Based in Buffalo, New York, Catholic Health is a billion-dollar health system with four hospitals on five campuses serving both Erie and Niagara Counties. Joyce Markiewicz, executive vice president of the health system and CEO of its home and community-based care division, notes that overall the health system employs 10,000 people, including 1,500 physicians. Along with the Michigan division of Ascension and the Cleveland Clinic in Ohio, Catholic Health is participating in a pilot of nonprofit health systems funded by the Ralph C. Wilson Foundation that aims to increase retention of certified nursing assistants (CNAs) and home healthcare workers.
As Amber Slichta, vice president of programs at the foundation, explains, the goal is not just to increase the status of care workers at the three institutions, but to change the field as a whole. The foundation, Slichta notes, is working with three institutions that have “incredible brand recognition.” The prestige of the hospital systems involved, notes Slichta, gives the participating hospitals an influence that extends beyond these institutions.
The goal, Slichta adds, is for the institutions after the pilot period ends to sustain the program financially. “If it works,” Slichta points out, “there is the opportunity to take the model to other organizations.”
The model being piloted is called THRIVE, which stands for Transformational Healthcare Readiness through Innovative Vocational Education. Initially developed at Cleveland Clinic, the program is now being expanded and piloted for a three year-period at not only the Clinic, but Ascension Michigan and Catholic Health. The foundation is providing $15 million over three years, including, Slichta notes, “$1.5 million for the evaluation to confirm we are asking the right questions and demonstrate from a financial, workforce, and organizational perspective that it really works to support scaling.”
The vision is to provide coaching for individuals, much more substantial training for workers, and the ability to tap into extra resources to keep workers from losing their jobs when life events arise. For instance, if a worker’s car breaks down, often that person is at risk of losing his or her job. With THRIVE, “supports are in place to avoid that situation. As far as we know, no one has ever tried to address retention in this comprehensive manner or at this scale,” notes Slichta.
The theory, Slichta adds, is that “Retention rates will go up because [workers] are more confident in their ability to do their job. They feel supported and more valued than the institutions value them now.” And if retention rates rise enough, then retaining costs will fall—hopefully by more than the amount of foundation funding. Presently, Markiewicz estimates that turnover is roughly 40 percent for homecare workers and 30 percent for in-hospital certified nursing assistants. Bringing those numbers down would reduce retraining costs substantially. Evidently, if costs fall sufficiently, then the program becomes financially sustainable without foundation support after the pilot ends.
The foundation found ready partners in the hospitals, which are eager to increase worker retention rates. Markiewicz explains that two years ago, her health system was having conversations about the fact that the aging population is rising but the number of caregivers is declining. The drivers of this mismatch are obvious. Markiewicz notes, “People have had less children. Families are more transient. Many are living with no one nearby to assist them. They depend on homecare companies. Those organizations are struggling because we are having more and more difficulty attracting and retaining people in those entry-level positions.”
As Markiewicz notes, the three institutions in the pilot “have a lot of similarities. We are all in Rust Belt cities that have had to reinvent ourselves. All three institutions exist in communities with high poverty rates, high levels of single parent households, and where healthcare is a major employer.”
Markiewicz notes that for her, the core idea behind THRIVE is to not just to provide skills-based training, but to “incorporate life skills into the training.” What does life skills training include? The range of issues is vast. Markiewicz notes that workers in the THRIVE program learn how “to open a conversation, how to deal with difficult family members who are not following the care instructions, and how to interact with a multi-disciplinary team and be a continuing member to that team.”
Markiewicz adds, “If you don’t have a lot of confidence, it can be very daunting. We are going to teach those types of skills. We are going to teach skills around money management and how to deal with personal issues at home.” All of this is on top of the wrap-around supports to “remove some of the barriers that exist,” such as childcare, transportation, or the cost of uniforms.
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One last major component, notes Markiewicz, is hiring work-life coaches. “Every individual who comes through training will have a coach,” Markiewicz explains. “We believe if we can get employees through the first year, we have a much better chance of keeping them employed.” Markiewicz says the health system has hired two coaches so far and expects to have at least four coaches in place by year-end. The health system may also add more if needed. Each participating worker will be assigned to a specific coach for their first year on the job.
Markiewicz says that the program began June 1, 2019, and that it will last for three years. She expects to work with about 440 care workers per year, which is similar to the number of expected participants at Ascension and the Cleveland Clinic.
Of course, increasing wage levels is also part of the mix. “That’s kind of a given for us,” says Markiewicz. Markiewicz notes that the minimum wage is rising in New York state, with the minimum wage slated to rise to $12.50 an hour in 2021 and $15 an hour for fast-food workers. Markiewicz adds that, “If we are too close on wages to grocery store checkers or McDonald’s or coffee shops, we are losing our pool of people.”
As Markiewicz recognizes, in the homecare industry, a major change in the business model is needed if workers are to be compensated fairly. Medicaid funding, Markiewicz explains, is one driver for the low wages that homecare workers receive.
For entry-level caregivers, Markiewicz notes, a large portion of the funding is linked to Medicaid. “Agencies that provide these services were given a rate,” Markiewicz says. “They had to run their business, pay their employees, and squeeze out a bottom line.”
This, Markiewicz adds, has served as pressure to keep wages down. Another challenge, Markiewicz observes, “is the way the care is delivered. It is usually short term, intermittent. You travel from one location to the next…people don’t have transportation. The wages are low.”
Historically, Markiewicz adds, “many agencies only hired these workers as per diems and didn’t provide benefits.” The current shortfall in workers, she notes, is forcing people to relook at that. “How do they provide this workforce with the ability to have health insurance so they can come up off Medicaid?” Markiewicz asks.
Homecare workers that work for hospital systems face somewhat better conditions than their agency counterparts. Catholic Health, for instance, offers paid time off and health care benefits. “We are part of a health system and we can absorb some of those costs,” Markiewicz notes.
THRIVE won’t solve all of these challenges, but it may help make the business case for a high-wage, high-training model. Markiewicz also calls attention to the process behind THRIVE. What you have here, she observes, “is three health systems come together to solve a problem that is a national problem.”
Typically, healthcare is fiercely competitive. For instance, in Cleveland, the Cleveland Clinic competes with University Hospitals. In Detroit, Ascension competes against Henry Ford Health System. In Buffalo, Catholic Health competes against Kaleida Health. Because the pilot brings together three hospital systems that do not directly compete against each other, cooperation is easier. “For us, to come together, it is unique, and it is exciting. We all have the same issues and the communities all need the care. It is very exciting to work with the two other health systems.”
Markiewicz adds that the foundation’s decision to support the THRIVE pilot was not just a matter of program officers deciding it was a good idea. Rather, support for care work was a passion of the late Ralph Wilson himself; indeed, he and his wife donated a million dollars to support homecare in 2010, four years before Wilson died at the age of 95 in 2014. As Markiewicz explains, “Mr. Wilson, as he started to age, needed more and more assistance. Fearing that time, he built relationships with the folks that were caring for him and learned a lot about the struggles they faced. He was very specific for his foundation. He wanted work to be done in the area—to raise the individuals up and have them be appreciated in the community. The work is difficult, and it really is underappreciated.”
