Challenges and Opportunities for the Vermont Health Care Workforce

Prepared by the Vermont Association of Hospitals and Health Systems The provision of health care in 2000 presents a variety of challenges. The driving force continues to be provision of high quality services in the face of shrinking financial resources and increased utilization by consumers. In Vermont, the more knowledgeable consumers become, the greater their demands are for access to state of the art technology and a variety of services in a variety of settings. This presents a conundrum for providers and regulators alike. To compound the situation are demographics of an aging population with increasing long term chronic illnesses. Pairing this with emerging, competing career opportunities for our youth, produces the ultimate challenge of filling the need for a competent, well educated work force prepared to respond to the medical challenges of a high-tech era within the cost constraints faced by Vermont’s healthcare organizations. In order to get a grasp of the situation in Vermont, it is important to explore recent background information, issues and areas of need that have become apparent, and strategies that are being contemplated and implemented. Once this is done, it will be important to determine if Vermont’s approach is as well coordinated as it could be and if we are providing consistent messages and appropriate supports to properly address the situation I.     Background Information A great deal of background research can be done on this topic. For the sake of brevity and relevance to Vermont, we have narrowed our search to include information provided by the Report on Nursing in Vermont (1998), the Survey of Vacant Personnel Positions at Vermont Health Care Organizations (1/14/2000), and information from the Bureau of Labor and Statistics. The following provides a brief summary from these three sources. The Report on Nursing Faced with multiple challenges in the profession of nursing in 1998, the Vermont Organization of Nurse Leaders and the Vermont Association of Hospitals and Health Systems hired Toni Kaeding, RN, MS, to research, write and produce the Report on Nursing. This report provides excellent background information on the state of nursing delivered by registered nurses in our state. In summary, the report points out that on the surface employment is up, nurse/patient ratios are stable, education is adapting, and more nurses have full-time employment than ever before. However, it also points out that there may be a number of converging variables which individually might not have an effect, but when grouped, may substantially impact the practice of nursing. Included here are increased non-clinical responsibilities, a 20% decrease in the number of LPNs over a five year period, increased patient acuity and decreased length of stay, decreased educational experience, increased overall admissions with the growth in ancillary and outpatient services, increasing average age of RNs, and increased information and technology. The result of aggregating all these variables may be a less well-prepared nurse work force with an expanded workload. The report suggests that further examination of these forces will enable the wise use of valuable nursing resources and benefit patients and providers alike. It also states that Vermont was not experiencing a nursing shortage in 1998 but warned that it was looming. Survey of Vacant Personnel Positions at Vermont’s Health Care Organizations By late 1999, members of the Vermont Association of Hospitals and Health Systems, felt the urgency to gather and examine data on the workforce needs in Vermont health care organizations. This data would serve as evidence of actual vacancies being experienced. On January 14, 2000 a survey of budgeted fulltime equivalents (FTE) and the number of vacancies for a variety of positions was conducted in hospitals, nursing homes, home health agencies, residential care facilities and physician offices. In addition, data on nursing positions in hospitals, nursing homes, and residential care homes was collected according to shift. In hospitals, nursing data was also collected by department. Response rates varied by setting, with the lowest being 28% for Residential Care Homes and the highest being 88% for hospitals. The response rates for all settings yielded statistically significant results. Setting and Number Responding Hospitals: 12 out of 15, representing 88% of licensed acute medical care beds Nursing Homes: 26 out of 44, representing 76% of licensed beds in the Medicaid program Home Health Agencies: 10 out of 13, representing 76% of agencies Residential Care Facilities: 28 out of 113, representing 28% of the licensed beds Physician Offices: associated with 8 out of 15 hospitals/health systems, representing 65% of licensed beds (approximately 26% of physician offices) Looking at an aggregate of data across all reporting care settings statewide, on January 14, 2000, there were a total of 165 RN vacancies, resulting in an overall RN vacancy rate of 7.4%; 55.6 LPN vacancies, resulting in an overall LPN vacancy rate of 11.3%; and 169.8 LNA vacancies, resulting in an overall vacancy rate of 13.3%. If 100% of hospitals, nursing homes, home health agencies, residential care facilities and physician offices had reported their vacancies, the total number of vacancies on January 14 would be 211.9 for RN, 81 for LPN, and 219.7 for LNA. Hospital Survey Data on the number of budgeted fulltime equivalents (FTE) and the number of vacancies was collected on twenty-four positions in hospitals. The report of the hospital data included historical comparisons on some positions, which have been tracked since 1988; others have been tracked for four years or less. A few of the highlights of the hospital survey show a vacancy rate for RNs (7.0%) that is close to the highest rate experienced in 1989, during the last shortage. The LPN vacancy rate (8.8%) is higher than in any previous survey. The licensed nursing assistant vacancy rate is in the double digits (16.2%). Pharmacist at 16.8% and Diagnostic Radiographer at 7.4% are also at an all time high. Other positions may have high vacancy rates resulting from only a few FTE vacancies. This is still noteworthy, because if the hospital relies on two or three fulltime professionals to run a particular service and one of them is missing, the hospital has difficulty offering the service. An additional aggregate breakout for hospital vacancies by department and by shift is also provided. The hospital department with the greatest number of vacancies is the Medical/Surgical unit. For RNs in the medical/surgical units, vacancies are spread across all shifts with days being highest, followed by evenings and then nights. The same is true for LPNs. However, for LNAs in the medical/surgical unit, the greatest number of vacancies are in the evening, followed by days and then by nights. The hospital department with the next highest number of vacancies is the Intensive Care Unit. The vacancies are primarily for RNs with nights being the highest number, evenings next, followed by days. Nursing Home Survey Data was collected on twelve nursing home positions. The positions with the highest vacancy rates and vacant positions were RN at 16.8%, LPN at 15.8%, and Licensed Nursing Assistants at 17.2%. Speech Therapy shows a high vacancy rate of 20.8%, with only one vacant position. An additional aggregate breakout for nursing home vacancies by shift is also provided. The greatest need for RNs is the day shift, followed by evenings and then nights. The greatest need for LPNs is evenings, followed by days and then nights. The greatest need for LNAs is also evenings, followed closely by days and then nights. Residential Care Survey Both level three and level four Residential Care facilities responded to the survey. Some of the residential care facilities are extremely small and the owner provides much of the care. For the facilities responding, no RN vacancies and only one LPN vacancy were listed. Four LNA vacancies out of 87.1 full time equivalent positions and one vacancy in dietary out of 27.5 positions were also noted. The nursing vacancies are all on the day shift. Home Health Agency Survey The home health positions with the highest vacancy rates are: Clinical Specialist Nurse at 16.5% representing 5.5 full time equivalent vacancies; RN at 3.1% representing 9.2 vacancies; LPN at 20.4% representing 4 vacancies; LNA at 6% representing 19.5 vacancies, and Personal Care Attendant at 15.3% representing 5.7 vacancies. Other professional areas such as occupational therapy, speech therapy and social worker/MSW have .5 to 1.8 vacancies, which result in noticeable vacancy rates, even though they are small numbers. Again, these professional vacancies can result in a service being unavailable from an agency. Physician Office Survey Hospitals and health systems have approximately 40% of physician offices in Vermont associated with them. The information provided by the responding organizations show a 10.4% vacancy rate for RNs, a 6.9% vacancy rate for LPNs, no LNA vacancies, and a 9.8% vacancy rate for medical secretary transcriptionists. Survey of Temporary/Traveling Nurses Despite a staffing shortage, it is necessary to continue to provide care and services to Vermonters. This is accomplished in the short term by hiring temporary or traveling nurses. As a part of the January 14, 2000 vacancy survey, hospitals were asked to provide the total number of traveling nurses employed in their facilities on that date. The statewide total number reported was 66.8 traveling nurses employed by Vermont hospitals on January 14. Hospitals were also asked to provide the total amount of money spent above the FTE budgeted cost, for traveling nurses in 1999. Four facilities reported that that figure was unavailable at the time of completing the survey. Six others reported expenditures ranging from $12,000 to $810,000. The total expenditure reported by these six hospitals on the January 14, 2000 vacancy survey was $1,522,132 above the FTE budgeted cost for RNs for 1999. Bureau of Labor and Statistics Research According to the Bureau of Labor Statistics, health services is one of the largest industries in the country, with about 11.3 million jobs, including the self-employed. U.S. employment from 1998 to 2009 is expected to experience a growth rate of 14%, while during the same time period health care average growth rate is expected to be 28%. Two out of the three fastest growing occupations out of the top 30 are in health care and computers. Six out of the top ten are in health care, the other 4 are in computers. The greatest growth will be seen for registered nurse, nurse practitioner, and nursing assistants. Occupations that will see the fastest growth in health care include physician assistant, respiratory therapist, physical therapist, medical assistant, physical and occupational therapy assistant, health record analyst and surgical technician. As so aptly described by one of our hospital representatives to a group interested in linking education and work place environments, "The health care workforce is a community within a community". Looking at the hospital facility alone shows a full spectrum of occupations and a full spectrum of educational backgrounds necessary to fill those occupations. On the support side is food service, housekeeping, waste disposal and maintenance. Each of these areas employs entry level workers who may have a high school degree or less; individuals with mid level training, such as a dietary technician with two years of education beyond high school; and individuals with bachelor degrees or higher, such as the dietician or engineer. There are information systems that require entry level secretarial and clerical services, medical record transcriptionists and coders with one or two years beyond high school, billing personnel that may have associate or bachelor degrees, and information systems personnel and analysts that may have college level or advanced degrees. On the clinical side there are physicians with approximately eleven years of education beyond high school, pharmacists with six years, physical therapists with five years, nurse midwives and nurse practitioners with graduate level degrees, physician assistants, registered nurses, occupational therapists, speech language pathologists, medical technologists, nuclear medicine technologists and radiation therapy technologists with bachelor degrees. There are also associate degree registered nurses, respiratory therapists, medical technicians, occupational and physical therapy assistants, radiographers, and ultrasound technicians. Licensed practical nurses have one year of training and licensed nurse assistants have two weeks training. In summary, hospitals employ a great mix of employees with a variety of skills and educational levels. According to the Bureau of Labor Statistics, about 1in 4 employees is a registered nurse, 2 in 10 are service level workers. In nursing and residential care facilities two-thirds of employees are service level workers, primarily nursing aides. In home health care services more than half the jobs are in service occupations, mostly personal care and home health aides. Salaries depend in large part on the scope of duties or practice, the level of education and skill required, the experience and level of competence exhibited, and to some degree, what the supply is for individuals with the appropriate credentials. II. Issue Areas and Needs Factors influencing the future supply of health care workers are competing career opportunities, perceptions of the work environment, public perceptions of the health care industry, the culture of our society, and the change in individual values among younger members of the work force. Competing Career Opportunities It is a well known fact that traditionally health care services, with the exception of physician services, have been delivered primarily by women. For many years nursing and education were among the few career choices for women. We are now in an era where more women are being accepted in career areas that were traditionally dominated by men. In addition, many of these areas provide regular work hour schedules, more compensation, more opportunity for advancement and personal growth, and greater respect from fellow workers and society. As a result, fewer women are selecting a health care career. Perceptions about the Work Environment Perceptions about the work environment are formed from interaction with the environment and from "stories" from friends and relatives who work in health care. Over the past several years the healthcare environment has gone through enormous change, largely resulting from efforts to reduce costs and increase efficiencies. More patients receive care as outpatients than as inpatients and inpatient stays have been drastically reduced. The resulting impact on health care workers, especially nurses, is the loss of the traditional reward, which came from caring for a patient through an illness and into recovery. Patients are in the acute care setting too briefly for a nurse to fully implement all he or she was trained to do. In addition, healthcare organizations have been forced to eliminate mid-level managers who provided support to staff workers. Without the reward and the support, healthcare workers are often left feeling overwhelmed and frustrated, rather than satisfied and rewarded. These feelings are aired with family and friends, leaving them with negative perceptions of the healthcare environment. Public Perceptions The media has a profound impact on public perception. Media reports rarely cover the accomplishments of healthcare workers and organizations in preventing and treating illness, or in creating healthy communities. They do, however, headline massive health care layoffs, restructuring issues, medical errors, and rising health care costs. These are not inviting messages to perspective employees, especially our youth, who want to feel they can contribute, make a difference, and earn a decent living in their communities. Culture of Society The culture of our society fosters an expectation that accessible, high quality care will continue to be available without a corresponding rise in cost. In this culture, consumers are not educated about the interrelationship of quality, cost, access and utilization; nor are they held responsible for their utilization of services. This lack of understanding of that interrelationship and failure to take responsibility, lead to further efforts to reduce costs which feed a downward spiral rather than developing an acceptable long term solution and recognizing the value of health care providers and organizations in our communities. Individual Values According to reports from hospital human resource executives some employees currently entering the work force exhibit a different work ethic from employees of previous decades. Recent articles in national publications, like Business Week, point out that the change in work ethic pervades all industries. What previous generations of women in the work force worked hard to accomplish in the way of recognition, promotions and benefits, younger workers now expect to have regardless of their contribution. At the same time the younger workers do not feel compelled to stay with the same organization or in the same industry over an extended period of time. A recent study by Yankelovich Partners found employees age 18 to 34 are less likely to feel allegiance to their companies than those who are age 35 and above. According to the study, there is a belief among younger workers that if they don’t like their job, they can quit and easily find another. This is problematic for health care organizations. With an increased shortage of nurses, coupled with changing values regarding stable employment, even higher turnover may result. All of these factors point to a need to look carefully at the external pressures that have forced health care organizations into roles that run counter to their visions and missions and interfere with creating a culture that supports the development of values that focus on the caregivers as well as on the patients. Strategies for Creating a Viable Work Force Some concrete strategies to consider in creating a viable workforce are changing the image of the work environment, creating supportive work environments, aligning compensation structures, establishing a comprehensive recruitment mechanism, addressing the educational needs of a rural state, and educating consumers and public policy makers. Additional strategies and solutions will result from further statewide discussions. Changing the Image of the Work Environment We need to proactively get the word out through every appropriate medium that there are a great deal of good things done in health care and by health care providers and caregivers. A coordinated statewide approach to change the public’s image is possible, using partners, such as the Vermont Broadcasters Association, the Times Argus/Rutland Herald and other newspapers, and the Hospital Public Relations Directors. Enhancing VAHHS’s web page with regular "good news updates" is another suggestion. Health care employees can be the greatest influence on public perception. Internally, strategies will need to be created to help employees feel less overwhelmed and more appreciated. Involving these employees in improvement initiatives, and giving them the time for this participation, might be one strategy. Brainstorming and sharing of ideas between members of organizations such as the Vermont Organization of Nurse Leaders (VONL), the Quality Improvement Forum (QIF), and the Vermont Healthcare Human Resource Association (VHHRA), will produce other positive suggestions that individual organizations may wish to adopt. Many healthcare organizations have already initiated programs that reward positive health behaviors as the result of some of these exchanges. In addition, some employees may benefit from education on interaction with patients and support in the work place to help them make positive changes. Creating a Supportive Work Environment Vermont’s healthcare organizations are making strides to create supportive work environments. Examples of this are the Nursing Internship Project and Preceptor model. Nurse leaders in the state have taken the initiative to develop an internship program for new graduates of registered nurse programs. While the academic offerings of the programs provide nurses with a strong theoretical background, they are not able to provide the time and experience needed to translate that to the bedside. For this reason the internship program was created and is being piloted in three hospital settings in Vermont as well as one in its second year at another hospital. A grant request has been submitted to HRSA to gain additional support for the effort and to help grow it into a statewide effort. Local preceptors are essential to an effective internship program. These individuals are the mentors who develop standards for the nursing process and create a nourishing environment in which new graduates can learn and practice clinical skills. Acting as a preceptor also enhances the registered nurse’s feeling of professional worth. Preceptorship then, in turn, becomes a tool for retention of highly skilled and knowledgeable registered nurses. Other strategies are being developed throughout Vermont health care organizations and sharing successes and learning from each other would be an added benefit. While the largest number of employees in health care organizations are nurses and it is important to think of strategies that will have positive impact on large groups of employees, these models need not be restricted to nursing. They are models that could be beneficial to all health professions in creating and sustaining supportive work environments. Aligning Compensation Structures There are pilot projects testing out different approaches to this at some of Vermont’s health care organizations. Rutland Regional Medical Center has implemented a new performance evaluation process, which recognizes and rewards employee contributions and team involvement. It begins with a baseline measurement of employee satisfaction, which will be repeated following implementation to assess the success of the strategy. The results of the follow-up survey information will be available to the organization in 18-24 months. Establishing a Comprehensive Recruitment Mechanism Vermont is fortunate to have a statewide, centralized recruitment and retention service that has successfully addressed and continues to address the shortage of providers in our rural state. In the past four years 139 providers have been placed throughout the state by the Vermont Recruitment Center and all but 12 of those placed continue to provide needed services to Vermonters. Included in this number are 88 physicians, 44 nurse practitioners/physician assistants/certified nurse midwives, and 7 allied health professionals. With this record of success, thought is being given to expanding the Vermont Recruitment Center’s operations and adding a consistent and time effective approach toward recruitment of registered nurses and allied health professionals on a regular basis. Given the amount paid out for traveling nurses, which in 1999 was a total of 1.5 million dollars above the budgeted RN FTE cost for six Vermont hospitals, this might be a long term cost effective approach. When looking abroad to recruit nurses, Vermont healthcare organizations have found some relief. Approval has been gained from the Vermont Board of Nursing to issue licenses for English speaking foreign nurses on a case by case basis. If the nurse has graduated from an acceptable foreign program and passes the Vermont examination, the requirement for passing the national nursing examination may be waived. This will enable Vermont hospitals to hire Canadian and other English speaking foreign nurses in a more timely manner. Recruitment of already licensed, competent individuals is the first choice. But this alone will not solve the long-term needs. In addition, Vermont needs to consider creation of a comprehensive recruitment mechanism by which capable Vermonters are attracted to the health care field. This is not a new venture. It is basically "feeding the pipeline". VAHHS coordinated a similar process from 1988 through 1996, aimed at junior high and high school students and adult career changers. The first step in developing a comprehensive recruitment program is designing the message. In order to do this it is necessary to find out why individuals stay in health care careers and why some leave. This can be obtained from "exit interview" information and interviews with long term employees. Next is to discover what students and young adults think an ideal career is and what they think about health care. Various studies from the Vermont Student Assistance Corporation, Lake Champlain Chamber of Commerce, and Department of Health Risk Behavior Survey have been reviewed, but none of these addresses those information items. It may be necessary to develop a questionnaire to be used with student and adult groups in three different areas of the state in order to obtain this information. The next step is to educate students on the opportunities and benefits of health care careers. Student groups include junior high, high school and college students. Program elements could include: Speakers Bureau: professionals presenting in science classes Student Newsletter: spotlight a particular career in each issue Health Career Directory: basic tool to ensure delivery of consistent information on a variety of careers. Formats would be CD-ROM, web, booklet Web page with links to career directory, newsletters, colleges, professional organizations, financial aid resources, etc. Daring to Care Program Explorer Posts Shadow Programs at health care organizations Health Career Fairs Video distribution (duplicate existing VAHHS video) Radio Ads Mailings to Principals, Guidance Counselors, and Science Teachers Vermont organizations that have expressed an interest in partnering in some of these efforts, or who could be approached to partner are: Area Health Education Center, Vermont Institute of Math, Science and Technology, Recruiters at College Health Care Educational Programs, Health Care Organizations, Boy Scouts of America, School Principals, Guidance Counselors and Science Teachers, the Vermont Broadcasters Association and local Vermont newspapers. In order to market to adult career changers, the informational materials listed above can be made available through the Internet, radio, newspaper, physician and dental offices and employment offices. Additional partners for this effort would include the Vermont Medical Society, the Vermont Dental Society, and the Vermont Department of Employment and Training. Addressing the Educational Needs of a Rural State Education for a health care career or profession can be considered from five aspects: secondary level preparatory education, technical or academic education for a specific health career area, matriculation from one level to another, internship and financial assistance. Secondary Level Preparatory Education Education on the secondary (high school) preparatory level has two tracks. Consideration of which track to take will depend on the capabilities of the individual and whether the individual’s goal is to enter a health service area or a health profession. If the end goal is health service, then a track through a vocational/technical process may be appropriate. To succeed in a health care profession the individual will need a more academic approach which encourages four years of math and four years of science as well as other college level preparatory courses for adequate preparation. In our last campaign, 1988-1996, we discovered that students who can academically achieve will not choose a health career profession if it is perceived within that school district as being part of a vocational/ technical track. Traditionally, selecting distribution of health career information through a vocational/ technical vehicle attracts service level employees such as licensed nursing aides, but will not attract professional level employees such as bachelor prepared registered nurses, pharmacists, and physicians. If a school district has successfully changed the image of technical education in its community into a track that includes a strong professional preparation, the response may be different in 2000. This should be tested prior to seeking a route for distribution of information statewide. Technical or Academic Education For a small state, Vermont has several associate degree and bachelor degree programs to prepare individuals for health careers. Vermonters are also able to access programs in neighboring states. We also have advanced practice nursing programs and a medical college. Programs we lack include pharmacy, occupational therapy, and medical record coding. Matriculation Helping Vermonters enter health careers at an entry level and gradually gain more education has been of interest to Vermont health care organizations for many years. All hospitals provide tuition reimbursement for employees and encourage continued learning in health care. What has not always been easy is the transfer of credit from one educational organization to another. Over the past few years nurse educators and nurse leaders in the state have addressed this in nursing. Improvements have been made and linkages from licensed practical nursing programs to associate degree registered nurse programs now exist in many areas of the state. A more natural link is from associate degree nursing programs to bachelor degree programs. Twenty-five associate degree nurses from Rutland Regional Medical Center have just completed a five-year program through Norwich University to get their BSNs. They were able to continue working fulltime with courses delivered to them in Rutland. In the past few years UVM has also instituted advanced nursing degree programs for bachelor prepared registered nurses who wish to continue to advance within their profession. For other professions within the state, VAHHS has not yet explored whether linkages exist between two-year and four-year programs. Another area to explore would be whether there are core courses for a variety of two-year health degree programs that could be provided throughout the state or through distance learning techniques to employees and other working Vermonters who may want to enter a health care field. This would be important to research in order to provide educational outreach in our rural state. Through this vehicle we might be able to encourage individuals, who cannot leave their communities due to family commitments, to work full or half time and gradually get the courses they need to qualify for two and four year degrees. This would involve assessing the individual’s secondary preparation and capability of succeeding in college level courses as well as considering flexible delivery modes for courses. Internship As mentioned previously, nurse leaders in the state have taken the initiative to develop an internship program for new graduates of registered nurse programs, which will enhance their clinical skills. This type of program paired with a sound academic background provides excellent preparation for all health professions. Financial Aid As also mentioned previously, Vermont hospitals provide tuition reimbursement to employees who seek additional education in the health care field. Hospital related associations, such as the Auxilians and the Vermont Healthcare Human Resource Association (VHHRA), also provide scholarships for students. Other possible solutions to consider would be to encourage other health care organizations to provide tuition reimbursement or scholarships, to establish an endowment fund for health care career scholarships, and to seek Department of Employment and Training workforce investment grant money to improve the level of education and earning potential of particular groups of health care workers. This past legislative session funding for nurse loan repayment was sought but defeated. Consideration might be given to raising the issue in the next session. Educating Consumers and Public Policy Makers To balance the public policy emphasis on cost containment, which has indirectly threatened the viability of our workforce, an effort should be made to better educate consumers and public policy makers on the complexities of health care delivery in Vermont. Consumers need to understand the interrelationships between cost, quality, access and utilization. Citizens of Vermont need to be better educated about their responsibility to use healthcare services wisely. They need to understand the negative impact that further cost constraints will have on access, quality and availability of a caring and competent workforce. Three avenues to explore for this work would be the Commission on Health Care Values and Priorities, the Vermont Ethics Network and the Business Roundtable. IV. Focus on Current Need for Entry Level Employees With all of this said, what has been brought to VAHHS’s attention at a recent Vermont Healthcare Human Resource Association meeting is a statewide sense that the shortages for professional level positions are real, but there are strategies to address them over time. The bigger problem left to solve, according to human resource representatives, is in the area of entry-level positions in dietary, housekeeping and licensed nursing assistants. These tend to be the lower paid positions that do not require a lot of skill, but they do require attracting responsible individuals. For licensed nursing assistants (LNAs) it is also important to attract individuals who are caring individuals who can learn the skills and coping mechanisms necessary for the job. A licensed nurse assistant helps registered nurses and licensed practical nurses in providing physical care to patients. They may also help family members in caring for patients in private homes. The LNA position is a critical one to fill in all health care settings and may require specific attention and a particular strategy. Vermont Healthcare Service Program One strategy to consider in addressing LNA shortages, which has garnered interest from several agencies and organizations in Vermont, is a Vermont Healthcare Service Program. Purpose of Program The purpose of the Vermont Healthcare Service Program is to provide program participants an opportunity to serve their local communities by helping elderly Vermonters who need health care services. If modeled after an Americorp type program, the benefit to Vermont is threefold. High school graduates who become program participants will learn a health care skill, qualify for a nurse assistant license, receive a stipend of $17,500 living allowance and receive education awards totaling up to $12,000 for two years of service. The elderly in Vermont’s communities will be able to receive the highest quality care in the setting of their choice within their own community or region. In time, Vermont’s health care organizations will be able to address the shortage of qualified, well-trained licensed nurse assistants, removing a barrier to access to services. The program will seek a two-year commitment from the program participant who has exhibited a commitment to care for others, an aptitude to succeed in the health care field, and evidence of team spirit. Administration & Funding of the Program If the program receives federal funding through the National Service Corporation, the Vermont Association of Hospitals and Health Systems will administer the program for our member hospitals and nursing homes and home health agencies who are experiencing difficulty recruiting licensed nursing assistants. Program participants would receive a stipend of $8750 per year plus a $4750 education award per year to be put toward higher education expenses from the National Service Corporation. Partnering health care organizations would pay program participants an additional stipend of $8,750 per year, based on a full time work schedule of 40 hours per week over a 52-week year. In addition, the health care organization would agree to contribute an additional $2,500 education award to program participants completing their second year of service. Partnering health care organizations would also be expected to pay a portion of the administrative expenses of the program, contribute to a program endowment fund, provide mentors and allow paid time for program participants to explore health career options. All of these expenses incurred by the partnering health care organization would be equivalent to no more than the average current LNA statewide annual wage for each service volunteer they sponsor. Training Program Program participants will be trained to care for patients as licensed nurse assistants (LNA) through existing training programs that are willing to add an "enhanced" feature and add a third week of education to the original two weeks. In addition, during the two-year time period program participants will receive ongoing education to help them refine LNA caregiving techniques. The program will be designed to help program participants handle the situations they will encounter within the health care organization or in a person’s home. In addition, a portion of the curriculum would be designed to teach program participants how to attain their highest potential for personal health while they attend to the health needs of others. Where possible, professors and experts throughout Vermont will be engaged in this ongoing education. Overcoming Fears of the Work Place The Vermont Health Care Service Program LNA initial training would be geared to assist the participants with overcoming fears associated with entering the work force. In addition, the mentoring aspect of the program would provide guidance and support to overcome perceived obstacles. The individual will learn how to dress, groom themselves, communicate with employers, and behave responsibly within the work setting. They will learn about safety precautions, personal hygiene and healthy lifestyle choices. If during the two years of service the individual chooses to pursue a career pathway, but is lacking some of the background high school class work to be accepted immediately into a program for higher education, other Vermont resources will be investigated, such as the Vermont Social Welfare Department’s Reach Up program, to meet this need. Mentor Program participants will also have an on-sight mentor, with a rich background of knowledge and experience, who will be able to answer any questions they have about the work they are doing. The mentor will also help the program participant to learn about other aspects of nursing, allied health and medicine, depending on what health career pathways are of interest to the individual. Since the program participants will be working within a community health system, arrangements can be made for them to talk with a variety of health care professionals and even spend a day shadowing a professional in a field of interest. They will be assisted through the process of investigating programs for higher education in the health care profession of their choice. Some of the career areas they will be exposed to, and which they might consider entering, are dietetics, nursing, medical laboratory technology, medical record abstraction and coding, pharmacy, physical therapy, occupational therapy, radiologic technology, respiratory therapy, and speech therapy. All of these professions present opportunities for increased levels of responsibility in Vermont care giving settings. They also open the door for salary levels that provide good livable wages. In some instances the income levels for two-income families would provide a very comfortable living. The mentor would be interviewed and selected by the facility and would be provided with ongoing education and support by the program’s link to the National Service Corporation’s resources. One possible idea for locating mentors might involve linking up with an existing community volunteer organization such as RSVP. It would be hoped that the RSVP organization could interest retired LPNs and RNs in sharing their years of knowledge and experience with a program participant working at a facility within their community. These individuals would be provided training in mentorship, training on the policies and procedures of the facility at which they are volunteering and would be given a flexible schedule and a respected role within the organization. In addition they would be recognized and honored as a volunteer leader in their community by the organization they assist and would receive a small stipend for their service from that organization. The Education Award At the end of each year of full time participation in the national service program, the program participant would qualify for an education award in the amount of $4750. At the end of two years of full time service the participant will receive an additional $2500 from the employing healthcare organization. The total amount of education award the participant may receive after two years of service is $12,000. The Education Award would be held for the individual in an account at the Vermont Student Assistance Corporation until needed for tuition. It may be used at the discretion of the student for any accredited educational program in the field of the student’s choice either inside or outside of Vermont. Where necessary VSAC will assist the student in procuring additional financial assistance for which the student qualifies in order to pursue a degree. Any additional resources the student may qualify for and receive will not affect the educational award amount. Any individual, who is interested in working toward an educational degree while serving the two years as an LNA, would receive tuition reimbursement from the employer and assistance in locating the appropriate courses. If upon completion of the two years of service the individual is interested in remaining in the work site as an LNA the individual may choose to have the education award put into a work incentive account. Instead of being used for education, the award could be used to add $1.00 per hour additional pay. Marketing of Program & Selection of Service Volunteers VAHHS will conduct an informational campaign about the Vermont Service Program for Healthcare opportunity and will seek applications from at least two graduating seniors at every high school in the state. Applications will be gathered centrally at VAHHS. From the potential 180 applications we will select 40 to 50 program volunteers each year for three years. This selection will be done through a committee of participating organizations. Member hospitals, nursing homes and home health agencies will commit to hiring the service volunteers prior to acceptance of applications and training of service volunteers. List of Steps to Operationalize a Vermont Healthcare Service Program Submit a proposal to Senator Jeffords for consideration of a new national service program aimed specifically at filling the needs for healthcare. Select existing LNA training programs that are willing to enhance their programs. Explore options regarding mentors. Design a marketing plan Print marketing materials and applications and send to all high school guidance counselors and science teachers Set up a selection committee process to review applications in conjunction with facilities that would be hiring the program participants. Select and Train Mentors Design a packet of information for selected program participants. Send notices of selection with the packet of information and registration  for the training program. Conduct training program Outline the on-going education, which will take place during the year Mentors meet service program participants at work setting and participate in orientation Program participants begin a regular schedule of work Program participants would participate in National Service Corp programs provided within Vermont. In the second year consideration could be given to having the program participants offer some aspects of the mentoring role to new volunteers. During the two years mentors would be provided with up to date information on health care opportunities and higher education opportunities where health care organizations are experiencing shortages. Mentors would provide this information to their program participants. Monitoring and Evaluation of Program Recruitment success Marketing materials and mailings meet scheduled deadlines Number of applications generated Number of acceptances for service volunteers (Closeness to capacity) Training success % of service volunteers who attend training session who pass the exam to be a licensed nurse assistant. Comparison of this rate to the current success rate for training programs in the state Supportive environment success Periodic evaluations of mentors produce an average score of very good or excellent from at least 85% of program participants % of Retention exceeds the current rate of retention of LNAs Turnover rate of program participants is less than turnover rate of current LNAs Success of introducing program participants to health care as a life career in a service  area Number of program participants who choose a higher education opportunity in the health care field Number of program participants who elect to continue as LNAs Attachment: Descriptions of possible health career pathways and associated average statewide salary levels Dietetics is a profession concerned with the science and art of human nutritional care, an essential component of the health sciences. It includes the management of group feeding and the imparting of knowledge concerning foods, which will provide nutrients sufficient for health and during disease or illness. Medical Laboratory Science uses state-of the art instrumentation and innovative testing to perform tests on body fluids. The results of these tests are used to diagnose and treat diseases. Medical technologists track down the chemical and biological clues that diagnose disease and monitor therapy. They identify the microorganisms that cause infections; test blood for proteins, vitamins, hormones, drugs and hundreds of chemicals including glucose (sugar), cholesterol and sodium; evaluate blood cells to detect anemia or leukemia; and match blood for transfusions and tissue for organ transplantation. Medical technologists also evaluate test results, monitor quality, troubleshoot problems and develop new methods. Medical Laboratory technician performs routine laboratory tests that assist in diagnosing disease and monitoring therapy. Nursing is a profession that combines clinical skills with the art of caring. A Registered Nurse is concerned with the "whole person" and therefore assesses the patient’s psychosocial and emotional functioning as well as their physical needs. They observe, assess, and record symptoms, reactions to therapy, and the patient’s ongoing clinical progress. They also administer medications; assist in convalescence and rehabilitation; teach patients and their families proper care; and assist individuals and groups in taking steps to improve or maintain their health. Individual work settings influence the scope of the nurse’s responsibilities. RNs may have attended a two-year or associate degree program, a four-year, or baccalaureate degree program, or a graduate level or Master of Science degree program. The Licensed Practical Nurse (LPN) is an integral part of the nursing profession within the health field. LPNs work within a variety of structured settings under the direction of physicians, dentists and registered nurses to provide bedside nursing care that includes giving medications. Occupational Therapy is concerned with human lives that have been disrupted by physical injury or accident, birth defects, aging or emotional or developmental problems. The occupational therapist evaluates a person’s ability to perform simple activities of daily living such as dressing and cooking, and develops a program which helps increase independent performance. The most common ailments among patients seen by the occupational therapist include stroke and its related problems, developmental disabilities, cerebral palsy, mental retardation and other mental health problems. Pharmacology is a science involving the interaction of chemical substances with body systems. The development and dispensing of medications is a major function of the pharmacist who verifies the validity of prescriptions; determines the identity, purity and strength of medications; and ensures that patients understand the instructions. Pharmacy technicians work under the supervision of a registered pharmacist and are responsible for a number of duties, including the mixing of pharmaceutical preparations under the direction and supervision of the pharmacist, replacing inventory, packaging and labeling drugs, and filling prescriptions and prepared drugs. Physical Therapy helps people of all ages who are disabled by illness or accident, or who were born with a disabling condition. The physical therapist performs tests, which provide information about joint motion, strength and endurance of muscles, functional ability, and status of muscle tone and reflexes, and the need for braces and prostheses (artificial limbs). Treatments given by the therapist helps the patient get the most from his/her body, whether recovering from an accident or stroke, or dealing with lifelong disability. The physical therapy assistant carries out the orders of the physical therapist, providing care to patients with various disabilities. Radiologic technology involves obtaining accurate radiographs, scans, or computer images of parts or systems of the body. Under the direction of a physician, the technologist performs studies using radiation and other imaging systems to diagnose or treat a number of diseases. It includes professionals trained to operate equipment used for diagnostic imaging and treatment, including radiography, nuclear medicine, radiation therapy, ultrasound, computed tomography and magnetic resonance. Respiratory therapy involves the diagnostic evaluation, treatment, management and care of people with cardiopulmonary (heart-lung) disorders. Respiratory therapists work in a wide range of settings, from providing care to patients in their homes to the management of life support equipment in critical care settings. Many therapists continue their careers as educators, administrators, heart-lung technicians and cardiopulmonary research assistants. Profession  #Years of additional education  Avg. Vermont salary for 2000 for fiscal year 2000 Dietician 4 17.72 /hour Dietetic Technician 2 10.57 Medical Laboratory Technologist 4 17.15 Medical Technician 2 14.29 Medical Record Coder 2 12.96 Medical Record Transcriptionist 1 10.96 Nurse Practitioner 6 26.89 Registered Nurse 2-4 19.03 Licensed Practical Nurse 1 13.12 Licensed Nurse Assistant 2 weeks 9.09 Occupational Therapist  4 21.51 Occupational Therapy Assistant 2 13.58 Pharmacist 6 29.13 Pharmacy Technician on the job training   10.91 Physical Therapist 5 21.16 Physical Therapy Assistant 2 13.58 Radiologic Technologist  2 15.73 Nuclear Medicine Technologist 2 18.25 Ultrasound Technologist 2 19.72 Respiratory Therapist 2 16.48