National Survey On State Initiatives To Improve
Paraprofessional Health Care Employment

October 2000 Results On Nursing Home Staffing

The PHI/NCCNHR November 1999 report on state initiatives to improve staffing shows that 40 states have been addressing inadequate staffing levels in some way. These states have recognized that, as the HCFA staffing study released in July 2000 points out, inadequate staffing levels are directly affecting the quality of care received by residents.

Preliminary results from this most recent survey, released in October 2000, show that, in the 40 states that responded to the survey, advocates and providers, often working together, are pursuing a variety of solutions. Although many states are pursuing legislation that would mandate improved staffing-to-resident ratios, some are looking at a broader array of reforms to help providers recruit and retain a stable, well-trained workforce. Most notably, a large number of states are seeking to improve wages for CNAs. Those that are most forward looking are also seeking to improve benefits, training, and opportunities for advancement in order to compete for workers in the new economy. Massachusetts successfully passed a comprehensive bill that authorized funds for wage increases, pre-certification preparation and certification training, and career advancement demonstration projects.

Summary of Findings

Staffing Ratios Several states have fully adopted changes in staffing ratios, while others achieved legislative approval, but not final gubernatorial approval. Maine has adopted new staff-to-patient ratios for staff responsible for "hands-on patient care" (including all nursing staff): 1 to 5 for days; 1 to 10 for evenings; and 1 to 18 for nights. Oklahoma has approved ratios of 1 to 8, 1 to 12, and 1 to 17, respectively, beginning September 1, 2000. Further increases, mandated for 2001 and 2002 eventually achieve ratios of 1 to 6, 1 to 8, and 1 to 15. (The Oklahoma ratio includes activity, social services, and therapy staff as well as nursing staff until 2002, when the ratios must include only CNAs). California passed legislation mandating minimum threshold of 3.5 hours of hands-on care per patient per day by 2004, unless a study commission develops an alternative recommendation by that date. Delaware also passed legislation mandating that minimum hours be increased to 3.0 hours per patient per day for 2001; a study commission has recommended increases to 3.2 hours by December 2001 and to 3.67 hours by January 2003.

Advocates also introduced legislation to set higher staffing levels in Michigan, New Jersey, New York, and Washington, DC, but efforts failed this year. Rhode Island's proposal to improve ratios to 1 to 8, 1 to 12, and 1 to 20 stalled in this session. The Arkansas legislature passed a new standard of 1 to 8, 1 to 12, and 1 to 18, but the measure was derailed in July 2000 by lack of departmental funding. Arkansas advocates continue to push for implementation. Most staffing legislation includes a requirement to publicly post staff on duty, reflecting a long-standing consumer demand.

Wages and Benefits In 1999, Connecticut, California, Florida, Maine, Montana, Virginia, and Wisconsin passed wage increases for CNAs. During 2000, more than 20 states (California, Colorado, Delaware, Idaho, Iowa, Illinois, Kentucky, Maryland, Massachusetts, Michigan, Minnesota, Montana, New Mexico, Nevada, North Carolina, North Dakota, Oklahoma, Oregon, Rhode Island, Texas, Utah, and Washington) introduced legislation to improve wages to direct-care workers, but many of the proposals either failed or were modest in scope. For example, Oklahoma's reform package set a minimum hourly wage for direct-care workers at $6.65.

Maryland and Minnesota took a more flexible approach to addressing low wages. Maryland passed legislation increasing Medicaid funding to the nursing cost-center by $10 million in both 2002 and 2003. These funds are not targeted specifically to CNAs-the funding can be used to enhance staffing levels, wages, or direct-care services. Minnesota's legislation offers even more flexibility. Rate increases can be used for compensation-related costs, including salaries, payroll taxes, and fringe benefits for all employees except managers and central office staff. An additional rate increase is also available for specific operating costs. In both Maryland and Minnesota, facilities have considerable flexibility in using the rate increases.

Wage pass-throughs are the most commonly proposed strategies to achieve wage increases. We are just learning the effects of different types of implementation on the actual dollars that CNAs receive. For example, in 1999, Virginia passed a package to improve CNA hourly wages by up to a $1/hour, but not all nursing homes applied for the increase. Because the legislation was poorly implemented and lacked accountability, many CNAs failed to benefit from the state authorization. Some states are asking nursing facilities to submit plans to their state Medicaid departments to define how they will use additional funds. Other states take a more standardized approach and determine exactly which staff are eligible and for what amount of increase. Some states have a clearly designated system for auditing these new funds, while others have not been as specific. (The North Carolina Division of Facilities Services will soon publish the results of their study of the efficacy of these different wage pass-throughs. See their most recent data at http://facility-services.state.nc.us/provider.htm.)

Only a few states offer any assistance with health insurance. CNAs benefit from state laws that address the health care needs of low-income workers in states such as Vermont and Hawaii. Vermont expanded a plan that allows individuals with incomes up to 300% of poverty to purchase prescription drugs at the Medicaid rate. Hawaii mandates that full-time workers receive medical coverage from their employers who must pay at least 50% of the premium. Although not yet extended to CNAs, Rhode Island has implemented a program to provide health care for child care workers through Medicaid. This model that could also work for low-wage health care workers. Most states, however, see health care as the responsibility of providers and have not begun to explore alternatives.

In truth, many direct-care workers have traditionally relied on health insurance and other benefits from the public assistance system. CNA wages have been so low that workers have been eligible for Medicaid to provide health insurance for themselves and their children. However, with the cutbacks generated by "welfare reform," more low wage and part-time workers are now left without any health insurance-from either their employer or the government-though their children are often eligible for their state's version of the Medicaid CHIP program. Research, however, indicates that many low-wage workers are not aware of this benefit and are not using it.

Training & Supervision Currently, the federal government requires 75 hours of training for CNA certification. About one-third of the states mandate additional hours of training, with California, Maine, and Oregon at the high end, requiring 150 hours. Advocates for increased training point to recent data about nutrition, hydration, dementia care, worker injury rates, and turnover rates to illustrate the need for better, more comprehensive training.

Ten states are pursuing efforts to increase or improve the training for CNA certification. Several of those are requiring unspecified additional hours, while California and Oklahoma, among others, indicate that those additional hours should address dementia care. New York advocates sponsored a conference focused exclusively on CNA training requirements, urging that soft skills such as communication and problem solving also be included in the required curriculum. They have also been lobbying for 160 hours of mandated training.

Advocates in several states-Delaware, Massachusetts, and North Dakota-are actively promoting career ladders as another aspect of training. Other states, such as Louisiana are focused specifically on curriculum development.

In contrast to a general push for more training, one bill has been offered in Congress and others have been proposed in the states -West Virginia, for example-for single-task, minimally trained workers. Rather than promoting a solution, the use of single-task, untrained workers poses a risk to the health and well-being of residents while perpetuating the poor quality of direct-care jobs by offering part-time work for even lower pay without benefits.

Finally, more than one-third of the states are looking at ways to shape incentives to promote better management, supervision, and other improvements in the nursing home workplace culture. Nine states have been able to access Civil Monetary Penalty funds to support new programs on training, supervision, and management.

Emerging Coalitions Of the 40 states that responded to the survey, 30 report that their state has either an informal or formally appointed taskforce or commission looking at long-term care workforce issues. Most of these work groups are comprehensive in that they include workers, consumers, providers, and government representatives. The work group in Massachusetts is perhaps most inclusive because it also includes representatives from community colleges as well as the welfare reform and traditional workforce development constituencies.

Notably, the Massachusetts legislature recently passed a bill that provides the most comprehensive approach to addressing workforce issues in nursing homes. In addition to a $35 million wage pass-through for CNAs, it includes $5 million for CNA career ladder grants, $l million for a scholarship program for certification training for new CNAs, and $1 million in training and adult basic education for prospective CNAs. The governor vetoed two proposals in the original bill: a study on health insurance for direct-care workers and a permanent Advisory Council on Nursing Home Quality to study and make recommendations on staffing levels and workforce issues. This new law is an important model for other states in its comprehensive approach to a multifaceted problem.

Conclusion

Seen as a whole, all these attempts by states are focused on finding ways to attract a stable, valued, and well-trained direct-care workforce for our nation's citizens who are elderly, ill, and living with disabilities. There is a shared recognition that improving the quality of care delivered to residents can only be achieved by enhancing the job quality of the frontline workforce. In some states, advocates are seeking to change a single aspect of the problem. In other states, successes in one year have lead to more improvements in subsequent years. Massachusetts, however, has taken a more comprehensive approach by addressing multiple issues in a single piece of legislation. Their success can be attributed to having created a strong, broad-based coalition that included consumers, workers, and providers who worked together to influence government officials. We must now track these changes over time to evaluate their effect on workforce stability and quality care.