The center's Career Pathways Program allow caregivers to earn credit for prior learning and lived experience to further their career.
Training by the Center for Caregiver Advancement (CCA) not only equips nursing home workers and caregivers with the skills they need to do their work effectively, but through its Career Pathways Program is enabling them to further their career as a caregiver.
Calling the work caregivers do “unskilled” is offensive and doesn't do justice to the intimate nature of their role, said Corinne Eldridge, CEO and president of the CCA, which has trained more than 20,000 nursing home workers and caregivers in the state of California since it was founded in 2000.
The “unskilled” label may also stem from structural racism and sexism, particularly around the fact that women of color and immigrant women are the main demographic who do this work, she said.
"It isn't done outside of the home or seen to be more skilled with degrees associated," she said to HealthLeaders. "You can see that framing based on how the workers were initially left out of the Fair Labor Standards Act, how there hasn't been sick pay, [and why] it's taken so long to get a level of benefits. It's taken a long time for the workforce to get to where it is today, and yet there's still a long way to go."
The vision behind the Career Pathways Program builds on the organization's idea of what should happen within home care and nursing homes overall—a progression of skills that caregivers learn while receiving credit for prior learning, which would enable them to further their career from caregiver based on their lived experience and competencies they develop through the different training programs.
The program has 120 hours of custom-built curriculum throughout five pathways, with 30 hours dedicated to their basic training. Results of the program thus far have shown reduced feeling of depression and isolation in caregivers, and an increase in skills and feelings of self-efficacy. These results have also led to a reduction in emergency room visits and hospitalizations for clients and patients.
The five pathways are: general health and safety; adult education; cognitive impairments and behavioral health; complex physical needs; and transitioning to home and community-based living. Courses on Alzheimer's disease and related dementias, as well as autism, have been popular options among caregivers.
"The caregivers know so well what their day-to-day experience is. They are a second set of eyes for the consumer that they care for," Eldridge said.
"Oftentimes, they are with the consumer that they care for more than anybody else, and so we trust what they say because their lived experience dictates where the need is,” she said. “Then we couple that with subject matter expertise in whatever subject it is that we know we need to pivot to."
The courses are completed over the duration of multiple weeks. California has also regulated the program where caregivers can enroll in however many classes they want in the order they want.
Courses are also taught in eight languages, with Vietnamese and Russian being added for the Career Pathways Program.
"The workforce is a middle-aged, predominately female workforce and our information and experience with the workers has shown us that with immigration patterns, they are they are not new [to the United States]," she explained. "They are monolingual speakers in their native language, and they are not learning English to become their predominate language."
While the CCA is based and focuses on caregivers in California, Eldridge said there are similar organizations in 10 other states. With the growing demand for aging services, organizations like CCA support the caregiver workforce, providing them with the training they need.
"They bring those skills back to the broader health system,” she said, “which results in lower turnover for the workers and better care for the consumers."
Rob Barrow has 13 years of experience in home health care operations.
As the new COO for PurposeCare, a home care and home health services provider, Rob Barrow is emphasizing improving quality outcomes, maintaining a good and productive workforce, and pursuing patient satisfaction.
Barrow may be new to the position, but he’s quite familiar with PurposeCare, as he previously worked with their leadership team as part of Lorient Capital, the investment private equity firm that developed and invested into PurposeCare.
Having grown up in England and moved to the United States in his early twenties, it was while working as an automotive design and manufacturing engineer that he developed the process-oriented mindset that he credits for his success in operations.
"Being an engineer and having that process mindset has really led to the success we've had at PurposeCare because it's really about making sure we've got good processes," he said. "I've learned the skill and craft of managing large-scale people organizations, whether they're caregivers, clinicians, or administrators."
Barrow's experience managing Lorient Capital's other home health agencies prepared him for his C-suite role at PurposeCare. Within those agencies, and now at PurposeCare, Barrow emphasized quality outcomes, a productive workforce, and patient satisfaction.
With more patients preferring to receive care at home, the home health sector is "eroding" facility-based care, he said.
"Patients are looking for a good quality outcome wherever they go, now it’s in the home. I think a lot of agencies that are short staffed maybe take shortcuts around that, but we put our quality outcomes as the top four or five key performance indicators for our business. We have to ensure that we're providing quality care."
This strategy, he added, is twofold as PurposeCare and other home health agencies provide care to dual-eligibility patients. This is why they focus on information about this demographic, such as the fact that patients' health can decline over time, they can develop a changing condition, and are susceptible to minor injuries like falls.
As the home health care sector continues to grow to meet the demand for aging services, there have been numerous announcements of home health agencies merging or being acquired by larger health systems or providers, a trend that Barrow attributes to business' need to scale.
Smaller organizations don't have access to the resources or clinicians that larger organizations do, so scaling up by either merging or selling an agency to a larger business, is a beneficial move.
PurposeCare has more than 20 home health agencies across four states, with more than 1,000 caregivers and clinicians providing care to about 3,100 patients each week.
"We have sophisticated electronic medical records, data systems, and we can hire and attract top talent because it's a big company," Barrow said. "We give a lot of flexibility to our clinicians, but we also provide them with the tools they to do a fantastic job, and I think that's harder to do in a small company."
The acquisition will simplify its organizational structure, ProMedica CEO Arturo Polizzi said.
ProMedica has entered an agreement with Gentiva, a hospice, palliative, and personal care company, for the acquisition of its Heartland hospice and home care agencies.
The terms of the transaction have not yet been disclosed, and is expected to closed in the second quarter of this year.
"As part of the Gentiva family, the Heartland agencies will be well-positioned to continue providing compassionate care that prioritizes patient comfort, dignity, and well-being throughout the care continuum," Arturo Polizzi, president and CEO of ProMedica said in a statement.
Polizzi added that the acquisition will help ProMedica's efforts to simplify its organizational structure and ensure the organization's long-term financial strength.
"This transaction is an exciting development for patients and their families that will enable us to extend our best-in-class caregiver recruitment and retention programs and provide high-quality care to more patients in more areas through the country," David Causby, president and CEO of Gentiva said in a statement.
Gentiva's 30,000+ associates and caregivers take care of more than 24,000 patients, on average, each day in 36 states. With a nurse-to-patient staffing ratio of 1:9 and caregiver recruitment and retention program, 96% of patients and their families would recommend Gentiva's services to others.
In acquiring Heartland Hospice and Home Care, Gentiva is looking to hire and invest in caregivers to ensure high-quality care for patients in its expanded service area.
"As a licensed nurse, I understand firsthand the pressures caregivers across the United States are facing," Causby said. "We are focused on developing systems and processes that address and overcome these challenges to remain an employer of choice, and I am excited to welcome Heartland's caregivers to our family as we continue to improve clinical outcomes and quality of life for patients in the markets we serve."
Home care will be 'untenable' without a rate increase, says chair of the Ohio Council for Home Care and Hospice.
With Medicare reimbursement rates no longer covering the cost of care and preventing agencies from paying competitive wages, the Ohio Council for Home Care and Hospice(OCHCH) is seeking rate increases.
Medicaid reimbursement rates are the same as they were in 2000—despite inflation rising more than 75%, according to Lisa Von Lehmden-Zidek, Cleveland-based chair of the OCHCH board.
"The cost of home care greatly exceeds what Medicaid covers, and it makes no sense because receiving home care is significantly less costly than institutional care," she said in a statement. "If this continues, home care will be untenable and the costs for all Ohioans will increase with institutional care and more hospitalizations."
Lack of adequate pay for caregivers adds to the ongoing healthcare workforce shortage, which has many home health agencies struggling to hire staff, no longer accepting Medicaid patients, or closing their doors completely. In Ohio, patients in underserved and rural areas have been affected the most.
"Within the next two decades, the population of those 60 and older is expected to grow more than four times faster than the state's overall population," Joe Russell, executive director of the OCHCH, said in a statement. "If we want to care for the influx of older adults to allow them to age in place, and to help others who are struggling with disabilities, chronic illnesses or recovering from surgery, we need to address the worker shortage and cover the costs of these services."
Founder and co-owner of Patriot at Home, a home health provider, Greg Davis said his agency loses $800 per patient when they admit a Medicaid patient. Over two years, he added, they've lost hundreds of thousands of dollars providing care to Medicaid patients.
Because there aren't enough providers to meet the demand for home health services, many state residents have been added to waiting lists where they're having to wait up to two years for services. As a result, they're forced to deal with inadequate care, depending on emergency rooms or nursing homes, which are often more expensive.
The state's home health issues can be addressed in its biennial budget, Russell said. Currently, advocates want to increase wages to $35 per hour for RNs and $20 for aides, which would also help cover overhead costs.
"We should value the health and safety of Ohio's most vulnerable in a way that's on par with Medicare and private pay. Ohio Medicare payments can be more than 300% what Ohio Medicaid pays for the exact same service," Russell said. "Our goal is for state Medicaid reimbursements to cover the actual costs for care."
In part two, Dalton-Kelly advises foundational change in how caregivers are viewed.
Aishling Dalton-Kelly is a private duty consultant, as well as president and CEO of Aishling Care Academy. Having previously owned an agency, Dalton-Kelly understands the importance and necessity of setting caregivers up for success and helping them see a future for themselves within an agency.
In the first part of the our interview, we noted the high turnover rate—57%—of caregivers leaving an agency within the first 90 days. In part two, Dalton-Kelly reiterates the need to equip caregivers with the tools and knowledge they need, as well as what should be done so more potential employees people will see a fruitful career path in the sector.
This transcript has been lightly edited for brevity and clarity.
HealthLeaders: How can agencies encourage or establish a cooperative relationship between management and caregivers?
Aishling Dalton-Kelly: Caregivers should be invited into meetings with upper management. There should be a caregiver present to represent other caregivers for everyone to be on the same page about the challenges and difficulties they face, because that's where they stem from–what happens in the field. They're never given a voice to say what they need to say.
HL: What needs to change within the sector in how caregivers are viewed?
Dalton-Kelly: The "unskilled" descriptor has to go. Think about how that makes them feel. It makes them feel like they're worth nothing and they're never going to amount to anything. In my opinion, that's what those words say. However, if we were to change it to be a caregiver and to go into the home and do what they need to do -getting someone in the shower, dressing them, making sure that they're eating properly- that takes intense skill, and there's no recognition for that. There has to be more respect at the entry level.
This is a great career. If you're someone who wants a career in healthcare, this where you can start. There are even apprenticeship programs where the employer doesn't even have to pay for the worker; they come through the program. If for some reason after getting their certificate they can't continue with being a CNA, all they have to do is keep it up to date and they can come back when they're ready.
There is no tracking mechanism for nonactive CNAs in the state of Illinois, and it’s a shame. The very people that can't afford to go to school went through the trouble of completing CNA school, getting their certification, and through miscommunications and not being told how to keep it, they left it and don't know how to get back in.
We should be looking for seniors who are willing to work as caregivers, as well. They have the life skills, and we can teach them the CNA skills. People at home love elderly caregivers because they've been through life. They get it.
We're not communicating the possibilities and we're not telling the caregivers where we can help them find money, and employers aren't investing in their caregivers because of the turnover. What I say to that is, why would they stay? You haven't encouraged them to do better. They're just a number in your agency.
HL: What are some areas necessary for training?
Dalton-Kelly: Focusing on the caregiver's rights; making sure they understand that they do have rights. Helping them understand that abuse isn't something that comes only in a physical format, because caregivers get physically abused, mentally abused, verbally abused. They don't know how to recognize that, how to report that. They think it's something they have to tolerate. Teaching them how to speak up for themselves, correctly, in the right way, is very important. There should be a self-defense component, from chair grabs to choke grabs, wrist grabs. Caregivers aren't taught that either.
I'm not saying all jobs are bad, but these are things that are missing from what we're trying to teach our folks. On top of that, we're saying they're unskilled, but we have to throw this training at them to make them be successful for the clients we put them with, whether it's in a facility or home-care setting.
Saratoga Center for Rehabilitation and Skilled Nursing Care is alleged to have violated the False Claims Act.
A now-closed upstate New York nursing home that submitted false claims to Medicaid and left residents to suffer “deplorable conditions and neglect” agreed to pay more than $7 million in a settlement with the U.S. Justice Department and the New York State Office of the Attorney General.
The former landlord and operators of Saratoga Center for Rehabilitation and Skilled Nursing Care in Ballston Spa, New York, will pay $7,168,000 to resolve allegations they violated the False Claims Act, according to a Justice Department announcement.
"Nursing homes should protect the health and well-being of every resident. That did not happen at Saratoga Center," U.S. Attorney Carla Freedman for the Northern District of New York said in a statement.
Saratoga Center has been closed since an investigation was initiated in February 2021, which found that in 2014, after a months-long vetting, the New York State Department of Health (NYSDOH) approved Alan "Ari" Schwartz and Jeffery Vegh to operate the facility alongside Leon Melohn, the landlord. This license gave Sschwarts and Vegh the non-delegable duty to oversee the nursing home’s operation. However, in 2017 Melohn, due to a financial dispute, required them to surrender control of the facility and replaced them with one of his business associates and Jack Jaffa. The new operators never obtained the necessary NYSDOH licensure.
Jaffa and Melohn's business associate operated Saratoga Center from February 2017 until its closing in February 2021. In that time, the investigation found the facility delivered “worthless” services to residents, knowingly submitting false claims for payment for Medicaid, the Justice Department said.
The facility's physical condition also deteriorated to the extent of violating federal and state regulations. In addition to being inadequately staffed, residents suffered medication errors, unnecessary falls, and pressure ulcers. There were also inconsistencies in hot water being maintained throughout the facility, its linen inventory, and its disposal of solid waste.
In 2019, Saratoga Center was placed on the Center for Medicare and Medicaid Services' Special Focus Facility list—a list of the worst-performing nursing homes in the United States—remaining on there until its closure.
"We trust nursing homes to protect New Yorkers during their most vulnerable days, but the owners, unlicensed operator, and landlord of Saratoga Center repeatedly violated the law for their own benefit," Letitia James, New York attorney general, , said in a statement.
"Instead of providing the quality care and compassion that residents deserved,” she said, “the owners of Saratoga Center deceived regulators and left residents to suffer deplorable conditions and neglect."
$726K grant will seek to provide resources for bereaved caregivers of late dementia patients.
A growing group of people who feel “ultra-invisible”— bereaved caregivers of late dementia patients— will be the focus of a study funded by a $726,000 grant to Arizona State University from the National Institute on Aging.
Most support available to caregivers focuses on those currently providing care, rather than those whose difficult days of caregiving are behind them because of the death of their loved one, hence the feeling of being “ultra-invisible,” said Zachary Baker, an assistant professor with the university's Center for Innovation in Healthy and Resilient Aging and the study’s principal investigator.
This quantitative study, however, will compile the largest sample of bereaved dementia caregivers to date with the purpose of providing tools and resources that could improve their lives as they grieve the death of their loved one.
"The reality is they lost their mom or their husband, or somebody really important to them, and as many as $25% of these former caregivers are getting clinical symptoms," Baker said. "And what I mean by that is not just normal grief or sadness but something that is stopping their life."
Goals for the study include understanding how a caregiver is feeling after the person in their care has passed away, looking at the methods those who are coping well are using, and sharing those solutions with those who are struggling.
"Aside from a lot of sadness and subclinical depression and less quality of life, we're talking about millions of people who can't function, but nobody is talking about them or thinking about their needs," he said.
Caregivers whose symptoms aren't at a clinical level will still have higher rates of depression and loneliness. Baker added that within 10 years, most patients with Alzheimer's or another type of dementia will die, which will result in more than 9 million bereaved caregivers.
Those interested in participating in the study, or know someone who may be interested, can call 602-543-4492, extension 34492 or email formerdementiacare@asu.
Baker and other researchers are also currently working on an initiative that would expand the study to Spanish-speaking caregivers.
The illegal agreement prevented patients and their caregivers from selecting their own providers.
A recent investigation by New York's Office of the Attorney General (OAG) uncovered an unlawful “no poach” agreement between Affordable Senior Care of New York and its competitor, Marks Homecare Agency. Laszlo Friedman, Affordable's founder, entered the agreement with Marks Homecare, which prevented them from taking each other's existing patients.
“On several occasions, vulnerable patients were unable to switch to a provider that could have paid their caregivers more,” according to the OAG.
Several patients who tried to switch to Affordable were rejected because they were patients of Marks Homecare, the OAG said. Additionally, Affordable and Marks Homecare also exchanged information about the hourly rates they were paying caregivers to reduce competition.
"Home care companies like Affordable Senior Care are entrusted to make it easier to take care of a loved one, but instead they broke that trust and broke state laws," Letitia James, New York Attorney General, said in a statement.
“Patients and their caregivers should be able to work with the provider of their choice,” James said. “This agreement puts an end to harmful backroom deals in the home care industry that limit patients’ options and reduce caregiver wages.”
As a result of the OAG's investigation, Affordable and Friedman aren't permitted to enter into future anti-competitive agreements, must pay a penalty of $400,000, and cooperate with the OAG in ongoing home care investigations. Additionally, Affordable will have to administer an antitrust compliance program with training for management and executive staff, providing annual reports to OAG on its compliance for the next five years.
High turnover of nonskilled caregivers in their first 90 days with an agency can be attributed to lack of attention and communication by leadership.
More than half—57%—of caregivers quit within the first 90 days of working for an agency, according to a report by MissionCare and the National Association for Home Care and Hospice. They're also seven times more likely to live at or below the poverty line.
Healthcare’s dire staffing shortages extend to unskilled workers, which means private duty agencies also are struggling to recruit and retain caregivers.
Aishling Dalton-Kelly is a private duty consultant, as well as president and CEO of Aishling Care Academy. Having previously owned an agency, Dalton-Kelly understands the importance and necessity of setting caregivers up for success and helping them see a future for themselves within an agency.
This transcript has been lightly edited for brevity and clarity.
HealthLeaders: What is something that should be included during a caregiver's training that isn't?
Aishling Dalton-Kelly: There isn't a history or discovery component for caregivers to understand the generation that they're taking care of. I think that’s a big issue because they don't always understand seniors and sometimes, they don't always see the genuine quality of knowledge they have because of ageism. They just look at the person as being old—"“They're just not useful anymore”, which is not true. If someone has some form of dementia, they've lost themselves.
HL: Is there a particular demographic that performs well as caregivers?
Dalton-Kelly: The demographic of people who do this work are very compassionate people, and you have to have that compassion first, not the skill set. You must want to take care of people, otherwise your work is very task-focused. If you don't understand the person you're taking care of, the relationship is never going to grow. Caregivers who do a wonderful job in the home and attract clients to their company, are able to do so because they're relating one-to-one with their client. They're able to communicate physically and mentally, and understand the person's background and what their needs are that day, in addition to delivering the traditional caregiving services in a very compassionate way.
We have caregivers from different cultures who have come to the United States and they're here to better their life and provide a better life for their family back home. In Nigerian culture, they look at their seniors as very special people. Caregivers from the Philippines are very dedicated to caring for their seniors. They come here and they want to be able to provide the best care.
HL: The percentage of caregivers who quit within the first 90 days is 57%. What do you think is the reason behind this statistic?
Dalton-Kelly: Oftentimes agencies will just hire a body because they need a person, but they're not hiring a caregiver. They're somebody who needs a job, somebody who needs the money, but they don't understand the job that they're going to do. Caregivers that do what I call the grunt work, the hard work, day-to-day care of our seniors, and they're not paid enough.
HL: What are some ways agencies can support the caregivers from the beginning?
Dalton-Kelly: In Illinois, we have certain units that we must train the caregiver in, like dementia. You have to pay a caregiver to do that training whether they do it at home or in the office. Imagine investing all that money, getting them to do it by the date that’s required, but along that journey you never actually sit down with them to see how it's going and get to know them, and how you can help them be successful.
With my agency, I used to tell employees to take their manual home and digest it, and that if they did, they'd be successful, and if they didn't, they'd be fired or quit because they didn't follow the policies and procedures. I always made the communication clear from the get-go because home care is a very serious business. You're taking care of somebody's life whether they're sick or not.
As an employer, you must understand what your potential candidate wants. We need to sit with them and get to know them or we'll lose them.
One program, which I've never seen implemented, would be to have someone who's been on the job six months be a mentor to them. Caregivers do well talking to one another; they don't do well talking to the owners of the agency. They say the office staff don't understand what it's like in the field. That is the No. 1 complaint I hear.
And then the question to ask is, “How do you show them?” It must be more, and it must be deeply rooted. We must show them we respect them.
Editor's note: This story has been updated. Look for Part 2 of this story in the coming weeks.
Agencies and providers already struggling financially are stretching their resources to attract talent in a competitive market.
HealthLeaders spoke with Eric Holwell, senior vice president of strategy at Bayard Advertising, who has worked with health organizations to help them refine the way they advertise their roles, on best practices, mistakes, and the art of a composing a job description.
This transcript has been lightly edited for brevity and clarity.
HealthLeaders: What is the first thing you do when healthcare organizations come to you for help with recruitment?
Eric Holwell: The first thing we do is audit what they're currently doing. When you do an audit, it's about getting to know the company or organization, and getting to know what works for them and then what they're missing—a variety of things that help us understand where we can come in and fill the gaps. We will then put together a brief or recommendation of what we would do, looking at a variety of different marketing channels that are designed to target specific audiences that would meet their talent needs.
HL: What are some common mistakes that you see?
Holwell: One is that they don't have a diversified marketing strategy. In [advertising] we call it a talent attraction strategy, so they're not nearly diversified enough when it comes to attracting talent. A lot of the time, organizations are betting on only two or three channels or vendors to help them recruit nurses. They might be using some of the big usual suspects [ie. LinkedIn, Indeed, etc.], but they're missing out on a lot of niche sites, a lot of social recruiting strategies, a lot of even recruitment tactics you can do through Google and all of their products.
They don't have a media strategy that's diversified in a way that can target a very large audience, and then they have a poor user experience for candidates.
HL: Would that include the application process?
Holwell: A user experience is a big part of the application process. If you're spending money to attract talent, which means it's some type of media that you've invested in to advertise that you have open positions, that candidate is going to click on that ad. They're then going to be directed to some type of page—job description, career homepage—and you want the candidate to have a very intuitive experience.
They shouldn't have to guess what they're there to do, they shouldn't have to guess what's next, they shouldn't have to search for the content that is relevant for [the position they're applying for]. You want them to be able to get to what you want them to do easily and quickly. Anything outside of that creates drop-off.
HL: How does the composition of a job posting play into this? What are some best practices?
Holwell: The job posting is important because it is the only content that the candidate will see, especially for an active job seeker. If the job description meets their expectations and they feel they're qualified for that position, they'll apply for that job.
It will also be the one place that the candidate gets to experience the employer’s value proposition, get information about the company, and understand the responsibilities and qualifications of the job, so you don't want it too long. It needs to be informative, so you don’t want it too short because you don’t want unqualified candidates applying.
I would say there are three things that should be in every job description: one would be the promise that you are making to a candidate—that's your value proposition. There should also be a very clear, but concise, description of the responsibilities and then the qualifications. [Third,] if you are an organization where your roles require long hours or very specific certifications, it should be very clear to candidates who are not qualified if they don't meet those criteria, or if they don't agree with the kind of responsibilities that they're going to take on.
HL: How are post-acute providers having to navigate how they advertise roles?
Holwell: There are some internal factors here and the biggest is pay. In the last two to three years, we've seen an increase in pay [in healthcare careers], and a lot of underpaid employees. One thing every organization is going to have to do is look at whether their compensation is competitive and if it's not, they're going to continue to have a very hard time recruiting, no matter what they do from a creative standpoint. That's a tough pill to swallow for organizations that are operating on tough margins already. If you do offer competitive pay it should be highly advertised. It should be highly advertised if you've raised your pay rates or offer bonuses or better benefits.
In addition to that is the workplace. People want to work with innovative companies, and they want to work in an environment they feel is safe and welcoming and inclusive, so company culture is going to be a big part of that. If your company culture is missing [that], that's another internal thing to do–listening to employees to create a more inclusive and encouraging work environment for all employees. Home health is a little tricky because you're on the road, but the support they get from their colleagues is important.
HL: Will healthcare’s workforce be able accommodate the influx of older adults that may need these services by 2030?
Holwell: It's not an organizational problem, it's an industry problem. Collectively, I think the industry and the leaders are going to have to start thinking of ways to get younger people more interested in a healthcare path. That's going to be the best way to solve problems that are 10, 15, 20 years down the road.
Marketing strategies are just short-term solutions. You have to get people to start thinking about healthcare as an interesting and exciting career path. That means getting in front of people in high school and college.
