The Commonwealth of Massachusetts initiated the Extended Care Career Ladders Initiative (ECCLI) as part of a broader Nursing Home Quality Initiative, adopted by the Massachusetts Legislature in 2000. Both acts were a response to high turnover and vacancies among paraprofessionals in long-term care, creating instability that threatens quality and access to health care. Basic to these initiatives is the equation of good care for consumers with good jobs and opportunities for frontline caregivers. This working paper is an 18-month evaluation of ECCLI Round 2, designed to use workforce development strategies to improve both worker and resident outcomes.
This report covers Round 2, building on a prior baseline report (and KSG Working Paper RWP01-035) dated September 2001. This paper evaluates activity, lessons, barriers, and achievements of seven consortia that included 27 nursing homes, two home health agencies, and about 20 workforce partners during the period July 2001 through May 2002. It uses a case study and interview approach as its main evaluation method, as well as reporting project-wide data where available. In total, we conducted more than 80 interviews with the seven project coordinators, 25 nursing home and home health managers, 10 community or workforce expert representatives and 41 workers. Survey data were collected from 161 training participants as well.
Training is one of ECCLI Round 2’s most visible accomplishments to date. More than 600 workers in 27 facilities or home care agencies were trained in a wide array of skills, ranging from clinical knowledge and care giving to generally applicable skills, such as English for Speakers of Other Languages (ESOL), teamwork, communications, and problem-solving. Most ECCLI consortia have also taken small steps in improving the earning power of nursing aides and service workers. Most case study sites reported wage increases, whether for completion of career ladder courses, or for moving to certified nursing assistant from dietary or housekeeping roles. The wage increments are modest, generally in the range of 3-4%, or from 30 to 50 cents per hour. More than seven in ten workers surveyed had received a pay increase because of the training; the majority found their raises moderately helpful but not significantly so. ECCLI employers are also finding it easier to find and keep workers since implementing the program, particularly in nurse aides and ancillary staff. Participating employers are seeing fewer vacancies, lower staff replacement costs, and a reduction in employee exits, agency costs, and turnover. Some progress in changing the practices of caregiving has also occurred, though not across the participating consortia. One of the most significant changes is the “individualized bathing” initiative adopted by several facilities in one consortium. Career ladders of some kind now exist for workers in all the consortia, though the level of institutionalization varies. Quality improvement outcomes cannot be demonstrated definitively pending further data acquisition, but qualitative evidence suggests improvements in several key areas.
Perhaps the greatest “internal” barrier to success has been balancing the implementation of a complex project with daily operational demands of running a 24-hour nursing facility. The compressed project schedule (of one year for implementation) contributed to these problems. State budget delays stalled the projects for six months in several consortia, further complicating implementation. Many positive lessons for how to implement career ladders and care giving improvements were identified in the evaluation report as well.