Advanced Direct Care Worker: A Role to Improve Quality and Efficiency of Care for Older Adults and Strengthen Career Ladders for Home Care Workers

This article was prepared by the Eldercare Workforce Alliance, a group of 30 national organizations who represent healthcare professionals, including direct-care workers, and family caregivers and consumers. The Alliance works toward practical solutions to strengthen the eldercare workforce and improve the quality of care. This article was originally published by the EWA as an Issue Brief in September 2014. For more information about the EWA’s membership and work, visit their website at www.eldercareworkforce.org. The positions of the Eldercare Workforce Alliance reflect a consensus of 75% or more of its members. Statements reflect the consensus of the Alliance and do not necessarily represent the position of individual Alliance member organizations. The Alliance is a project of the Tides Center.
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In its historic 2008 report, Retooling for an Aging America: Building the Health Care Workforce, the Institute of Medicine (IOM) recommended changes both to how care is delivered and the preparation of the healthcare workforce to provide that care. Specifically, it urged expansion of team-based approaches to healthcare delivery, with care provided by a better-prepared healthcare workforce, all working to the top of their skill sets. In line with the IOM recommendations, the Eldercare Workforce Alliance (EWA), with input from its member organizations, has identified gaps in care and inefficient uses of the current workforce. In this brief, EWA proposes one solution for improving care for older adults.

The Alliance believes that with the appropriate training, supervision, and support, some home care workers can play an enhanced role, with more responsibility for improving safety and quality of care for older adults and their family caregivers (in this paper, older adults are also referred to as consumers as well as person within the phrase person- and family-centered care). We recommend fostering an advanced direct care worker role that both improves the quality of person- and family-centered care and addresses current and future demand for a high-functioning eldercare workforce. Developing such a role and deploying workers in this capacity can lead to better health, better care, and potential cost-savings.

Our focus in this discussion is on advanced roles for direct care workers within the home care setting, although we recognize there may be opportunities for advanced roles within other settings. And, while our focus here is on direct care workers, we believe that all members of the care team should be supported to work to the top level of their skill set. Finally, while our proposal is for a subset of home care workers to receive additional training to perform advanced functions, we believe that all direct care workers should be well-trained and supported in their role and we echo the IOM’s call for strengthening training standards and improvements in training programs for the workforce as a whole.

In the interest of a clear, targeted dialogue and because of the anticipated surge in demand for home care, our discussions focused on the potential for an advanced direct care worker role in the home-care setting, with the understanding that this is a developing concept and no one model will meet the varied needs of every consumer. Further, implementation of advanced roles for direct care workers will likely occur at the state, local, and provider level. Federal demonstration projects may be an effective means of testing the concept. EWA’s goal is to outline a concept, which represents a consensus by varied members of the healthcare team and can be drawn upon by those developing advanced direct care worker roles to achieve the highest-possible quality of care and support for older adults and their family caregivers.

The Need for Advanced Direct Care

Every 8 seconds, a person turns 65 in our country; that’s more than 10,000 people a day. Within 20 years, 1 in 5 Americans will be over 65 and by 2050 an unprecedented number—19 million—will be over 85 years old.¹ Trends suggest these individuals will want to age in place. Most of these individuals will have one or more chronic conditions—potentially increasing hospitalization rates—that require skilled care. Currently, direct care workers provide an estimated 75% of the paid hands-on care. However, if no action is taken to stabilize the eldercare workforce, vacancies will only become more acute in the future as the need for services and supports increases.

One solution is to allow all healthcare providers to provide services to the full extent of their current knowledge, training, experience, and skills where evidence indicates services can be provided safely and effectively. The proposed advanced direct care worker role calls for expanding roles for home care workers commensurate with their demonstrated competency to take on additional responsibilities. Indicators of competency could include the amount of time on the job, successful completion of certain classes, level of education achieved, evaluations from individuals and families served, and evaluations by agency supervisors.

Wages would be commensurate to the advanced direct care worker’s training and experience and higher than those of current direct care workers, creating an incentive to remain in this field. By creating a meaningful career ladder for home care workers who wish to advance within their field, we will be better able to attract and retain a quality workforce, potentially keeping experienced workers in the field. This can help to create a home care workforce able to provide support and services that improve quality and continuity of care for the consumer while reducing burdens on family caregivers.

Methods and Background

Between November 2010 and June 2013, the EWA convened a series of roundtable discussions to explore the perspectives of various members of the interdisciplinary care team with regard to advanced roles for direct care workers. With support and input from member organizations, EWA conducted in-person roundtable discussions with representatives from the direct care, nursing, social work, and physician workforces. Through an online survey, family caregivers identified areas of needed support, which helped to identify potential advanced direct care worker roles. A summary of the findings specific to these roundtable discussions and survey can be found in the Table. 

The development of advanced roles for some direct care workers does not negate the essential role of traditional home health aides, home care workers, and personal care attendants, and of the invaluable supports they provide. Nor does it negate the ongoing need for nurses and social workers and the important roles that they play in home care service delivery and care coordination. The advanced direct care worker concept is intended for the segment of direct care workers who have the experience, knowledge, and training, demonstrated competency, aptitude, and desire to take on more advanced roles. For a growing number of older adults who wish to age in home- and community-based settings, advanced care will be needed and can benefit their quality of life.

Findings

Points of consensus stemming from the roundtable discussions and survey input are outlined below.

Need for Improved Respect, Engagement, and Training for All Direct Care Workers

All direct care workers should be recognized as integral members of the care team with valuable and unique information to contribute. Workforce development strategies that ensure all direct care workers receive high-quality, comprehensive training, supervision, and support will enhance direct care workers’ effectiveness within the interdisciplinary team and will maximize the biopsychosocial well-being of older adults and family caregivers. Direct care workers play an important role in interdisciplinary team work, contributing first-hand information and hands-on experience.

Training

One key to successful implementation of advanced roles for direct care workers is support from the interdisciplinary care team and demonstrated competency to meet the responsibilities of an advanced role. For advanced direct care workers working with older adults, training specific to geriatric syndromes and the unique needs and symptoms of older adults is necessary for this role to effectively improve outcomes. Additionally, training for the advanced direct care worker in effectively communicating with the interdisciplinary care team, the consumer and family members—as well as for the team members in communicating with the advanced direct care worker—is essential.

Due to the evolving development of this concept, EWA does not currently recommend a specific number of training hours to be required for an advanced direct care worker role. Rather, we emphasize more generally that an expanded role should be commensurate with demonstrated competency to take on additional responsibilities. This will be essential for realizing the full potential of advanced roles for direct care workers. Training should exceed levels required for current direct care workers and address cultural diversity, person-centered care, advanced illness and palliative care, communication, disease education and interventions, and competency in skills needed for the role. It may be advisable to require demonstrated competency for advanced direct care and to require continuing education for certification renewal.

Support and Supervision

Ongoing support and appropriate levels of supervision (and/or oversight) for advanced direct care workers is important in achieving the desired health and quality outcomes, strengthening the workforce, and reducing liability. Oversight should be provided by the most appropriate person or interdisciplinary care team member, with consideration given to program purpose, design, and when applicable, level of consumer direction. In many cases this could be a registered nurse or social worker. Current efforts, such as nurse delegation models could mean an expanded supervisory role for registered nurses.

Observe, Record, Report

An advanced direct care worker can fill crucial gaps in care (see sidebar, Identifying Gaps in Care). Because of their regular in-person interaction with consumers, often over an extended period of time, all home care workers are in a unique position to identify shifts in consumers’ health. With additional training in particular illnesses and conditions, and with the consent of the consumer, an advanced direct care worker can observe, record, and report changes in consumer status or function to the appropriate team member. Early detection of these changes can be key to discovering or treating geriatric syndromes, chronic disease, cognitive changes, and complications. Recognizing changes in mobility, appetite, fluid intake, weight, skin color or condition, activity, mood, energy, and communication, and then reporting the information to the other team members can better meet the medical and social needs of the consumer. Such detection and communication could also help to prevent avoidable hospitalizations, readmissions, or institutionalization. Advanced roles, combined with technology and tele-health services, could be especially beneficial to consumers living in rural areas.

Assist With Tasks

Increasingly, family caregivers and some home care workers are being asked to perform medical and nursing tasks, often with minimal or no training.⁸ An advanced direct care worker could be provided additional training in order to safely assist with more advanced tasks and provide individualized, hands-on support and guidance to family caregivers. Subject to state scope of practice laws and contingent upon appropriate training and demonstrated competency, tasks performed by an advanced direct care worker could include: inserting, removing, and maintaining catheters; overseeing nebulizer treatments; administering enemas and suppositories; assisting with minor cuts, abrasions, and wound care; taking readings and measurements, such as those from a pulse oximeter; monitoring insulin levels, including performing finger sticks; and supporting pain management. Tasks and procedures should be supervised by a registered nurse or other member of the interdisciplinary care team. With training, supervision, and demonstrated competency, advanced direct care workers could perform many of the tasks currently performed by family members or consumers.

While restrictions differ from state to state, an advanced direct care worker could help support medication adherence by helping to monitor and/or administer medications, potentially including injectable, topical, oral, and suppositories. Appropriate training could include the recognition of side effects, knowledge of negative drug interactions, and the reporting of individuals’ and families’ medication-related concerns.

Generally speaking, many states will permit family members to be trained to perform health maintenance tasks, but will not allow paid direct care workers to be taught to perform them. Thus, family caregivers may have to rush home from work at lunchtime to administer medication or a tube feeding that direct care workers are prohibited from administering. Hiring a nurse to perform these routine procedures, typically performed several times a day, is not feasible nor efficient. Therefore, allowing nurses to train and delegate these tasks to advanced direct care workers could ease the burden on family caregivers.

Provide Health Information and Resources

Communication among interdisciplinary team members, including health care professionals, consumers, and their family caregivers, is vital to quality care. An advanced direct care worker could enhance channels of communication by serving as a link for consumers and family members to the other team members and by helping individuals and family members to navigate the health care system, when it is their wish and with their consent. With support from other members of the care team, an advanced direct care worker could educate consumers and their family caregivers on particular health conditions, share information on community resources and supportive services, navigate health coverage and schedule appointments, and when desired, advocate for the consumer and provide emotional support.

Additionally, the advanced direct care worker could serve as a significant resource by helping to provide continuity through care transitions across settings. By communicating with the interdisciplinary team and identifying and reporting status changes, the advanced direct care worker can help prevent avoidable hospitalizations or miscommunication. To address privacy concerns, it should be clear to the consumer what information would be shared with other members of the care team, and occur only with their consent.

Promoting healthy practices, through nutrition and dietary planning, physical activity, oral health and hygiene, vaccination, and disease and health self-management, can also be valuable roles for the advanced direct care worker to play. Additionally, assisting individuals with doing exercises, such as range of motion activities prescribed by a physical or occupational therapist or physician, could improve health outcomes and quality of life. Such health promotion and behavioral management can be especially beneficial for: management of diabetes, heart disease, and mental health conditions; prevention of pneumonia, flu, and falls; and maintenance of general mobility and socialization.

Condition-Specific Roles

While any direct care worker should be trained to recognize and report signs of mental health issues, advanced illness and palliative care needs, and early signs of dementia, an advanced direct care worker with specific skills could significantly improve quality for individuals with these specific needs. For example, an advanced direct care worker specializing in advanced illness and palliative care can support the individual’s advance directives, support a pain management plan, and support individuals and their families. The same is true for Alzheimer’s and dementia care, for which an advanced direct care worker could learn to recognize and defuse behavioral symptoms of distress, reduce triggers for agitation or confusion, stimulate the individual through non-medical engagement, and support families. While maintaining a whole-person approach, an advanced direct care worker with condition-specific training could provide critical guidance and expertise within the care team, enhancing the quality of care provided.

Conclusion

At this point, demonstration projects should be created to test the viability and functionality of advanced direct care worker roles. Quality care for older adults, now and in the future, depends upon the quality of the workforce providing that care, as well as other factors. In order to achieve our goals of better care and lower cost, it is essential to raise the skill level, especially with respect to geriatrics and gerontology, of all healthcare providers. The future cost and quality of healthcare will be determined in part by whether we have a well-trained, coordinated workforce. An advanced direct care worker has the potential to help meet the needs of our burgeoning older adult population by providing person- and family-centered care effectively and efficiently.

Table. Summary of Advanced Direct Care Worker Roundtables

References

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