ASPE, (Office of the Assistant Secretary for Planning and ...



"Maryland Regional Direct Services Collaborative"Education and Training Task Force""Issue Brief for the Annual Meeting on September 27, 2018"Background and PurposeThe purpose of this Issue Brief is to provide background and analysis of “Training and Education” of Direct Service (DS) Workers. Training and education, as well as other issues such as compensation and benefits, are key to the efforts to expand and vitalize the DS workforce. This Issue Brief, prepared by the Education and Training Task Force, provides a framework for wider discussion which will occur at the “Reinventing the Direct Services Workforce” meeting in September, 2018. In September, 2017 concerned citizens and professionals gathered for the “Area wide Summit on Direct Care and Paraprofessional Development” sponsored by the Willging Endowment and the Erickson School at UMBC. The “Summit” addressed resources and needs affecting all the core elements in DS workforce development such as compensation, working conditions, career pathways, training, certification, delegations, apprenticeships, mentoring, job satisfaction, professional and public recognition etc. (Willging, 2017). As a result of these efforts, in January 2018 the “Maryland Regional Direct Services Collaborative” was formed and with the assistance of the Rodham Institute at George Washington University, the Collaborative has established a leadership group and identified the following three priority areas for examination and action:Wages and Benefits Expanding the WorkforceTraining and EducationIt was recognized that the “Training and Education Task Force” issues are intertwined with the issues under consideration by the “Wages Task Force” and “Workforce Expansion Task Force”. Research indicates, for example, that enhanced training results in improved employee retention and satisfaction (Dill, 2014) and conversely, poor training, orientation, and continuing education are predictors of job dissatisfaction (Ejaz et al, 2008). While these dimensions are intertwined this Issue Brief focuses attention on training needs and issues recognizing that the Collaborative’s eventual action plan will serve to integrate the three DSW vitalization efforts. Finally, expansion and enhancement of direct service worker professions will not be achieved solely through enhanced wages, training and formalized career paths. Promoting the importance and dignity of “serving professions” and the lifestyle challenges for many when adjusting to entrance level workforce jobs warrants attention. This dimension, though not explicitly addressed in this Issue Brief, is fundamental to advancing the direct health service workforce (Moore-Duggan). Training and Education Issues: Maryland RegionDirect service workers include various categories and job titles in the long term supports and services industry serving the older adults and individuals with disabilities. The labor categories which are of primary interest in this Issue Brief are: CNAs/GNAs, personal care aides, and home health aides. The size of the Maryland CNA/GNA workforce alone is noteworthy (Table 1). Also of note is the high ratio of inactive certified workers.Table 1: CNA/GNA Certification and Practice, 2018Certification Type?June, 2018Certified Nursing Assistant (CNA)/???Total Active??180,058?? 63,593?Geriatric Nursing Assistant (GNA)/?Total Active?? 80,586? 30,559(Board of Nursing, 2018)While training and education requirements vary among the categories of direct service worker, the following background and issues generally pertain. Training/Licensing requirements. Current federally mandated direct care worker training requirements apply to certified nursing assistants, geriatric nursing assistants, home health aides and certain other workforce positions such as hospice aides. The minimum requirement of 75 hours of training established by the “Nurse Aide Training and Competency Evaluation Program” of the Omnibus Budget Reconciliation Act (OBRA) of 1987 applies to certified nursing assistants and home health aides and has long been viewed as inadequate for the scope and depth of the direct service worker responsibility (AAHSA, 2010). There is wide variation among the states regarding required hours beyond the minimum. Maryland currently requires 100 hours including 60 hours of classroom and 40 hours of clinical training (Comar 10.39.02.07 B) and the District of Columbia requires 120 hours of preparation. There are approximately 150 CNA training sites approved by the Maryland Board of Nursing. There is no minimum federal requirement for personal aides and other support service workers. As long ago as 2008, an Institute of Medicine report (IOM, 2008) noted that the federal government requirements for nurse aides and home health aides working in Medicare/Medicaid-certified agencies are minimal and are significantly less than training requirements for similar wage earners in other technical positions inside and outside the health sector. Recommendations have been forthcoming over the years to expand the federal minimum requirements to 120 hours (IOM, 2008). A more foundational concern is that the regulatory required minimums reflect an hour based requirement (“seat time”) rather than a competency based requirement. (Lewin, 2008). Competency based curriculum for DS workers in aging and disability services has been developed by PHI and includes personal care skills, health related tasks, infection control, nutritional support and self care. (Lewin, 2008)Nursing homes/SNFs There are approximately 240 nursing homes facilities in Maryland and DC employing thousands of Certified nursing Assistants (CNAs) Approximately 40 Maryland nursing facilities are certified CNA training sites (Board of Nursing, 2018). As previously noted, improved training corresponds to higher job satisfaction and reduced turnover. Hospitals in Maryland, provide relatively higher wages and often require some previous experience. This can result in a hospital draw down of CNAs from nursing homes. In the absence of corresponding significant wage enhancement within the long term care industry this structural challenge is likely to remain. Medicaid’s low payment levels for nursing home care presents a structural impediment for nursing homes attempting to establishing career ladder programs with accompanying salary enhancements. Other nursing home employer retention options include initiatives that subsidize the CNA’s educational expenses. In these arrangements the facility provides staff time for specific competency training and to distribute a retention bonus or wage increase to nursing assistants upon completion. (AAHSA). Some states have developed strategies to provide training and technical assistance to organizations that employ DSWs. The training topics often include recruitment, retention, and training programs such as train-the-trainer approaches and competency based training. (Lewin, 2008). The State of Maryland does not currently offer this technical assistance. Career Ladders/Lattice: Career advancement opportunities for direct care workers include career ladders and lattices and peer mentoring. These opportunities provide additional training and often, pay increases. Studies show that the lack of these opportunities is a key reason why workers leave the direct care field. (AAHSA) High turnover of DSWs is a chronic problem for institutional employers and home/community based agencies. The causes of turnover are multi-factorial but a significant contributor is the job dissatisfaction resulting from lack of career opportunities rewarding onsite training and additional certifications in core competencies. Partnerships between employers and off-site training/education institutions through tuition remission and scholarship opportunities are sometimes used as benefit enhancements for retention purposes. “Peer mentoring” programs and demonstrations have also provided expanded career ladder opportunities for mentors and enhanced training for mentees. (Hegemon, 2008). It is also acknowledged that onsite competency training and career ladder approaches require a financial investment by the employer (IOM 2008) if they are to be successful. The business case for increased competency training, more professional certification, and increased advancement opportunity has been advanced in a broad based study of “innovative” organizations (Dailey, 2015).Secondary Education: Many innovations have been introduced in the effort to stimulate interest and commitment in DS careers at the high level. Maryland’s Allied Health Career and Technical Education (CTE) programs provide a pathway into direct service careers. The Academy of Health Professions (AHP), a Career and Technology Education (CTE) program through Maryland State Department of Education (MSDE), provides opportunities for students to prepare for a career in allied while still in high school. There are approximately 30 high school training sites statewide (Board of Nursing, 2018). These designated school sites in each Maryland County provide CTE programs of study that prepare students to pursue careers as CNAs and other health career paths. Enrollment in Maryland’s Allied Health related CTE programs was over 8,700 students in 2017. Almost 90 schools across the state of Maryland offer an allied health related program of study.? Challenges to the AHP include recruiting instructors for the program who are required by the State to have instructional certification and recruiting clinical sites that will host high school students. Nationally, Career and Technical Education (CTE) programs at the state education level are sometimes linked with registered apprenticeship (see description below) programs (Rice, 2010). In 2018 Maryland State Department of Education (MSDE) developed a youth apprenticeship program, the Apprenticeship Maryland Program (AMP), for implementation by local school systems in 2018. AMP is coordinated through a partnership between MSDE and the Maryland Department of Labor, Licensing and Regulation (DLLR). The program, for students ages 16 and older, is based on a partnership among employers and mentors, school districts, and students and parents. Eligible employers (approved by the Maryland Apprenticeship Training Council (MATC) through DLLR) hire high school juniors and seniors to work in eligible career track occupations, including those focused on allied health careers. Students also receive training in employability skills, interpersonal/social skills, and a general knowledge of the world of work. Expansion of the AMP is dependent on interested employers agreeing to be Participating Youth Apprenticeship Employers. Nursing Delegations and Enabling: Boards of Nursing determine the scope and responsibilities specifying what duties and tasks can be delegated to nursing assistants working under licensed nurse supervision. Duties frequently performed by CNAs may under certain circumstances be delegated to technical staff. It has been contended that the broadening and restructuring of DS workers’ duties and responsibilities will improve the quality of care for patients and lead to better jobs and higher wages (Osterman, 2017). Maryland regulations stipulate that a nurse may delegate treatments of a routine nature if:(1) The licensed nursing staff of the specific unit of care has identified the function as being routinely performed; (2) The specific treatments are performed at a high frequency necessary to retain competency; (3) The treatment has an inherently low risk to the client; (4) There is a quality assurance mechanism in place to assure the function is performed safely and client outcomes meet accepted professional nursing standards… (Maryland Code, Subtitle 27 BOARD OF NURSING (Chapter 11 Delegation of Nursing Functions) A more detailed listing of delegation guidelines is included in the Appendix.Registered Apprenticeships: Sponsored by the U.S. Department of Labor, Registered Apprenticeships are designed for certain occupations, combining work based and formal learning in a program leading to certification. Most of the cost of the program is the responsibility of the employer. The Long Term Care Registered Apprenticeship Program (LTC RAP) has been utilized by employers, employer associations and labor-management organizations, to provide formal training and work experience for DS workers in long-term care settings. This program includes apprenticeships specifically for CNAs and Home Health Aides. The goal of LTC RAPs is to “significantly improve worker skill development, job mobility within long-term care settings, organizational productivity, and quality of care.” (ASPE 2010). As of 2016 there were no functioning LTC RAPs operational in Maryland. Community Colleges and Universities: Community Colleges and some university programs prepare the majority of Certified Nursing Assistants, Geriatric Nursing Assistants, and certifications for other allied health and medical assistant workers. Of the sixteen Community Colleges in Maryland 14 offered CNA programs in 2016. Student CNA enrollment in FY 2016 was 1,513 (MACC, 20) and completion of CNA/GNA Community College programs has increased significantly as shown in the following table (Kunsman, 2018). Fiscal YearCNAGNATotal CompletersFY17 (07/16 – 06/17)8271841,011FY16 (07/15 – 06/16)70572777Several Community Colleges in Maryland have experienced a lack of student interest in “geriatric” concentrations within their CNA preparation programs. This has resulted in the elimination of GNA specific certification programs. “Letters of Recognition” in geriatrics have requiring completion of core courses on aging have been established in some colleges in lieu of a GNA certification. Certification requires training in both theoretical and clinical skills (competency) testing. Clinical placements and curriculum development are advanced through college/employer interchange and partnerships. These interchanges can hinge around tuition remission or internship initiatives. Core competency training has been advanced through various private training and advocacy agencies including PHI. Cultural Adaptations and Communication skills: It has been estimated that 30% of health care aides and 20% of CNAs are immigrants. (Osterman, 2017). CMS quality ratings for facilities and home care services have given increasing prominence to patient participation in the development of care plans as well as satisfaction with service provision. These factors contribute to the need for “soft” skill training (e.g. communication skills) as well as the clinical training. The long term care workforce is challenged with developing a cultural and language responsive curriculum and PHI and other agencies have responded to these needs (NDSWRC, 2014). Increased importance by CMS on nursing home patient satisfaction and patient driven care highlights the importance of effective interaction with DSWs who provide most of the routine face-to-face care for patients/residents.Maryland home based Medicaid programs. Personal care services through Medicaid 1915 waiver programs were expanded through The Affordable Care Act which provided increased federal financing and flexibility for State Medicaid agencies. The Maryland Community First Choice (CFC) program is one such expansion. CFC provides mostly personal care services for community dwelling individuals who may otherwise require nursing home care. In 2016 the program served approximately 12,000 older adults and people with disabilities. (Davis, 2018). The program contracts with licensed agencies. The Maryland Community Personal Assistance Program (CPAS) provides personal care assistance to Maryland residents who need support with activities of daily living. Personal care aides in both programs are not subject to federal training requirements. State Medicaid agencies approve participant directed service models (CMS 2013) which, in Maryland may include family members as paid aides. The Maryland contracted agencies conduct background checks and match the personal care aide with the individual receiving assistance. Considerations Going ForwardEducation and training exercise an important role in the expansion and enhancement of the direct service profession and the lives of direct service workers. Imparting the value of participation in a “helping profession” is an underlying value which cannot be overemphasized in any training or promotion endeavor. Education requirements related to certification of CNAs and training of personal care aides prompt several issues and concerns including:Establishing requirements beyond the Federal minimumAppropriate ratio of classroom to clinical trainingDevelopment of core competency standards and competency testing vs “seat time” requirementsAs a primary employer of DS workers, nursing homes play a key role in the training of DS workers. Education issues associated with nursing facilities include:Training and retention of DS workersMaintaining competitive wage levels in view of Medicaid payment levelsCreation of scholarship and other education related benefitsProviding input into DS curriculum development through partnerships with Community Colleges and other educational agenciesTechnical and other assistance through state agencies in developing retention, peer mentoring, career ladders and other incentives for DS workers at the facility levelCareer and Technical Education (CTE) and apprenticeship programs provide a pathway into direct service careers. Issues include:Promotion and expansion of CTE programsRecruiting certified instructors for the CTE programsRecruiting clinical sites that will employ high school students Establishing Long Term Care Registered Apprenticeship programs including the partnership arrangements required for successful implementationCommunity Colleges play a significant role in preparing CNA students and face issues regardingRecruiting of studentsPromotion of geriatric concentrated studiesPartnering with employers in the Long Term Supports/Services industryPreparing a culturally diverse student population for successful participation in the DS workforceFinally, the scope of work and responsibilities of DS workers requires ongoing attention. Workers performing beyond the current delegation limitations needs surveillance and increased responsibility under expanded delegation guidelines must be kept current. The role and responsibilities of CNAs and other allied health workers are likely to continue changing rapidly due to changing payment/financing systems from payers, technology introduction, and competency based practice guidelines. Sources:AAHSA “Direct Care Worker Retention: Strategies for Success”, 2010ASPE, (Office of the Assistant Secretary for Planning and Evaluation, DHHS) “A Descriptive Analysis of the U.S. Department of Labor’s Long Term Care Registered Apprentice Programs”, 2010.Board of Nursing, Maryland. Statistics, (mbon.) CMS: “Coverage of Direct Service Workforce Continuing Education and Training within Medicaid Policy and Rate Setting: A Toolkit for State Medicaid Agencies”, 2013.Dailey, Wayne et al. “Workforce Development Innovations with Direct Care Workers: Better Jobs, Better Services, Better Business”, Community Mental Health Journal, 2015.Davis, Karen et al. “Designing a Medicare Help at Home Benefit: Lessons from Maryland’s Community First Choice Program”, The Commonwealth Fund, Issue Brief, June 2018.Dill, Janette, et al. “Frontline health care workers and perceived career mobility: Do high performance work practices make a difference?”, Health Care Management Review, 2014.Ejaz et al, “The Impact of Stress and Support on Direct Care Worker Job Satisfaction”. The Gerontologist 48, Special Issue, 2008.Hegemon, Carol. “Peer Mentoring of Nursing Home CAN’s: A way to Create a Culture of Caring”, Leading Age, 2008.IOM, Institute of Medicine. Retooling for an aging America: Building the health care workforce. Washington, DC: The National Academies Press, (2008).Kunsman, Kip. Anne Arundel Community College, personal communication.MACC, “Report on Non-Credit Continuing Education Licensure and Certification FY 2016” Maryland Association Community Colleges, 2017.Moore-Duggan, Toni. Clinical Instructor, Caroline Center Gibbons Common, St. Agnes Hospital. E-mail and telephonic communication, Aug 10 – 24, 2017.NDSWRC, “Direct Service Workforce Training Resources Toolkit: A Companion Resource” National Direct Service Workforce Resource Center, 2014.Osterman, Paul. “Who will care for us?”, Russell Sage Foundation, 2017.PHI “Introducing Peer Mentoring in Long Term Care Settings” 2004Rice, O., Hudson, J., Foster, L., & Klein, S. (2016).?“Connecting secondary career and technical education and registered apprenticeship: A profile of six state systems”. Office of Career, Technical, and Adult Education, U.S. Department of Education.RTI, “A Descriptive Analysis of the U.S. DOL Long Term Care Registered Apprenticeship Programs”, 2010.The Lewin Group, “A Synthesis of Direct Service Workforce Demographics and Challenges Across Intellectual/DevelopmentalDisabilities, Aging, Physical Disabilities, and Behavioral Health”, 2008.Willging Endowment, “Area Wide Summit – Direct Care and Paraprofessional Workforce Development” Report of Proceedings, 2017.AppendixCode of Maryland Regulations Ch 10.27.11 The nurse may delegate the obtaining of specific information to an unlicensed individual or certified nursing assistant.D. When implementing the plan of care, the nurse may delegate a nursing task to an unlicensed individual or certified nursing assistant after the nurse has completed a client assessment and when the delegation of that task does not jeopardize the client's welfare.E. The nurse may delegate the responsibility to perform a nursing task to an unlicensed individual if:(1) Acceptance of the delegated nursing task does not become a routine part of the unlicensed individual's job duties; or(2) An unlicensed individual merely provides assistance with activities of daily living unless the client's needs are such that adverse health consequences are predictable.F. Administration of medication is a nursing function. As such, the nurse retains full responsibility for medication administration.G. The following activities related to medication administration may not be delegated except as provided in §H of this regulation:(1) Calculation of any medication dose;(2) Administration of medications by injection route;(3) Administration of medications by way of a tube inserted in a cavity of the body; and(4) Administration of medication by intravenous route.H. Delegation of Medication Administration.(1) The administration of medication as listed in §H(3) of this regulation may be delegated to certified medicine aides and medication technicians only in compliance with §H(2) of this regulation and when clients meet the requirements of Regulation .03F or .04D of this chapter in the following situations:?(a) Supervised group living settings;(b) Supervised or sheltered work settings;(c) Independent living settings;(d) Schools;(e) Correctional institutions;(f) Hospice care;(g) Adult medical day care centers; and(h) Child care centers established for children with health or medical conditions or both.(2) A nurse may delegate to a medication technician or certified medicine aide under this section when:(a) The nurse has provided instruction and direction; and(b) The medication technician or certified medicine aide is on site in the unit of care on a continuing basis to:(i) Monitor the therapeutic effects of the medication;(ii) Observe, record, and report untoward effects of the medication;(iii) Perform monitoring procedures required for each medication;(iv) Observe for changes in the individual client's behavior and clinical status;(v) Record and report the changes observed to the delegating nurse; and(vi) Withhold administration of the medication.(3) A nurse may delegate administration of the following medications to a medication technician or a certified medicine aide according to Regulations .03F, .04C, and .05H(1) of this chapter:?(a) Medication by metered dose inhalant, nebulizer, and oxygen by nasal cannula or mask;(b) Medication by gastrostomy tube or rectal tube if the nurse has calculated the dosage;(c) Oral medication, including:(i) Measuring as prescribed an amount of liquid medication where the nurse has calculated the dose; and(ii) Administering a fraction of a tablet if the nurse has cut the tablet;(d) Medication by subcutaneous injection if the nurse has calculated the dose;(e) Medication administered by topical route excluding stage III and IV pressure ulcers and wound care;(f) Medication administered by suppository route;(g) Medication drops administered by routes involving eye, ear, and nose; and(h) Where the registered nurse makes an on-site visit at least every 7 days to assess the client status and the performance of the medication technician's or certified medicine aide's administration of topical medication to stage three or four pressure ulcers or wounds.About Us|?Contact UsCopyright ? 2017 by LegalZone. All rights reserved. ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download