Description

Cooperative Home Care Associates (CHCA) uses a model for recruitment, training, and retention that encompasses five primary elements: targeted recruitment, enhanced entry-level training, supportive services, opportunities for advancement, and wage and benefit enhancements.

Sponsoring Organization

Cooperative Home Care Associates is a worker-owned home care agency in the South Bronx (NY), which employs 800 direct-care workers. CHCA has developed its recruitment, training, and retention program in cooperation with the Paraprofessional Healthcare Institute (PHI), a not-for-profit health care employment and advocacy organization in the South Bronx.

Setting

CHCA provide services to elderly and non-elderly people living with disabilities in the Bronx and upper Manhattan.

Target Group

CHCA targets public assistance recipients and other low-income individuals who may be seeking more secure or meaningful employment to participate in its direct-care training and employment programs.

Start Date

CHCA was founded in 1985 and has worked to refine its recruitment, training, and retention program since that time. The agency has done all its own training since 1987.

Objectives

• To create high-quality jobs for home care workers by offering enhanced training, a supportive work environment, and opportunities for personal and professional growth.


• To improve the quality of care delivered to people living with disabilities by creating a more stable workforce

Key Components

To recruit new workers, CHCA targets candidates likely to succeed in direct-care work and provides them with a learner-centered environment, supportive services, and guaranteed employment for those who graduate. To retain staff, CHCA offers enhanced wages and benefits, opportunities for professional growth, and ongoing support from both supervisors and peers.

Targeted recruitment

• Assessment and selection. Rather than accepting large numbers of trainees, CHCA uses a layered assessment and selection process to identify the candidates most likely to succeed as caregivers. Recruiters look for people with some formal or informal caregiving experience who express compassion for other human beings and demonstrate an ability to set priorities and resolve problems. Only about 35 percent of those who interview are enrolled in the training program. Of these, over 80 percent graduate and become CHCA employees.



• Recruitment partnerships. To enhance its ability to recruit appropriate candidates, CHCA has built strategic relationships with the public welfare department as well as a range of public and private human service organizations, most of which assist low-income individuals in securing employment. Though it takes time to cultivate these relationships, they have contributed to agency's rapid growth over the last five years. CHCA's challenge is first to target agencies that serve populations who are likely to include prospective direct-care workers and then to communicate clearly to agency staff the qualities that make a successful home health aide, so they recommend people who fit the profile.

• Learner-centered training. CHCA invests significant resources in its training program. Entry-level training runs for four weeks, significantly longer than the 75-hour minimum required for home health aides. Instructors strive to create a safe but challenging learning environment for trainees who may have had little formal education or work experience. Rather than using traditional lecture methods, they emphasize active learning techniques such as role-plays, case studies, and team discussions to make the direct-care job 'come alive' in the classroom. In addition, team teaching, often with senior aides participating as peer educators, allows for individualized attention and support.
  
• Communication and problem solving. In addition to teaching clinical skills, the curriculum includes modules on non-technical skills that are critical to success on the job, such as team-building and respecting differences. It also includes modules that focus on helping participants enhance their communications, problem-solving, and critical-thinking skills. The 4P Communication and Problem-Solving Curriculum, which was developed by Home Care Associates of Philadelphia and is now used by CHCA, breaks problem solving down into four concrete skills: paraphrase, pull back, present options, and pass it on. Trainees practice each skill, learning how to think objectively about an interpersonal conflict, communicate clearly, and find solutions without allowing emotions to overwhelm rational thinking.
  
• On-the-job training. CHCA provides three months of on-the-job training. During this time, new employees receive peer support from mentors, close oversight from supervisors, and frequent opportunities to gather for peer exchanges, problem-solving sessions, and additional clinical skills training as required.

• Employment counseling. CHCA employs an employment counselor to help trainees and employees overcome obstacles to success on the job; for example, lack of reliable childcare or transportation or an unstable housing situation. The employment counselor meets with each new trainee to discuss his or her situation and to assist in accessing any public support services for which the trainee is eligible. This service is also available to employees.
  
• Coaching supervision. CHCA has trained its supervisory and management staff in a coaching style of management, which offers support in resolving performance issues while holding employees accountable for their actions. This management style is used often with professional employees but rarely with entry-level staff. When a problem arises that affects performance, coaches try to understand the employee's perspective and works with him or her to analyze the problem and come up with a solution, always ensuring that the employee takes responsibility for solving the problem. The coach then follows up to ensure that progress is being made. This method often resolves problems that would otherwise lead to an employee being disciplined, or even being terminated or quitting in frustration.

• Worker participation in agency decisions. As a worker-owned agency, CHCA wants its employees to be knowledgeable about the home care industry and influence agency decisions. Geographically based worker councils meet to discuss important issues facing the agency, to air concerns and grievances, and to contribute to management decisions. In addition, worker-owners elect representatives to the board of directors.
  
• Career advancement. CHCA home health aides have moved into training positions and into the patient services department, where they have become patient service coordinators. CHCA has also developed a career ladder to train senior aides in peer mentoring skills.
  
• Leadership development. CHCA aides participate each year in PHI's Paraprofessional Assembly, which brings together aides from all Cooperative Healthcare Network agencies. Attendees celebrate their role as caregivers and learn advocacy and leadership skills. Some aides also develop these skills at work by participating in CHCA's policy action group, which has sponsored voter registration drives, met with local legislators to discuss policies that impact home care workers, and provided speakers at statewide conferences and other events.

• Base wages. CHCA rewards longevity by using a tiered pay scale that ranges from $6.40 to $8 per hour. Although still low for a region with a high cost of living, these wages are $2 an hour higher than average for New York home care agencies.
  
• Guaranteed hours. Aides who have been with the agency at least three years are paid for at least for 30 hours a week, even if they work less than this threshold amount, if they agree to accept case assignments on alternating weekends and any substitute assignments offered. Since aides typically work 36 hours per week, CHCA rarely pays for hours not worked, but this arrangement guarantees senior aides a stable income.
  
• Wage differentials. Aides who take weekend assignments or work with clients with complex care needs earn an additional 50 cents an hour.
  
• Benefits. CHCA pays 100 percent of the premium cost for full-time employees' health insurance and prorates the payment for part time employees. In addition, it provides a 401(k) retirement fund, five paid vacation days, and annual dividends for all worker-owners.

Results, Outcomes, Evaluation

Of the aides CHCA trained between July 2001 and June 2002, 87 percent were employed with the agency after 90 days and 72 percent were still there after one year. The agency's turnover rate between August 2001 and August 2002 was just 22 percent. (To calculate turnover, the agency divides the number of terminations by the average number of employees. Employees hired 90 days prior to the end of the year are not included in the calculation of terminations. The average number of employees is estimated by adding the number employed at the beginning of the year to the number employed at the end, then dividing by two). Furthermore, more than 25 percent of its workforce has been with the agency for more than five years. This is extraordinary when growth is taken into account: the agency has doubled in size over the past five years.

Informal information shows that many workers have stayed with CHCA for years because CHCA is not just a workplace but also a community. Workers often talk about how important it is for them to feel that their employer truly respects them and the value of their work. In addition, clients often request aides from the agency because the service is reliable, client-centered, and compassionate. The quality of CHCA's service is recognized by the New York Visiting Nurse Service, which has made CHCA a preferred provider.

Lessons Learned

For CHCA, the first step toward creating a stable workforce is finding the right people for the job. The next step is offering an extended training program that provides opportunities for new workers to learn not just clinical skills but also things such as how to function in a work environment, how to be a team player, and how to resolve personal problems that interfere with work performance. How these things are taught is almost as important as what is taught. Instructors must respect the trainees and draw on their life experiences to build knowledge and understanding.

CHCA notes that an employee doesn't make a single transition into the workforce. Instead, there are a series of small transitions, some predictable, some not. An agency that assists employees through these transitions is less likely to lose them along the way. To avoid turning into a social service agency, CHCA has arranged a structured support system that includes employment counselors, supportive supervision, and peer mentors.

Because the quality of direct-care workers' experience is heavily influenced by their interactions with their immediate supervisors, CHCA has found it pays to invest in training supervisory staff. Its coaching supervision method has improved relationships between frontline workers and supervisors and decreased the need for disciplinary actions.

PHI shares the lessons learned at CHCA with a group of direct-care staffing agencies and training programs known as the Cooperative Healthcare Network (CHN). Although they operate in geographically diverse areas, and although some are worker-owned while others are more traditionally structured, each CHN site has successfully adapted several of the recruitment, retention, and training strategies outlined above. As a result, all five report successes in helping people with limited education and skills enter the workplace and provide high-quality service. CHCA's greater success, as measured by its rapid growth and above-average worker retention rates, is probably due primarily to market conditions. However, other factors also contribute. One CHN site, for example, has had retention problems because it places aides in facilities where it has no control over the quality of the job, creating a gap between the values and sense of community nurtured by the agency and the aides' actual working environments. In addition, not all of the agencies provide the wage enhancements and guaranteed hours offered by CHCA.

Costs and Funding

It costs CHCA approximately $3,500 to train and employ a home health aide. CHCA receives funds from private foundations and public welfare-to-work contracts to defray these costs. In addition, PHI provides CHCA with development assistance and works with the agency to refine its recruitment and training programs.

Contact Information

Peggy Powell
Director of Workforce Strategies
Paraprofessional Healthcare Institute
349 E. 149th St., Suite 401
Bronx, NY 10451

t: (718) 402-7463
f: (718) 402-7463
e: peggy@paraprofessional.org
Website: www.paraprofessional.org

Other Resources

Clark, Peggy, and Steven L. Dawson with Amy J. Kays, Frieda Molina, and Rick Surpin. 1995. Jobs and the urban poor: Privately initiated sectoral strategies. Washington, DC: The Aspen Institute together with the Charles Stewart Mott Foundation.

Paraprofessional Healthcare Institute. 2000. Recruiting quality health care professionals. Bronx, NY: Paraprofessional Healthcare Institute.

Paraprofessional Healthcare Institute. 2001. Creating a culture of retention: A coaching approach to paraprofessional supervision. Bronx, NY: Paraprofessional Healthcare Institute.

Inserra, Ann, Maureen Conway, and John Rodat. 2002. Cooperative Home Care Associates: A case study of a sectoral employment development approach. Washington, DC: Aspen Institute.

Glasser, Ruth, and Jeremy Brecher. 2002. We are the roots: The organizational culture of a home care cooperative. Davis, CA: Center for Cooperatives, University of California.

Creating a culture of retention: A coaching approach to supervision

The Cooperative Home Care Associates: A case study of a sectoral employment development approach

Recruitment and hiring process to identify suitable direct support workers

Jobs and the urban poor: Privately initiated sectoral strategies

Recruiting quality health care paraprofessionals

We are the roots

Training Quality Home Care Workers

Training TANF recipients and low-income populations for long-term care paraprofessional jobs