Turning around employee turnover
Reorganizing helps one agency cut losses by 17%
Ever feel just like a hamster on a treadmill - when you think that despite your best efforts you're not making any progress?
You work and work, hiring and training new home health aides, but you always find yourself understaffed. One new aide has started calling in sick. Another can't seem to find a baby sitter, and still a third is having car problems. Back to the drawing board, you think, as you prepare to fire up another spate of hirings.
If you recognize yourself in any one of these situations, you aren't alone.
While there are aides that will stay with your staffing agency for 10, 15, even 20 years, it's more likely that a majority of them will disappear after the first six months and leave you with a stack of caseloads. Not only have you lost a worker, but now additional time and money will be spent in recruiting, hiring, and training a new employee.
Considering that the average cost of getting a new home health aide up to speed is estimated at between $3,000 and $3,500, that can add up quickly, especially if your turnover rate is at 50%, say industry experts.
So, is this just the cost of doing business in the home health care industry? That's what administrators at one agency say they thought. Last year, American Nursing Care, a Milford, Ohio-based home health aide staffing agency with 18 offices across Ohio, Kentucky, and Indiana, was experiencing a 69% turnover rate, says Terry Pope, regional manager.
"We're a private, for-profit home health care agency, and we staff like a temp organization. When we have work, we offer it. We wanted as many people as we could employ so that when we had a need, we could fill it," she says. "The problem was that it created unpredictable work for the aides, and they couldn't live like that."
Pope says the agency would hire an aide who met all the criteria, an instance few and far between, she adds, and then would match that employee with a case. "But those cases are giving fewer and fewer hours because of Medicare reimbursement issues. So an aide would have an assignment. It was great for the patient and the agency, however, we'd just given someone a 12-hour work week. Not surprisingly, aides would go somewhere else and get a second job or even a third," she says.
To make matters worse, she says, "We would talk aides into all sorts of jobs so that many times they were stuck doing things they didn't like. Then they weren't good employees, and a vicious cycle started. The result is that as an aide, if you have more than one company competing for your time, you'll go with the one that offers you what you want."
Stanching the flow
Faced with continuous turnover, the agency, which also employs nurse aides (the hospital or nursing home equivalent of home health aides), decided it had to take action. "We sat down and thought about what it would take to be an ideal home health provider, and how we would have to reformat the organization to best attract more aides," explains Pope. As a result, in the past year, the agency's turnover is down to 52%.
Before enacting any sweeping changes, the agency began conducting some rather extensive testing. Over the course of a year, says Pope, the agency conducted three focus groups of home health aides.
"We approached them with questions on what would it take for them to think they had the best employer possible," explains Pope. "Then we took the results back and looked for likenesses or similarities. Sometimes even if things looked different on the surface, they led to the same outcome."
The outcome in question was a set of 10 major themes or areas of need, says Pope. Armed with this information, she and her team went to "every home health aide and nurse aide in our company and asked them to rank them one against the other." In comparing the first item to every other area on the list, and then doing the same with the second, and third until the list was complete, American Nursing Care was left with a set of priorities. (For a list of those priorities, see box, p. 138.)
"I learned what home health aides want from us," Pope points out. "What they were telling us is, 'Give us a job, a full-time job. Don't just give me an 11-to-7 shift.'"
The idea of giving 40-hour work weeks to what had been temp employees was a major change for American Nursing, but one that the company felt was necessary if it was to continue to grow. The first step in accomplishing this was to analyze the client base, examining all the hours in a given day and sorting them on a geographical basis. The plan was to offer core home health. "The aide would have a 35-hour a week job, and we would guarantee them those hours every week.
To do it, meant picking up cases that would be done by flex staff who only wanted occasional work," Pope explains, adding the goal was to keep the aides who wanted full-time employment from working for another agency at the same time.
Another addition to the agency's offerings was the implementation of a career ladder, which offers employees an opportunity for limited advancement, "more in expertise than in promotion," Pope says. In doing so, American Nursing set out four career levels with pay advancing accordingly.
The first and lowest level is that of a new hire. The second level comes after an aide has completed six video training sessions facilitated by a registered nurse. The third focuses more on specialties within the field, such as diabetes, mental health, and cardiac care. "We also use videos here to support the training," Pope says, "but they're more nurse-oriented, unlike Level 2, where the videos are targeted at home health aides."
The fourth and final career level is that of mentor. At this level, the home health aide acts as a role model to new-hires, accompanying them on the first few visits to patients, a situation that benefits both the agency and the new employees. "The aide can get some important feedback, and we can see how that person will do and if they need any additional training," she says.
Education has proven to be a critical factor in retaining home health aides, and an integral portion of American Nursing Care's program relies on a series of training videos. "So often, in my experience, aides are in a situation where they're unprepared," says Karen Schmidt, president of Instructional Media Network (IMN), a Dayton, Ohio-based producer of instructional videos whose products American Nursing Care has incorporated into its training program. "Because of this they may make a mistake or anger the patient, and they leave feeling terrible about themselves. They leave feeling it was an awful experience, and they don't go back.
"But if you can take an aide and say this is what CHF is and this is what you'll encounter, the aide has knowledge that he or she can use and has the feeling that he or she has accomplished something when [the training is over]. [The aide] feels useful."
Videos target home health aides
IMN's videos are geared toward educating home health aides. "When we first started out three years ago, we thought we could ride the line between home health and nurse aides. But when we really got into it we realized that home health is really so unique you can't combine the two." (For information on the videos, see box, p. 139.)
Because so many new home health aides are younger, Schmidt and her partner, who is a videographer, chose to concentrate on a format other than the traditional "talking head." "They're so used to MTV that we've taken humor, music, and animation and tried to entertain while we educate. We try to keep things moving. We're very high on graphics. For example, with our cardiac video, we show how blood moves through the body using a tiny person who travels through the veins and capillaries explaining as he goes," says Schmidt.
Each package includes a video, an outline of the program - "really the script in outline form," Schmidt says, a list of learner's objectives, and a pre- and post-test. The agency purchases the video and then can use it as part of group inservice training that is counted toward the home health aide's annual criteria of 12 hours of continuing education (CE).
Agencies are encouraged to expand upon IPN's seven themes through role-playing or hands-on demonstrations, Schmidt explains. Thanks to the format which provides the answers to the post-test at the end of the video, if an aide is too busy during the work week for an in-house training session, he or she can take it home to watch. In addition, because the video session counts toward a home health aide's annual CE hours, a report form is included certifying that the viewer has fulfilled CE requirements.
Response has been good, Schmidt says, admitting that several nurses have complained about the films being too basic. "I have to tell them, 'Let your home health aide watch and critique it.' Our videos aren't for nurses. Our goal is to know our audience and help them assimilate the information, because if it doesn't connect with them, it won't change their behavior. For the aide, knowledge really is power," she says.
Hindsight is 20/20
Pope and her co-workers at American Nursing Care had no idea how large a project they had begun when they started in 1996. Not only did it take more than a year to put their plans into action, but it took a considerable paradigm shift within the company, explains Pope.
"No one had any idea how large the project would be and how hard a shift it would be or how the schedulers would handle it," she says. To ease the transition, the agency christened the project Independence Day, since implementation began near July 4, 1997. Over the course of that summer, each office was closed for a day to conduct an in-house training seminar for agency staff.
"We tried to make the sessions very inspirational with music and prizes," says Pope. "We did a whole session on the research we conducted and how we came to the conclusions we did so that when it was time to put the changes into action, the staff would have been through the whys and hows and would buy into it."
Patients, too, had to be considered in the reassignments and in some instances, patients couldn't handle the change so other plans had to be made. "Since we always want to please the patient, doing that but in different ways was tough on the office personnel," she says, noting that changes did not include raising patient fees. In fact, thanks to the reorganization both recruiting and training costs have been lowered somewhat, she notes.
The only problems that have occurred are complaints from some aides who don't understand why some of their flex cases are taken away to give another aide a full-time schedule. "We've taken some gains, and we've taken some losses," Pope explains. "But we think, overall, it's a better way to build loyalty and more consistent employment."
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