Direct Care Workers and HighValue Nursing Home Care

1
Direct Care WorkersandHigh-Value Nursing Home
Care

• November 14, 2003

2
Culture Change

• Strategic organizational change focusing on
  direct care workers
• Objective add value to nursing home services
• Do research results support the focus of
  organizational strategies on direct care workers?
• Gaps What do we need to learn?

3
Two Views of Nursing Home Services

• View One A day is a day is a day
• Medicaid pays for days
• States regulate minimum inputs
• Quality as minimizing poor medical outcomes
• Implication minimize costs for standard care

4
Two Views of Nursing Home Services

• View Two A customized service package
• Meet resident needs
• Medical
• Compensation for disabilities
• Accommodate resident preferences
• Meals, sleep schedule, activities
• Foster relationships
• Family, friends
• Care providers
• Implication Focus on the Direct Care Worker

5
What produces high-value service?Hypotheses

• Staffing enough staff time--
• To carry out tasks
• To individualize service
• To build relationships
• Training to do tasks better
• Continuity of staff
• Autonomy fosters pride in job
• Leadership
• Support DCWs work and potential to build
  relationships
• Wages, benefits, advancement recognize value of
• Continuity
• Caring
• Other HR practices

6
What produces high-value service?Research
Findings are Sparse

• Staffing
• Focus has been on medical quality
• CMS Report to Congress sheds light on staff time
  to complete tasks
• Continuity of staff
• Turnover link to quality of care not verified
• Autonomy
• Case study of self-managed work groups affects
  TO
• Wages, benefits, advancement
• Affect CNA turnover but results mixed

7
Learn from other customer-service industries

• Relating to the customer adds value
• Work load, work pace, autonomy affect burnout and
  turnover for workers
• Service teams succeed with relational
  coordination
• Shared goals
• Shared information
• Mutual respect

8
Improving Institutional Long-Term Care for
Residents and WorkersThe Effect of Leadership,
Relationships and Work Design 
9
Project Team

• Senior Investigators
• Christine E. Bishop, Ph.D., Brandeis
• Susan C. Eaton, Ph.D., Harvard
• Jody Hoffer Gittell, Ph.D., Brandeis Dana
  Beth Weinberg, Ph.D., Brandeis
•  Student Research Assistants
• Almas Dossa, MPH, MS, Brandeis
• Susan Pfefferle, M.Ed., Brandeis
• Consultants
• Barbara Whalen, M.P.A., Harvard Frank
  Porell, Ph.D., U Mass Boston  

10
Research Questions

• How do organizational factors and leadership
  shape care practices, teamwork and workplace
  relationships in nursing homes?
• How do these factors and mechanisms ultimately
  shape outcomes for workers, facilities and
  residents in nursing homes?

11
Philosophy of Care Philosophy of Management
Management Practices hiring, training, staffing,
assignment
Residents (satisfaction)
Direct Care Workers (satisfaction, turnover)
12
Are some nursing home management and work
practices --

• Better for CNAs --
• Less burnout?
• Greater job satisfaction?

13
Are some nursing home management and work
practices --

• Better for residents --
• Better quality of life?
• Greater resident satisfaction?

14
Are some nursing home management and work
practices --

• Better for nursing homes --
• Lower turnover costs?
• Higher quality ratings?
• Quality improvements that increase demand?

15
Implications for Policy

• When the product is a DAY of care
• Medicaid pays for DAYS not quality of life
• Regulators look for errors, not relationships
• Will Medicaid/ other payers be willing to pay for
  a high-value customized service package?
• Resident Centered Care

16
For Better Jobs and Better Care -- Demonstrate
Value

• For rate setters
• Generate evidence about the value of resources
  for direct care and leadership
• For quality regulators
• Generate evidence of the value of fostering good
  work processes and resident satisfaction

17
Direct care workers are the heart and hands of
nursing home care