Insights and Innovation: How a Local Public-Private Partnership is Building Home Care

Abstract

Recent national reports asserted an urgent imperative for transforming working conditions for the direct care workforce in the US. These clarion reports identified key influencers in reform as federal and state governments, workers’ unions and coalitions, individual and organizational employers. Equally essential and well-positioned local actors have been overlooked in the conversation—namely, municipalities, area agencies on aging, higher education, philanthropic entities, and community. Although deemed “essential,” direct care workers have been disproportionately affected by the COVID-19 pandemic. This paper examines an early public-private partnership initiative designed to recruit and train PCAs in Virginia.

Keywords

home and community based care and services home care training community

What this paper adds

• Recognizing local change makers in creating collective impact for direct care workforce.

• An appreciative, learner centered approach is essential to workforce development. Training the workforce exceeds curriculum delivery.

• Meeting community-identified needs requires community voice, local advocates bridging policy and practice.

Applications of study findings

• Recommendations for public-private partnerships transforming home and community based services.

• Best practices in public-private partnerships enhancing home care capacity, grounded in community voice.

• Direct care workforce support demands strategic narrative work.

Introduction

In a 2021 report for PHI, an association devoted to improving conditions for the long-term care workforce in the United States, Campbell and colleagues projected that the long-term care sector will add a “further 1.3 million direct care jobs, primarily personal care aide (PCA) positions, from 2018 to 2028 — more new jobs than any other occupation in the U.S. economy” (p. 6). Demographics and consumer preferences are key reasons for this rising demand (Campbell et al., 2021). For example, chronic disease prevalence is rising, more people are living with chronic disease longer, and, simultaneously, many prefer to live and age in their own homes (Bryant et al., 2021; Campbell et al., 2021; Reichel, 2018).

As the COVID-19 pandemic developed, long-term care settings were impacted by widespread contagion and deaths among residents/clients and high attrition of direct care staff. Nationally, “the number of direct care workers dropped by 280,000 during the first 3 months of COVID-19 from March to May 2020. Home care workers accounted for 232,000 of those losses” (Campbell et al., 2021, p. 77). In an assessment of the needs of older adults living in the Richmond, Virginia metropolitan area relative to COVID-19, conducted throughout 2020 and 2021, local home care agencies reported hardship in meeting the demand for personal care assistance “due to difficulty in hiring enough direct care providers” (Watson et al., 2021, p. 35). The same assessment found that non-profit home care agencies in the region had stopped accepting new clients during COVID-19 because of the loss of PCAs (Watson et al., 2021, p. 35).

Recent national industry reports (Bryant et al., 2021; Campbell et al., 2021) asserted an urgent imperative for transforming the direct care workforce and improving direct care job quality. Proposed changes included a living wage, equitable benefits, consistent scheduling, and full-time opportunities (Campbell et al., 2021). Additional recommendations cited as essential to a stable, thriving direct care workforce included opportunities for advancement and improved training and professional development (Campbell et al., 2021). Combined, these clarion reports identified key influencers in reform as federal and state governments, unions and coalitions composed of workers, and both individual and organizational employers (Bryant et al., 2021; Campbell et al., 2021).

All of these actors are necessary to transform conditions for direct care workers. However, local actors have been overlooked in the conversation, but are equally essential and well-positioned to become changemakers at this crucial moment—namely, municipalities, area agencies on aging, institutions of higher education, philanthropic entities, and community coalitions representing elders and their families. While a search of the literature returned no evidence supporting the essentiality of local public-private partnerships to improve home care training specifically, several local collaborative models have demonstrated such success in other health care domains, namely, direct care work in behavioral and mental health and substance use services (Dailey et al., 2015; Rubin & Kilgore, 2020) and family caregiver supports (Parmar et al., 2021). This paper examines a local public-private partnership initiative established pre-COVID-19 and designed to recruit and train personal care aides (PCAs) in Charles City County, Virginia (Charles City)—a rural locality in the metropolitan region of Richmond, Virginia. The partnership is composed of representatives from county government, the area agency on aging, a major research university, a collective impact coalition, direct care workers, and a non-profit home care employer. Initially, no designated funding source supported the pilot, rather the partners offered in-kind services, space, and time. As the pilot has expanded, regional philanthropic entities joined the partnership and funding has followed.

Defining Personal Care Aide (PCA)

The term Personal Care Aide (PCA) is one of many labels used to describe home care workers trained in assisting and supporting older adults in their chosen living environments (Campbell et al., 2021). Campbell et al. (2021) defined the role of a PCA as a “direct care worker who assists individuals with ADLs and/or IADLs in their homes and communities, and who may also support individuals with employment and other forms of engagement” (p. 4). The Charles City pilot focused on PCAs, specifically.

Need for PCA Training

The need for consistently and appropriately trained PCAs is a critical component to providing quality care for promoting longevity equity—the idea that a long and well-lived life should be attainable by all people regardless of race, ethnicity, socioeconomic status, or other factors (Longevity Project for a greater Richmond [LPgR], 2021). Prior to the COVID-19 pandemic, county administrators in rural central Virginia reported an inability to meet the demand for home care services due to difficulties hiring and retaining qualified direct care providers, a condition that has worsened dramatically during the unfolding of COVID-19.

This supply shortage affects older adults and their family members who are unable to arrange for appropriate care and are, thus, often left with a dismal choice: forego care or relocate to a new community with residential long-term care capacity. Supply shortage equally affects community residents and home care agencies. Rural residents who seek gainful employment suffer due to lack of jobs in their communities, as do home care agencies that do not have workers willing and able to drive to outlying jurisdictions.

Continuity and Standardization

Nationally, there is very little oversight for comprehensive and consistent PCA training programs (Bryant et al., 2021), hence, many PCAs work without credentials (Luz & Hanson, 2015). Bryant et al. (2021) stated that the Virginia Department of Medical Assistance Services (DMAS) provides oversight for monitoring PCA training programs in the Commonwealth. This has historically been the case; however, DMAS no longer performs this role (personal communication, Virginia Department for Aging and Rehabilitative Services, 2019)—a change in procedure that has been neither widely understood nor circulated within the long-term services and supports (LTSS) network. The DMAS-approved PCA training curriculum from 2003 (DMAS, 2003) serves as the de facto course content of PCA training programs in Virginia, but this curriculum is no longer maintained or monitored.

Training Curriculum Content

One reason cited for the direct care provider shortage in the United States is a failure to properly train and prepare care providers for their roles and responsibilities (Stone & Harahan, 2010). Luz and Hanson (2015) insisted that direct care workforce gaps must be filled with “a skilled workforce that can provide competent, safe, person-centered care” (p. 150). A core competency of PCAs is to offer support with tasks related to activities of daily living (ADLs) and instrumental activities of daily living (IADLs). Importantly, support with ADLs and IADLs occurs within a relationship (Campbell et al., 2021) that, ideally, is centered on the biological, psychological, social, and spiritual dimensions of both provider and client.

Yet in practice, training for direct care providers tends to focus primarily on skills and tasks associated with ADLs, failing to emphasize interpersonal skills, which are the essence of the PCA role (Campbell et al., 2021; Heliker, 2009; Heliker & Nguyen, 2010) and essential to person-centered care practices. For example, researchers have noted that the majority of direct care provider training is based on routine, task-filled content (Campbell et al., 2021; Heliker, 2009), and, further, that direct care workers are often unaware of the backgrounds and life events of those in their care, which results in a workplace rife with alienation and dehumanization (Heliker, 2009; Kusmaul & Anderson, 2018).

Direct care providers working in home care and other settings have consistently reported that they reap emotional rewards and satisfaction from the relational aspects of their jobs (Amateau et al., 2022; Campbell et al., 2021; Franzosa et al., 2018), and, simultaneously, that what is most stressful for them is how often they feel devalued, disrespected, and disregarded on the job (Amateau et al., 2022; Campbell et al., 2021; Franzosa et al., 2018). Moreover, the literature shows that direct care providers want additional services and supports with managing the emotional aspects of their jobs, supports that might include peer support, counseling, stress management, and mental health services (Amateau et al., 2022; Campbell et al., 2021; Franzosa et al., 2018). Peer support opportunities for people working in home care offer access to personalized wisdom, experience, information, and social bonding to a workforce that is largely in isolation on the job (Campbell et al., 2021; Franzosa et al., 2018). Therefore, it is essential that training prepares PCAs for the emotional labor inherent in the role and educates PCAs on knowledge, resources, and assistance to ease their own emotional suffering.

Additionally, critical thinking and decision-making skills are instrumental in providing workers with needed knowledge on person-centered and trauma-informed care (Kusmaul & Anderson, 2018; Berta et al., 2013). In addition, PCAs who receive cultural competency training are more likely to develop a better understanding of how to integrate skills and care for the diverse population of older adults (Campbell et al., 2021; Papadopoulos et al., 2016).

Project Design

The Charles City pilot sought to develop a PCA training curriculum centered around the relational role of PCAs, the health and wellness of PCAs, and gerontological evidence. This meant our curriculum addressed the skills necessary to assist with ADLs and IADLs with emphasis on person-centered, trauma-informed care, ethical decision-making, cultural competence, and social connection. Before describing the curriculum, however, we will share some key elements of the Charles City pilot that contributed to its success. These attributes included the focus on a rural community, partnership governance, and accessibility to trainees.

Rural Community Focus

Nestled between Williamsburg and Richmond, along the Route 5 Scenic Byway and the Virginia Capital Trail, Charles City County describes its character as defined by “four centuries, three cultures, and two rivers in one county” (Charles City County, n.d.). Demographic data show that 24.3% of county residents ages 65 + are at risk of social isolation and 32.8% face the challenges of economic vulnerability (United Way of Greater Richmond & Petersburg, 2019). Within the county’s 204 square miles, there is no public transportation system, nor do any long-term care providers operate in or serve the county. As a result, elders who are connected many generations-deep to Charles City must either rely on untrained family members or untrained private duty workers or relocate to a community where they have no ties in order to access the support they require.

In the fall of 2018, the county administrator for Charles City, Michelle Johnson, approached Senior Connections, The Capital Area Agency on Aging and Virginia Commonwealth University’s (VCU) Department of Gerontology with an urgent need to find a solution to serve an increasing number of older adults needing in-home care. Her purpose was three-fold: to expand the LTSS capacity of Charles City, to create economic opportunity for county residents seeking employment in home care, and ultimately, to make community living viable for Charles City elders who need quality care to remain in their homes. Exploratory meetings between the three founding partners discovered philosophical and strategic alignment, and the idea for a rural PCA school, serving both Charles City and neighboring rural New Kent County emerged. The first steps toward this long-term vision were to demonstrate that a local public-private partnership could succeed and that a person-centered, trauma-informed curriculum based in gerontological theory and evidence would engage and prepare learners for the role of PCA.

Public-Private Partnership

With the county government, area agency on aging, and university in alignment, a backbone partner was needed to coordinate the pilot. As a regional coalition managed jointly by Senior Connections and VCU’s Department of Gerontology, the Longevity Project for a greater Richmond (LPgR) offered both capacity and vision alignment. LPgR (2021) works to achieve longevity equity through:

• Systems-level change to increase access to support and improve outcomes for older adults

• Deep neighborhood engagement and community voice

• Person-centered, trauma-informed training and programming

• Community convening and partnerships to share knowledge and tools of transformation

With the backbone partner in place, the partnership added representatives from Family Lifeline, a regional non-profit home care agency that committed to hire graduates of the program to expand coverage into Charles City. After a six-month planning period, the Charles City pilot launched in the spring of 2019 with a faculty team that included two gerontologists (one of which was actively employed as a PCA), one gerontology candidate, one care coordinator, and one registered nurse. Community guest lecturers augmented the pilot curriculum in specific content areas (e.g., dementias, community resources).

Accessibility for Trainees

Luz and Hanson (2015) argued that excellent PCA schools are insignificant if they are inaccessible by potential learners. The Charles City pilot aimed to assure accessibility specifically for Charles City learners. Accessibility pertains not only to the location of the intervention but also whether the intervention is available, acceptable, accommodating, and affordable (Penchansky & Thomas, 1981). The training site, in the heart of Charles City, was offered in-kind by the county government, along with food and beverages during training. Situating the on-site portion of the course in the community where learners lived removed the barrier of traveling thirty-to-forty miles into Richmond for the course.

The project addressed acceptability and accommodation by assisting with needed supports such as childcare, eldercare, and transportation. Respite care was offered for learners requesting support with family care and delivered through Senior Connections’ short-term home care division. Availability was ensured by offering the course during weekends and evenings within a flexible learning environment, delivered via a hybrid format including face-to-face and self-study components. Affordability was addressed by offering the course at no-cost and providing learner supports to mitigate indirect costs.

Continuous Evaluation and Improvement

To assess progress, the pilot followed a multi-method evaluation approach that examined attendance rates, completion rates, and final exam pass rates, along with qualitative measures collected through learners’ narrative feedback obtained following modules, instructors’ reflective narratives, weekly homework review, class discussions, and weekly meeting notes. A logic model and data measurement plan were developed prior to piloting the training.

Person-Centered, Trauma-Informed Curriculum

The 40-hour training curriculum consisted of 25 hours of on-site training and 15 hours of self-study using modular learning and co-learning approaches where instructors provided evidence-based information, learners shared their experiences, and best practice methods were discussed and created. Associated homework assignments were reviewed by an instructor then reviewed as a cohort. Self-study modules reinforced the content and prepared learners for PCA skills and competencies. Personal wellness practices were incorporated at the beginning and end of each module. The entire curriculum was composed of ten modules and supplemental resources, as depicted in Table 1.

Table 1.

Charles City County Primarily Personal Care Aide Pilot Curriculum Modules.

Module	Description
1: Person-centered care	A caring response ethical decision-making framework, principles of person-centered care, plan of care, bio-psycho-socio-spiritual approach to care
2: Trauma-informed care	An introduction to trauma and resilience, six principles of trauma-informed care, stress response, supporting life transitions, elder abuse prevention
3: The resilient compassionate care giver	Compassion satisfaction, compassion fatigue, building personal resilience. Related back to person-centered care, trauma-informed care, and a caring response
4: Who is a personal care aide?	Role definition, dos/don’ts, plan of care, mandated reporter, and skills, where appropriate
5: Infection control	Didactic and skills-based knowledge and practice of skills
6: Home safety	Medications/Beers checklist, falls prevention, home management/AARP home safety checklist, proper body mechanics when assisting with transferring, and skills, where appropriate
7: Diseases and body systems	Chronic disease, major body systems, and included nutrition, meal prep, medication safety and skills, where appropriate
8: Structural cognitive disorders and disabilities	An introduction to Alzheimer’s disease, other dementias, and developmental disabilities
9: Death and dying	Advance directives, role of hospice care; relates back to person-centered care, bio-psycho-socio-spiritual approach
10: Now what?	Selecting an agency, comparing work environments, measuring support provided to you (e.g., availability of RN and agency), employer-employee communication
Supplemental materials	Community resources, glossary of terms, and resources for further learning

Lessons Learned and Post COVID-19 Directions

The lessons outlined below reinforce evidence in the literature regarding the importance of learning format, setting, and culture as key aspects of delivery (Kemeny & Mabry, 2017; Tompkins et al., 2020).

Learner outcomes

The first cohort of six students achieved 100% attendance and a 100% pass rate on the final exam. All learners reported that the PCA course changed the way they think, feel, and act relative to caring for elders and caring for themselves. For example, one learner, who described herself as a hugger, expressed a dramatic change in how she viewed non-consensual physical affection shown toward her client. Other learners appreciated instruction and practice using a gait belt to assist with transfers. Learner feedback identified three goals they hoped the course would offer: (1) feeling competent to develop a positive, supportive relationship with someone in their care, (2) knowing when, how, and who to contact for assistance with difficult situations, (3) confidence and competence in the hands-on skills needed to assist with ADLs and IADLs. In response to this feedback, these three learner goals are incorporated into the course evaluation instrument for future cohorts.

Curriculum

Learner engagement and feedback suggested that scenario-based examples of ethical decision-making and problem solving helped learners to imagine themselves in the role of PCA. They reported valuing opportunities to learn new material and then work through a story together. All of the learners entered the pilot with some exposure and experience at caregiving, either paid or non-paid for family, friends, or neighbors. They appreciated opportunities to contribute to the learning community by sharing their own experiences. As a result, the curriculum was revised to include additional linked stories centered around a PCA-older adult relationship and to include more practice pauses where learners engage with course content through the lens of their own experiences.

Additionally, a core concept woven throughout all modules was the caring response (Doherty & Purtilo, 2016), a three-part framework for delivering person-centered care. The caring response model explicitly notes providers’ obligation to deliver good care to themselves, and our learners wanted more emphasis on their personal development and growth such as identity, time management, wellness, and employer-employee relationships. Therefore, we revised the curriculum to include more portable wellness practices, make space for conversations about feelings of guilt that prohibit self-compassion, and place greater emphasis on selecting and interviewing with prospective employers.

All of these curriculum changes made good sense in response to what we observed and heard from the pilot cohort, and our team planned for a 25 person cohort in the spring of 2020. The COVID-19 pandemic soon disrupted that schedule, and the partnership reviewed and revised the curriculum again in response to the pandemic home care environment by adjusting the modules related to infection prevention and control, skills, and community resources. For example, the community resources module was revised to emphasize the local information and referral infrastructure, COVID-19 vaccine and testing information, and no-cost resources to improve social connection. Every module was modified in some way to emphasize how COVID-19 was impacting older adults, PCAs, home care agencies, and the broader community. Also relative to curriculum delivery format, the COVID-19 pandemic compelled the partnership to flip the format into an online option, which necessitated a dramatic overhaul of the skills and testing portions of the course.

Learner Supports

During the pilot, learner supports included assistance with transportation, childcare, respite services, options counseling, food security, and career advising. While we could not have anticipated the unique needs of every learner, the pilot demonstrated that personalized, flexible supports are essential to learners’ abilities to engage with the curriculum and their peers, and ultimately, to complete the course. Attending to learner supports also offers insights into recruitment and retention needs as PCAs enter the workforce. Tangibly addressing the national call for workforce support in turn demonstrates goodwill to local partners and promotes program success and sustainability. We also learned from the pilot cohort that learners felt valued and respected when they raised barriers and the project team resolved them. In consideration of future cohorts participating via virtual programming, an additional learner support emerged: Internet access and technology equipment and support. Going forward, this lesson resulted in the addition of an extensive pre-enrollment telephone interview where PCA school staff get to know prospective learners, explore enrollment and engagement barriers, and make a plan for support. Lastly, after the pilot and in response to the stressors on the workforce that were emerging from the pandemic, the project team unanimously elected to implement a stipend for all learners who completed the course as an expression of furthering valuing learners and their time.

Recruitment

Success in Charles City was directly tied to the leadership and personal investment of the county administrator. It has been more difficult to recruit learners in other rural localities outside of Charles City, despite government officials from around the Richmond metropolitan region raising the issue of home care provider shortages, both pre- and post-2020. As a result, a next step will be to identify rural champions and to leverage the leadership role of the Charles City administrator in promoting the program to her peers.

In the interim between the pilot and the first cohort, the supply line for direct care workers in our region was significantly, negatively influenced by the COVID-19 pandemic. Home care agencies, both for profit and not-for-profit, reported long waiting lists and severely reduced capacity due to hiring difficulties (Watson et al., 2021). In response, the PCA school broadened its scope to recruit learners from across the entire metropolitan area.

In addition to developing rural champions, two other recruitment strategies have emerged. First, as asserted by Campbell and colleagues (2021), some pilot projects have found success in recruiting Title V Senior Community Service Employment Program (SCSEP) participants seeking part-time, encore careers. As a sector, home care attracts older workers (Campbell et al., 2021); thus, the strategy of integrating SCSEP into recruitment efforts is now a part of a multi-pronged, ongoing recruitment effort. SCSEP is a community service and work-based job training program for older Americans authorized by the Older Americans Act for participants aged 55+ with incomes of no more than 125% of the federal poverty level (USDOL, 2019). A second strategy, suggested by the SCSEP program manager, was to conduct outreach about the PCA school with public housing apartment complex managers who often serve as resource brokers and information hubs for residents.

Employment Pipeline

While the ultimate goal is for the PCA school to serve as a direct pipeline to employment, the aim of the pilot was to establish a working partnership among the founding partners and to implement a more holistic PCA curriculum. During the pilot, each learner was offered literature and information about employment opportunities with Family Lifeline; however, they did not meet or engage with representatives from the agency during the course and their contact information was not shared.

Thus, no students applied to the agency, for a variety of reasons, as we discovered from learner follow up. Several were already working as private duty aides in Charles City but had never participated in training and wanted to become certified. Some were caring for family members, and one was interested in a future post-retirement PCA role.

In future cohorts, registered nurses and direct care providers with prospective employers will be invited to participate throughout the course as mentors and support instructors. Additionally, we have modified the curriculum to spotlight employment opportunities. Also, going forward the pre-enrollment interview serves as the beginning of a conversation about future employment, including formally asking learners if we may share their contact information with home care agencies. Lastly, given the patterns of informal, unpaid and private, paid caregiving situations of our pilot learners, we wrestled as a team with whether or not to exclude learners who were interested in PCA certification for reasons other than agency employment. Ultimately and unanimously, all agreed that whether learners pursue agency employment or no employment, that all would graduate better able to offer person-centered care to our community’s elders and, subsequently, would be personally connected to a supportive network of peers and educators.

Career Pathways

Often, a single career trajectory is promoted—from PCA to certified nursing assistant to licensed practical nurse to registered nurse—however, many PCAs desire to advance along pathways other than nursing (Campbell et al., 2021). The pilot cohort feedback reflected a desire to use their new skills for multiple purposes and in a variety of settings. Future cohorts of the PCA school will be offered an appreciative advising component that is person-centered and respects the satisfaction and purpose that PCAs gain from their work and explores a constellation of career possibilities that may include a nursing pathway or any number of other options: care manager, community health navigator, direct care specialist, or direct care coach or mentor.

Discussion

PCAs and other direct care workers are sometimes labeled as “low-skilled workers,” a misnomer that conflates job quality with job skills (Campbell et al., 2021). As Campbell and colleagues (2021) showed, poor job quality due to low wages, low benefits, inconsistent work hours, and low respect is the primary barrier to recruitment into the field. Despite poor job quality, the reality remains that personal care assistance requires technical skill, subject matter expertise, creativity, and relational skills (Campbell et al., 2021; Franzosa et al., 2018; Luz & Hanson, 2015). The Charles City pilot aimed to develop a PCA certification course that acknowledged the complexity of the role, fully prepared PCAs for the work, and demonstrated respect and appreciation for the role of PCA and for each learner’s individual journey.

One might argue that a small pilot would be limited in its ability to improve job quality or to influence the home care labor supply; however, the process of creating and implementing the project did not occur in a vacuum but within a discourse and advocacy community that involved local public and private actors, aligned around a community-identified need. Guided by a national call to action, this small pilot has sparked big impact through responsive and mutually beneficial local partnerships to deliver sustainable and lasting change. Through shared vision, this public-partnership uplifts community agency and self-efficacy; the PCA school addresses the national call to action. Throughout the pandemic, the LPgR and the LTSS network consistently promoted the value and necessity of the PCA workforce to local governments, philanthropic partners, and individual stakeholders. As a result of a unified front and the strong relationship between LTSS providers and philanthropic organizations, several important investments were made during COVID-19 that are propelling the expansion of the PCA school and strengthening home care in our community. Foundations offered hazard pay grants for direct care providers, supported home care business model consultancy, and subsidized non-profit home care operations. In 2021, Senior Connections received its first grant to support expansion of the PCA school, and additional funding soon followed to scale and sustain the initiative.

Conclusion

To be sure, the COVID-19 pandemic has been a catalyst that provided urgency to the national conversation about the roles, work, and value of PCAs and other direct care providers. A gap in the national conversation to date has been the inclusion of local actors. The lives of our elders and PCAs are most definitely influenced by policies and practices that take place at the national and state levels, and yet our elders and PCAs live and work in specific communities with specific and, often, unique needs that must be infused with local experiences and lifted up and addressed by a cadre of local leaders who believe in the power and promise of their own people and places. Though early in its development, the Charles City PCA pilot has proved that local public-private partnerships can change the landscape for PCAs and elders. Ideally, state and national actors will turn toward local initiatives for insights and innovation that can be modeled and sustained throughout the nation.

Campbell et al. (2021) emphasized the importance of changing the narrative of the direct care workforce. In our community, this project is situated within a much larger conversation that is doing exactly that: lifting up the stories of the direct care workforce and advocating to transform working conditions and job quality.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

E. Ayn Welleford

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