Rutgers University
October 24, 2002

Susan Reinhard: Welcome to this audio conference you have just heard and I
hope you know that it is on Long-Term Care Workforce: What are states doing?
My name is Susan Reinhard and I direct the Community Living Exchange
Collaborative at Rutgers Center for State Health Policy. I will be the
moderator for the call, but you will hear lots of other people today. This
conference is funded by a grant from the Centers for Medicare and Medicaid
Services and it has been organized by my Center for State Health Policy in
collaboration with ILRU who is our technical assistance exchange partner in
Texas.

Almost all of you, all of the Systems Change Grantees have told both Richard
Petty and I about how concerned you are about recruiting and retaining a
committed and qualified workforce for people of all ages and all different
support needs. Many of you have been asking us, so what else is going on?
What are other states doing? How can we find out so that we can learn from
what they are doing from both their mistakes or their challenges as well as
their successes? That is what we want to do today.

So it is a broad overview and we are going to begin our conference today with
presentations by several nationally-known experts. These are people that
spent a lot of time thinking about the issues that worry you. They will
complete their presentations, rather informally I should say. It is more of
a discussion we will be having. We will encourage you to ask questions after
their presentations. So that will be roughly around quarter to four or
thereabouts.

Our conference operator, Gentry, will let you know how to dial in to ask a
question when we get to that point.

So let me begin by introducing Susan Harmuth. Susan is a long-term care
specialist for the North Carolina Department of Health and Human Services.
She is responsible for coordinating and implementing direct-care workforce
initiatives in North Carolina. Susan is a state person and what strikes me
about her is that out of her own curiosity about what states were doing, she
began conducting national surveys on direct workforce issues beginning in
1999. So far, she has been conducting four of these surveys. We sent you
the website link in our introduction to this audio conference. The latest
one is known as the 2002 National Survey of State Initiatives on the Long-
Term Care Direct Workforce.

This last survey was conducted in collaboration with our second guest, Steve
Edelstein, who is a policy specialist with the Paraprofessional Healthcare
Institute. Steve is with PHI, a national, non-profit healthcare employment
development and policy organization, which is based in the South Bronx. He
is the project director of two federally-funded research projects
investigating recruitment and retention of direct-care workers and long-term
care. He has over 15 years of health policy experience including eight years
as a policy analyst and advisor in Washington, D.C. specializing in long-term
care and health access issues. Steve's organization has just released an
issue brief, which we also call to your attention. That is known as The
Right People For the Job: Recruiting Direct-Care Workers For Home- and
Community-Based Care. We also provided you the web links to this publication
before this call.

So welcome to both Susan and Steve. I am going to ask Susan to start us off
by telling us more about the purpose of your survey and who do you send it
to? Who answers these questions?

Susan Harmuth: Thank you, Susan. Generally our purpose has been to
collect information from states about public policy efforts to address
direct-care workforce issues in their states across the long-term care
spectrum, including home-care, assisted living and nursing facilities. Since
1999, it has been very interesting to see the tremendous increase in activity
across states to address workforce shortages. We send the surveys to state
unit on aging directors and state Medicaid directors as our starting point.
Typically, we get responses from one or both of these agencies. In the event
that they are not the appropriate entity, they typically will field it out to
a more appropriate organization in the state. But we are very grateful to
the folks who have taken the time to fill these surveys out because it can be
somewhat time consuming and we have had a tremendous response from states for
each of the surveys that we have conducted.

The most recent survey that we conducted with PHI had several specific
purposes. First, we wanted to determine in light of the economic slowdown
whether direct-care workforce shortages continued to be a major issue in
states and also to determine the extent to which the slowing economy may be
impacting the number or the extent of the shortages in states. Another
purpose was to determine whether the slowing economy was having any impact on
state initiatives to address shortages that were underway or planned. We
also wanted to collect any new information we didn't previously have from
states about new initiatives. Finally, we thought it might be useful to pull
together all the information we have already collected as well as the
information PHI had collected so we could have in one document sort of an
overview summary on a state-by-state basis of what states have done to date
that we were aware of.

Susan Reinhard: I noticed you had all of the System Change Grantees, what
they are doing. Where did you get that information?

Susan Harmuth: We had gotten some information from a compendium of Real
Choice Grant activities and tried to pull out from that the states that had
workforce activities.

Susan Reinhard: Janet O'Keeffe is on the line from RTI. I am sure she is
delighted to hear that. Nice to know when your work is being used.

So you did this survey. You have done it four times now. What are you
finding across the states, particularly that is different than you found four
years ago?

Susan Harmuth: One thing that we found was similar and we somewhat
anticipated this, but of the 43 states that responded to the most recent
survey, 86% said that shortages continued to be a major workforce issue.
This is not unlike the earlier survey we did in 1999 when the economy was
booming, when 88% of states indicated that shortages were a major issue. So
it just reinforces the fact that it isn't just a cyclical issue that is tied
to the economy. There are indeed barriers to the job and factors about the
job that are impacting these shortages statewide. Only four states in the
most recent survey indicated that shortages were not an issue in their state.

With regard to the economy, there was a mixed impact of the slowing economy
on the direct-care workforce shortages. Eight states reported they saw
somewhat of a positive impact, however it is important to note that as might
be expected, some of the changes they were seeing that were impacting the
shortages of workers were somewhat temporary in nature. Primarily due to
more people willing to work for lower wages due to job loss. There was a
reduced reliance on temporary agency staff, which certainly costs more than
regular in-house staff. They saw a slight decrease in an already high
turnover rates.

There were also negative impacts. Some states indicated that their primary
workers were having to relocate to other states and they took with them the
secondary workers who very often were working in lower wage jobs. So there
was sort of a mixed impact on the economic slowdown.

Then we asked the question about the degree to which the slowdown was
impacting state initiatives and state funding for specific activities to
address workforce issues. Many states indicated they had to readjust their
budgets due to the economy. This certainly did have an impact on a number of
states. In fact, eleven states reported decreases or termination of planned
funding for existing initiatives or planned initiatives. For instance,
Connecticut reduced the number of hours of direct care for home-care clients.
In Florida, future funding to increase nursing home staffing ratios was in
question. Also Montana indicated that their wage pass-through for 2003 was
in jeopardy as a result of the economic slowdown and the subsequent budgeting
issue states were facing. So there certainly was an impact resulting from
the economic slowdown.

But to move on to some examples of what states are doing. Generally, state
initiatives, and this has been fairly common across the years, fall into
several major categories: wages and benefits being one, training and career
ladder issues, the establishment of task forces and commissions, a broad
category that relates to recognition, public education and awareness, data
collection and analysis efforts, which is really somewhat in just the past
couple of years we have seen more of that occurring and initiatives related
to staffing ratios.

But one of the key things we have seen through this most recent survey is the
fact that there has been extensive collaboration across state agencies to try
to address the problem. Almost half of the states, actually 25 states did
indeed report that they were working with other state agencies such as their
department of labor or their department of education, community college
system, welfare-to-work agencies, boards of nursing. Everybody seems, a
large percent realized that they have to collaborate across spectrums in
order to have a significant impact. In some states they are using (unclear)
to help address workforce issues and training and other funding sources as
well.

I know there will be some discussion later about some of the Department of
Labor initiatives, so I will not concentrate on those. But I do want to talk
a little bit about some of the training and career ladder efforts that are
underway. With regard to career ladders, a number of states, and we have
noted that at least five either are or have developed a medication-aid job
category for one or more long-term care settings. Typically the number of
hours and the parameters and settings where the aid can work may vary, but
that certainly is a job category that has cropped up and been fairly
prevalent.

Massachusetts has had a major initiative relative to training. They have
also had significant funding to put into this. They have had money for CNA
training scholarships. They have also funded supervisory training, which we
hear often that relationships between frontline workers and supervisors have
a significant impact on turnover. They also had funding for English as a
second language class and adult basic education to help prepare people for
additional training, those frontline workers down the road, career ladder for
nursing homes.

Some of the other things states are doing with regard to career ladders;
Montana has developed an add-on curricula to make it a little bit easier for
nurse aids to become licensed practical nurses. Some states have tried to
develop new job categories in a career ladder within the paraprofessional
framework. For instance, perhaps a senior CNA-type job level or a mentoring-
type position. North Carolina is developing a geriatric nurse aid job
category. So there are efforts to try to develop within the paraprofessional
level some job categories that would be meaningful both for employers from
the standpoint of being willing to pay for that type of a job category and
making it worthwhile for them to deploy their staff more effectively as well
as provide an advancement opportunity for workers.

Those are just a few of the examples that relate to training and career
ladder initiatives, Susan.

Susan Reinhard: Thanks. Let me turn to you, Steve. You have been
collaborating on this latest survey. I know that you and your organization,
aside from this survey, look at a lot of the issues that Susan has been
discussing. One of the things she hasn't talked yet about is about wage and
benefit enhancement. I know a lot of the folks on the phone are thinking
about those issues. Can you tell us what states are doing?

Steve Edelstein: Sure. Thank you, Susan. Basically based on the last
survey, we found that approximately 20 states had implemented wage pass-
through initiatives; an additional allocation to providers to enhance wages
and benefits. I wanted to look into that a little bit more closely to see
what the states were doing and what issues they may have had around the
implementation.

I would say overall that from the provider perspective, generally when they
have additional funding for wages, it is appreciated. Sometimes there are
issues around how the state implements it in terms of whether they feel they
have sufficient notice and instruction about how to implement the wage pass-
through and sometimes also issues around the auditing and how burdensome they
feel the requirements are there.

From the worker perspective, again, generally to have additional money
towards wages again is appreciated, but sometimes there can be disappointment
if there is not clarity in advance about exactly what workers should expect
in terms of an increase. Typically the amount is calculated in one way and
there can be a misunderstanding about what that is going to translate when it
actually gets to the worker level. So it is important that there is an
effort in terms of creating expectations that are reasonable based on what is
funded.

Beyond that, we have identified several issues that impact on the success of
a wage pass-through initiative. For the Systems Change Grantees, an
important one is which workers are covered? Oftentimes a legislature might
focus specifically on facility-based workers and so additional funding for
home- and community-based workers is now provided. So one thing to look at
is which workers are being covered by the legislation.

Beyond that, other issues, which impact the pass-through include the size of
the salary increase, whether it is enough to affect worker behavior and keep
them in the jobs. How much specificity is provided to providers in terms of
how they can use the funds, whether they have flexibility to use it for
things like shift differentials or hiring other workers or is it just limited
to increasing base wages?

Other issues include whether provider participation is optional or mandatory,
the type of accountability that is required by the state, whether there is
ongoing funding for the pass-through or whether it is a one-time
intervention. This especially could be an issue for both providers and the
workers if there is not a certainty that there is going to be money in the
next year to fund the increase, then it may have a dampening effect on
whether it is effective. Finally, as I mentioned previously, whether
providers have sufficient notice and are educated on how to implement the
pass-through.

Susan Reinhard: Steve, you mentioned, was it 20 states?

Steve Edelstein: Twenty, yes.

Susan Reinhard: Do you have any sense which ones are looking more at home-
and community-based care and which ones are really more nursing homes?

Steve Edelstein: I don't have a specific breakdown on that. It definitely
is a mix. Some states have looked across settings while other states have
limited to a particular sector. But it definitely is a mix.

Susan Reinhard: OK. Another area of that is of great interest to a number
of grantees has to do with worker registries or worker guilds, associations,
a number of different terms and forms for trying to have support for the
workers. Does your survey give you any insight into what states are doing?

Steve Edelstein: In terms of our look at what the System Change Grantees are
doing, certainly they have expressed interest in doing both of those. A
number of states have said they are interested in establishing registries.
Among them Arkansas, Georgia, Maine, New Jersey and Oregon. Other states
have said they are interested in setting up worker associations including
Alaska, Maine, North Carolina and Vermont. There are some examples already
out there in California as part of their public authorities; the counties
have registries as well. A number of state provider associations, excuse me,
worker associations already are operative in Iowa, Wisconsin and Michigan.
So there are definitely models that the grantees can look to in terms of
setting up their own programs.

Susan Reinhard: Thanks, Steve. I think there may be some questions about
this from some of our participants and we may come back to this. But I want
to bring into the discussion at this point two of our other speakers.

The first is Dr. Robin Stone. Many of you know her. She is a noted
colleague who is the executive director of the Institute on the Future of
Aging Services in Washington, D.C. I have worked with Robin and I think the
world of her. She is well known in the field of aging and disabilities
services. She is one of the chief architects of the Cash and Counseling
Demonstration Program, which you heard about last month in one of our audio
conference calls and I will bring up again at the end of this conference
today. Robin served the White House as Deputy Assistant Secretary for
Disability, Aging, and Long-Term Care Policy and as Acting Assistant
Secretary of Aging in the Department of Health and Human Services. She has
been devoting a lot of her time to this issue on long-term care workforce and
she has a major announcement, we hope, that she will make at the end of this
call or whenever she feels like doing that, so stay tuned.

Joining us also is Dale Lanenga. He is the executive director of the
Pennsylvania Intra-Governmental Council on Long-Term Care whose purpose it is
to advice the governor on long-term care issues. He has worked in the fields
of aging, disability and long-term care in Pennsylvania for 28 years. He
designed and implemented the Attendant Care Services Program for Adults with
Physical Disabilities, which is a program that has been nationally recognized
for its consumer direction.

Robin, I know that you have both worked a lot with both Susan and Steve and
are very familiar with their survey and that you have done a lot of work from
a research perspective and talking to providers around the country. Can you
tell us what your thinking is on this issue about what states are doing and
what providers should be doing about long-term care workforce concerns?

Dr. Robin Stone: Sure. Hi Susan, hi everybody else. I think there is
incredible opportunity in looking at this workforce issue for states. I know
when we started working on this a couple of years ago, there was a real
struggle in trying to identify what the policy levers were. It is clear to
us that in addition to wages and benefits and the development of career
ladders, that states are significant players in terms of looking at how the
workforce can actually be developed. I know there was some discussion
previously about the need for collaboration and evidence that there has been
increasing collaboration across state agencies. Susan pointed that out in
terms of the results of their surveys.

But I wanted to highlight the importance of, particularly the folks who work
on long-term care and support and the Systems Change Grants. The real
importance of looking at Department of Labor dollars and other such dollars
that are passed through the states and then to local communities. I am going
to speak about just a couple of examples of how states and localities have
used some of these monies. I know Dale has some examples from Pennsylvania
and I know that both Steve Edelstein and we also have Steve Dawson from PHI
listening in on this, may have some input as well.

I think the main point here is to recognize that you have other partners in
the state that may have access to sometimes substantial resources that need
to be leveraged and if you aren't partnering with your counterparts in your
state department of labor, whatever that happens to be called, you are really
missing out on an opportunity. These are dollars that go through the
Department of Labor through a number of different avenues, but the major
funding is the Workforce Investment Act. I just want to give you a couple of
examples of activities that have been going on in the long-term care arena.

Dale may speak to this, but in Lancaster County there has been a major
healthcare worker media campaign that was actually supported by both the WIA
and health and long-term cares providers coming together. They actually have
created a permanent infrastructure with the health and long-term care
providers and the local WIB, which is the Workforce Investment Board in
Lancaster County, to basically put together a television media campaign to
increase the supply of workers in healthcare and long-term care. They have a
media campaign that averages about 30 messages weekly during high-profile
time slots. The message has a toll-free number and then has healthcare
career briefings and a whole lot of other activities that are built into this
campaign. Each of the initiatives actually is supplemented by funding from
employers themselves because they sell these employer recognition tags for
each televised message. So it is truly a partnership and at least
anecdotally we have evidence that this has really helped in creating an
awareness and in the recruitment of a lot of the frontline workers. That is
just one example.

Another example, and I don't know whether Dale will talk about this in more
detail, actually these are a couple that are happening in Delaware County,
Pennsylvania. There is a CNA Training Pilot Project between the Delaware
County Workforce Investment Board and the Women's Association for Women's
Alternatives, the Delaware County Community College and the Fair Acres
Geriatric Center and they work together to reduce turnover rates of entry-
level employees by providing them with the skills and support services,
enabling them to succeed in a job and move up in a career ladder.

We also have examples of capping new worker pools. There is a Migrant Farm
Worker Caregiver Training program in Riverside and San Bernardino Counties,
California, that uses the local WIB, the California Employment Development
Department monies and the National Farm Worker Jobs Programs as well as the
California Workforce Association to develop partnerships with these migrant
workers and to train these non-traditional populations for the long-term care
field.

There is another one in Charlotte, North Carolina that looks at students as
workers. In this case they were accessing the Perkins Act and State General
Revenue's dollars. The Perkins Act is actually vocational training dollars
that comes through the Department of Education. Here they are preparing high
school students for employment and/or continued education by providing them
an opportunity to master a skill set and then expand the number of qualified
long-term care workers.

So just to give you a sense of this, you have a lot of idiosyncrasies here,
but you need to know what resources are out there for you. Because on the
training and development side, these partnerships can be invaluable.

The other thing that I wanted to say about this, and this is sort of
something that has become very clear as I have been going around the country
and a number of us have been working on these projects. That is that you
can define part of this issue as a workforce issue, but you can also define
this issue as a quality issue. Because you cannot provide quality services
and supports if you don't have a quality workforce. So for you, for the
state folks, to think about couching this workforce issue also in terms of
quality improvement and quality assurance and figuring out how you build
these activities into any kind of quality efforts that may be going on
through the Systems Change Grants, through other efforts on the home- and
community-based care side, building on what is happening in the Nursing Home
Quality Initiative, which by the way, within the next year or two, the QIO's
in each state are going to be responsible not just for nursing homes but for
homecare as well.

So thinking about how you build in quality initiatives. The whole concept of
culture change. Culture change is not about just in nursing homes. It is
about culture change in assisted living. It is about culture change in home-
care. It is about figuring out how we provide in the consumer-directed
model, a better culture for the worker as well. I think there are real
opportunities in framing the issue in these terms because there may be funds
out there that could be used for quality activities in which you could
actually sort of through the back door, be using some of these funds to also
work on the workforce issue.

I will give you a real quick example. That is that we have had some calls
from the Wisconsin Family Care Program people who were interested in looking
at a quality improvement activity in Wisconsin in 11 nursing homes, the Well
Spring Model. They actually were interested in looking at that and beginning
to apply those same principles to their family care workers because one of
their major concerns, and there may be some folks from Wisconsin on this
line, but one of the major concerns has been actually finding workers to
provide the services.

So I guess those two messages, one is thinking about partnering with labor
and also accessing department of education dollars and other dollars that may
be available. And then thinking about this within the quality context as
well as within the workforce context.

Susan Reinhard: That is good advice. Try to figure out where the money is,
where the effort is, and try to hook on to it, if I can be as blunt as that.
That is what you are saying, right Robin?

Dr. Robin Stone: Yes, definitely. I think partly it is the money. It is
also the sort of infrastructure that you can create at the state and local
level by partnering with these other agencies and hopefully sustaining your
efforts. One of the things that we have seen is that a lot of these
activities are sort of one-shot deals and that really may address some of the
more real short-term problems. The more long-term systemic problem is that
we will see a shortage of workers because of the demographics and we have to
find and prepare and sustain quality folks so that we can retain them and
actually not have to worry about the horrific turnover that many places have
been experiencing.

Susan Reinhard: Thanks. Dale, have you been able to find any of those
resources and develop those cooperative relationships that Robin is
describing in your state?

Dale Lanenga: Yes, and thank you Susan, and hello everyone. We have been
able to do that. The way I think we have done it is partly by nature of our
existing organization, our Long-Term Care Counsel, that has all of the key
stakeholders at the table. We have the State Agency Secretaries, we have
legislators, and we have associations of providers, consumers, all at the
table. So when we started working on workforce issues, we had I think the
key players together.

What we discovered was that other parts of the industry, especially on the
acute care side, had already been doing a lot of documentation of their
workforce shortages. So one of the first things we did was to do a study to
document what our needs were in long-term care. We covered the spectrum from
all direct care workers from nursing homes through adult day care, personal
care homes, home-care agencies, etc. But when we designed the study, we
designed it so that the data would be collected consistent with workforce
investment geographic areas. So we could take our data and go talk with each
of our workforce investment boards about our needs. It was that kind of
information that got the project going that Robin was referring to in
Lancaster County. The Workforce Investment Board picked up on our study and
said look, here is the real need and let's try and find some additional
money, which they were able to do. The documentation of the study really
helped.

Simultaneously we wanted to talk with the direct care workers themselves,
which is what our focus is on. We have met with them each year now to find
out what they see the needs as being. It is not always the same as what the
providers are telling us. As a result of that, we have been able to get into
our state budgets. This past year about $36 million for a direct-care work
initiative. Based on what we have found through our studies within the
state, it was clear that the problems are not of recruitment and retention,
are not the same in different parts of the state or different parts of the
long-term care network. There is some differences between nursing homes and
home health agencies, differences between urban areas and some of the very
rural areas here in Pennsylvania.

So we took the money that we received through the state budget and made it
available to local service providers, that they could use it in whichever
ways they really thought were most appropriate to meet their local
recruitment retention needs. We ensured that they worked with direct-care
workers in putting together what they, the plans that they came up with.

That has produced lots of small projects having to do with bonuses. Things
having to do with training, benefits, the image of direct-care workers,
recruitment efforts, a variety of different things. We are now to the point
where we have been able to obtain a little additional money and we are
wanting to take some of those individual efforts that have been tried in
various places around the state and bring them together into more regional
kinds of demonstrations. I think we are going to be able to do that.

It has been helpful to work with our Workforce Investment Board. They are
the ones that have an incredible amount of money for training. Getting
several of them to understand what the needs were in long-term care and that
was very difficult because their attention was much more focused on acute
care. But I think we have been able to get some of them to understand the
long-term care needs and they are now starting to develop projects such as
the one that Robin mentioned.

We are also going to do one other thing. This past year five of the
departments in Pennsylvania were able to put together some of their monies
that they had for job training outside of the Workforce Investment Boards and
came up with is called a Critical Job Training Project. There is about $24
million that was set aside. It was first thought that that money would be
used in technology and manufacturing. Much to the surprise of everyone,
about 60% of the requests came in from healthcare and specifically from long-
term care so that the majority of those funds have gone out now to training
efforts in the healthcare field, especially in long-term care. That in
itself has helped others in the state to realize that we have this need and
there is some things that we need to do.

Susan Reinhard: Sounds like a success story. Do you know of other people
in other states that have been doing this, Dale?

Dale Lanenga: Not in the same way. I know that there are other efforts
based on documenting what the need is and trying different things, but I am
not aware of anybody who has taken that kind of comprehensive approach and
then put the money out to the local agencies determined how they wanted to
spend it.

Susan Reinhard: So if there are members on this call today that would like
to know more about it, are you available to talk with them?

Dale Lanenga: Yes I would be.

Susan Reinhard: Great. Robin, I just want to come back to some of the work
you have been doing with providers and maybe you have said enough on that
issue, if not feel free to now. Also about, I am hearing a lot of stuff
going on about a major new workforce initiative that you will be directing.
I wondered if you are free to tell us about it yet?

Dr. Robin Stone: Yes. I am free to tell you about an initiative that we
have been working on for over a year in collaboration with the
Paraprofessional Healthcare Institute and we have finally put it all together
and we have about $12-13 million that we will be putting out in the field.
Actually the calls for proposals will be going up on the RWJ website on
October 28. These are dollars; this has been jointly funded by the Robert
Wood Johnson Foundation and Atlantic Philanthropies, which is a foundation
out of New York. It is called Better Jobs, Better Care. My Deputy Director
for that program is Deborah Lipson who is here with us at the institute. Our
major subcontractor is PHI who will be doing the lion's share of the
technical assistance.

The two pots of money, there will be two separate calls for proposals. One
will be, and some of you know this because we have been sort of scouting
around for the past year or year and a half finding out what is going on in
states, but one will be we will be funding up to five state-based activities
in the area of really changing both policy and practice in the frontline
workforce arena. That really means that these projects must represent major
coalition or partnership activities that are focusing on some major policy
change as well as working at the practice level. The money will go to a non-
profit organization, not to the state. The goal of this is really to build
on activities that are already going on in states. Trying to solidify them
and move them to the next step, which is to get activities statewide and to
have potential for sustainability. So one pot of money, on average we are
looking at about $1.2 million or $1.5 million per grant over a, there will be
a planning period and then an additional three and a half years of work in
each of those.

Then there will be a separate pot of money for up to twelve grants looking at
applied research in the area of the frontline workforce. That really is to
test and to assess and to evaluate activities that are already going on out
there in the field so that we can learn a little bit more about what works
and what doesn't work.

The emphasis is across all settings. We are interested in the frontline
workforce in all long-term care settings. We are strongly encouraging
proposals that focus on home- and community-based services.

Susan Reinhard: Robin, this is fantastic news. One main question. Who is
eligible for applying for one of the five big grants?

Dr. Robin Stone: This will become clearer when the calls come out, but a
non-profit organization is eligible.

Susan Reinhard: So that is not a state, right?

Dr. Robin Stone: Yes, a state is not eligible. This money will not go
specifically to a state. However, what we are hoping is that states will be
strong participants as partners in these projects. In addition, we are
requiring a match. A match that would either be from a state, from a
locality, from a state or local foundation, but some evidence that there is
commitment at the state and/or local levels to sort of make this happen.

The whole goal of this is really to build on what is already out there. I
think it is fair to say that states that probably don't have a whole lot of
activity in this area to begin with would be at somewhat of a disadvantage
because these are not really seen as developmental grants; these are really
seen as grants that help move a process along.

On the other hand, I think it is also an opportunity for states where there
has been a lot of disparate activity going on to really bring it together and
coalesce it at the state level.

Susan Reinhard: That is fabulous. Just to find those that are interested,
they should check the RWJ Foundation Website or yours?

Dr. Robin Stone: You should check the RWJ website and we have a very, very
large mailing list that will also be receiving a printed copy of this which I
think is being mailed out sometime around November 4.

Susan Reinhard: Great. Well, congratulations to you and to Steve Dawson
and Steve Edelstein. Thank you to Susan, Steve, Robin and Dale for their
presentations and we do want to start bringing the participants on the line
for questions.

Before we do that, I want to encourage all of you to ask questions and also
to let us know what we can do as a technical assistance collaborative to
provide more information or to focus in on any topic on workforce that comes
from this conversation or things that we have not discussed. So please feel
free to use this time to tell us or you can certainly contact us after this
call.

So, Gentry, can you tell our participants how they can get into this
discussion?

Gentry: Ladies and gentlemen, at this time we will begin the question and
answer session. If you have a question, please press the "*" followed by the
"1" on your pushbutton phone. If you would like to decline from the polling
process, press the "*" followed by "2". You will hear a three-tone prompt
acknowledging your selection and your questions will be polled in the order
that they are received. If you are using speaker equipment, you must lift
the handset before pressing the numbers.

One moment please for the first question.

Susan Reinhard: Thank you.

Gentry: Once again, ladies and gentlemen, if you have any questions or
comments at this time, press the "*" followed by the "1".

Our first question comes from the line of Jane Church from Michigan. Please
go ahead.

Susan Reinhard: Michigan?

Jane Church: Good afternoon.

Susan Reinhard: What was your name?

Jane Church: My name is Jane Church.

Susan Reinhard: Hi Jane.

Jane Church: Hello. I am most interested in hearing about the media
campaign that is going on in Pennsylvania and was wondering if Dale could
give us some contact information?

Susan Reinhard: Dale?

Dale Lanenga: Yes, I can give you that information. Do you want it right
now or can we do this afterwards?

Susan Reinhard: Well, if it is short enough, there may be others that are
interested as well.

Dale Lanenga: OK, let me try and locate it quickly.

Susan Reinhard: Otherwise, you can give it to me and we will send it out to
all participants.

Dale Lanenga: That would probably be better. It could be more complete
that way.

Susan Reinhard: All right, that is fine.

Jane Church: Thank you.

Gentry: Our next question comes from the line of Randall Blume from New
Jersey. Please go ahead with your question.

Randall Blume: Yes, I am coming from the home and community based
perspective, first of all, rather than the nursing facility perspective. I
am at the point that there is some degree of additional training, career
ladders have been established at some level, and thinking as a payer, what
kinds of things can a payer do to verify that a higher-skill level employee
is needed? And then make sure that they get one, presuming they have the
dollars to pay more?

Susan Reinhard: Randy, I just want to verify your question that you want to
know how the provider can determine whether a higher skill level...

Randall Blume: No.

Susan Reinhard: Could you repeat it?

Randall Blume: Yes. How the payer, how the third-party payers, for
instance, very frequently it would be the state, but whatever the third party
source is. Going to home-care, it seems to add a new dimension to
authorizing services and specifying the services that one wants. Is that
clearer?

Susan Reinhard: I think so. Perhaps I should direct that to Susan?

Susan Harmuth: I am not so sure how to respond other than to say that the
information we have gotten and what we are doing here in North Carolina is to
try to respond to employer's need for how to utilize staff better and how to
improve the skills of staff and we are in North Carolina realizing that
probably from a payer's standpoint there may not be any increase in
reimbursement from payers for these services. However, employers have
indicated that from a quality standpoint as well as ability to deploy
existing staff differently, that that may be more cost effective to them and
make them able to offset those increased costs they may incur from these new
job categories they are able to put in place. Maybe some other folks on the
line can help address that.

Susan Reinhard: Is there anyone else who wants to respond to Randy?

Dale Lanenga: This is Dale. That is one of the areas that we are looking
into with the money that we have put out within the past year into all these
different projects. We are now beginning to look at whether or not, what
effect it has had in terms of career ladder. We know that there are some of
the projects that were attempting to develop a career ladder based on
additional compensation and additional training. Shortly we will begin
looking to see whether or not that works.

Susan Reinhard: Thank you, Dale. Are there other questions? Or Randy, did
you have a follow up?

Randall Blume: No, I don't think so.

Susan Reinhard: OK. Thanks.

Gentry: Our next question is from the line of Judy Sitski from Wisconsin.
Please go ahead with your question.

Susan Reinhard: Hi, Judy?

Judy Sitski: I just wondered about those small projects, if there is a
report about those projects from Pennsylvania?

Susan Reinhard: Dale, do you have any of this written up?

Dale Lanenga: We don't have it written up in a lot of narrative. I do
have a chart and a matrix as to how the money was spent for what purposes in
which areas, whether urban, rural, etc. But we aren't yet to the point of
having anything written up in sort of a large narrative.

Judy Sitski: Are you planning to do that?

Dale Lanenga: Yes we are.

Judy Sitski: I wondered if that could be made available to the people on
the line too?

Dale Lanenga: Yes.

Susan Reinhard: Judy, do you mean what he has already or do you want to
wait until there is more information?

Judy Sitski: I am more interested in the narrative description of the
projects.

Susan Reinhard: Dale, when do you think you would have that information?

Dale Lanenga: That could be a number of months yet before we are able to
do that.

Susan Reinhard: OK?

Judy Sitski: Ok, thank you.

Gentry: Our next question comes from the line of Karen Tritz from
Maryland. Please go ahead.

Susan Reinhard: Hi Karen.

Laverne Ware: Hi, actually I am Laverne Ware and I was invited by Karen
Tritz so she is here with me along with several others.

Susan Reinhard: Laverne, hi.

Laverne Ware: Hi. My question actually is to Dr. Stone. My question
also is about the Lancaster County and Pennsylvania media campaign with the
toll-free numbers. She indicated that there is evidence that this has been
helpful. I was just interested in what types of evidence is it that she has
seen. Has it been an increased volume of participants? Have there been
workers with higher levels of quality or what types of evidence were they
actually measuring?

Susan Reinhard: Robin, you made the statement, but Dale may want to respond
as well.

Dr. Robin Stone: I can respond only about the evidence that I was reporting
on is purely anecdotal which means that we talked to the folks at the
Workforce Investment Board and talked to some of the long-term care providers
who were involved in these activities. Feedback was that it had, that there
were a lot more people who were actually going to some of the technical
schools in the area and that employers saw more people actually coming to
work with them, both in the nursing home setting and in assisted living. But
to my knowledge, and Dale may know better, I don't think there was any formal
evaluation done of that program.

Dale Lanenga: I don't believe there was any formal evaluation, but
clearly in talking to the people at the Workforce Investment Board there,
they were able to document a serious increase in the number of people who
inquired at the Career Link sites and at the different providers who were
participants in this campaign.

Steve Edelstein: Susan?

Susan Reinhard: Yes?

Steve Edelstein: This is Steve Edelstein. I just wanted to mention also
that as part of the project we are collaborating on with Robin and the
Institute for the Department of Health and Human Services, we are producing a
paper on public awareness campaigns and that should be available before the
end of the year.

Susan Reinhard: That's great. And how would they get that?

Steve Edelstein: They could get it through our website, the Direct-Care
Clearinghouse on the Direct-Care Workforce or they could get it through the
Institute's website, I am sure.

Susan Reinhard: Can you mention your clearinghouse again, Steve, because I
don't think you did during your presentation. Just say a little bit about
what it is.

Steve Edelstein: The clearinghouse was an effort by PHI to make available to
the field resources relative to the direct-care workforce. The address is
www.directcareclearinghouse.org. Through that site they can access policy
papers on the topic. We also are producing a number of resources under these
projects, one of which is a database of provider practices that are impacting
recruitment and retention and that is actually going up over the next day or
so. That is something that the folks out there might be interested in.

Additionally, the public awareness paper that I mentioned and other resources
and tools are available there as well.

Susan Reinhard: That's great, thanks. Is there another question?

Gentry: Of course. Our next question comes from the line of Stuart
Brinksman from Maine. Please go ahead with your question.

Susan Reinhard: Hi Stuart.

Stuart Brinksman: Hey Susan, how are you?

Susan Reinhard: I'm good, thanks.

Stuart Brinksman: My question I guess is both for Robin and for Dale. I was
curious whether any of the Workforce Investment Act projects are focusing on
changing not just on bringing more people into training programs or expanding
training programs, but also if any of them are focused on changing the nature
of the training to make it provide more hands-on experience, to give people
who are in training a clearer idea of what the work is actually about? I
have read in some of the PHI publications that one of the problems, one of
the issues is that people go through training programs that don't give them
very much hands-on or direct experience and when they actually start doing
the work, they realize the work is very different from what they expected
when they were in the training.

Susan Reinhard: Good question. Robin?

Dr. Robin Stone: Yes, I think there are examples of, I mean there are
examples that are outside of the Workforce Investment Act, the WIB projects.
There are also examples of projects that have used WIB dollars to actually
focus much more on not only sort of different kinds preparatory skills
including life skills and ongoing peer mentoring and coaching as well as real
support once the person is in a particular setting. So I think there are a
range of activities out there. In fact, again, I would highly recommend that
you rather than going through the litany of them now, we tried to identify
some of those in the best practices clearinghouse that Steve was just talking
about. As he said, that is going live I think within the next couple of
days, but we have about 25 practices up on the clearinghouse already and some
of those actually speak to some of the questions that you were raising.
Which is really a different kind of investment. I think this is a critical
question. We have found that the training that is typically provided is not
what is really needed to develop and sustain the workforce.

Susan Reinhard: When you say that Robin do you mean it is inadequate?

Dr. Robin Stone: It tends to focus on orientation. Very didactic training,
sort of your typical educational format that number one doesn't work very
well. Number two, that really don't address the full range of skills and
needs that people have when both they come to the job and then when they are
actually on the job. So a lot of these efforts are really focused on
different kinds of training and a lot more, as I said, peer mentoring,
coaching, mentoring and following through. Because we know, for example,
that a lot of turnover that we see across settings happens in the first three
months on the job and even actually shorter than that. So there is a really
important transition period for many of these folks and most training
historically has not dealt with that.

Susan Reinhard: Thanks. Dale, did you have anything you wanted to add?

Dale Lanenga: That is exactly what we heard from the direct-care workers
across long-term care. When we went out each year to talk to them, the first
year they were very clear in telling us what Robin was saying, that the
training that they were receiving was inadequate, there was not enough of it,
and in many ways was really kind of inappropriate. The example they give,
for example, is the person who, they are trained on how to make a bed, but
they are not trained on how to make the bed when there is a person in it who
may not be cooperative. They are not trained in areas having to do as they
said with the softer skills of relating to people. Much of it was very
technically oriented when what they really needed was how to deal with the
person who may be dying. That sort of area they just did not have the
training.

So with that knowledge and going back then each year when we talked to them,
there seems to be a little bit of improvement, but for the last two years we
consistently are hearing from the workers that very little has changed in
that area. That is one of our focuses within the state now to try and look
at the training to see if there aren't some ways that it can be changed.

Susan Reinhard: How would you go about doing that, Dale? Are you going to
recommend curricula and training practicums?

Dale Lanenga: It is a combination. Again it is a collaborative effort.
We know there are a lot of different training programs out there and our
intent is to bring together a number of the key areas that are doing
training. Some of the community colleges, some of the associations. We will
be talking with the Department of Education and getting them together to
begin looking at what are their requirements for training and how can we
improve that in order to make it more responsive to what the aids are telling
us they really need?

Susan Reinhard: That sounds like a good way to go about it, to get
everybody together. Do we have another question?

Gentry: We have a follow-up question from Judy Sitski from Wisconsin.
Please go ahead.

Susan Reinhard: Judy?

Julie Whitaker: Hi, it is actually Julie Whitaker who is sitting in with
Judy.

Susan Reinhard: Hi Julie.

Julie Whitaker: Hi. I was looking through some of the overheads that Robin
Stone sent out prior to the conference and was curious about one of the key
determinants of job satisfaction that she mentions which was that wages and
benefits are not as important as expected and I would like for her or other
people who are speaking to kind of clarify what that means that wages and
benefits are not as important. I assumed she and others know that they are
important because they are talking about wage pass-throughs and other types
of initiatives, but could she or others clarify what their research shows to
date on the importance of wages and benefits? And also how they disentangle
elements of job satisfaction. How did they know that they are not as
important?

Susan Reinhard: OK. Robin?

Dr. Robin Stone: Yes, there isn't a whole lot of empirical work that has
been done in this area, but I did a literature review about a year and a half
ago and there are really a handful of studies. One in particular on the
nursing home side and one in particular on the home-care side. There was a
study by Banecheck and Whole that was done on the nursing home side and Penny
Feldman's major demonstration work on the home-care side. These are probably
the two most scientific studies that have been done that actually look at
what happens when workers are actually given these whole range of options so
that in the case of Banecheck Whole they had a ten-state study where they
looked at the effects of all kinds of interventions; wage increases, enhanced
benefits, they looked at the supervisor/frontline relationship, looked at a
lot of other job design and working condition factors. And also looked at
the, sort of the economic status of the local community in which care was
being given.

In both of those cases, and this is substantiated in a lot of other smaller
studies, the major key elements that came out in the regression analyses and
any of the other multi-variant techniques indicated that it was the most
important factors had to do with number one, the local economy. Which is to
say that if you are in a much more prosperous economy, the market is tighter
and you are going to have a lot more issues around turnover.

But in addition to that, and probably more important than that were the
issues around management, particularly the communication between supervisor
and frontline staff. The building in the worker into not just the care
planning meetings, but actually having them involved in the actual
implementation of the care plan. The wage piece of it in particular wasn't
as important as these other variables. Now that doesn't mean that they are
not important in and of themselves; it just means in relation to some of
these other pieces, empirically it looks like the job design and
communication and management relationships were more important.


We also, however, I hypothesized that a lot of this has to do with the fact
that most of these wage increases were relatively low. So if you are getting
a 57-hour increase in wages, the effect of that is not going to be very
strong. I don't think we have actually given significant livable wage
increase tests, you know, the real tests. So I don't think it should be taken
to say that money isn't important. I think it was more to make the point
that work environment, job re-design and in particular these management
relationships, whether it is in a nursing home, home-care, or even frankly in
consumer-directed care, the relationship between the consumer and the person
that is employed is really important.

Susan Reinhard: Julie, you sent questions ahead of time so I wanted to give
you an opportunity to mention your second point which I think members of this
call might appreciate about the Community Links Workforce Project in
Wisconsin. Can you describe that project a little bit?

Julie Whitaker: Well, my job with the Bureau of Aging and Long-term Care
just started less than two weeks ago. So (laughing) as a new person on the
job, I was hired as a Long-Term Care Workforce Specialist. The person
sitting next to me, Judy Sitski, has been with the Bureau for a lot longer
than me and actually was much more involved in the project originally, so I
am going to hand it over to her just to give you a little bit more of a
background on it because she is more knowledgeable.

Susan Reinhard: I just thought some of the folks on the call might want to
hear this. Thank you.

Judy Sitski: Well, we have been studying some state money with counties
to let them try different types of projects that they think might help in the
workforce areas. We have had one county develop what they feel to be a very
successful worker-owned co-op. It is in a very small rural county. Many
people said it couldn't be done. There are lots of issues with distance and
transportation and those kinds of things, but after about a year and a half
of operation they are making a profit. The workers have gotten increased
wages. They have health insurance and they have had one round of actual
profit sharing. There are about 80 worker-members in the co-op in a county,
which has a population in the entire county of about 20,000 people. The
county seat has 1,700. I was wondering whether there are any other worker-
owned co-ops taking place around the country today that anybody knows of.
Especially in a rural model.

Susan Reinhard: Thank you. So any participants who want to respond to any
of our speakers, we would like to hear from you too.

Steve, I know you have the one in Bronx, the Bronx co-op effort. Are there
others that you are aware of?

Steve Edelstein: There aren't that many out there and it is interesting that
the one in Wisconsin happens to be one that we do include in the Provider
Practice Database as an interesting example. We happened to touch with
people in other locations who are interested in the design, but at present
there are not that many similar models out there.

Susan Edelstein: OK. If anyone has information, let us know either on this
call or otherwise.

Is there another question?

Gentry: Not at this time, Maam. Please continue.

Susan Reinhard: OK. Do any of our speakers want to add anything? We had
one question that came from RTI about this was directed to you, Steve. That
might also be Susan, about your handout, must have been your handout showing
that nine states are collecting and analyzing evaluative data on one or more
of the direct-care initiatives and they were wondering if you could share
more about what is going on with Minnesota and Montana?

Susan Harmuth: We have some very brief information from both of those
states. Basically I think that the Minnesota evaluation with regard to their
wage pass-through and they do audits of providers and provider plans for how
those pass-through funds would be used. They also, excuse me, that was
Montana. Also with regard to Montana, I understand that they had legislation
that was passed to have the public health department collect wage information
and benefit information so they could do an analysis of comparable wage
classes and reimbursement rates for those wage classes with public funds.

In Minnesota, I think that they were doing evaluative data of their nursing
facility turnover data and for their wage pass-through. We did not have any
more extensive information from them than that on the survey response we had,
but Steve may have some additional information.

Susan Reinhard: Thank you, Susan. Steve, did you want to add anything?

Steve Edelstein: No.

Susan Reinhard: Are there any other questions?

Gentry: Yes we do. The next question comes from the line of Janet
O'Keeffe from North Carolina. Please go ahead with your question.

Susan Reinhard: Hi Janet. Hello?

Janet O'Keeffe: Hi. I have a question about the media campaign thing. Was
the intent of that solely to bring in new potential workers who would
otherwise not be applying for jobs? Has any work been done to see exactly, I
mean I think Robin spoke to this a little bit, but exactly how many who
inquired actually went on to do training and so on. A lot of the grantees,
not a lot, but a number of the grantees, the System Change Grantees who were
planning to do these media campaigns, but I had never seen anything, which
had kind of documented their effectiveness both in recruiting and more
importantly in retention?

Susan Reinhard: Robin?

Dr. Robin Stone: Hi Janet. There has been very little done in looking at
any of these awareness campaigns as far as I could see. We have identified a
few others. I think Judy Sitski was talking about some of their community
options programs, community links projects in Wisconsin. There has been an
effort in Kenosha County to do an awareness campaign and a somewhat sort of
formative evaluation was done on that. That was really about trying to
attract new people into the field, but also basically raising general
awareness of this as a job. Part of this is all about valuing the job as
well as actually really getting new recruits. But we don't have a lot of
evaluation data out there at all. So unless somebody else is in the
audience that has any better information, I don't think we have a lot to
learn from what has happened so far other than through anecdotes.

Janet O'Keeffe: Do you have any suggestions for, I mean because they said
there are a number of states. Susan, I can't remember how many, I think at
least four or five of the grantees who were planning to do this. Do you have
any suggestions for how they might do some even sort of basic monitoring to
see exactly what the impact was? It would be a pity for them to do the
activity and not have us really sort of be able to learn from it.

Dr. Robin Stone: Obviously you want to have some baseline. You want to have
some kind of encounter data in which, whether it is, depending on what
activity you are using, what kind of hits or interest have been expressed
from whatever interventions are being used in the campaign. I think also
sort of making sure that the providers, the agencies or the consumers that
are involved in this that are actually looking to hire this workforce
register whether they see any effects from it. I think it is a very hard
thing to measure because you have a lot of other external noise going on
simultaneously.

It also depends on what the intervention is. Feedback that I got from folks
in Kenosha County for example was that they did not feel that the investment
in the more high-tech sort of PSA-type activities was as useful as some of
the other things that they did like flyers and working through churches and
other types of organizations. So some of this has to do with figuring out
even what are the most useful interventions for the workforce, for the
potential workforce.

Dale Lanenga: If I could just jump in with that. We have not studied it
and we would like to find out more about all of our different initiatives.
But clearly anecdotally it really does make a tremendous difference what the
nature of the area is. In a rural area it is very, very different. There
are some things being done by some of our direct service providers that we
might even, might sort of almost laugh at and say boy that seems rather a
silly approach. But which seems to work in their particular area which we
would probably never consider doing in an urban area. And things going on in
an urban area that just would not work in a very, very rural area. It really
is pretty much dependent on really knowing what works, how your area
functions.

Janet O'Keeffe: There was a public service announcement on the television,
which could be very expensive, would reach a lot of people who simply would
have absolutely no interest in it whereas a more targeted approach might like
you say, through churches or other institutions, that would have people go to
them who might be out, potentially people to work would be more effective?

Dale Lanenga: Right. For example, in some of the, I recall one of our
rural areas talking about using placemats in restaurants. Paper placemats
with information on and response they got from that which probably would not
work in certain other areas of the state.

Susan Reinhard: Maybe we ought to get some of the grantees that are doing
this on the phone together and have this conversation.

Janet O'Keeffe: Yeah, I think that would be very useful.

Susan Reinhard: Thanks, Janet. I'm sorry, who is this?

Gentry: This is Gentry. Our next question comes from the line of Dann
Milne from Colorado. Please go ahead.

Susan Reinhard: Hi