Building Professionalism In Turbulent Times

May 1997 - Caring Magazine
By Judith B. Clinco, R.N,

Health care budgets are being slashed at the same time that the aging of the baby boomers will increase the need for in-home senior care delivery in the next few decades. New regulations will likely be introduced in conjunction with this caseload influx; to prepare to meet such demands, providers need to anticipate a program of national standards and upgrade the skills of their adult care staff accordingly.

Today’s headlines have a lot to say to adult home care professionals:

First Baby Boomers Hit 50
Health Care Costs Soaring
Medicare Could Be Broke by 2006
Social Security—Bust Coming?
Most Not Saving Enough for Retirement

The baby boomers are nearing retirement age just as the safety nets that supported previous generations in their senior years are showing signs of collapse. Despite warning signs, many baby boomers seem oblivious to looming changes in the social contract that will profoundly affect them.

The implications for adult home care are no less profound. Already the fastest-growing employment sector, this industry will see an explosion in demand for its senior services as the boomers age and as federal, state, and private planners, confronted with dwindling health care funding, seek the most cost-effective delivery model for geriatric and disabled support.

The industry seems unprepared to meet this demand. Although adult home care has many positives, the industry is—in many instances—still an unregulated patchwork of providers and individuals delivering senior services that range in quality from excellent to unacceptable.

Adult home care still has a few years to achieve a consistent level of quality and professionalism. The adult care industry should work to develop national certification standards, transferable training credits, increased training time, and a national employee-screening database.

NATIONAL CERTIFICATION STANDARDS

The only national standard for home care workers is the federal requirement that certified nurse’s aides employed by Medicare-accredited adult home care agencies complete a 75-hour training curriculum. Some states have voluntarily adopted higher standards; others have not. Beyond this single requirement, no standards exist.
Nursing homes provided the lobbying push for this 75-hour training standard. For nursing homes with high standards of supervision, such a low minimum level of training might make sense. It helps keep their costs down, and the constant presence of skilled supervisors helps ensure that senior clients receive appropriate care. The adult home care environment, however, is different. The in-home caregiver must work without constant supervision provided by a structured institutional setting.

What is a reasonable standard for a nationally recognized level of training appropriate to the home care setting? The following is a three-level proposal, based on the author’s 15 years of experience owning and operating an adult home care agency:

• Level 1—homemaker-companion. Thirty hours of classroom time, taught over a period of two weeks.
• Level 2—personal assistant. Seventy-five hours, taught over a period of four to six weeks.
• Level 3—nurse’s aide. One hundred fifty hours, taught over a period of six to ten weeks.

Because senior services provided in the home by these caregivers are in most cases not eligible for Medicare reimbursement, they are not subject to federal requirements for certification. Consequently, the impetus for adoption of these or other standards must come on a state-by-state basis.

TRANSFERABLE TRAINING CREDITS

Mobility is a defining characteristic of American society. If adult home care is to emerge as a viable career field, and if home care employees are to think of themselves as professionals, their qualifications and training must be able to move with them when they relocate.

Adopting a series of skill levels—based on a common set of standards recognized by adult home care providers nationwide—would enable caregivers to build toward higher levels of skill, responsibility, and remuneration despite changes in residency.

Everyone wins in this scenario. The provider benefits by the availability of a professional work-force and by the knowledge that the prospective employee has achieved a clearly defined skill level. The caregiver benefits because he or she is relieved of the need to start on the bottom rung of the career ladder after every job change.

INCREASED TRAINING TIME

Training for nurse’s aides focuses on hands-on caring skills, which is only part of the home care picture. Because the curriculum leaves out the development of skills in cooking, home management, and time management, newly graduated nurse’s aides are not fully prepared to be single-source caregivers.

Medicare and some state programs provide supportive senior services for indigent clients. In most cases, however, the current division of skills dictates that the senior client receives services from two different caregivers—a nurse’s aide and a homemaker. The nurse’s aide is responsible for skilled services such as transfers, assistance with hygiene, and the administration of medications. Meanwhile, the homemaker might be doing the shopping, preparing meals, and handling the many other details of home management. Eventually, these two job descriptions will likely be combined into one. The cost savings are clear; more training would be the only additional cost to providers.
As the baby boomers develop medical needs with costs that begin to exceed their assets, the possible collapse of Medicare system looms. The Medicare model will soon require a drastic overhaul. In the future, it is likely that more clients will pay out-of-pocket for senior home care services. Those with the resources and foresight to invest in insurance will rely on long-term care policies to plan for those costs.

NATIONAL EMPLOYEE SCREENING DATABASE

Checking the background of prospective caregivers is a fundamental business activity for home care providers.

Vulnerable clients in a home setting are targets for abuse.

A meaningful background check, however, can be difficult, costly, and labor-intensive. Because few providers have the resources to do background checks themselves, they often outsource the process to a security agency. These agencies charge from $15 to $25, and in some areas up to $50, to check one applicant’s history of criminal convictions, Social Security number, driver’s license and driving record, and record of outstanding arrest warrants. This type of background check is considered to be basic; a more thorough check can easily cost $200. And results vary, because record keeping practices differ from state to state. In many cases, records are available only on a county-by-county basis; consequently, a criminal record on file in a neighboring county may never show up in a basic background check.

Currently, day care workers comprise the only screened labor pool of professional caregivers in the United States. A national database helps assure employers, parents, regulators, and others that the peo-ple hired to care for children are trained, qualified, and safe.

Is it less important that individuals at the other end of life be provided with safe and appropriate care? If a national database can be established for day care workers, why not do the same for home care professionals?

THE BOTTOM LINE

To prepare for the changes, challenges, and opportunities of the 21st century, the adult home care industry should work to develop the following:

• Increased training for each home care job description
• Background screening for every trainee
• A national employee screening database
• An industry wide training curriculum to set minimum training standards

What are the likely outcomes for these innovations? Such results might include:

• Happier senior clients—the individuals receiving home care services (and their family and friends) will appreciate an increased quality of care

• A reduction in worker’s compensation claims
• A more professional and stable staff

Most people want to perform their jobs well; better training would give them the resources to follow through on that desire. Beyond that, because their job skills would be transferable and upgradeable, their opportunities for personal growth would keep pace with the growth of their profession.

Data projections show home care employment growing at a fevered pace. As reported in the May 1996 issue of CARING magazine, “the department of Labor’s employment projections from January 1996 show that [job opportunities for] personal and home care aides will grow at a rate of 119%, making them the most rapidly expanding occupation in the next 20 years” (Dittbrenner 1996).

For adult home care employers, that projection is wonderfully encouraging. But the downside for providers is increased competition for qualified workers and high turnover rates. According to the Wall Street Journal, worker shortages and turnovers in the indus-try are as high as 50% in some parts of the country (Shellenbarger 1994).
Much of that turnover is attributed to low pay and lack of benefits, a problem that will be solved in part by the supply-and-demand forces of the market-place. Individual providers, however, can begin to inch the pay scale a little higher. The increase in payroll costs will be offset by the loyalty of grateful em-ployees. Lower employee turnover means lower costs for training replacement workers. Workforce stability translates directly into savings.
Providers cannot depend on the federal or state governments to take the lead on these issues. The mood of the country seems to be leaning away from the establishment of new regulations. Therefore, it falls to the adult home care industry to press for change.

Adult home care has a long way to go. The upheavals coming in the next decade will provide the opportunity for fundamental change and improvement in the way home care providers operate. Innovation, persistence, leadership, and determination will make it happen.

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