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Sing the strains of retention with training, benefits
By Judith Clinco, RN, BSN, CHHCE
President and Chief Executive Officer
Catalina In-Home Services Inc.
Finding good home care workers is never easy. Right now, thanks to an extremely low unemployment rate, the job is especially tough. But agencies can still grow a bigger and better work force without having to lock all the exits to do it.
At Catalina In-Home Services, the private pay personal care company I founded 18 years ago, we’ve managed it by creating an environment of acknowledgment, appreciation, and self-worth for our employees. We offer extensive training and a good benefit package so there’s no conversation about going anywhere else; and people think of Catalina as "home." The results speak for themselves; our retention rate hovers around 72%.
I strongly believe that when people realize you’re investing in them, it generates loyalty. With training and education, employees develop confidence about their work and it gives them a sense of self-worth and security. When they feel good, they’ll perform better. Then the client sees what good work they’re doing and that brings more praise.
Our quest to improve employee retention began when the company started. The first week we opened our doors, I found that we had difficulty recruiting people with the right experience and skills. So we quickly put together a 30-hour training program to attract and support new employees and have them bond to us. From that initial effort, we’ve gradually expanded our training programs over the years.
Today, the centerpiece of Catalina’s staff development program is a 150-hour course leading to qualification as a certified nurse’s aide (CNA). We developed the program with a job training matching grant from the Arizona Department of Commerce. Certified by the Arizona State Board of Nursing, it is 50 hours above what the state requires for CNA certification.
We went above and beyond the minimum so we could convey not just the technical aspects of personal care, but also what it takes to excel. Anyone can make a bed if given instruction, but we want our caregivers to do it the client’s way — always.
The course lasts just over 10 weeks and covers topics such as infection control, aging, and working with elderly clients, nutrition, family dynamics, home management, time management, and communication. A master’s-prepared nurse with extensive experience in adult education developed and conducts the program.
Over the 10-week course, classes meet for nine hours each week during weekday evening sessions. On seven consecutive Saturdays, students also complete 49 hours of practicum at a local Veterans Affairs (VA) skilled nursing facility. This arrangement not only gives our trainees experience, but it helps the VA meet patients’ personal care needs during a normally low staffing time.
About 125 trainees have completed the course since it began as a pilot five years ago. Because many trainees have had unsatisfactory school experiences in the past, we keep the class size small, allowing plenty of one-on-one time with the instructor. Catalina realizes a slight profit when more than eight students are in the class.
Tuition is $600. In the past, trainees paid a non-refundable $150 downpayment and were hired after completing the course. Unfortunately, only about half elected to join Catalina. So in January 1998, we switched to a new plan. Now, we hire trainees before they begin the course. We ask them to commit to work for Catalina at least 32 hours a week for a year after graduation. They also pay a $100 deposit. After a year on the job, we refund the deposit and forgive the $600 tuition. This approach is more costly, but it pays off with higher retention.
Although every program graduate has gone on to pass the state CNA board exam, not everyone makes it through the entire 150 hours. People think this is something they want to do and they get into it and decide it’s not for them. Others find they can’t devote the time required. We try to eliminate the ones who decide they don’t want to be a CNA by screening heavily before the program starts. For those who have a time conflict, we offer homemaker and personal assistant (PA) certifications after 30 and 75 hours, respectively.
To make things fun and keep trainees focused on their goal, we celebrate the course halfway point. Each trainee receives half a certificate and half a handshake, and we provide half of a cake. A more complete event marks the end of the class when we host a potluck dinner for trainees and their families. The trainees provide the main dishes; Catalina provides the cake, beverages, and table settings.
Our other major staff development program is a voluntary 18-hour postgraduate specialty course for working with clients who have mental illness and advanced confusion. We created this program about two years ago by revamping the 15-hour supportive home care aide curriculum originally developed by the Massachusetts Council for Home Care Aide Services.
Topics include understanding the dementia disease process, setting boundaries, and learning how not to take client behaviors personally. Taught by an RN with a background in psychiatric care, the course runs for three weeks, with two three-hour evening sessions each week. About 30 employees have completed the program; they earn $1 per hour more than other CNAs when scheduled on assignments that require these skills.
Over the years, we’ve found our staff to be like sponges. Once they get grounded in their jobs, they’re very interested in doing it the best they can. To capitalize on their desire to learn, we offer monthly continuing education in addition to the certified programs.
We also require minimum continuing education (CE) credits each year for all field staff: PAs must complete 10 hours; nursing assistants and CNAs 12. To discourage procrastination and identify non-compliant staff more easily, we require employees to accumulate credits throughout the year. Workers receive their regular hourly rate during CE classes; those who work 40 hours per week during course weeks get time-and-a-half.
Since CE classes are lectures only, we do not limit their size. This makes possible a novel arrangement with local adult care homes. Under Arizona law, these facilities must provide six hours of training each year for their employees. Catalina invites the facilities to send their staff to its CE lectures free of charge, thus satisfying their training mandate and, at the same time, making us much more visible to the adult and home care industry — and more likely to get referrals.
We also have a skills lab for both annual competency testing and pre-employment skills verification. Staff respond well to the lab because it lets them refresh their skills, and shows that we take them seriously as professionals.
The lab is in a space rented from a nearby church and includes three hospital beds and various pieces of equipment. CNAs must demonstrate their competency in:
• taking a blood pressure reading and other vital signs;
• performing transfers;
• repositioning clients in bed;
• ensuring basic client hygiene.
Testing takes about two hours; CNAs receive their normal hourly rate while being evaluated. We do not pay for pre-employment screening.
Few training aids are as powerful as television. We searched in vain for videotaped materials that would fit with the home management portion of our CNA certification course. We found a lot of boring training videos, none that supported the adage that learning is fun. So, we created our own. The four-tape Little Things Mean a Lot series includes:
• bed-making excellence;
• getting laundry and ironing right the first time;
• simple style and charm in table setting;
• taking initiative.
The tapes each last between seven and 12 minutes; we use them in both orientation and training. They all get a serious point across with a healthy dose of humor. Three characters, played by the same professional actor, appear in all four tapes. Slovenly Slob and Drill Sergeant each do everything in their own very different ways, while the Trained Professional does it right: the client’s way.
In the laundry video, for instance, Slob first appears leaning over the washing machine complaining about the client being upset with her for being a "little" late. She has on a bright pink headband with huge loop earrings, a rip in the back of her dress, and a bright pink slip that hangs below her skirt. She has the equivalent of three loads of laundry, but crams everything into the washer at one time. "I’ll show you how to get it done all at once," she says, adding "I can stay down here and read, and the client will never know the difference."
We’re pleased with the results of our training initiatives, but they didn’t come without cost. We spent about $6,000 developing the CNA training program and around $32,000 for the videos.
To recoup some of our investment, we offer training to local governmental agencies, community service organizations, home care, and assisted living providers. For example, we’ve established CNA training contracts with the Pima County employment agency and a local community service organization, and we offer our 18-hour psychiatric program to assisted living centers and adult group homes. We also sell our CNA training course and videos, and perform skills testing on employees of local home care agencies.
An aggressive training program goes a long way towards building a professional and stable staff. But workers have human needs too. Caring for the caregiver helps everyone — the employee, the client, and the agency. So we’ve developed an extensive benefit package that includes:
• Medical insurance.
After their initial 90-day probationary period, employees can participate in Catalina’s health insurance plan, which includes health maintenance organization coverage. Premiums range from $110 per month for an individual to $360 per month for a family of three or more. Built into the plan is an appealing reason to stay with Catalina: For employees who work more than 32 hours a week, we pay a share of the individual premium, following a sliding scale based on longevity. The scale tops out at five years; by then we pay 50% of an individual premium. Our cost ranges from $22 to $55 per employee per month. Sixty employees participate in the health insurance plan.
• Eye care and dental insurance.
Catalina does not subsidize eye care and dental insurance, but we have arranged group rates for employees interested in such coverage. They can purchase benefits after they complete their probationary period.
• Paid vacations.
After a year of service, both full- and part-time employees receive paid vacation time equal in hours to the average number of hours worked in a week.
• Credit union participation.
Employees are eligible to open an account at a local credit union as soon as they join the payroll.
• Employee assistance program.
Under contract with a local work life provider, we offer employee assistance services to all employees. This costs Catalina $2 per employee per month, and is free of charge to employees. We strongly promote this confidential counseling program. Many of our workers need help dealing with stress, emotional, and financial issues, but can’t seek it because of the cost. Our plan allows them and a family member up to six counseling sessions per issue.
• Referral bonus.
We offer employee and client referral bonuses. For many years, we paid employees a $25 bonus for referring an hourly employee or client; $50 for live-ins. More recently, we sweetened the client referral pie. Now, employees who refer a client receive 2% of revenue off that case for as long as the client is on service and the employee remains continuously employed.
• Bereavement pay.
Employees past their probationary period can purchase Catalina services at a 25% discount for members of their immediate family.
There’s nothing secret or magical about any of these initiatives. We just decided to devote resources to caring for the caregivers already on board rather spending even more considerable time, energy, and money beating the bushes for replacement workers.
Retaining staff is costly, but I think we have to be honest about what it costs to produce care. At the beginning of 1999, we raised our rates by $1.75 per hour. As I explained in a letter to our customers, 90% of this increase went to employee wages and benefits. I really worried that we would lose clients, but not one person left. I think they understand the difficulty of finding good people, and would rather pay more and know they will have the quality of service they expect. And I would rather not accept a case than send the wrong person.
Still, I understand that every provider does not operate in the same environment. Those with a large Medicaid service, for example, may not be able to afford the same level of employee investment. Yet in the long run, retaining good staff is the key to remaining competitive.
Editor’s note: Catalina In Home Services’ CNA training course and Little Things Mean A Lot video series are available for purchase. The training course, including teaching materials and class handouts, comes on floppy diskette. It sells for $1,000. The four-video series and accompanying teaching materials cost $375. For more information, contact Judith Clinco at (520) 327-6351.
The Massachusetts Council for Home Care Aid Services’ Supportive Home Care Aide Curriculum is available for purchase. It costs $103 for non-members. For more information, contact Peggy Monroe at (617) 227 6641.