Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005
Intervention #1: Offer affordable and subsidized health coverage through Maine's new state
supported, DirigoChoice.
I. Explanation of Intervention
DirigoChoice is the state sponsored health insurance product, one component of Maine’s Dirigo Health Reform Act. DirigoChoice was developed to be a competitive insurance product for targeted markets in Maine. It is being offered statewide through a public – private partnership with Anthem Blue Cross Blue Shield. The public component of DirigoChoice is managed by the newly formed state entity, Dirigo Health Agency which manages the program of discounts for low income individuals and families. The private component, the insurance product, is managed and marketed by Anthem BCBS and its authorized agents (producers). DirigoChoice is a controlled and highly politicized product that has a goal of serving the uninsured and Maine employers by offering a competitive and affordable product. Participation is voluntary and businesses must pay a 60% premium for each participating employee and an annual administrative fee. DirigoChoice was targeted in this grant as a beneficial product based on the discounts being offered to eligible employees with a sliding scale that reaches household incomes within 300% of the federal poverty level. Discount levels extend to options for 100% discounts covering all premium, deductible and co-payment costs. The program also has advantages over Medicaid coverage. For coverage details go to: http://www.dirigohealth.maine.gov/dhlp02.html Other sources used for outreach and information include: http://mainecahc.org/foundation/publications.htm and www.mainepasa.org (see May newsletter). This project targets home care and home health agencies with efforts to provide access to this affordable coverage option. The activities planned and being conducted are providing information and support services to expose and encourage the agencies to offer employer-based insurance to their direct care employees. Efforts to reach the workers directly were also planned.
II. Review of Grant Activities:
The grant proposal workplan/timeline activities #1, 5, 6, 7, 8 & 10 all involve organizing grant partners, outreach, marketing, informational and support activities intended to increase access to information about DirigoChoice and support the targeted agencies’ first steps to enrollment. SubContracts with partner organizations proposed in the grant are being implemented to conduct the outreach, information sessions and support services with home health agencies and their employees. The grant activities supplement the marketing being done for DirigoChoice statewide through numerous newspaper, television and radio ads. The program is also regularly featured in news programs and publicity about the political and programmatic policies, costs and administration. Significant efforts are being made to market DirigoChoice and to enroll small businesses, sole proprietors and individuals. Programs about the other components of the Dirigo Health Reform Plan also serve to market the product. The grant activities to accomplish Intervention #1 are being conducted in accordance with the evaluation plan for the grant as to not interfere with the research workplan. In a separate outreach the certified and licensed home health agencies in the state were invited to participate in the evaluation component of the grant in year one. Twenty six agencies agreed to participate over the three year grant period and data is being collected from them as well as 1,124 workers and 34 supervisors, as Maine Status Report, October 2005 1
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005 detailed in the evaluation workplan. The description of the activities conducted for Intervention #1 are described in the on-line reporting template in the partnership listing and Intervention #1 activities listing.
III. Status Report:
The enrollment activity of home health agencies into DirigoChoice is slow and may not meet proposal projections. This is consistent with the statewide response from all small businesses. The exact numbers of agencies and direct service worker enrolled in DirigoChoice is uncertain at this time. 10 of the 26 agencies in the sample study group report offering health insurance coverage of some kind. We expect data from the evaluation surveys to show a low number of direct service workers enrolled in these plans. Grant activities to inform and support the agencies and workers to increase enrollment are continuing as planned.
IV. Changes to Workplan
1. Workplan Activity #5 states that the Dirigo Board, overseeing DirigoChoice, would consider expansion to open enrollment eligibility to larger employers. This has not been approved to date. However, the grant outreach activities have included the larger sized employers and some are participating in the evaluation sample study group. 2. Workplan Activity #8: Report on employer response to outreach is pending. A preliminary report from year two outreach efforts is in draft form. This will be supplemented with outcome findings from outreach activities scheduled for the upcoming quarter (October – December 2005). 3. Workplan Activity #7: The plan to utilize the Employer of Choice (Intervention #2) as an incentive for agencies to enroll in DirigoChoce was dropped in year two when it was determined by talking to agencies that the financial burden of covering insurance premiums would not be alleviated by the additional program option. An adjustment was requested and granted by CMS for this change. 4. Workplan Activity #10: Outcome projects for DirigoChoice enrollments are projected to be 9001200 lives by the last quarter of year three. Study sample employers/workers enrolled in health insurance products other than DirigoChoice will also be counted. While low enrollment and participation rates in this intervention have been influence by delays in the start up of the insurance enrollment period in year one, other circumstances appear to be influencing the response as well. There is controversy that has developed over the last year about Dirigo Health as a road map for health reform and about DirigoChoice as a subsidized insurance product. While this has increased the publicity and public awareness of access to health insurance and its costs it has also increased the uncertainties of its access and sustainability. Other influencing factors to enrollment will be identified in the evaluation process. 5. Workplan Activity #11: Additions to the evaluation workplan are being drafted in order to capture information from the agencies to explain the DirigoChoice enrollment outcomes.
V. Proposed Activities for the Next Quarter:
Activities are planned, and listed in the on-line report, that are consistent with the grant workplan for doing outreach and support to home care agencies and direct service workers to increase their exposure to and eventual enrollment into DirigoChoice. Maine Status Report, October 2005 2
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005 1. More outreach and support to agencies and workers: A new open enrollment period this Fall provides more opportunities to market the product and provide timely support and encouragement. In addition to Dirigo Health Agency and Anthem marketing the grant will: a. Implement a subcontract with Consumers for Affordable Health Care, a grant partner, to conduct a targeted outreach effort to reach the agencies and develop services and tools to support their process of gathering information and decision making about DirigoChoice enrollment. Support will also be offered to their employees. b. Products to market DirigoChoice to small businesses and workers are being developed and distributed by CAHC and support tools for the target agencies will be prepared. c. The Maine Personal Assistance Services Association, Maine PASA will complete website development and activities that involve workers in efforts to raise awareness about health care coverage for workers. They are also working with affiliated partners at the Paraprofessional Healthcare Institute (PHI) to increase health care coverage options for workers. 2. Evaluation data is being compiled and will be reported to agencies. Plans are also being discussed to expand the evaluation workplan to add activities that will capture more information about the affordability and feasibility of employer based health insurance in this sector.
Maine Status Report, October 2005 3
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005
Intervention #2: Develop and deliver a package of workplace services designed to make
employers an "Employer of Choice".
I. Explanation of Intervention
The second intervention involves working with individual agencies to develop customized on- site programs to address their recruitment and retention needs while involveing their direct service workers in the process. The Employer of Choice program is a model program with a framework developed for long term care and home health employers that is focused on the employment of the direct care, paraprofessional workforce (CNAs, PSS/PCAs, HHA and Homemakers). The intervention will involve the delivery of a package of services designed to make each participating employer an “Employer of Choice”. Activities are planned to highlight these employers through the state-based worker association website and newsletters.
II. Review of Grant Activities:
The Employer of Choice program was selected for demonstration and evaluation because of its objectives to help long term care and home care organizations to recruit and retain quality direct care staff and some preliminary successes reported by users outside of Maine. A randomly selected list of the agencies participating in the grant evaluation study and data collection was offered the opportunity to participate. The program offered: Grant funds to help pay for staff participation time, meeting costs, resource development and training services for your agency; Consultation services for recruitment, retention and staff development program assessment and development; A Coordinator to facilitate an employee/management team and on-site meetings to develop and implement a workplan of customized programs to address priorities for staff recruitment and retention; Technical assistance to compile the needs assessment information, identify priorities, develop and implement a workplan and identify community based resources; Recognition through grant associated press and grant partner groups (Maine PASA, PCA Provider Network, Home Care Alliance of Maine, Direct Care Worker Coalition); Documentation and reports of activities and outcomes; The opportunity to build an in-house program that supports your mission and your employees.
III. Status Report:
The selection of agency sites for the implementation of this intervention was completed earlier this year and four sites are well into the implementation phases of the project. While this is fewer sites than proposed the challenges encountered during start up, the delays in start up and the competing issues for the home health agencies limited the size of the outreach group of agencies and the response. The number of agencies contacted during the outreach was also restricted in order to fit within the proposal and evaluation workplan. The primary outreach for agency participation in the grant focused on DirigoChoice and the evaluation study. The Employer of Choice program was planned to be a secondary program.
Maine Status Report, October 2005 4
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005 The last two quarters of the project have involved implementation of the workplan activities for starting Employee Advisory Teams and completing needs and interest assessments. These activities have been significant additions to the four agencies and monthly reports from each site document the challenges and developments. Each site has developed workplans for implementing programs, has administrative support and active involvement of direct services workers.
IV. Changes to Workplan
The primary change to the workplan has been the decision to implement the Employer of Choice program as a separate intervention rather than as an incentive program attached to DirigoChoice. This was necessary due to the delays in the DirigoChoice enrollments and was based on feedback from the agencies that while the Employer of Choice program had value it did not provide direct funding that would help in their financial decisions on the affordability of DirigoChoice for their businesses. The consequence of these developments is that the intervention will not meet the project outcomes listed in the grant workplan, Activity # 10 which projected implementation in 15-20 small agencies and 3-5 large agencies. The four sites that are participating are being carefully monitored and more sites are not likely to be added due to the limited implementation time left in the grant before the final evaluations to assess impact will be conducted.
V. Proposed Activities for the Next Quarter:
The activities listed on the on-line report for this intervention include: Activity 1: Product Development Activity 2: First Group: Site Recruitment, Selection and Start up (4 agencies) Activity 3: Establish Employee Advisory Groups (4) that include Direct Service Workers Activity 4: Employee Advisory Groups developing workplans for identifying and implementing interventions. The work activities for implementing site specific workplan programs have been started and are contracted to continue through June 2006. The procedures and tools utilized for the assessment, site start up and the Employee Advisory Committees is being compiled on the project website http://mainecahc.org/foundation/publications.htm . The development of a tool kit for starting and facilitating the Employee Advisory Committees for an Employer of Choice program are being completed in the October – December 2005 quarter.
Maine Status Report, October 2005 5
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005
Intervention #3: Design an incentive payment for employers who improve retention rates and
other workplace indicators.
I. Explanation of Intervention
An incentive payment plan was proposed for implementation in the final quarters of the grant. This was not proposed or designed as an intervention intended to directly impact worker recruitment and retention but rather as an incentive plan to sustain the Employer of Choice programs following grant completion. The Maine Department of Health and Human Services, which sets reimbursement rates for Medicaid and state-funded community support services, will design a “Maine Retains” incentive payment for employers who improve retention rates and meet other workplace improvement indicators. The incentive payment will be implemented toward the end of the project, just as grantfunded activities are ending, giving employers the means to continue successful interventions. To ensure sustainability, the incentive payment will not include grant funds, but will be provided as part of rate increases implemented by the Department.
II. Review of Grant Activities:
The major activities are described in the grant workplan Activity # 4; Select criteria for payment; Determine size and form of payment; Establish review panel; Make first awards. Based on the grant workplan the activities were not scheduled to continue throughout the project but rather explored in the early stages of the grant and implemented in the final quarters of year 3.
III. Status Report:
Work on these activities was delayed to year three due to changes in state staff, reporting structures and budgets, and have been initiated for the October – December 2005 quarter. Staff have been selected and contacted to serve on the workgroup and there is a high level of interest in this component of the grant. Other initiatives in the state, like the CMS-QIO, 8th Scope of Work and the trend towards payfor-performance programs support the interests in this initiative. There are questions about the feasibility of implementing this program while the state budget and Medicaid are being challenged. More will be known about the status of this program when the criteria and funding sources are identified over the next two grant quarters.
IV. Changes to Workplan
Rather than develop the criteria in the first year and implement the program at the end of year three the initial steps were delayed. The steps to develop the program are now underway for the upcoming quarters.
V. Proposed Activities for the Next Quarter:
A kick off event to initiate work on this intervention was conducted in early October. Debra Lipson, MHSA, Deputy Director, Better Jobs – Better Care, the Robert Wood Johnson/Atlantic Philanthropies’ funded project on direct care workforce recruitment and retention, and noted author on the topic, was invited to Maine to present to an audience of the grant advisory members and state administrators. Her presentation and the discussion served as a primer for the work to be done. A workgroup of state administrators and grant advisory members will begin meetings during this quarter to review the literature and program models being implemented in other states. This group will work on completing the balance of activities planned for the grant. Maine Status Report, October 2005 6
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005
Intervention #4: Evaluation: To evaluate retention by comparing characteristics of workers;
To evaluate turnover by comparing characteristics of agencies; to evaluate the impact of interventions 1&2. (NOTE: The Evaluation is listed on the on-line web report as an intervention in order to capture the many activities being conducted by grant staff. The workplan for the evaluation was submitted with the grant proposal with specific workplan, see Appendix D)
I. Explanation of Intervention
The grant workplan includes the design and implementation of an evaluation study. The study includes pre/post measurement of outcome indicators at the worker and employer levels, with 3 comparison groups. The comparison groups will allow analysis of the effects of the project’s two major interventions. Quantitative and qualitative data will be collection from workers and the employer. Worker level outcomes of interest will include job satisfaction, job retention/duration, and individual and family participation in the Dirigo Health plan. Employer-level outcomes of interest will include participation in Dirigo Health plan, use of full-time versus part-time workers, use of temporary workers, vacancy rates, and staff turnover and retention. The research and evaluation methodology, instruments and workplan are fully described in the proposal Appendix D. An overview/outline of the evaluation study plan is attached at the end of this report.
II. Review of Grant Activities:
Please refer to the evaluation study documents referenced above for a listing or proposed activities for designing the study and the collection of quantitative and qualitative data. The survey instruments are posted on a project website: http://www.mainerealchoices.org/workforce_workdemo.htm Developing and managing the sample study of agencies and collecting baseline data and payroll data has been and continues to be a major grant activity.
III. Status Report:
The development and implementation of the evaluation study is being completed. Recruitment to the sample study involved a wide outreach to home health and home care agencies statewide. There was some delay in starting the outreach work, and the response rate was low. The follow up calls and a high level of contact and support was helpful to recruiting the sample study group and setting up the procedures for collecting data. The sample study appears to include a cross section of agencies that will fit into the three comparison groups proposed. The overall number however is smaller (26) than the 50 proposed. The baseline surveys were conducted with the agency administrators (employer-level data) and the workers. Reports on this data are being written. Retaining the agencies in the sample study group and working with them to collect the administrative data to evaluate turnover requires regular attention.
IV. Changes to Workplan
Changes made to the implementation of the evaluation study workplan include the decisions not to collect administrative data from Unemployment Insurance records to track worker employment records and wages, and the omission of a 6 month, mid-study worker survey. The administrative data being Maine Status Report, October 2005 7
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005 collected from each agency will be used for the longitudinal assessment of turnover and worker level surveys will be conducted at two points, baseline and 18 months. An adjustment was also made to the plans for collective qualitative data through site visits. The site visits and interviews with both agency administrators and workers were conducted in coordination with the Employer of Choice needs assessment rather being done at the end of the project. Other changes to the evaluation study and workplan are being discussed that will involve additional survey work and site visit interviews to capture information regarding employer response to the DirigoChoice enrollment option. Design, IRB approval and implementation plans will be proposed and submitted to CMS.
V. Proposed Activities for the Next Quarter:
The evaluation staff will continue activities to collect agency administrative data monthly/quarterly for longitudinal tracking and to compile data into reports that will be discussed with study participants. In addition the evaluation plan and tools for surveying agency response to DirigoChoice will be developed and proposed to University Office of Research Compliance and to CMS.
Maine Status Report, October 2005 8
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005
Overview of Workforce Evaluation Study
1. Goal/Purpose
The demand for home and community based services and the shortage of workers to fill direct care and aide positions has placed a priority on efforts to understand the factors that influence workforce turnover. Using both before and after and comparison group analyses and a mixed method design will examine the factors that influence recruitment and retention and test the impact of Dirigo and Employer of Choice. Examine/analyze the factors (agency and worker-level) related to turnover among direct care workers Describe what agencies are doing currently to retain and recruit direct care workers Measure and track turnover among direct care workers Test the impact on recruitment and retention of Dirigo and Employer of Choice interventions for participating agencies and/or workers.
2. Objectives of Workforce Evaluation Study
3. Components of Workforce Evaluation Study
Sample: 50 agencies and the direct care workers they employ Needs Assessment/Site Visits of 50 agencies (Gail and Steve) i. Purpose: 1. To collect baseline and qualitative data/information on what agencies are currently doing to address recruitment and retention 2. To begin the assessment of how close/far to being an “Employer of Choice” an agency is and begin to collect information that will help in the design/customization of EOC intervention. ii. Components: 1. 1.5 hour in-person semi-structured interviews with administrator/supervisor/owner 2. 1.5 hour in-person semi-structured interviews with2-3 direct care workers Surveys (Lisa and Al)
i. Purpose: 1. To collect more quantitative data on the agency and worker-level factors related to turnover and retention from larger samples of workers and supervisors 2. To assess the impact of Dirigo and Employer of Choice interventions for participating employers ii. Components: 1. 2 waves: this fall and 18 months later 2. Worker Survey a. Closed-ended and more quantitative measures of: i. Job title, role, tasks ii. Compensation, benefits, flexibility, etc. iii. Job tenure, hours, days, shift iv. Job satisfaction v. Job stress
Maine Status Report, October 2005 9
Direct Service Worker Grant: Maine
Explanation and Status of Grant Activities: October 2005
vi. relationship and dynamics with supervisor, co-workers, clients, etc. vii. worker demographics 3. Supervisor Survey a. Closed-ended and more quantitative measures of: i. Management practices and style ii. Workplace culture/attitudes iii. Organizational structure iv. Work systems v. Learning/training opportunities vi. Grievance procedures vii. Compensation, benefits, flexibility, etc. viii. Perceptions of causes of turnover
ix. Hiring and recruitment x. Orientation xi. Retention xii. Training xiii. Job descriptions/titles xiv. Communication between management and workers xv. Performance and Evaluation xvi. Benefits xvii. Promotion and Advancement Tracking agency turnover (Lisa and Julie) i. Purpose: 1. To track turnover rates (agency level) over time; to establish before and after measures of turnover in order to assess impact of Dirigo and Employer of Choice ii. Components: (quarterly) using personnel/administrative agency records 1. agencies will supply us with the following data on all DCWs in their employ: hire date, employment status (regular employee, on call, temporary
agency worker, on leave of absence), typical hours worked/week, hourly wage rate, departure date (last day worked, last day paid) quarterly
2. turnover-rates and job duration will be calculated by worker type (PT, FT, etc.)
Maine Status Report, October 2005 10