BY: MARY ANN WILNER, PhD
Dr. Wilner is director of health policy at Paraprofessional Healthcare Institute, Bronx, NY.
Administrators in Catholic health systems face unprecedented pressures. Change may be inevitable, but the speed of change is now so great that it threatens to distance us from the very reasons we entered this work: to provide valued care to the ill, the elderly, and the disabled.
Unfortunately, the size and complexity of our health systems may be expanding faster than our ability to manage them. Consolidation, partnerships, and alliances all create new layers of people who must be consulted, additional forms that must be filed, and more papers that must be read, all of which threatens to obscure even further our view of what healthcare really means for the clients we serve.
However, one type of healthcare employee has no trouble keeping in touch with her clients: the paraprofessional "frontline" worker. She is the human hands, heart, and voice of healthcare for millions of healthcare consumers. Increasingly, we are relying on the paraprofessional to deliver care: More than 2,300,000 aides and attendants now work in this country's hospitals, nursing homes, and home care agencies — more than 20 percent of the entire nation's healthcare workforce. Paraprofessionals provide 75 percent to 85 percent of direct care for clients at home, and they provide 80 percent to 90 percent of the direct care given to nursing home residents.
The restructuring that is so dramatically changing our work life is forcing change on the paraprofessional as well. Some of it is positive, and some of it is potentially damaging to both the direct-care worker and her client. At a time when the distance between the client and healthcare decision makers is becoming greater and greater, administrators must place new attention on the role of the paraprofessional.
A "High Investment" Strategy
Clients want direct-care workers who are reliable and sensitive, who speak their language, who are kind to them and trustworthy, and who stay. Yet paraprofessional care is, as the U.S. Department of Health and Human Services admits, ridden with high turnover. Low wages, part-time hours, inadequate training, and few benefits result in an annual turnover rate among paraprofessionals in the home care industry of between 40 percent and 60 percent, and in nursing homes between 70 percent and 100 percent.
In turn, health and long-term care providers all over the country bemoan their inability to attract or retain good frontline workers. Yet some healthcare organizations are exceptions, retaining staff by building frontline-oriented cultures and treating the direct-care worker as they want that worker to treat her clients.
For example, the Paraprofessional Healthcare Institute is affiliated with Cooperative Home Care Associates (CHCA) and a network of other worker-owned home health companies that employ more than 650 women, primarily African-American and Latina, in New York City, Boston, Philadelphia, and Waterbury, CT. CHCA, based in the heart of the South Bronx, has an annual turnover rate of 18 percent among its paraprofessionals, even though more than 75 percent of CHCA's employees were formerly dependent on welfare.
Throughout this network of cooperatives, we have sought to replace the typical "low-investment," "temporary personnel" approach with a strategy of "high investment" in frontline employees, emphasizing careful recruitment, decent wages and benefits, full-time work, extensive training, counseling, and support. Our worker-ownership model further reinforces the enterprise, both as a paraprofessional-oriented business and a community of coworkers. Each employee has the opportunity to own a single share of the company, and annual dividends paid to worker/owners in recent years have ranged between $250 and $600.
Frontline Workers Need Support
Our experience within our network of worker-owned home care agencies, as well as my and others' research on paraprofessional services within residential settings, demonstrates that frontline workers need the following kinds of support to ensure both a decent job and delivery of high-quality care.
Adequate Compensation Frontline workers need to be paid a living wage with benefits. Most health paraprofessionals are women who are working, but poor. In 1993 more than 600,000 direct-care workers lived below the poverty line. Furthermore, how can paraprofessionals be asked to provide high-quality healthcare if they are not themselves provided health insurance?
Stability To have a job that is financially secure, aides need guaranteed hours of work. Agencies that typically offer only part-time jobs, such as home care services, have found that offering guaranteed hours to a portion of their workforce dramatically reduced turnover.
Selection
Retention of high-quality workers requires careful selection of employees who are mature, sensitive, and interested in caregiving work. Careful screening can save agencies both time and dollars by reducing expensive turnover.
Sufficient Training Organizations that believe in the capacity for employee growth must provide opportunities for them to grow. CHCA in the South Bronx provides four weeks of training, twice the federal requirement, and emphasizes communication, problem solving, psychosocial development, and job readiness, in addition to the required clinical skills. Many of the trainers are former home health aides who have been promoted to associate instructors, and who are powerful role models for new trainees.
Supervision Paraprofessionals need good supervision to manage the complex cases they are now seeing in homes and nursing facilities. Yet few nurses or coordinators have been trained in management and supervision. Our network's Home Care Associates of Philadelphia has begun a coaching program that provides support and supervision to aides.
Support Peer support is as important as supervisory support. In some areas, frontline workers are starting peer support groups or paraprofessional associations. In other places, nursing homes are starting to sponsor CNA support groups in which aides can exchange patient information and caring techniques, support one another, practice communication skills with peers and supervisors, and grieve for residents who have died. At CHCA, a senior trainer conducts a "rap session," a peer-oriented support group for new aides.
Upgrading and Promotion Although many paraprofessionals love their one-on-one work and have no desire to become trainers, nurses, or supervisors, they want the respect and pay increases that seniority deserves. CHCA has promoted a small core of aides to administrative positions and to RN status, and has offered college courses, delivered on-site at the workplace, for paraprofessionals to expand their knowledge and advance their education.
What is critical here is not the specifics, but the intent: to focus new attention on the frontline worker, and to design the provision of care around the all-important relationship between the client and her direct caregiver.
Our healthcare world has changed entirely. Technology, managed care, and government financing have restructured nearly everything we know. That is precisely why we must change how we support, train, and pay our paraprofessionals, if the value of our care to our clients is to remain the same.
WELFARE-TO-WORK INITIATIVE
The Catholic Health Association (CHA) is collaborating with the Catholic Campaign for Human Development (CCHD) of the U.S. Catholic Conference and Catholic Charities USA on a five-year welfare-to-work initiative to promote the dignity and self-sufficiency of vulnerable persons by creating new businesses that employ former welfare recipients.
Working with healthcare systems and sponsors, the three national Catholic organizations are promoting the replication of successful day care and home care companies that employ low-income people at wages above industry norms and provide for worker ownership of the companies. By 2002, the initiative aims to start up four new home healthcare businesses employing more than 350 persons each and four new day care companies employing more than 50 people each. The initiative is raising funds to assist businesses with training costs and start-up capital.
To ensure local projects' success, CHA, CCHD, and Catholic Charities USA will contract with technical-assistance providers experienced in the development of the businesses and the management of worker-owned enterprises.
Representatives from the three organizations and from successful companies are making visits to healthcare organizations to explain how the initiative serves workers, communities, and the mission of Catholic healthcare organizations.
For more information about the initiative, contact Julie Trocchio at CHA (202-296-3993); Steve Callahan at CCHD (202-541-3376); or Jane Stenson at Catholic Charities USA (703-549-1390, ext. 120).
PHI
The Paraprofessional Healthcare Institute (PHI) is a nonprofit organization, based in the South Bronx, that links a network of worker-owned healthcare providers specializing in paraprofessional services. The mission of PHI is to (1) provide high-quality healthcare to clients who are elderly, chronically ill, and disabled, and (2) create decent jobs for low-income women, with an emphasis on those who are unemployed or making the transition from welfare to work.
Copyright © 1999 by the Catholic Health Association of the United States
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