applied research and evaluation programs—to test new approaches to providing a more stable and qualified long-term care staff and evaluate what works best to achieve this objective.
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Background to BJBC
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In 2001, the Office of the Assistant Secretary for Planning and Evaluation in the U.S. Department of Health and Human Services and RWJF funded the Urban Institute and the Institute for the Future of Aging Services (the latter part of the American Association of Homes and Services for the Aging) to develop research and demonstration agendas for the recruitment and retention of direct care workers in long-term care. Project staff conducted a literature review and established a technical advisory group. This group developed three expert panels to address specific issues related to long-term care frontline workers: (a) rewards and incentives, (b) workplace culture, and (c) labor pool expansion. The panels, which met separately in Washington, DC, included providers, researchers, funders, consumers, and staff from federal and state governments. The rewards and incentives panel evaluated the benefits and wages of the long-term care frontline workforce and the effects on turnover and the quality of care delivered. The workplace culture panel assessed organizational structure, including communication, teamwork, training, culture, supervision, and peer mentoring. The labor pool expansion panel examined options for finding a supply of frontline workers from new sources such as the family, older workers, students, and so on.
The three technical expert panels developed recommendations to address the shortage in the frontline workforce in long-term care (i.e., Summary of Meeting of the Technical Expert Panel on Extrinsic Rewards and Incentives, June 15, 2001; Summary of Meeting of the Technical Expert Panel on Organizational Cultural Change, November 30, 2001; and Summary of Meeting of the Technical Expert Panel on Labor Pool Expansion, December 14, 2001). The advisory group recommended that a research and demonstration program be developed that included all settings of long-term care (including nursing homes, assisted living facilities, boarding homes, and community-based services) to test the effectiveness of specific interventions (e.g., incentives and benefits, organizational structure, and expansion of the labor pool) on improving the recruitment and retention of the frontline workforce. Atlantic and RWJF referred to these recommendations when developing BJBC. You can find the citations for these reports in the Appendix.
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Structure of BJBC
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The program included two components: a demonstration program and an applied research program. The Institute for the Future of Aging Services operated the program in collaboration with the Paraprofessional Healthcare Institute, which provided technical assistance to the selected sites. Program developers issued a Call for Proposals to attract applicants for each program component.
The demonstration component focused on the implementation of policy changes and practice interventions aimed at attracting and retaining high-quality paraprofessionals. Grantees for this component had to be nonprofit organizations working in collaboration with policy makers, key stakeholders, providers, workers, and consumers in long-term care. Grant funds were used to strengthen policies and implement workplace improvements in one or more provider networks. Selection criteria included past successes of coalitions; evidence that all key stakeholders would participate; inclusion of direct care workers in coalitions; commitment by multiple providers to project participation; ability and capacity of the lead agency; understanding of the problem, characteristics of the direct care workforce, linkage between quality of care and the direct care workforce, and the nurse's role with direct care workers; ability to demonstrate measurable improvement in vacancy and turnover rates; and presence of at least a 20% match.
The applied research component supported studies of workplace innovations and public policy interventions aimed at attracting and retaining high-quality paraprofessional direct care workers. These research projects form the basis of this issue of The Gerontologist and are described throughout. Program developers expected recipients of grant funds to participate in an independent evaluation conducted by The Pennsylvania State University Department of Health Policy and Administration from November 2003 through October 2008. This evaluation was designed to achieve two goals: (a) document and analyze the effect of the coalition activities on state- and market-level outcomes and provider-level change, and articulate the successes and challenges encountered; and (b) assess the effects of state-level coalition activities and provider-level practice changes on direct care workers' jobs. The evaluation team attended site visits, reviewed relevant documentation, developed a management information system for direct care worker data, and surveyed providers to gather information (see Kemper, Brannon, Barry, Stott, and Heier).
BJBC involved a National Advisory Committee in helping to shape the selection criteria, review proposals, participate in applicant site visits, and make recommendations for funding. The Committee was a broad-based, diverse group of 20 content experts (9 for the research grantees and 11 for the demonstration grantees) appointed by Atlantic and RWJF. The Committee made recommendations to which the foundations gave great weight, but it was ultimately the funders' decision as to whom to award the grants.
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Demonstration Component Grantees
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Out of 200 proposals submitted for the demonstration component, 5 grants were awarded in July 2003. Many successes came from these projects. Some states developed a core curriculum for direct care workers, many states worked on better peer mentoring programs, many created cultural competence models and occupational profiles, and two states developed direct care worker associations. Although each state project had its own objectives, some states worked on overlapping objectives. Specifically, the five demonstration projects were the following:
- The Iowa CareGivers Association (Des Moines, IA) expanded its peer mentoring training programs at provider sites, expanded and enhanced its state registry of direct care workers, and examined alternatives for increasing the health insurance of direct care workers.
- The North Carolina Foundation for Advanced Health Programs (Raleigh, NC) designed a special licensure designation called the North Carolina New Organizational Vision Award for nursing homes, residential facilities, and home care agencies. This first-in-the-nation voluntary state licensure program rewards long-term care providers who invest in building a high-quality workforce and achieve high workforce standards and outcomes of increasing retention and worker satisfaction. The goal of the program is to seek a reimbursement differential for organizations that attain the special licensure designation.
- The "Oregon Works! Coalition" (Salem, OR) improved working relationships between direct care workers and their supervisors, as well as between workers and the families of the persons they serve in eight provider organizations. The project agenda, focused on person-centered care, aimed to promote the advancement of direct care workers and increase the diversity of the workforce.
- The Center for Advocacy for the Rights and Interests of the Elderly (Philadelphia, PA) developed five regional coalitions to support job quality enhancements including wage raises, mentoring programs, and a uniform training curriculum in all long-term care settings.
- The Community of Vermont Elders (Montpelier, VT) expanded and improved training programs for direct care workers. The project worked with 12 provider sites, identified their recruitment and retention needs, and designed and delivered trainings to address those needs.
See the BJBC Web site (www.bjbc.org) for more details on each of these demonstration projects.
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Two Participating Foundations
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The RWJF Human Capital portfolio is based on the Foundation's longstanding recognition that the strategies for social change do not succeed without the leaders and workforce to develop and carry forward the ideas. A capable and diverse health and health care workforce is necessary to improve the health and health care of all Americans. RWJF makes investments to build specific fields within health and health care and to help ensure that the nation has a sufficient, well-trained workforce that provides direct care and services to patients. Particularly, the Human Capital portfolio supports work to help attract, develop, and retain high-quality leaders and workers in health and health care. The Human Capital portfolio's current work concentrates in three areas: policy and leadership, field building, and workforce development and diversity (RWJF, 2007). In 2006, RWJF awarded a grant to Jobs for the Future in Boston to develop a national program called Jobs to Careers. The goals of this program are to (a) provide frontline health care workers opportunities for increasing learning and skills, better job performance, rewards, and career advancement; (b) support health care employers, educational partners, and other partners in making systematic changes to support frontline workers; and (c) advance the practice of work-based learning and demonstrate the effectiveness of work-based learning as a tool to support frontline workers. For more information on RWJF, visit its Web site at www.rwjf.org.
Atlantic is a limited-life foundation dedicated to bringing about lasting changes in the lives of disadvantaged and vulnerable people. The international grant-making programs of Atlantic cover seven regions of the world where the problems they seek to address are acute and where grant-making can have an impact over the next 15 years: Australia, Bermuda, Northern Ireland, the Republic of Ireland, South Africa, the United States, and Vietnam. Atlantic's Ageing Programme operates in four of these geographic areas: Bermuda, Northern Ireland, the Republic of Ireland, and the United States. Atlantic's U.S. aging program focuses on two major objectives: (a) increasing civic engagement opportunities for older adults and (b) improving health and support services for older adults through a strategy of human capital development. The BJBC initiative was funded within the grant portfolio dedicated to this second objective, which includes an emphasis on improving the quality and increasing the supply of key professionals (including physicians, nurses, social workers, and direct care workers) as well as improving self-care by older adults and their family members. For more information about Atlantic, its grant-making, and its philosophy, visit its Web site at www.atlanticphilanthropies.org.
As funders, we are both committed to continuing to support workforce initiatives. We recognize the need to create systems that help frontline workers who directly contact clients, because these workers are essential to the quality of the nation's health care system.
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Footnotes
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or Brian F. Hofland, PhD, The Atlantic Philanthropies, 125 Park Avenue, 21st floor, New York, NY 10017-5581. E-mail: b.hofland{at}atlanticphilanthropies.org 
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References
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Appendix Sources of More Information on Better Jobs Better Care
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- Bowers, B., (2001). Organizational change and workforce development in long term care. Paper prepared for the Technical Expert Panel Meeting, Washington, DC. November, 2001.
- Holzer, H., (2001). Long term care workers and the low wage labor market: Current characteristics and future trends. Paper prepared for the Urban Institute and the Institute for the Future of Aging Services, Washington, DC. June, 2001.
- Institute of Medicine. (2001). Improving the quality of long term care. Washington, DC: National Academy Press.
- McCall, N., (2001). Who will pay for long term care?. Chicago: Health Administration Press.
- Tilly, J., & Wilner, M. A., (2001). Options for research on extrinsic rewards. Paper prepared for the Urban Institute and the Institute for the Future of Aging Services, Washington, DC. December, 2001.
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Background to BJBC
Structure of BJBC