Certified Nursing Assistants in Nursing Homes: Quality of Care, Immigration, and Injuries Joshua M. Wiener, Ph.D., Wayne L. Anderson, Ph.D., and Galina Khatutsky, M.S. RTI International 1
Acknowledgement and Disclaimer Thanks to Nicholas Castle, Ph.D., for many helpful comments on this research Thanks to Stephanie Robinson of the Research Data Center at the National Center for Health Statistics, without whose help this project would not have been possible This research is funded by a grant from the Retirement Research Foundation, Nancy Zweibel, Ph.D., project officer The views expressed in this presentation are those of the authors and do not necessarily represent those of the Retirement Research Foundation or RTI International 2
Introduction LTC workforce problems, especially for certified nurse assistants, home health aides, personal care workers Shortages Low wages with limited fringe benefits Poorly trained staff High turnover affecting continuity of care Hostile organizational culture Increasing future demand will worsen problems Provisions in health reform to address workforce issues 3
Introduction (cont.) Policies issues related to: Quality of care in nursing homes The high and growing role of immigrants as CNAs in nursing homes The high level of physical injuries among CNAs in nursing homes 4
Do Workforce Factors Affect Quality of Care in Nursing Homes? Joshua M. Wiener, Ph.D., Wayne L. Anderson, Ph.D., and Galina Khatutsky, M.S. RTI International 5
Introduction Dissatisfaction with quality of nursing homes (IOM, 2001) 195,000 complaints in 2008 (2008) Almost 25% of homes had deficiencies for serious harm or jeopardy (2008) Poor quality facilities cycle in/out of compliance 6
Introduction (cont.) Interest in addressing workforce problems motivated by belief that it will improve quality Lot of research on determinants of intermediate outcomes, such as staff turnover, but rarely linked to direct measures of quality With exception of staffing levels, not much research on effect of workforce factors on quality of care 7
Research Objectives Using Centers for Medicare & Medicaid quality data, assess whether workforce factors improve quality in nursing homes: higher wages and more fringe benefits mentoring and better training more empowering, collaborative organizational culture more staffing per resident 8
Merged Data Sources 2004 National Nursing Home Survey (staffing; insurance coverage) 2004 National Nursing Assistant Survey (pay/benefits, training, organizational culture) Approximation of the Centers for Medicare & Medicaid Services 5-Star quality rating system for 2004 (quality measures, inspection score) Online Survey, Certification, and Reporting System (case mix) Area Resource File (worker supply/demand, area characteristics) 9
Nursing Home Quality Measures In 2008, CMS implemented 5-star rating system to aid consumers using: 10 of the 19 quality measures based on the Minimum Data Set (MDS) Survey and certification inspection scores Staffing variables (not used as dependent variables; used as independent variable) 10
Independent Variables Extrinsic rewards Wages Various types of days off Health insurance coverage 11
Independent Variables (cont.) Initial training for job and reasons for working as certified nursing assistant (CNA) Assigned mentor in first job Rating of how well initial training prepared for work Important reasons for being CNA 12
Independent Variables (cont.) Organizational culture (as identified by CNAs) Supervisor and co-workers reasons to work Respected/rewarded for work CNA has opportunity for working in teams CNA can decide how to do work/work challenging CNAs do not always care for same residents Society values CNAs work 13
Independent Variables (cont.) Staffing Certain characteristics of administrator Job tenure of director of nursing, registered nurses, licensed practical nurses and CNAs CNA and RN hours per resident day Majority of CNAs have English as 2 nd language CNAs required to work overtime RN and CNA staffing hours per resident per day 14
Independent Variables (cont.) Case Mix (Quality Measures already case mix adjusted; measures below serve as extra control variables) ADL count measure (ranges for 0-6) Proportion residents receiving injections Proportion residents receiving rehabilitation services Variety of other control variables 15
Overall Summary of Findings Many workforce variables not significant Most significant variables had modest effects Significant variables often differed between MDS-derived quality measures and survey and certification-derived quality measures Higher wages not significant Health insurance positively associated with quality Paid days off positively associated with quality 16
Summary of Results (cont.) Some training variables significant, but some variables wrong sign RN and CNA staffing levels not statistically significant, but job tenure mostly positively associated with quality More collegial organizational culture associated with better quality Casemix strong negative relationship with quality measures, but not health inspection scores 17
Conclusions/Implications Variety of workforce factors modestly affect quality of nursing home care Surprising that wages and staffing levels not significant Significant organizational culture change variables suggest their importance, but not many direct policy levers Several unexpected significant results (e.g., CNA tenure) with wrong sign for quality measure index 18
Conclusions/Implications (cont.) Different variables affect separate measures, suggesting separate quality dimensions or that measures are of limited validity Unexpected results and large coefficients for casemix suggest that quality measure index may reflect facility casemix in addition to quality of care Further research needed to: Refine organizational culture and training variables and quality of care measures Build business case for workforce interventions 19
Immigrant and Non-Immigrant Certified Nursing Assistants Working in Nursing Homes: How Do They Differ? Galina Khatutsky, M.S., Joshua M. Wiener, Ph.D., and Wayne L. Anderson, Ph.D. RTI International 20
Introduction Shortage of certified nursing assistants (CNA) in nursing homes Nursing homes are increasingly turning to immigrants to fill the shortage: About 1/5 of CNAs are immigrants Because of the ease with which the immigrant labor supply could be increased if desired, these workers represent a particularly attractive source of labor to fill jobs that nativeborn Americans do not want Worker advocates want to reform the CNA position 21
Policy Issues Immigrant long-term care workers may be less qualified than native-born workers in terms of training, ability to communicate with residents, and cultural competence Immigrant workers may face discrimination or may be taken advantage of Because of their possibly lower competency and discrimination, immigrants may work disproportionately for lower-quality facilities 22
Research Questions How do the personal characteristics and training of immigrants compare with those of non-immigrants? How do the wages, fringe benefits, and working conditions of immigrants compare with those of non-immigrants? How do the facilities at which immigrants work compare with the facilities at which non-immigrants work in terms of quality, staffing, and resident characteristics? 23
Data and Methods Linked 2004 data from the: The National Nursing Home Survey (NNHS) The National Nursing Assistant Survey (NNAS) The Area Resource File (ARF) Nursing Home Compare (NHC) The Online Survey, Certification and Reporting (OSCAR) system Descriptive statistics 24
Results: Personal Characteristics, Training, and Language Ability Immigrants were significantly older and more likely to be married than native-born workers Immigrants were more significantly likely to have at least some college education than were native-born workers (50% vs. 21%) Immigrants much less likely to report English as their primary language than were native-born workers (51% vs. 100%) 25
Results: Personal Characteristics, Training, and Language Ability Immigrants more likely to report problems communicating with residents than were native born workers, but the percentage for native born workers was surprisingly high (51% vs. 41%) Similar results for communicating with staff (31% vs. 25%) 26
Results: CNA Job Characteristics, Satisfaction, and Job Environment Number of hours worked per week about the same and having to work mandatory overtime Immigrant workers received higher average wages than native born workers ($11.20 per hour vs. $10.20 in 2004) Fewer immigrant workers reported bonuses and training reimbursement, but larger proportion reported paid holidays and subsidized child chare Health insurance availability about the same, but immigrants more likely to participate 27
Results: CNA Job Characteristics, Satisfaction, and Job Environment Immigrant workers more likely to report being discriminated against due to race or ethnicity than nativeborn workers (17% vs. 6%) Immigrant workers report more positive attitudes and perceptions of their supervisors than native born workers Overall job satisfaction slightly higher among immigrants 28
Results: Quality of Facilities Percent Medicaid residents the same, but immigrants more likely to work for very high Medicare facilities Immigrants more likely to work for facilities with high disability levels of residents, but more likely to work for low-staffed facilities Fewer immigrant CNAs than native-born CNAs reported working for facility for less than a year (22% vs. 29%) Based on a modified version of 5-Star rating system, immigrants more likely to work for highest quality facilities (5 stars) 29
Conclusions At least with nursing homes, concerns about immigrant CNAs largely unfounded Immigrant CNAs are older and better educated Language barriers an issue, but communication issues also for native-born workers Highly satisfied with work, although response bias possible While some reports of discrimination, wages and fringe benefits at least as good Mixed views on quality of facilities: More 5-Star facilities, but lower staffing 30
Galina Khatutsky, Joshua M. Wiener, and Wayne L. Anderson. (2010). Immigrant and Non-Immigrant Certified Nursing Assistants in Nursing Homes: How Do They Differ? Journal of Aging and Social Policy, 22:267-287. 31
Work-Related Injuries among Work-Related Certified Injuries Nursing among Assistants Certified Nursing Working Assistants in Nursing Nursing Homes Homes Galina Khatutsky, M.S., Joshua M. Wiener, Ph.D., and Wayne L. Anderson, Ph.D. RTI International 32
Introduction Caring for nursing home residents is difficult, physically and emotionally In 2006, the U.S. Bureau of Labor Statistics reported 8.9 non-fatal injuries per 100 workers in nursing and residential care facilities Paraprofessional workers in long-term care have the 3 rd highest rate of workforce injuries, placing behind truck drivers and laborers/movers Large workloads, inadequate supply of assistive equipment, and lack of training often cited as causes 33
Data 2004 National Nursing Assistant Survey (NNAS) 2004 National Nursing Home Survey (NNHS) Online Survey, Certification, and Reporting (OSCAR) Area Resource File (ARF) 34
Research Questions What is the impact of injuries in the workplace? What assistive technology is available in nursing facilities, and how is it used? What is the extent and quality of training CNAs receive in injury prevention and assistive technology use? What are the personal, facility and workload characteristics that increase the likelihood of being injured? 35
Results 59% of CNAs report being injured over course of year; 4.5 injuries per year Almost 16% of those injured reported a transfer to restricted/light duty at work Almost a quarter of injured CNAs reported being unable to work due to their injury, missing average of 3 days or work While back and other muscle injuries important, many injuries inflicted by residents (e.g., human bites 12%) 36
Results (cont.) Lifting residents is one of main causes of injuries To reduce injuries, many lifting devices Lifting devices widely available (88% always available), but only 61% of CNAs always use lifting devices Multivariate analysis did not find that availability of lifting devices reduced probability of being injured Multivariate analysis found that mandatory overtime, poor training, being new worker, and not having enough time to provide ADL help increased probability of injury 37
Conclusions Injuries major issue Several possible interventions More comprehensive training Reducing mandatory overtime Providing support for CNAs new to field 38