Initiatives to Improve LTC Direct Care
Workforce Retention: What is the
Evidence Base?
Lauren D. Harris-Kojetin, PhD
Institute for the Future of Aging Services
www.futureofaging.org
Lharris-kojetin@aahsa.org
AcademyHealth Annual Research Meeting
Boston, MA
June 26, 2005
Presentation Overview
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Background
Purpose
Context/Conceptual Models
Research Synthesis
– Methods
– Key findings on effective interventions
• Implications
• Resources
Background
“Education and training of staff, supervision,
environmental conditions, attitudes and
values, job satisfaction and turnover of staff,
salaries and benefits, leadership,
management, and organizational capacity
are all essential elements affecting quality of
care to residents.”
IOM, Improving the Quality of Long-Term
Care
• Over 2.4 M paraprofessional LTC workers
form the core of the formal LTC system
• Turnover ranging from 45% to over 100%
• Between 2002 – 2012, 888,000 more
DCW jobs
• 27 M Americans are projected to need LTC
by 2050
• Significant societal factors converging 
“care gap”
• Variety of factors associated with LTC direct care
workforce (DCW) recruitment & retention
problems
– inadequate training, job orientation & lack of
mentoring
– poor public image of LTC direct care workforce
– low pay & insufficient benefits
– few opportunities for development within the position
– poor supervision
– emotionally & physically hard work
– workplace stress & burnout
– personal life stressors
– lack of respect from residents’ families
– short staffing
Purpose
– States, providers & worker groups have
designed & implemented a variety of
initiatives intended to address DCW LTC
problems
– Some of these initiatives have been evaluated
– Current state of evidence base on relationship
between how LTC work is
organized/structured & DCW
turnover/retention
Context/Conceptual Models
Local
Environment
Labor
Market
Regulation
Model of Nursing Home Quality – Eaton
(2000)
Work
Organization
Profit
status
Chain
Competitive
Strategy
Teams
Structure
Religious
status
Training
Management
Philosophy of
Care
Medicalcustodial
Assignments
Size
Medicalrehabilitative
Human
Resources
Practices
Case mix
Regenerative
Wages
Benefits
Values &
Beliefs
Hiring
Turnover
Resident
Outcomes
Quality of
Care
Quality of
Life
Employer-Related Factors
Associated with Turnover
Adapted from Banaszak-Holl and Hines, 1996
Turnover
Retention
Initial & On-Going Training
Personal Characteristics &
Competing Demands
Organizational
Commitment
Compensation & Benefits
Quality of Work Environment,
Job Design, Job Stress
Employer Organizational
Characteristics
Job
Satisfaction
Research Synthesis
Recent Insights about Frontline
Long-Term Care Workers: A
Research Synthesis 1999-2003
Lauren Harris-Kojetin, PhD
Debra Lipson, MHSA
Jean Fielding, MGS
Kristen Kiefer, MPP
Robyn I. Stone, DrPH
Funded by ASPE, DHHS
Methods
• Search sources: Ageline, PubMed, Internet
searches, personal communications,
conferences, initiatives in Stone (2001)
• Eligible materials: Published & gray literature
• Search terms (examples): LTC workforce, labor
force, recruiting, paraprofessional, job tenure,
work environment, intervention
• Timeframe: 1999 – 2003
• Outcomes: turnover and/or retention
• Data collection: Study documents abstracted &
categorized by intervention type, evaluation
design & results
Types of Interventions Evaluated
1999 - 2003
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Alternative labor pools
Career ladders
Culture change
Enhanced staff-family communication
Multi-faceted initiatives
Peer mentoring
Self-managed work teams
Wage enhancements
Types of Initiatives Evaluated
1999 – 2003 (continued)
• 15 interventions reviewed
– 2 had not (yet) had outcome evaluation
– 2 did not measure actual turnover or retention
– 8 showed non-significant, negative, or
inconclusive results or did not use robust
quasi-experimental design
– 3 showed significant positive
turnover/retention results using a pre-post
comparison group design
Key Findings on Effective
Interventions
Growing Strong Roots –
Peer Mentoring
• Trained, experienced certified nursing
assistants (CNAs) matched with new CNAs
• Training & manuals for project coordinators
& mentors
• Booster training & newsletters for mentors
• Mentoring active 8 weeks
• Salary increase for mentor
Growing Strong Roots
Evaluation Results
• 12 nursing homes in New York state
• Statistically significant improvement in
retention among those mentored
– 18 point increase in average retention rate
while increase not significant among
comparison group
WIN A STEP UP –
Education & Payment Incentives
• 10 modules on clinical skills, interpersonal skills,
and communication
• Nurse aides (NAs) get $70 per completed
module
• Facilities must agree to commit staff time & give
either retention bonus ($75) or wage increase (>
$0.25/hr) 3 months after completion of modules
• NAs who complete > 7 modules & stay at facility
> 3 months after training get matching $75
bonus from WIN A STEP UP
WIN A STEP UP
Pilot Evaluation Results
• 4 nursing homes, 1 home health agency, 1
adult care home in NC
• Annual turnover rates significantly lower
for NAs in the program compared to those
in the matched comparison group (15% to
32%)
Wellspring – Quality Improvement
& Organizational Change
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Alliance super structure
Leadership & clinical training modules
Shared advanced practice nurse
Coordinator in each facility
Care resource teams
Systematic collection & use of outcome data
Non-hierarchical management philosophy
Wellspring
Evaluation Results
• Wellspring facilities fared better than other
Wisconsin facilities on retention & turnover
– Wellspring CNA retention increased by 6%
while other homes decreased by 6%
– CNA turnover rates increased for both
Wellspring & other homes, but increase
was smaller for Wellspring
Summary – What Works?
• 3 of 15 interventions using a pre-post
comparison group design had significant
improvements in retention and/or turnover
– Management buy in & sustained commitment
– Facilities commit to give staff time
– Direct supervisors committed to working
with DCWs
– Follow-up & support beyond initial training
– Financial incentives to DCW in 2 of 3
interventions
– Clear, consistent messages & expectations
Implications
Strengthen Evidence Base
• Evaluate innovative workforce improvement
models
• Examine linkages among workforce & quality of
care & life outcomes
• Strengthen evaluation designs
– Measure longer-term effects
– Measure variation within facilities (units, shifts)
– Measure actual behavioral outcomes
– Measure outcomes consistently
– Use of a comparison group
• Examine other LTC settings
• Determine transferability of evidence-based
models across settings
Promote Evidence Base
• Provide technical assistance to LTC providers to
implement & sustain new models
– Give on-going feedback to providers
• Determine how to replicate effective
interventions beyond the initial demonstration
(inform technical assistance)
• Determine how to sustain interventions
• “Incentivize” the use of evidence-based models
– Make the case for evidence-based workforce
interventions with payors, regulators and providers
Resources
• Synthesis paper available at:
http://aspe.hhs.gov/daltcp/reports/insight.
pdf
• Measuring Long-Term Care Work: A
Guide to Selected Instruments to Examine
Direct Care Worker Experiences and
Outcomes
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