Understanding Multilevel Factors Related to Retention Among the Direct Care Workforce: Incorporating Lessons Learned in Considering Innovative Interventions

GOAL

This article explores how broad, contextual factors may be influential in the retention of direct care workers (DCWs; i.e., entry-level caregivers) who provide vital support to patients in healthcare settings. We reflect on lessons learned from an evaluation of a multisite intervention to improve retention among DCWs employed primarily in hospital settings at three health systems.

METHODS

We evaluated a multitiered program for entry-level caregivers that included a risk assessment, a 4-day curriculum, and follow-up sessions, as well as workforce coaching at the three health systems. As part of our evaluation, we collected data on roughly 3,000 DCWs from the three health systems; the information included hiring date, any transfer date, and any termination date for each new DCW, as well as demographic information, position characteristics, and termination status and reasons for any termination. In addition, we collected information about organizational characteristics, including staffing and number of employees. We also conducted interviews with 56 DCWs and 21 staff members who implemented a retention program across each of the three health systems and remotely conducted virtual observations of the curriculum sessions at each system.

PRINCIPAL FINDINGS

Although the program we evaluated focused on individual-level factors that may affect retention, our findings revealed other broader, contextual challenges faced by DCWs that they said would have an impact on their willingness to stay in their positions. These challenges included (1) job-related factors including limited compensation, aspects of the job itself, and the inability to advance in one's position; (2) health system challenges including the mission, policies, staffing, and organizational culture; and (3) external factors including federal policies and the ongoing COVID-19 pandemic.

PRACTICAL APPLICATIONS

As the direct care workforce continues to grow, interventions to improve retention should consider the interconnectedness of these multilevel factors rather than solely individual-level factors. In addition, further research is needed to rigorously evaluate any potential intervention and consider how such an approach can target DCWs in hospital-based settings who are most affected by the multilevel challenges identified. Finally, any intervention to improve retention must be also aligned to ensure equity, especially in this population of low-wage DCWs, many of whom are marginalized women and individuals of color.

Having a Say Matters: The Association Between Home Health Aides' Voice and Job Satisfaction

Purpose

Despite a rapidly growing need for home health aides (HHAs), turnover rates are high. While this is driven in large part by the demanding nature of their work and low wages, another factor may be that HHAs are often not considered part of the medical team which can leave them feeling unheard by other healthcare professionals. We sought to determine whether this concept, or HHAs' perceived voice, was associated with job satisfaction.

Methods and Design

This cross-sectional survey of English- and Spanish-speaking HHAs caring for adults with heart failure (HF) was conducted from June 2020 to July 2021 in New York, NY in partnership with a labor management fund of a large healthcare union that provides benefits and training to HHAs. Voice was assessed with a validated 5-item scale (total score range 5 to 25). Job Satisfaction was assessed with the 5-item Work Domain Satisfaction Scale (total score range 5 to 35). Multivariable linear regression analysis was used to examine the association between voice and job satisfaction.

Results

A total of 413 HHAs employed by 56 unique home care agencies completed the survey; they had a mean age of 48 years, 97.6% were female, 60.2% were Hispanic, and they worked as HHAs for a median of 10 years (IQR, 5, 17). They had a median Voice score of 18 (IQR 15-20) and mean job satisfaction score of 26.4 (SD 5.6). Higher levels of voice (1.75 [0.46-3.04]) were associated with greater job satisfaction (p=0.008). When adjusting for Race/Ethnicity, HF training, and HF knowledge, the association between Voice and job satisfaction remained significant ((1.77 [0.40-3.13]).

Conclusion

HHAs with a voice in the care of their patients experienced greater job satisfaction. Voice may be an important target for interventions aiming to improve HHAs' retention in the field.

Working Conditions Affecting Home Care Workers' Stress and Turnover Intention

This study explored how working conditions influence the psychological outcomes of paid family and non-family home care workers, focusing on the interaction between institutional and recipient effects. Using data from the 2019 Korean Long-Term Care Survey (N = 998), we performed regression analyses on home care workers' stress and turnover intention. For both types of home care-workers, inadequate working conditions and high occupational hazards influenced stress, while good working conditions and low occupational hazards influenced turnover intention. Overall, the findings suggest that wages, working hours, and work intensity must be reformed in a home care-worker-friendly manner; the wages for home care workers must be raised to a level appropriate to their care work; the services provided by home care workers should be explicitly stipulated; and, to eliminate occupational hazards, environments for fostering cordial relationships between recipients and home care workers must be developed.

Formative Evaluation of a Workforce Investment Organization to Provide Scaled Training for Home Health Aides Serving Managed Long-Term Care Plan Clients in New York State

As part of its Medicaid program restructuring, New York State funded 11 Workforce Investment Organizations (WIO) to support training initiatives for the long-term care workforce. Focusing on one WIO, this formative evaluation examined quality improvement training programs delivered to 11,163 Home Health Aides employed by home care agencies serving clients of Managed Long-Term Care plans. Results are presented from a thematic analysis of qualitative interviews with organizational and program stakeholders examining contextual factors influencing program objectives, implementation, barriers and facilitators, and perceived outcomes. Findings suggested that WIO training programs were implemented during a period of shifting organizational strategies alongside value-based payment reforms and challenges to aide recruitment and retention. Stakeholders appraised WIO training programs positively and valued program flexibility and facilitation of communication and collaboration between agencies and plans. However, delivery and implementation challenges existed, and industry-wide structural fragmentation led stakeholders to question the WIO's larger impact.

Eliciting the educational priorities of home care workers caring for adults with heart failure

BACKGROUND

Although home care workers (HCWs) are increasingly caring for adults with heart failure (HF), many feel unprepared and lack HF training. To serve as the foundation for a future educational intervention, we aimed to elicit HCWs' HF educational needs.

METHODS

We partnered with the largest healthcare union in the US to recruit 41 HCWs employed by 17 home care agencies. Using the nominal group technique, we asked HCWs to respond to three questions: When caring for an HF patient: (1) What information do you want? (2) What symptoms worry you? (3) What situations do you struggle with? Participants ranked their responses by priority. Data were consolidated by question.

RESULTS

For question 1, participants ranked HF signs and symptoms most highly, followed by HF treatment and medications. For question 2, chest pain was most worrisome, followed by neurologic changes and shortness of breath. For question 3, participants struggled with encouraging patients to follow a heart-specific diet.

CONCLUSIONS

HCWs expressed a need to learn more about signs and symptoms of HF and ways to assist patients with HF self-care. These findings can inform the development of an HF training program for HCWs that specifically addresses their expressed needs.

Relationship Between Working Conditions, Worker Outcomes, and Patient Care: A Theoretical Model for Frontline Health Care Workers

Despite the integral role that frontline health care workers play in providing care to older adults and those with chronic conditions and disabilities, few studies have examined the relationships between the working conditions endured by this workforce, the quality of the care they deliver, and the outcomes of patients for whom they care. Thus, the authors: (1) developed a novel conceptual framework that highlights these relationships and (2) performed a comprehensive search and analysis of the literature (PubMed, AgeLine, Cumulative Index to Nursing and Allied Health Literature (CINAHL), JSTOR, Scopus, Web of Science) to assess the relationships proposed in the framework. A total of 31 studies were included. The results suggest that working conditions affect workers themselves, the care they deliver, and their patients' outcomes. Additional studies, as well as policy solutions, are needed to address the issues faced by this workforce in order to improve health care delivery.

Prevalence and Correlates of Gray Market Use for Aging and Dementia Long-Term Care in the U.S

OBJECTIVES

To estimate the national prevalence and sociodemographic correlates of gray market utilization, consisting of paid providers who are unrelated to the recipient, not working for a regulated agency, and potentially unscreened and untrained, for aging and dementia-related long-term care.

METHODS

We surveyed a nationally representative sample of 1,037 American Life Panel respondents aged 18 years and older.

RESULTS

Nearly a third of Americans who arranged paid care sought gray market care for persons with dementia, and most (65%) combined it with unpaid care. Respondents who arranged gray market care had 66% lower odds of currently working, and those living in rural areas had an almost 5-times higher odds of arranging dementia gray market care.

DISCUSSION

Gray market care represents a substantial proportion of paid, long-term care for older adults and may fill gaps in access to care.

Interventions to Reduce the Impact of Client Death on Home Care Aides: Employers' Perspectives

For home care agencies and aides, the death of clients has important, yet often unrecognized, workforce implications. While research demonstrates that client death can cause grief and job insecurity for aides, we currently lack home care agencies' perspectives on this issue and approaches to addressing it. This study uses key informant interviews with leaders from a diverse sample of eight New York City home care agencies to explore facilitators and barriers to agency action. We found that agencies engaged primarily in a range of informal, reactive practices related to client death, and relatively few targeted and proactive efforts to support aides around client death. While leaders generally acknowledged a need for greater aide support, they pointed to a lack of sustainable home care financing and policy resources to fund this. We recommend increased funding to support wages, paid time off, and supportive services, and discuss implications for future research.

The Effect of Ageist Behaviors on Home Care Workers' Job Satisfaction and Retention in Long-Term Care

OBJECTIVES

This study aimed to examine how intrinsic and extrinsic factors of job satisfaction affect home care workers' intention to stay and determine whether ageist behaviors moderate the relation between job satisfaction and intention to stay.

METHOD

We recruited 380 participants to complete measures of job satisfaction, ageist behaviors, and intention to stay.

RESULTS

Monthly wages, extrinsic and intrinsic factors, and positive and negative ageist behaviors were significantly related to home care workers' retention. Both positive and negative ageist behaviors negatively moderated the relation between job satisfaction and retention.

CONCLUSION

Home care workers' retention may be increased by providing reasonable extrinsic rewards and enhancing the intrinsic nature of the job itself. Reducing negative ageist behaviors and increasing positive ones for those with low job satisfaction could be related to higher retention. The harmful effects of positive behaviors should be addressed. These findings could contribute to workforce retention in long-term care.

Heart Failure Training and Job Satisfaction: A Survey of Home Care Workers Caring for Adults with Heart Failure in New York City

Background

Home care workers (HCWs), who include home health aides and personal care attendants, frequently care for adults with heart failure (HF). Despite substantial involvement in HF care, prior qualitative studies have found that HCWs lack training and confidence, which creates challenges for this workforce and potentially for patient care. Herein, we quantified the prevalence of HF training among HCWs and determined its association with job satisfaction.

Methods

We conducted a cross-sectional survey of agency-employed HCWs caring for HF patients across New York, NY from 2018-2019. HF training was assessed with, "Have you received prior HF training?" Job satisfaction was assessed with, "How satisfied are you with your job?" The association between HF training and job satisfaction was determined with robust poisson regression.

Results

323 HCWs from 23 agencies participated; their median age was 50 years (IQR: 37,58), 94% were women, 44% were non-Hispanic Black, 23% were Hispanic, 78% completed ≥ high school education, and 72% were foreign-born. They had been caregiving for a median of 8.5 years (IQR: 4,15) and 73% had cared for 1-5 HF patients. Two-thirds received none/a little HF training and 82% felt satisfied with their job. In a fully adjusted model, HCWs with some/a lot of HF training had 14% higher job satisfaction than those with none/a little HF training (aPR 1.14; 95% CI 1.03-1.27).

Conclusions

The majority of HCWs have not received HF training. HF training was associated with higher job satisfaction, suggesting that HF training programs may improve HCWs' experience caring for this patient population.

Understanding the Workflow of Home Health Care for Patients with Heart Failure: Challenges and Opportunities

BACKGROUND

Readmission rates are high among heart failure (HF) patients who require home health care (HHC) after hospitalization. Although HF patients who require HHC are often sicker than those who do not, HHC delivery itself may also be suboptimal.

OBJECTIVE

We aimed to describe the workflow of HHC among adults discharged home after a HF hospitalization, including the roles of various stakeholders, and to determine where along these workflow challenges and opportunities for improvement exist.

DESIGN AND PARTICIPANTS

In this qualitative study, we used purposeful sampling to approach and recruit a variety of key stakeholders including home health aides, nurses, HF patients, family caregivers, physicians, social workers, home care agency leaders, and policy experts. The study took place in New York, NY, from March to October 2018.

APPROACH

Using a semi-structured topic guide, we elicited participants' experiences with HHC in HF through a combination of one-on-one interviews and focus groups. Data were recorded, transcribed, and analyzed thematically. We also asked selected participants to depict in a drawing their understanding of HHC workflow after hospitalization for HF patients. We synthesized the drawings into a final image.

KEY RESULTS

Study participants (N = 80) described HHC for HF patients occurring in 6 steps, with home health aides playing a main role: (1) transitioning from hospital to home; (2) recognizing clinical changes; (3) making decisions; (4) managing symptoms; (5) asking for help; and (6) calling 911. Participants identified challenges and opportunities for improvement for each step.

CONCLUSIONS

Our findings suggest that HHC for HF patients occurs in discrete steps, each with different challenges. Rather than a one-size-fits-all approach, various interventions may be required to optimize HHC delivery for HF patients in the post-discharge period.

"Who's Caring for Us?": Understanding and Addressing the Effects of Emotional Labor on Home Health Aides' Well-being

BACKGROUND AND OBJECTIVES

Interventions to strengthen the home care workforce focus on workers' economic and physical well-being, without acknowledging the caring labor affecting emotional well-being. Our study examined workers' perceptions of the emotional effects of caring work, coping mechanisms, and desired support.

RESEARCH DESIGN AND METHODS

We conducted 4 worker focus groups (n = 27). Moderators cross-checked codes and themes, and aides provided input through report-backs.

RESULTS

Building close, trusting relationships with clients was central to aides' emotional well-being. Well-being was also influenced by relationships with client families and agency supervisors, work-life balance, and the level to which aides felt their work was valued. Aides were largely alone in managing job stressors and desired more communication, connection, and support from supervisors and peers.

DISCUSSION AND IMPLICATIONS

Recognizing and supporting the emotional demands of caring work is crucial to strengthening the workforce. Policy makers and agencies must realign reimbursement systems, job descriptions, and care plans to include measures of emotional labor, improve communication between workers and supervisors, and provide training, mental health benefits, and peer support.

Racial–Ethnic Differences in Turnover Intent Among Home Health Aides

Home health aides are crucial to ensuring quality services for the growing older adult population needing home-based care in the United States. We utilize data from the nationally representative 2007 National Home Health Aide Survey ( N = 3,344) to analyze racial–ethnic disparity in turnover intent. Non-Hispanic Black and non-Hispanic Other home health aides had higher all-cause turnover intent than Non-Hispanic Whites. Cause-specific turnover intent varied by race–ethnicity. Compared with non-Hispanic White home health aides, (a) non-Hispanic Black home health aides were more likely to leave due to low pay and educational/advancement opportunities; (b) Hispanic home health aides were more likely to leave due to a perceived lack of respect or difficulty with their supervisor/agency; and (c) non-Hispanic home health aides were more likely to leave due to an impending move. Findings suggest that efforts to address high levels of turnover intent among home health aides should account for differences in race–ethnic groups.

An international perspective on improving occupational conditions for direct care workers in home health

The occupational health and safety of direct care workers in the home health setting has been the focal point of a somewhat scarce, though highly important, body of research. Although the demand for home care services continues to expand with the rapidly growing population of older adults worldwide, home care workers - such as home health aides and personal care attendants - do not have the same level of protections by workplace safety policies such as those implemented in hospitals and nursing homes. This commentary synthesizes international perspectives on the occupational health and safety of home care workers, including the problem of workers’ rights violations and abuse by clients and their families. Prior policy and practice efforts have focused on improving the training, supervision, job satisfaction, and retention of home care workers, but have focused less on addressing issues of abuse. This paper recommends potential strategies to be developed and tested to provide a stronger support system for home care workers, more fully integrate them into the care team, and improve the occupational health and safety of this diverse, rapidly expanding workforce.