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Preparing America to Care: Training our Nation’s Homecare Workers
posted 01.16.2013

By Dorie Seavey and Abby Marquand

One of the greatest challenges we face in the immediate future is building a skilled, stable caregiving workforce to help meet the daily needs of America’s rapidly aging population. Homecare is the nation’s fastest growing job category, underscoring the reality that insufficient numbers of family members—primarily spouses and adult children—are available to provide needed care. Millions of Americans struggle to balance paid employment with caregiving.

But while the homecare and personal assistance industry is adding jobs faster than any other U.S. industry, the problematic quality of homecare jobs—poor wages, inadequate training and lack of supervisory support—undermines our efforts to recruit and retain workers.

Training Matters: Rationale and Recommended Actions

In a recent survey by the National Consumer Voice, aging adults made it clear that their preference is to age in place. Yet we also know families are increasingly stressed, providing medical care and other support that requires time and skills. A well-trained homecare workforce is the foundation of an effective homecare system, one that empowers elders to make their own choices, improves health and safety, reduces hospitalization and medical costs, and provides family caregivers with the respite and support they need. We recommend the following strategies for building a better homecare workforce:

  • Establish comprehensive training standards that address critical skills—including communication and problem-solving;
  • Design a credentialing process that integrates with home health aide and nursing assistant standards and encourages career mobility;
  • Build a training infrastructure that makes training accessible and effective for diverse populations; and
  • Provide public reimbursement of training expenses for PCAs who provide Medicaid-funded long-term services and supports.

—Dorie Seavey and Abby Marquand

Training, the research literature suggests, is a critical factor in creating a viable workforce and providing high-quality care. Lack of training and poor supervisory support are associated with higher injury rates, lower job satisfaction, higher turnover and lower care quality. Kindness and compassion are essential, but workers also need the skills to effectively communicate with clients and their families, to recognize symptoms that could quickly compromise their clients’ health, and to safely lift, transfer, bathe and feed clients. Yet there are no federal training requirements for most homecare workers, and where they exist, they have not changed since 1987.

The homecare workforce consists of two occupations: home health aides and personal care aides (PCA). Federal standards require home health aides employed by agencies delivering Medicare- and Medicaid-funded services to have a minimum of 75 hours of pre-employment training, an amount that a 2008 Institute of Medicine report ( argued was inadequate for caring for an aging population with increasingly complex medical conditions. For PCAs, who provide services similar to home health aides, there are no federal training standards. Consequently, training standards for PCAs, where they exist at all, vary by state and by program. This leads to major differences in the level of preparedness of these workers across the country—and even within states.

PCA 50-State Training Survey

PHI recently completed a two-year effort to catalog and assess PCA training requirements by state. Researchers examined training requirements for PCAs in Medicaid State Plans and HCBS waiver programs serving older adults and individuals with physical or intellectual and developmental disabilities using two lenses: the rigor of requirements, and the uniformity of training requirements across programs within a state. The latter is particularly important when considering how to make PCA credentials portable so workers can easily change jobs and care for people with different types of functional limitations. 

Our findings indicate that, in general, states have few training requirements for agency-based PCAs, leaving personal care aides woefully unprepared to meet the needs of consumers, as follows:

  • Nearly a quarter of states have no training requirements for any PCA program;
  • Nearly half of states (45 percent) have at least one Medicaid-funded personal care program with no training requirements;
  • Fewer than one-third of states have programs with specified minimum hours of required training, and of these, 68 percent specify 40 hours or less; and
  • Fewer than one-quarter of states have a state-sponsored PCA curriculum or require certification.

Finally, of 19 states with uniform requirements across all PCA programs, only five (Wash., Va., Minn., Ariz., Ark.) specify particular skills and have a state-sponsored curriculum. Three states (Fla., Ky., Okla.) and Washington, D.C., require PCAs to complete home health aide training and a competency evaluation.

With respect to PCAs working in participant-directed programs in which consumers hire and train their own aides, PHI found that while three states (Idaho, S.C., Wash.) extend similar training requirements to both agency-based and participant-directed PCAs, the vast majority of states either leave training up to program participants, or do not address training for these aides.

The PHCAST Demonstration

To address the need to bolster this essential workforce, the Affordable Care Act included the Personal and Home Care Aide State Training (PHCAST) demonstration program. With PHCAST grants, six states—Maine, Mass., Mich., Calif., Iowa, N.C.—are identifying core competencies for PCAs, testing curricula and training methods, and evaluating outcomes in order to inform an evidence- based “gold standard” for PCA training. Several states are using this opportunity to develop learner-centered training programs that better meet the needs of trainees who have learning barriers like not speaking English as a first language. They are also testing alternate ways of delivering training, such as via online classes.

PHCAST is laying the groundwork for a more rational approach to PCA training that will build skills and career paths, thereby reducing turnover and improving care quality.

All these steps are essential to meeting the challenge ahead—providing home-based support for a rapidly growing elder population. Continuing with a haphazard approach to training PCAs will undermine the ability of families to find the peace of mind that skilled, compassionate caregivers provide.

Dorie Seavey, Ph.D., is PHI’s (Paraprofessional Healthcare Institute) director of policy research. 
Abby Marquand, M.P.H., is a PHI policy research associate.
PHI is a national nonprofit dedicated to bettering long-term services and supports by improving the jobs of direct-care workers. To learn more about PHI’s 50-state survey of PCA training requirements, visit PHI PolicyWorks online.

Editor’s Note: This article appears in the January/February 2013 issue of Aging Today, ASA’s bi-monthly newspaper covering issues in aging research, practice and policy nationwide. ASA members receive Aging Today as a member benefit; non-members may purchase subscriptions at our online store.

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