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Correspondence: Address correspondence to Melanie Hwalek, President and Founder, SPEC Associates, 615 Griswold, Suite 1505, Detroit, MI 48226-3992. E-mail: mhwalek{at}specassociates.org
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Abstract |
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Key Words: Workforce • Low income • Title V • Nursing home • Home health care
While the number of older Americans grows, their economic problems grow as well. In 2000, the mean income for persons 65 years and older who reported having an income was $16,088 (U.S. Census Bureau, 2000). For the 43 million elders who reported their incomes in 1999, 34% reported less than $10,000, and only 23% reported an income of $25,000 or more (U.S. Census Bureau, 2000). For many adults, staying employed or returning to employment is increasingly becoming a necessity rather than a choice.
AARP conducted a national study of 2,518 workers aged 45 to 72 that revealed that 69% of this workforce intends to work after they retire from their current jobs (Montenegro, Fisher, & Remez, 2002). The study also revealed a variety of motivations for working after the age of 45, including to earn income, to maintain or obtain health care coverage, to contribute to society, to help people, and to continue to have a sense of belonging and community (Montenegro et al., 2002).
At the same time that there is an expanding group of older workers willing or needing to work, the need for paraprofessional workers in the long-term care industry is reaching a crisis level. In a review of the research on long-term care workers, Harris-Kojetin, Lipson, Fielding, Kiefer, and Stone (2004) concluded that there are "unprecedented vacancies" (p. 1) among direct care workers in most states. Employee turnover has long plagued this industry, but now employee availability is increasingly becoming the first concern (Robert Wood Johnson Foundation and Atlantic Philanthropies, 2003).
There is a clear need to find available and qualified persons willing to take frontline jobs offered by nursing homes and home health agencies. What research has not addressed is whether the older workforce represents a viable pool of candidates for these usually low-wage direct care jobs. In fact, Harris-Kojetin and colleagues' (2004) review noted that the typical direct care worker is younger than age 54, the mean age of home care aides declined between the 1980s and 1990s, and median wages of home care and nursing home aides are not much more than minimum wage.
Operation ABLE organizations could be pipelines for filling direct care jobs in the long-term care industry if low-income older workers are interested, able to perform in these jobs, and are placed into the most appropriate frontline jobs to match their interests and abilities. Operation ABLEs are employment and training organizations specializing in the recruitment, training, and redeployment of older workers (those aged 40+) into the workforce. Many Operation ABLEs began in the 1960s when Title V of the Older Americans Act was passed. Title V provides assistance to low-income older workers interested in being trained in 21st-century workplace skills. To be eligible to receive training and employment-related support under Title V, an individual must be aged 55+ and have an income no more than 125% of the poverty guidelines established by the Office of Management and Budget ("Public Law 106-501, 2000"). Thus, many Operation ABLE job seekers are low-income older people actively seeking to be retrained and redeployed into the workforce. Given this participant pool, Operation ABLEs were a logical context for studying the alignment of low-income older workers' employment needs with the needs and requirements of lower paying jobs in the long-term care industry. Although Operation ABLE participants may be just the right workforce to fill some of the need for long-term care workers, little, if any, research has examined the interest of this population in this type of work.
Recent research has addressed employers' perceptions of older workers. Although some research found generally positive attitudes from employers about their older workforce (e.g., Munnell, Sass, & Soto, 2006), other studies, such as Barth, McNaught, and Rizzi (1996), indicated that employers have concerns about hiring or retaining older workers, including fears of lost productivity, higher employee health insurance costs, and greater absenteeism (Barth et al., 1996). These concerns may be even greater among long-term care employers because frontline work is physically demanding. We found no published studies specifically on long-term care employers' interest in hiring older workers for direct care work.
This study aimed to develop a deeper understanding of the needs, wants, and concerns of low-income older workers regarding their choices about working within the context of long-term care. It also looked at the perceptions that long-term care employers have about older workers. This study contributes significantly not only to recruitment strategies and workforce designs to attract and retain low-income older workers, but also to policy and program development that affects training and subsidized employment dollars.
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Study Questions |
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Methods |
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Preliminary Focus Groups
The study began with nine preliminary focus group interviews involving long-term care employers and low-income older workers in three of the study states: Michigan, Nebraska, and California. Three focus groups were conducted in each state, one with each of three study groups: nursing home employers, home health agency employers, and low-income older workers participating in Operation ABLE. In total, 9 employers from nursing homes, 17 employers from home health agencies, and 40 low-income older workers engaged in the focus groups. Employer focus group participants were randomly selected from the publicly available lists of certified nursing homes and home health agencies available from the Centers for Medicare & Medicaid Services. In light of the distance they would have to travel to get to the focus groups, only facilities within a 2 hr driving distance from the focus group site were invited to participate. The 40 low-income older workers were all aged 40+ and were recruited by staff of the Operation ABLE agencies. They represented a convenience sample of participants who would be eligible to participate in the large-scale telephone survey (according to the requirements described in "Low-Income Older Worker Survey"). Employers were given an incentive to participate. Employers were paid different amounts in different states, between $50 and $125, based on the distance they would be expected to travel. Older workers were given $40 for their participation plus parking expenses if needed. Some of the employers donated their compensation to tenant/resident council funds at their agencies.
The purpose of the preliminary focus groups was to identify issues related to the research questions that would need to be addressed in the telephone surveys with workers and employers. Prior to the focus groups, the research team reviewed several survey questionnaires and publications related to frontline workers in long-term care. (Documents reviewed during the design of the survey instruments included Bell, 2001; Hams, Herold, Lee, & Worters, 2002; Health Care Association of Michigan, 2000; Knowledge Systems and Research, n.d.; Livingston, 2001; Mathematica Policy Research, 2003; Medical Expenditure Panel Survey, 1998; Paraprofessional Healthcare Institute, 2000, 2002a, 2002b, 2003a, 2003b, 2003c; State of Wyoming, Department of Health, 2003; Straker & Atchley, 1999.) Information from this review was presented as background information during the focus groups. Focus group participants were then asked to discuss each of the research questions. Responses from the focus groups were used to develop closed-ended responses to similar questions created for the telephone surveys.
Low-Income Older Worker Survey
Workers eligible for the telephone survey were those aged 40 or older, who were at or below 125% of the income associated with the federal government's definition of poverty, who were or had been enrolled in an Operation ABLE retraining and redeployment program, and who consented to be interviewed between March 2004 and May 2005. Staff from Operation ABLEs invited eligible workers to participate in the study. At each Operation ABLE, staff used a standard set of recruitment materials and consent forms that had been approved by an institutional review board for the protection of human research participants. Interested workers completed and signed a consent form that was faxed to SPEC Associates, the research firm responsible for data collection and analysis. A total of 1,291 workers consented to be interviewed. The exact percentage of older workers that these consenting respondents represented is unknown. Each Operation ABLE had agreed to target the number of eligible older workers that they expected to serve during the study period. (Executives of Operation ABLEs met at the beginning and end of the study and maintained communication through e-mail so they could provide input in the development of procedures and questionnaires [mostly for the worker survey]. They also contributed their interpretations of the data.) However, budget cuts and other factors resulted in some Operation ABLEs looking to their past participants to meet their quota. A total of 1,091 interviews were completed.
Of the 1,091 Operation ABLE survey respondents, 696 (64%) were aged 55+ and are the focus of the analyses reported here. Although the 40+ population is the official government designation for the class of workers protected under the Age Discrimination in Employment Act, the interest of consumer organizations such as AARP is on the 50+ population, and Title V targets workers aged 55+. Therefore, the seven Operation ABLEs believed that the results would be more informative to policy makers if the 55+ population was the first focus of analysis. Future analyses will compare the survey responses of those aged 55+ with those aged 40 to 54 who completed the survey.
Table 1 shows the demographic characteristics of the 55+ low-income older workers sampled.
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Professional interviewers trained in the use of this study's particular survey instruments conducted interviews over the telephone. Respondents were paid $25 for participating in the survey. The survey questionnaire for low-income older workers covered the following topics:
Nursing Home Survey
Nursing homes eligible for the survey were all facilities listed on the Centers for Medicare & Medicaid Services publicly available list of certified nursing homes. A total sample of 891 nursing homes was randomly selected by state. Random numbers were created and assigned sequentially to each home on each state's list. The list was then sorted, and the first 891 nursing homes listed were chosen to be contacted. Letters were sent to the human resources managers of the selected facilities explaining the study and inviting them to participate. Nursing homes that were listed and chosen for the sample, but in actuality no longer existed, were replaced with other nursing homes listed.
Most respondents were administrators or directors of human resources at their respective agencies. A total of 615 respondents participated in the survey. Because some respondents owned several nursing homes, each was asked to respond with respect to the one facility that was listed in the invitation letter that they received.
Table 2 shows how the nursing home employers described their organizational structure and workforce.
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Nursing home employers were not asked about the certification of their direct care workers because in all of the sampled states, direct care workers in nursing homes were required to be certified. This means that they have completed at least 75 hours of training and have passed a certification test mandated by the state.
The same trained professional interviewers who conducted the interviews with other study samples conducted telephone interviews with nursing home employers. The survey questionnaire covered the following topics:
The questions asking employers to compare older and younger workers did not specify "low-income" older worker. This was because employers were asked, specifically, to compare older and younger direct care workers. Because direct care work is typically a lower paying position, the research team felt it would unnecessarily complicate the interview to ask employers to focus only on the low-income direct care workforce that was 55 years or older.
Home Health Agency Survey
Home health agencies eligible for the survey were all organizations on the Centers for Medicare & Medicaid Services publicly available list of certified home health agencies. The sample of 642 home health agencies was randomly selected using the same strategy as for the nursing home sampling described in the previous section. Letters were sent to the human resources managers of the selected agencies explaining the study and inviting them to participate. A total of 410 respondents participated in the survey. Typically they were the owners or directors of human resources at their respective agencies.
As shown in Table 2, few (8%) of the home health agency employers described their organizations as being part of a chain. Agencies were almost equally divided between being independently owned and operated (43%) and being a part of a larger system of health care services (45%). More were nonprofit (53%) than for profit (40%).
Because certification of home health agency direct care workers is not mandatory, these survey respondents were asked about the certification of their frontline workforce. A total of 81% of the respondents reported that their direct care workforce consisted predominantly of certified workers (see Table 2).
The survey questionnaire for the home health agencies was essentially the same as the questionnaire used to interview nursing home employers. However, the research team realized during the pilot testing of the questionnaire that many home health agencies employ both certified and noncertified direct care workers. Because there could be differences between certified and noncertified direct care workers in terms of wage scales and other characteristics, it was important to be clear about which type of worker the employer should be referring to as they answered the survey questions. So as not to overcomplicate the interview by asking the same questions twice (once in relation to certified workers and again in relation to noncertified workers), the research team decided to ask home health agencies how many certified and noncertified direct care workers they employed. The interviewer was instructed to ask the survey questions relative to the predominant type of direct care worker employed by the home health agency. If the number of certified and noncertified direct care workers was equal, the interviewer was instructed to ask the questions relative to noncertified workers. This was to ensure that there would be enough home health agencies in the noncertified group to compare wage rates between certified and noncertified direct care workers. Certain questions (e.g., about certification training) were asked specifically about certified direct care workers regardless of the predominance of these workers at the agency.
Table 3 shows the number of survey respondents from each group from each state. The variation in the number of nursing homes and home health agencies from each state largely reflected the populations of nursing homes and home health agencies in each state. The variation in the number of low-income older workers from each state resulted from a number of factors. Some Operation ABLEs were more rigorous than others in recruiting potential study participants. Additionally, some Operation ABLEs had more funding for their low-income older worker training programs and therefore had more potential study participants than others.
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Because the Operation ABLE staff were to recruit workers for the focus groups, and the telephone surveys were confidential (i.e., staff could not be told who did or did not respond), the sampling frame for the focus groups with low-income older workers was current Operation ABLE clients aged 40 to 70 who had an income within 125% of the federal guidelines defining poverty level, who could speak and understand English, and who represented, to the extent possible, as diverse a group as possible in ethnicity, physical ability, and gender. Each Operation ABLE was asked to recruit no more than 12 low-income older workers for the focus groups. The research team prepared a recruitment script approved by an institutional review board and gave it to Operation ABLE staff.
As with the preliminary focus groups, both employer and older worker participants were given financial compensation for their participation. Employers were paid between $100 and $150, depending on the distance they had to travel. Workers were paid $40 as well as parking expenses if needed.
In total, there were 12 employers of nursing homes, 12 employers of home health agencies, and 48 Operation ABLE participants in the focus groups. The purpose of the focus groups was to obtain insights about the interpretation of the survey results. Participants were shown charts and graphs of the key study findings. Operation ABLE participants were asked to discuss what the older worker survey results told them about (a) how to find a job, (b) where or how to get themselves trained for this job, and (c) what agencies need to do to keep them happy in the job. These three questions were posted on large paper to be easily viewed by the group members.
During the focus groups with employers of nursing homes and home health agencies, participants were shown the results from their respective surveys and asked to discuss the results in response to four key questions: (a) Should (nursing homes/home health agencies) recruit mature workers as direct care workers? (If yes, why? What is the best way to recruit mature workers?) (b) What is the best way to train mature workers as direct care workers? (c) What could (nursing homes/home health agencies) do to retain mature workers in direct care positions? (d) Should public money be spent on recruiting, training, or retaining mature workers for direct care positions? (If yes, what is the best way to spend public money on recruiting, training, or retaining mature workers?)
Data Analysis
For all three telephone surveys, descriptive statistics were the predominant analyses used. When comparisons were made between nursing homes and home health agencies, "meaningfulness" was the criteria used to identify major differences, rather than inferential statistics. The research team decided that a difference between groups of 10% or greater would constitute a meaningful difference. Differences that were 10% or greater were also tested using chi-square and t tests and did, in fact, achieve statistical significance. The reason for the focus on meaningfulness is that, given the large sample sizes in each group, even small differences of a few percentage points would likely be statistically significant. The research team believed that it was more important to set a concrete standard for representing differences that were meaningful to the reader rather than to beset the study with numerous reports of statistical significance.
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Results |
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What Aspects of Direct Care Work in Long-Term Care Appeal to Low-Income Older Workers and Why?
Finding 1: Older Workers Are Interested in Paraprofessional Health Careers
In all, 43% of the low-income older workers expressed an interest in direct care work. A total of 60% indicated that they would like to work 30 hours or more per week, and 55% said that they would attend a 75-hr certification training to become a direct care worker. More (69%) said they would like to work in someone's own home as compared a nursing home or other institutional setting (57%). Particularly interesting is the finding that 86% of these low-income older workers reported an interest in career advancement opportunities.
Finding 2: Frontline Jobs in Home Health Agencies Are More Appealing to Older Workers Than Are Direct Care Jobs in Nursing Homes
As mentioned earlier, the majority of older workers reported that they were interested in working in someone's own home (69%). A lesser number reported an interest in working in a nursing home or other institution (57%). When respondents were asked about specific job tasks, most popular jobs were those more likely to be found in home health agencies. For example, 76% of older workers said they were interested in supervisory tasks such as teaching someone how to dress themselves, guiding someone to walk somewhere, or reminding someone to take medication. The majority (69%) also said they were interested in emotional support tasks, such as sitting by someone's side, calming down an upset patient, or giving someone a hug or touch for support. Notably fewer workers (28%) said that they were interested in hands-on tasks, such as bathing, dressing, helping someone eat, clipping toenails, or transferring someone from a bed to a wheelchair.
Home health agencies were more likely than nursing homes to match worker interests and abilities with clients. In the employer surveys, 48% of home health agencies compared with 19% of nursing homes reported differentially assigning clients to workers based on the physical strength of employees. Similarly, 50% of home health agencies compared with 25% of nursing homes reported differentially assigning clients to workers based on other characteristics of the workers.
When asked about their 55+ certified nursing aide (CNA) workforce, nursing home employers reported, on average, that 18% of their certified workers were aged 55+. This compared with an average 55+ population of 27% among the home health agency employers.
A comment from a home health agency employer corroborated the survey data suggesting that home health agency settings are more amenable to older workers than nursing homes. This person remarked, "I get a lot of people coming from the nursing home saying that they just can't do it anymore. The lifting, that it's too demanding, and they go into home care because it's less demanding."
Finding 3: Frontline Jobs in Nursing Homes That Interest Older Workers Are Infrequent Job Positions in Nursing Homes
Low-income older workers tended to be more interested in the job positions of activity aide, medication assistant, or rehab aide than in the position of direct care worker. Survey results revealed that 74% of low-income older workers reported that they would be interested in a job as an activity aide, described in the questionnaire as someone who plays games, does crafts with people, and helps the activity director prepare and conduct special events. Similarly, 67% reported that they would be interested in a job as a medication assistant, described as someone who helps people only with their medicine, giving it to them or helping them take it. Also, 58% of workers reported that they would be interested in a job as a rehab aide, described as someone who helps people only with physical therapy, such as practicing walking or exercising. Moreover, 52% reported that they would be interested in a job as a feeding assistant, described as someone who works in a nursing home or other institutional setting only helping people to eat or feeding people who are unable to feed themselves. In contrast, only 27% of workers reported that they would be interested in a job as a bathing assistant, described as someone who helps people only with bathing when they cannot bathe themselves.
According to the nursing home employers, very few nursing homes had job positions of medication assistant (26%), bathing assistant (14%), or feeding assistant (8%). Although the majority of nursing homes had job positions for activity aide (81%) and rehab aide (63%), according to employers in the interpretive focus groups, typically there are only one or a few of those positions in a nursing home. One employer explained, "[The job] is at the nursing home, but there's maybe only like one person that's a paid position."
Employers in focus groups also reported that these job positions are often given as perks to frontline workers who have seniority.
What Unique Attributes Can Older Workers Bring to Long-Term Care Jobs?
Finding 4: Nursing Homes and Home Health Agencies Have Very Positive Perceptions of Older Workers
Except for their perceived willingness to use new technology, the majority of employers reported positive differences between their direct care workers who are aged 55+ and younger workers. Figure 1 shows the list of characteristics that 50% or more of the employers reported workers aged 55+ are more likely to have, in comparison with younger workers. As Figure 1 shows, with regard to work behaviors, employers reported their 55+ workers to be more loyal, independent, knowledgeable, motivated, and more likely to act as team players and be independent problem solvers. With regard to clients, employers reported their 55+ workers to be more understanding and patient, have greater desire to care for the sick and disabled, and be better able to communicate and gain the trust of clients.
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Although 70% of nursing home employers and 74% of home health agency employers said that they are willing to use terms such as older worker and senior citizen in advertising for older workers, only 3% of nursing home employers and only 6% of home health agency employers targeted recruiting to 55+ workers. When this inconsistency was discussed during the interpretive focus groups, employers pointed to health care costs and laws barring age discrimination.
Regarding health care costs, during the interpretive focus groups some employers commented that older workers utilize health care to a greater extent than younger workers. Some reported having corporate pressure to hire younger workers because of the increased health insurance costs associated with hiring older workers. The validity of the claim of increased health care costs for older workers was questioned by one nursing home employer, who commented as follows:
I don't know if you can believe what insurance companies tell you [regarding] how they are underwriting.... They supposedly say you are community rated based on the age and sex of your workers. That is supposedly the only thing they offset for. I can't believe that in the age of computers ... they don't have programs that are writing down all the claims they have come in on all the workers in the previous, last year, 2 years. But you know, one of the detriments I think is more general [other than age] ... when you have women of childbearing age. That is a costly workforce to afford from a health insurance standpoint, and [women of childbearing age] makes up a large part of our workforce.
In the low-income older worker survey, 66% of workers reported having health care coverage, including Medicare or Medicaid, and typically this coverage was not through their spouses' jobs. The survey did not differentiate whether older workers' coverage was through Medicaid, Medicare, personal pay, or an employer.
Regarding laws barring age discrimination, employers in both the surveys and the focus groups noted that they had been told by their human resources or legal departments that a phrase such as older workers welcomed would violate Equal Employment Opportunity Commission (EEOC) regulations. Therefore, although they were willing to use these terms, their perception was that it would be illegal to do so.
An objective deterrent to hiring low-income older workers was their reliance on and the limited availability of public transportation. In the low-income older worker survey, 34% of the workers said that they rely on public transportation. This compared with only 5% of the 50+ population in a recent AARP research report (Ritter, Straight, & Evans, 2002). In a similar vein, a nursing home administrator lamented during a focus group that public transportation was the biggest cause for employee turnover, regardless of age:
Transportation is a huge thing, because at my center, we are not on a reliable bus transportation system, we have [name of bus route], and it's not reliable, because the last bus that leaves our center is at like around 7:00. A lot of the shifts are 3 to 11, and then the bus comes like maybe right at 7:00. So, it's very difficult to retain employees, because the only means of transportation is either [to] rely on another aide or someone else or to catch a cab, and the amount of money it costs them to catch a cab is not even conducive to what we pay them an hour. ... Now, they are contemplating removing our bus line entirely, so that is going to reduce a lot more employees.
CNA training requirements was another possible deterrent to hiring older workers. Regarding CNA training, 56% of nursing home employers and 78% of home health agency employers said that all of their direct care workers were already certified when they applied for work. As specified earlier, 55% of older workers indicated a willingness to attend a 75-hr training program to become a CNA. However, some workers in the focus groups commented that they were concerned about the costs of training, and some worried that they could not keep up with intensive educational coursework. They made comments such as "I think it's scary for some people to have to think ... ‘Here I am, at my older age, and ... I have to get training.’ Now that would be scary."
As indicated previously, in the employer surveys, 59% of nursing home employers and 57% of home health agency employers believed that older workers were less likely than younger workers to be willing to use a computer, palm pilot, or other technological device to record information. This conformed with recent research by AARP (2000) that senior-level human resource executives perceive older workers as resistant to learning new technologies.
Finally, the average hourly wage for direct care workers may dissuade older workers from seeking employment in long-term care. In the older worker survey, wage expectations for direct care work averaged $10/hr. This is more than the $8/hr average wage of personal care aides reported in research by Wright (2005) and the $6/hr average wage of home care aides and $7/hr for nursing home aides reported in Harris-Kojetin and colleagues' (2004) review.
Finding 7: Stereotypes About Physical Capacity Should Not Dissuade Long-Term Care Employers From Looking at Older Workers for Frontline Work
Employers in the interpretive focus groups indicated that age is not the major criteria that they use when assessing the functional abilities of potential direct care workers. Rather, they look at characteristics regardless of age. For instance, one comment made by a nursing home employer suggested that obesity can be a barrier for workers of any age:
You see a lot of the older folks that are doing these jobs ... are overweight [which] contributes to the concerns about their day-to-day function. And if we were to go about employing older workers, especially for that kind of work ... I would pay attention to whether the individual was overweight. ... If someone is overweight the demands that are placed upon them tend to be of a greater concern.
Some employers indicated during the interpretive focus groups that they do a functional assessment of potential employees prior to making the hiring decision. There were variations among focus group employers in the extent of their functional assessment or whether the assessments were validated.
The majority of workers reported being able to do all of the physical functions needed in direct care work (see Figure 4). However, one employer noted during the interpretive focus group that the survey data appeared to be liberal estimates of the capacities of older workers. The "real" question was whether a worker could do these functions for extended periods of time, day after day.
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The mechanical devices that are available for use in a given facility and the facility's enforcement of [the use of] those ... if those devices are available, and the individuals are required or forced to use them through some reasonable protocols ... that in itself should play into the lessening of concerns about how those individuals create wear and tear in their bodies, and I think [it] reduces concerns about age in some respects.If older workers are to be retained, public policy might suggest that public money should be spent on better approaches to ergonomics and other tools that will let them do their jobs more safely.
What Do Employment and Training Providers Need to Do to Meet the Training Requirements of the Long-Term Care Industry?
Finding 8: Employment and Training Organizations Can Reduce Technological Barriers to Employing Older Workers in Nursing Homes and Home Health Agencies
Survey results indicated that employers believe older workers are less willing to learn to use new technologies. Survey results also found that very few employers know about the technology training provided by Operation ABLEs or access federal monies available to support employment training for older workers.
As mentioned previously, the majority of employers, both from nursing homes (59%) and home health agencies (57%), said that their 55+ direct care workers are less willing to use a computer, palm pilot, or other device to record information. About one third of the employers, both from nursing homes (28%) and home health agencies (36%), said that their 55+ direct care workers are less likely to be able to learn new technologies. Fewer than half of the employers, both from nursing homes (46%) and home health agencies (33%), said that in the past 5 years they recruited direct care workers for permanent employment from employment and training organizations. Only 10% of nursing home employers and 13% of home health agency employers were aware of the Operation ABLEs in their localities.
Only 7% of nursing home employers and 4% of home health agency employers reported having received public money in the past 5 years to support the recruiting, training, or retaining of direct care workers, regardless of age. When employers did access money, most often funds came from their respective state governments (72% of nursing home employers and 67% of home health agency employers who received public funds).
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Discussion |
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TOPAbstractStudy QuestionsMethodsResultsDiscussionReferences |
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Study results revealed that low-income older workers are more interested in supervising someone doing tasks of daily living and in providing emotional support to clients, rather than doing hands-on tasks. They are also interested in more highly skilled jobs, such as activity aide, medication assistant, and rehab aide.
A significant number of Operation ABLE participants surveyed have post-high-school education and therefore may be able to perform well in these types of jobs. Similarly, the vast majority of low-income older workers surveyed in this study are interested in career advancement opportunities. Taken together, the study results support the idea of targeting low-income older workers for frontline work in nursing homes and home health agencies.
Operation ABLEs Provide Essential Services in Preparing Low-Income Older Workers for Frontline Work in the Long-Term Care Industry
This study supported findings from the studies of Munnell and colleagues (2006), Barth and associates (1996), and AARP (2000) that revealed both positive and negative perceptions of employers about older workers. According to the employers surveyed, many positive attributes make older workers attractive as employees. The one negative attribute employers ascribed to older workers was their lack of willingness to learn new technologies. Yet technology training is exactly the area in which Operation ABLEs excel. These results suggest that Operation ABLEs can provide a valuable service, specifically for the long-term care industry, by making desirable employees even more desirable by reducing their technological limitations.
Older Workers Bring Many Positive Characteristics to Long-Term Care Employers
One positive attribute of the low-income older workers included in this study is their interest in career advancement opportunities. Nursing homes and home health agencies that offer career ladders might use this feature of their workplace to attract low-income older workers. Harris-Kojetin and colleagues (2004) also found career ladders to be beneficial in long-term care, particularly in staff retention. Advancement in career is very feasible in the study population, as 61% have education beyond their high school diplomas. This level of education is well above that of typical direct care workers as reported both by Wright (2005) and Yamada (2002). Both of these studies found fewer than 40% of direct care workers in nursing homes and home care aides had completed at least some college.
Another positive attribute of the low-income workers in this study is that the majority reported having health care coverage, including Medicare or Medicaid. This suggests that employers' fears about having higher health care costs if they hire more older workers may be unfounded. More information is needed about insurance regulations related to higher health care premiums for older workers to draw further conclusions on this issue. Consideration of how insurance companies use age as a factor in calculating insurance premiums and the savings that accrue from smaller turnover and fewer personal days that employers attribute as characteristics of older workers would be useful information to gather, but this was beyond the scope of this study. It may be that increased insurance premiums are more than offset by recruitment and training costs saved when older workers are employed.
Concerns Exist Regarding the Recruitment of Low-Income Older Workers for Frontline Work in the Long-Term Care Industry
Study findings suggest that low-income older workers look for jobs in many of the same places where long-term care employers advertise. More noticeable among older workers, as opposed to employers, is the seeking of job opportunities at senior centers and places of worship. A wider and more diverse recruitment net may need to be cast to find older workers interested in long-term care jobs.
This study found that employers were willing to advertise specifically for older workers, and older workers would respond favorably to such advertising. However, very few employers indicated that they target their recruiting efforts to the 55+ workforce. Some employers fear that they would be liable under EEOC laws if they targeted recruitment to older workers in their advertisements. Increased targeting of older workers in recruitment efforts requires further investigation of the conflicting focus of the EEOC and the Age Discrimination in Employment Act. Because workers aged 40 and older are protected by the Age Discrimination in Employment Act, it is not clear whether advertising specifically for older workers would violate EEOC regulations.
Given this age discrimination concern of employers, whether warranted or not, Operation ABLEs might advise potential employers about ways to be welcoming to older workers without using exclusionary terms in their recruitment materials. Alternatively, if employers post job announcements at senior citizen centers, there would be no need to use terms that might violate EEOC regulations. By simply building relationships with Operation ABLEs that are funded by Title V, employers could easily tap into the low-income older population for potential employees. It may require some effort on the part of Operation ABLE public relations staff to educate employers about the existence and mission of these organizations, as very few of the employers in this study were aware of their local Operation ABLEs.
Training Needs to Be Tailored to Adequately Prepare Older Workers for Long-Term Care Work and Address Their Particular Needs
In addition to the technology training described previously, older workers wanting to pursue work in nursing homes need to complete their state's required CNA training program. Study results found that the majority of low-income older workers sampled are willing to complete this intensive training. Another training issue not necessarily unique to older workers but relevant to any worker with physical limitations is the proper use of assistive devices, such as mechanical lifts.
One advantage of studying the low-income older workers who participate in Operation ABLE programs is that this population is self-contained and easy to access through the network of Operation ABLEs. These workers may also be easily identifiable at other employment and training organizations that have age and/or income eligibility requirements. Publicly funded workforce programs could capitalize on this easy-to-access older workforce, coupled with the technology training provided by Operation ABLEs, to fill the need for direct care workers.
In order to do technology training, however, one must identify the specific technology needs of nursing homes and home health agencies. Operation ABLEs may need to enhance the technology in their classrooms to include more portable devices, such as laptop computers and personal digital assistants, as well as software commonly used in the long-term care industry. This would require an investment of dollars in new technologies and processes. What needs further investigation is whether these upgrades in technology, assessment, and training would be allowable expenditures under the Workforce Investment Act and/or Title V dollars.
Operation ABLEs can help to employ older workers in long-term care in other ways that also fit their mission. They can develop or identify a functional assessment tool based on employer needs and screen participants for the ability to do frontline work in nursing homes and home health agencies. They can partner with health care training providers to provide low-cost certification training tailored to the learning styles of older workers. They can focus job search activities on long-term care jobs and educate their program participants about the positive perceptions that employers have about older workers. Indeed, study results found that most of the long-term care employers hire older workers who are already trained rather than providing their own certification training. Offering a pool of older workers already trained, not only in direct care hands-on work but also in leading-edge technologies, could reduce employers' perceptions that older workers are less willing to learn new technologies.
The Sample of Low-Income Older Workers in This Study May Not Be Representative of the Population
One limitation of this study is that it is unknown how representative the low-income older workers who completed the survey are of the broader community of low-income individuals who are aged 55 or older. It is still unknown whether other low-income senior citizens have as high a level of interest in long-term care jobs as those Operation ABLE participants included in this study. Operation ABLEs serve only a fraction of the 55+ population, and only those who have taken action to become retrained and redeployed in the workforce. Therefore, Operation ABLEs are a very small pipeline for preparing low-income older workers for frontline work in long-term care. If the study population is representative of all low-income senior citizens, a much larger system of recruitment, assessment, and training could be established in order to realize the potential of low-income older workers in meeting the needs for frontline workers. If the study population is unique in its interest in long-term care jobs, older workers may not provide as big an opportunity for shrinking the gap in frontline workers as this study suggests.
Recommendations for Policy Makers
Study findings point to several ways that policy makers can increase the use of older workers in filling the need for frontline workers in long-term care. One concrete way is to target Title V funds toward specialized training of older workers for jobs in long-term care. This study found that most employers in long-term care hire workers who are already certified. Low-income older workers' comments during the focus groups indicated that some fear they cannot afford the costs of the 75-hr certification training, and some lack confidence in their ability to complete a rigorous training program. Title V specialized training funds can be targeted to increase the pool of direct care workers who are aged 55 and older by paying for the tuition costs of certification training and the development of certification programs that are tailored to the learning styles of older workers and that will build workers' confidence in learning new skills.
Another way policy makers can help fill the gap in frontline workers is by targeting federal faith-based initiative dollars toward recruitment efforts at places of worship. The majority of workers in this study said that they would look for job openings in bulletins at their churches, synagogues, mosques, or other places of worship. Thus, it seems that this population of older workers would be of interest to federal faith-based employment placement initiatives. It seems appropriate for faith-based job training initiatives to focus some effort on educating long-term care employers about the employment needs and wants of their low-income older congregation members. It also seems appropriate for faith-based initiative dollars to be targeted toward recruitment and training of congregations specifically for long-term care industry jobs.
Policy makers can develop or strengthen policies requiring employees to use mechanical devices and to be adequately trained in the proper use of these devices. A clear message from this study is that age itself is not the main deciding factor in employers' decisions to hire direct care workers. It is also clear that mechanical devices can be used both in nursing homes and in the community to greatly reduce incidents of workplace injuries and allow older workers with less physical strength to effectively perform frontline work. Employers voiced that although these devices are expensive, the expense may be offset by the reduction in injury-related costs. This study did not investigate current policies requiring the use of mechanical devices, but it seems that a good use of public money would be to help employers purchase mechanical devices. Alternatively, tax incentives could be created to encourage employers to use such devices. Good policy would require that employees be trained in the use of these devices and be required to use them in an appropriate and caring manner.
Policy makers can investigate how state workforce development funds can support direct care worker initiatives. Results clearly show that very few long-term care employers have accessed any public money to recruit, train, or retain direct care workers. When employers did access public money, most often the funding came from the state. This study did not investigate whether the state funds originated from federal money. In any case, it appears that direct care worker initiatives may be more successful in advocating for support locally rather than federally. Workforce investment boards, for example, might be one mechanism for obtaining resources to develop a system to screen for the physical capacity of older long-term care job candidates and for giving grants to agencies to cover the cost of certification training.
Much can be done to further the development of the low-income older workforce in a way that helps to fill the shortage of frontline workers in long-term care. This study offers many insights into directions policy makers, employers, and employment and training organizations can take to expand the long-term-direct care labor force using low-income older workers.
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Karen Kosniewski is now with Junior Achievement of Southeastern Michigan, Detroit.
1 SPEC Associates, Detroit, Michigan.
2 Operation ABLE of Michigan, Detroit.
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