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USC-Brookings Schaeffer on Health Policy

A win-win: home health aide training program creates better care for patients, better jobs for workers

An earlier post in the Health360 blog noted that one of the implications of the U.S.’s aging population is increasing demand for long-term care.  Occupations such as personal care aides, nursing assistants, and home health aides all have strong projected job growth.  And yet, although these direct care positions are foundational to providing high-quality services to the elderly and people with disabilities, they typically pay low wages, do not require much education and training, and experience high turnover.

A variety of initiatives around the country are taking different approaches to improve the skills of direct care workers, and not incidentally, job quality as well. 

One such initiative is the Advanced Home Care Aid Apprenticeship operated by the SEIU Healthcare NW Training Partnership in Washington state. The Training Partnership, an independent labor-management organization, launched the first registered apprenticeship program for home care workers in 2012 and has since graduated 215 students with another 100 currently enrolled.  The apprenticeship provides 75 hours of training required by the state for most new aides, another 70 hours of advanced training, and 12 hours of peer mentoring from an experienced home care aide.  Employers pay apprentices their regular wages (an average of $12 per hour) during training. Apprentices earn a raise of 25 cents per hour upon completing the first 75 hours of training and passing the state certification exam and another 25 cents per hour upon completing the apprenticeship. 

I had an opportunity to discuss the program with  the Training Partnership’s Executive Director, Charissa Raynor. Below is a brief Q&A.  

Q.  The Apprenticeship is described as “competency-based.”  What does that mean, and why is it important?

A. In a competency based education program, students progress to more advanced work when they demonstrate mastery of a specific set of skills.  Students move through the training at their own pace.  Those who need more time take more time, and those who have already mastered specific competencies (as measured through high-fidelity assessments) do not waste time or money sitting through unnecessary training  —  particularly important for working adults.     

Q. What are the skills the apprenticeship covers in its advanced training, and how did you incorporate employer input?

A.  To assess the skills we need to cover in our training and to build learning experiences, we leverage our labor-management platform to aggregate information on home care worker responsibilities and duties spanning more than 40,000 workers, a dozen employers, state agencies, and tens of thousands of consumers. We use a disciplined research and design approach and are stepping out of a traditional role of “training to the job” and more into the role of a business partner. We anticipate how jobs and the healthcare industry are changing, and train for what jobs are likely to be, not only what they are today. 

Q. While the 50-cents-an-hour raise upon completing the apprenticeship is notable, it leaves home care workers (HCWs) in the low-wage category.  A more significant wage increase would probably require a more wholesale change in how care is delivered or financed.  For example, if higher-skilled HCWs are associated with reduced emergency room or hospital visits, a portion of the savings could be directed to increased wages.  Does that seem possible?

A. It’s not only possible, but imperative.  We are entering an unprecedented period for healthcare driven by an aging population and dominated by high demand for healthcare services, relatively fewer workers to meet that demand, high healthcare costs, and relatively fewer dollars to pay for those costs. There simply won’t be enough physicians and nurses to meet the need, and all untapped resources, like HCWs, must be optimized.  The Training Partnership has a “return on investment” experiment underway to test new roles for HCWs as partners in health, rather than workers who simply carry out largely pre-determined tasks.

Q. One impediment to raising wages or adjusting job descriptions is that often, HCWs are not seen as “real” professionals with something to offer beyond relatively simple caretaking tasks. How do you address that?

A. Part of what feeds this view is a myth that HCWs are pouring tea and playing bridge with Grandma. In reality, 21st century HCWs are supporting complex care for individuals living with Alzheimer’s disease, paraplegia, and severe mental illness.  More than 80 percent of our students care for consumers who are dually-eligible for Medicaid and Medicare, a population recognized as one of the most complex and costly to care for. As population care needs evolve, so should the roles of health care workers. Policymakers, payers, and providers need to see HCWs for what they can be, not what they have been.  

In conclusion, the HCW apprenticeship is a promising approach to providing better care while reducing the growth of health care costs and improving job quality.  By virtue of their regular contact with patients, HCWs are well-positioned to observe health condition changes, identify problems, and facilitate communication between the patient and the rest of the healthcare team to improve care – but they need the skills to take on these roles.  The evaluation (and others like it, such as a CMS-funded evaluation of a California training program for long-term care workers) will shed much-needed light on whether HCW upskilling has an impact on costs, health outcomes, and workforce stability.

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