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Addressing the Crisis in the
Long-term Care Workforce
Report and Findings of the Senate Committees
on Aging, Health, and Labor
Senators Rachel May, Gustavo Rivera,
and Jessica Ramos, Chairs
July 27, 2021
Table of Contents
A. Executive Summary..............................................................................................................................................................................1
B. Key Findings .............................................................................................................................................................................................. 2
C. Facts and Figures About Long-Term Care in New York State ............................................................................. 4
1. Demographics
2. Workforce Trends
3. Skilled Nursing Facilities (Nursing Homes)
a. The Skilled Nursing Facility Workforce
b. Impact of Staing Shortage
c. Impact of the Pandemic on Skilled Nursing Facilities
4. Assisted Living Facilities
5. Home Care
a. The Home Care Model
b. The Home Care Workforce
c. Pandemic Impacts on Home Care
6. Family Caregivers
D. Stories from Witness Testimony ..............................................................................................................................................9
1. Workers
a. Skilled Nursing Facility Workers
b. Home Care Workers
2. Employers
a. Skilled Nursing Facility Industry
b. Assisted Living Industry
c. Home Care Industry
3. Care Recipients, Family, and Advocates
E. Solutions ....................................................................................................................................................................................................17
1. Pay and Benefits
2. Workforce Development and Career Advancement
a. Training and Mentoring
b. Opportunities for Advancement
c. Other Incentives
3. Sustainable Financing and Support for Employers
4. Oversight and Quality Control in Skilled Nursing Facilities
5. Supporting Family Caregivers
6. Reforming the Long-Term Care System
7. Additional Research Needs
F. Witness List and Testimony .......................................................................................................................................................25
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A. EXECUTIVE SUMMARY
Chairs and members of the Standing Committees on Aging,
Health, and Labor of the New York State Senate received
spoken and written testimony from stakeholders aected by
the long-term care workforce shortage on July 27, 2021. The
eight-hour hearing included more than forty witnesses,
including front-line workers, care recipients and their family
members, employee unions, managerial and clinical sta,
professional and trade associations, senior advocacy groups
and grassroots coalitions, legal and academic experts,
operators of skilled nursing facilities and assisted living facili-
ties, and home care providers. Fifty written documents were
submitted in addition to spoken testimony highlighting the
enormous impact of long-term care workforce challenges
and oering solutions.
3.5 million New Yorkers are currently aged 65 or over, and this
is by far the most rapidly growing segment of the population.
Over half of people aged 65 and older will need some kind of
long-term care in their lifetime, as well as over a million New
Yorkers with disabilities, chronic illnesses, or other functional
complications. The state’s long-term care system is insui-
cient to meet the needs of New Yorkers now, and the problem
gets worse each year. The COVID-19 pandemic has only
exacerbated a workforce shortage that has been dire for
many years.
Caregiving is the most rapidly growing industry in New York
State, but it cannot keep pace with demand. The reason for
the chronic shortage is clear: New York State has failed to
make the needed investments to support a living wage and
benefits for long-term care workers. Years of austerity
measures, including an across-the-board cut at the outset of
the pandemic, have squeezed the Medicaid budget to the
point where reimbursements to providers do not cover costs,
and wages have failed to keep up not only with inflation but
with minimum wage standards and median pay in sectors
that compete for the workers, like fast food.
We heard powerful stories from workers about inadequate
pay and benefits, stressful working conditions, wage theft,
inconsistent and unpredictable hours, and limited opportuni-
ties for career advancement. One witness admitted he had
just come from working three back-to-back shifts, because
that was the only way he could make ends meet.
We also heard compelling testimony from nursing homes and
assisted living operators and home care agencies. One
witness reported turnover rates as high as 94% in skilled
nursing facilities, even before the pandemic. Others spoke to
the issue of retroactive rate-setting by the Department of the
Budget, whereby facilities and agencies would not learn their
reimbursement rates for as much as a full year after they had
hired the labor and provided the care. And they all had been
stretched to the breaking point by pandemic-related costs
and time-consuming protocols that further stressed their
limited sta. High turnover among managerial sta made all
the other stresses worse.
Care recipients, family members, and their advocates made
emotional pleas for policy action to address the workforce
shortage and high turnover rates. They stressed the need for
reliable, consistent care as not only optimal for them but
cost-eicient to the Medicaid budget, as it helps keep people
out of emergency rooms or skilled nursing facilities unneces-
sarily. Without reliable home care, family members often have
to leave their own jobs to care for a loved one, which further
hurts the economy.
The good news is that a robust investment in the long-term
care sector promises to yield excellent returns. The recent
City University of New York (CUNY) report, “The Case for
Public Investment in Higher Pay for NYS Home Care Workers,”
shows that investing $4 billion in a living wage for direct care
workers results in a $7.6 billion return from savings to state
and local budgets by lifting the workers o public assistance
and keeping seniors in their homes, and increased tax
revenue due to the higher wages and spending and more
family members being able to work outside the home.
With new leadership at the state level and added resources
from the Federal government and the recovering economy,
New York State has an opportunity and an obligation to build
a thriving caregiving economy. Every New Yorker has the
right to live a healthy and independent life in the least
restrictive setting. This report oers an analysis of ways the
current system is broken or inadequate and a host of
recommendations for action the state can take to invest in
models of care that enable people to live safely and inde-
pendently, reduce costs and unnecessary hospitalizations,
and provide a living wage and economic security to long-
term care workers.
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B. KEY FINDINGS
1. Workers
For workers, the most pressing issue is inadequate pay and lack of benefits (see section D.1.). Many workers rely on
public assistance and lack health insurance despite working full-time or multiple jobs. Other worker issues include:
• Stressful, complex, and high-risk work environments. Compensation does not reflect the skill and occupational risk
associated with their roles, and higher wages and hazard pay are warranted.
• Failure to receive full pay for all hours worked. The “24-hour rule” allows workers to be paid for only 13 hours in a
24-hour shift. We also heard reports of wage theft.
• Gaps in employment after a client dies or is hospitalized, resulting in inconsistent hours and fluctuating income.
• A lack of opportunities for career advancement, promotions or raises.
• Excessive caseloads and understaing in skilled nursing facilities.
• Women, people of color, and immigrants make up the majority of this workforce, so addressing long-term care
workforce issues will support gender and racial equity.
2. Employers
For employers, the key issue is New York State’s low Medicaid reimbursement rates (see section D.2))
• New York State Medicaid reimbursement falls well below the cost to provide long-term care.
• Inadequate reimbursement has reduced providers’ ability to oer higher wages for direct care workers. While
long-term care worker wages remain at or near minimum wage, wages have increased in other sectors such as fast
food that compete with the long-term care sector for workers.
• Responsible budgeting is extremely challenging, as the Medicaid reimbursement rate is set retroactively, sometimes
a year late.
• Staing shortages in home care agencies mean they must turn away as many as 30% of new cases.
• High turnover is costly and time-consuming. Average sta turnover in 2017 and 2018 was 94%; many nursing homes
exceed 100% turnover in a one-year period. This requires rehiring and training the entire direct care workforce,
including CNAs, LPNs and RNs.
• Many providers reported diiculty retaining managers due to the challenges of navigating shifting COVID-19 guid-
ance, burdensome reporting requirements, and strict enforcement of fines for bureaucratic issues.
3. Care Recipients, Family, and Patient Advocates
For families and patient/resident advocates, the key issue is the need for consistent, reliable care with low turnover
(see section D.3.)
• Consistency of care is instrumental to care recipients’ health, quality of life, and independent living, and services.
• The need to find or recruit new caregivers is time-consuming and highly stressful for care recipients and family
members.
• Inadequate home care services resulted in preventable health crises for individuals and produced strain for family
members required to balance their job or school responsibilities with intensive caregiving roles.
• High turnover among long-term care workers impedes eective communication and collaboration with families.
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• Underpaid home care workers are more likely to miss shifts due to transportation or child care issues.
• The fact that many home care workers have to work multiple jobs means they are more likely to contract COVID-19 or
other illness and pass on the infection to their clients.
• The Consumer-Directed Personal Assistance Program (CDPAP) is a valuable and eective model for staing home
care
• Training guidelines for long-term care workers are outdated and inconsistent; they do not meet Core Competencies
developed by CMS for the direct care workforce.
• Foreign language skills and cultural competencies are needed for long-term care workers to best serve diverse popu-
lations across the state.
• The Long-Term Care Ombudsman Program is an important tool for residents and families to register complaints about
care at skilled nursing facilities, but it is primarily staed by a dwindling number of volunteers and needs greater
visibility.
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C. Facts and Figures About Long-Term Care in New York State
1. Demographics
Over 3.5 million adults aged 65 and older, representing 16 percent of our state’s population, make New York their home. The
oldest members of the Baby Boom generation are now in their 70s; they will soon reach their 80s, when long-term care needs
become more common. Between 2015 and 2040, the number of New Yorkers aged 65 and over is projected to increase by 50
percent, while the population aged 85 and older is projected to more than double. Over half of people aged 65 and older will
need some kind of long-term care in their lifetime, as well as over a million New Yorkers with disabilities, chronic illnesses, or
other functional complications.
As New York’s older adult population grows, projections indicate that the state’s working-age population (ages 18 to 64) will
decline, reducing the potential workforce available to care for an expanding older adult population. By 2040, the number of
working-age adults for every state resident 65 or older will decline from 4 to 3, and the number of working-age New Yorkers
per resident 85 or older will go from 29 to 15. According to Ami Schnauber of LeadingAge NY, these demographic trends will
magnify existing shortages of working-age adults to provide both paid long-term care and unpaid family care to address the
care needs of an aging population.
Figure 1 - Percent Change in New York Population by Age Group
Source: LeadingAge NY testimony
2. Workforce Trends
Health care job growth in New York State exceeds job growth in every other sector. Most new health care jobs are in long-
term care, according to testimony from LeadingAge and a 2018 report by the SUNY Albany Center for Health Workforce Studies.
Of the 150,000 health care job openings anticipated annually, 89,000 (60 percent) are for personal care aides (PCAs), home
health aides (HHAs), and nursing assistants (Figure 2, LeadingAge). Between 2016 and 2026, annual openings for HHAs and
PCAs are projected to grow by 52 percent and 41 percent respectively, while openings for registered nurses (RNs) are project-
ed to grow by 20 percent and for nurse aides by 16 percent.
The supply of workers has fallen so far below demand that skilled nursing facilities, assisted living facilities, home care
agencies, and hospice programs are frequently unable to fill existing job openings. Workforce shortages present challenges
for the stability of the long-term care sector, increase stress on workers, and have resulted in preventable health crises and
injuries and intolerable living conditions for older adults in need of care.
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Figure 2 - New York State Department of Labor Employment Projections
Source: LeadingAge NY testimony. Data from New York State Department of Labor Employment Projections
3. Skilled Nursing Facilities (Nursing Homes)
New York’s 619 skilled nursing facilities serve 109,000 residents. Over the past decade, the share of skilled nursing facilities run
by counties or not-for-profit mission-driven organizations has declined. More than 65% of facilities are currently owned and
operated by for-profit companies. In New York State in 2017, Medicaid reimbursement rates are $243.33 per resident per day for
skilled nursing facilities, while the actual cost of providing care is $307.51, resulting in a shortfall of $64.18 per resident per day,
according to a report commissioned by the American Health Care Association. Compounded, this adds to a $1.5 billion dollar
shortfall for facilities across the state (for 2017), the greatest loss compared to 28 states surveyed. Over 70% of New York’s
skilled nursing facility resident care is paid for through Medicaid.
a. The Skilled Nursing Facility Workforce
Skilled nursing facility workers often do not receive benefits, and low wages mean that 36% of nursing home workers qualify
for public assistance. Also, relative to the typical U.S. worker, nursing assistants are three times more likely to be injured on the
job. When workers take time o due to their injuries, 63% do not receive pay while they are away from work.
Jim Clancy of the Healthcare Association of New York State (HANYS) testified that even before the pandemic, turnover rates in
skilled nursing facilities were as high as 94%. A published report by Gandhi, et al., indicates that this number includes average
turnover rates exceeding 100% across the three most common direct care nursing home providers: registered nurses
(140.7%), certified nursing aides (129.1%) and licensed practical nurses (114.1%). Grace Bognadove of 1199SEIU reported that
turnover of Certified Nurse Aides (CNAs) in a typical nursing home in New York State was 25 percent, but regional median
turnover rates vary from a low of 9 percent in New York City to a high of 52 percent in the Bualo region. She also noted that
skilled nursing facilities with the highest median turnover rates had the lowest CMS overall star ratings, while turnover was
lowest at highest-rated facilities. High turnover is costly to the facilities and a threat to continuity of care for residents.
Nursing assistant graduation rates in New York have decreased in recent years, contributing to a shortage of qualified
workers. Nursing homes across New York State reported the greatest diiculty recruiting experienced registered nurses (RNs),
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and the greatest diiculty retaining certified nurse aides
(CNAs), newly licensed RNs, and licensed practical nurses
(LPNs), according to a 2018 Center for Health Workforce
Studies (CHWS) report. The median age of working nurses is
rising, and a growing number of nurses retiring in the coming
years is expected to exacerbate already severe workforce
shortages. Low wages and poor working conditions are the
leading factors the CHWS report identified as contributing to
recruitment and retention issues for CNAs and LPNs.
b. Impact of Staing Shortages
According to the New York State Nursing Association (NYSNA)
testimony, there is a direct correlation between poor staing
and higher death rates for skilled nursing facility residents.
Mortality rates were 44% higher in nursing homes with poor
staing, according to the 2021 Attorney General’s report.
Federal law requires nursing home inspections at a minimum
of every 15 months with an overall average every 12 months.
While facilities with violations receive more frequent inspec-
tions, gaps between inspections often last for months,
leaving vulnerable residents subject to inconsistent or
inadequate care in facilities with chronic violations. Accorda-
ing to NYSNA, while 67% of nursing homes currently are
operated by for-profit providers, not-for-profit nursing homes
make up 88% of the highest rated, 5-star facilities, while the
for-profits account for 81% of the lowest rated (1 and 2 star)
facilities.
Recent legislation in New York requires skilled nursing
facilities to direct a minimum of 70% of their revenue toward
direct resident care and to provide a minimum of 3.5 hours of
nursing care per resident (S.6346 [Rivera]). Advocates argue
that 4.1 hours is the minimum standard recommended by the
federal government and falls short of the amount of care
required. While many facilities satisfied these minimum
standards at the time the legislation was enacted in April
2021, witnesses expressed concern about the continued
ability of skilled nursing facilities to sta up to these levels,
given worsening workforce shortages.
c. Impact of the Pandemic on Skilled Nursing Facilities
The COVID-19 crisis took a devastating toll on skilled nursing
facility residents and sta. An estimated 14,000 residents in
New York died from the virus. Not only did the virus target
older adults and those with weakened immune systems, it
also aected many nursing home workers, causing staing
disruptions, shortages, and burnout among those who were
able to work. The pandemic also cost many workers their
lives and losing co-workers to COVID-19 also led many skilled
nursing facility workers to leave the workforce to protect
their health. Skilled nursing facilities faced additional
challenges that strained both sta time and the bottom line:
rapidly changing and often unclear guidance from DOH on
infection control, development and implementation of new
protocols, increased reporting procedures, the need to
secure and provide PPE, and providing additional training to
support the ongoing changes. The fact that DOH was not
reporting accurate data about nursing home fatalities, and
that this became a highly charged political issue, also
increased the stress on skilled nursing facility operators,
sta, residents, and families.
4. Assisted Living Facilities
Assisted Living Facilities are non-medical residential commu-
nities for older adults who need some care for activities of
daily living (ADLs). There are currently 547 Assisted Living
Facilities serving more than 50,000 older adults in New York
State. Assisted Living Facilities rely on what is often referred
to as “private pay,” or self-pay for long-term care services.
Many families utilize their life savings to maintain a place for
their loved one to live safely. While Assisted Living Facilities
are less impacted by Medicaid caps, they did not receive any
of the relief funds provided to skilled nursing facilities despite
the high costs of ongoing pandemic-related expenses.
5. Home Care
The vast majority of older adults prefer to age in place rather
than in an institutional setting, as long as there is a support
system in place to assist with any everyday activities that are
challenging. Aging in place is also normally far less costly
than in an institution, both to the individual or family, and to
taxpayers, who foot the bill for Medicaid, which covers most
skilled nursing facility residents. “With the demand for
homecare increasing, and with the nursing home crisis that
escalated during the pandemic, it is clear that the home care
model should be preserved and elevated if New York is to
remain dedicated to healthy aging and keeping older adults
in their communities,” said Tara Klein of United Neighborhood
Houses.
a. The Home Care Model
Home care workers provide assistance to address a wide
range of support needs. These range from relatively low-in-
tensity support for “independent activities of daily living”
such as cooking and shopping, to more intensive support for
“activities of daily living” such as bathing and toileting. Some
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home care worker roles provide in-home skilled nursing
services for medically complex patients requiring a tracheos-
tomy tube or ventilator care. Health impacts of a shortage of
home care workers include increasing the risk of injury,
malnutrition, and preventable hospitalizations. Home health
care is especially important for immigrant seniors and
families because language-accessible and culturally compe-
tent home care options are available, while these options are
lacking in institutional settings, as Carlyn Cowen from
Chinese American Planning Council (CPC) discussed.
New York’s home care sector is made up of a variety of
organizational models. These include certified home health
agencies (CHHAs); licensed home care services agencies
(LHCSAs); hospices; Programs of All-Inclusive Care for the
Elderly (PACE); long term home health care programs
(LTHHCPs); consumer directed personal assistance program
fiscal intermediaries (CDPAP FIs), independent living centers,
and community support organizations, among others. The
Expanded In-home Services for the Elderly program (EISEP),
administered by the New York State Oice For Aging (NYSO-
FA) via the state’s county-based Area Agencies on Aging,
supports non-medical in-home services for older adults who
want to remain at home but who need help with everyday
activities and do not qualify for Medicaid. Managed Long
Term Care (MLTC) plans are insurance plans that are paid a
monthly premium by the New York State Medicaid program to
approve and provide home care and other long term care
services. Services may include nutrition, meals, physical
therapy, medical equipment and/or transportation, depend-
ing upon the specific services authorized for an individual.
Medicaid is the primary funder for home care services in New
York state, representing 87% of home care and personal care
services. Many non-profit home care programs are 100%
Medicaid funded.
b. The Home Care Workforce
New York has 250,000-400,000 home care workers and
530,000 direct care workers, according to testimony from Al
Cardillo of the Home Care Association of New York State and
Hannah Diamond of PHI. About 100,000 new home care
workers are needed each year, including about 27,000 to
meet rising demand and 72,000 to replace departing workers.
Ilana Berger of the Caring Majority Panel noted that the
number of exits from home care far exceed those in any other
sector. Tara Klein from United Neighborhood Houses said
33% growth in the home care sector was expected by 2025,
and Bryan O’Malley from the Consumer Directed Personal
Assistance Association of NYS said a recent report from
Mercer Consulting predicted a shortage of over 83,000 home
care workers in New York by 2025.
Data from the U.S Census Bureau and the Bureau of Labor
Statistics indicate that nine in ten homecare workers are
women, more than half are persons of color, the median age
is 45, and 39% earn below 200% of the federal poverty line.
Mr. Cardillo estimated a poverty rate closer to 50%. According
to LiveOn NY’s testimony, New York’s home care workers’
median annual salary is only $22,000, while the median
salary for fast food workers has grown to $24,429. Over one in
seven low-wage workers in New York City is a home care
worker, one in four workers live below the federal poverty
line, and more than half rely on public assistance. Home care
workers who have the advantage of being in a union typically
have health insurance, but one in five are uninsured. Many
homecare workers also lack access to reliable transportation
and childcare, resulting in diiculty accessing clients and
responding to unpredictable schedule changes.
An October 2020 survey of home care and hospice providers
conducted by the Home Care Association found that 85% of
agencies reported structural workforce shortages, especially
among nurses and health and personal care aides. Dana
Arnone of Reliance Home Senior Services discussed findings
of a recent statewide survey of home health-care agencies,
which found that 23% positions were left unfilled due to sta
shortages, meaning that agencies were unable to accept
nearly 30% of new cases.
c. Pandemic Impacts on Home Care
The COVID-19 pandemic accelerated the rebalancing of
services from skilled nursing facilities to the community that
was already underway prior to the pandemic. The increase in
demand for home care services coincided with unprecedent-
ed workforce challenges in the home care sector, as many
home care workers left the workforce due to COVID-related
parental/family responsibilities, or their own COVID-19 illness
or exposure and isolation requirements. The result has been
a significant gap between need for services and available
workforce supply, with negative impacts on clients, families,
workers, and providers. However, severe home care work-
force shortages were projected before COVID-related
workforce disruptions and increases in demand.
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During the pandemic, home care providers received a rising number of referrals for more complex, intensive and earlier
discharges from hospitals. Several providers described facing obstacles to admitting patients authorized and approved for
home care due to workforce shortages. Al Cardillo from the Home Care Association of NYS reported that 65% of the state’s
home care agencies saw an increase in referrals to home care during the pandemic, and 76% of agencies reported challenges
in accepting these new referrals.
6. Family caregivers
According to testimony from Maggie Ornstein of New York Caring Majority, as many as 10% of family caregivers leave the
workforce in order to provide care at some point in their careers. An AARP report on New York’s family caregivers estimated
that in 2017 there were 2.5 million unpaid caregivers in the state, providing an estimated value of $31 million annually. Many
women left the workforce during the pandemic to provide care for young and old family members due to reduced access to
home care and childcare services, both reducing economic activity and widening gender inequality.
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D. Stories from Witness Testimony
1. Workers
“The work is undervalued and underpaid, and it creates hardship for the aides who stick with the work and
makes it harder to find new workers.” Lilieth Clacken, home health aide
Despite the fact that long-term care is the most rapidly growing industry in New York State, chronic underinvestment has
resulted in a diminished and undervalued long-term care workforce, with negative impacts for millions of New Yorkers such
as inadequate care options and lower-quality care for those that do receive services. Inadequate pay and benefits are the
most pressing issues for long-term care workers. Long-term care workers described wages insuicient to cover basic living
expenses. Many direct care workers rely on public assistance and lack health insurance despite working full time. Workers
report feeling ill-equipped for a demanding, volatile workplace. High-risk work environments, stressful working conditions,
inconsistent hours, and limited opportunities for advancement are chronic challenges. The sta that have remained working
at the facilities are now being asked to do more jobs and duties than one person can accomplish. They are overworked, burnt
out, and stressed, according to written testimony from Rhonda Butler of Interfaith Works.
a. Skilled Nursing Facility Workers
“So instead of a worker shortage, the reality is that inadequate pay and benefits, poor working conditions, and the
inability to have a seat at the table on matters concerning resident care are driving caregivers from the bed-
side.” Grace Bogdanove, 1199 SEIU
Pay inequities: In their testimony, skilled nursing facility workers repeatedly expressed a passion for their work, knowing that
it provides a valuable, much-needed service to support the health and wellbeing of facility residents. Workers who testified
implored legislators to acknowledge the complexity of the work and support a system which would pay long-term care
workers accordingly. William Roe, who left a job as a stockbroker on Wall Street after the 9/11 attack to go into nursing care,
said,
“Dignity can’t be paid. It cannot. Can’t pay for my dignity. But you can meet it with a proper wage. You can meet
it with proper PPE equipment. You can meet it with respect and dignity… We have to pay workers a wage that
recognizes the dignity and importance of the work we do every day. If we can keep them safe and pay them the
wages that reflect the importance of the work, they will come into the facility.”
As nursing home workers are predominantly female and racial/ethnic minorities, the poor working conditions and inadequate
pay for skilled nursing facility workers perpetuate long-standing gender and racial/ethnic inequities. Workers described the
exhaustion and demoralization of intense work demands coupled with the financial stress of low wages. As Tonya Blackshear,
nursing home worker, put it,
“I know it takes a special person to work in a nursing home. But it shouldn’t just be that way. Employers need
to value the work we do. Employers have to start paying wages that are well above fast food if they want to
keep people who are coming in the door.”
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Several skilled nursing facility workers discussed the complexity of skilled nursing facility residents’ medical issues and the
skill required to manage resident treatment to maintain and improve health. While skilled nursing care is intensive and
requires skill and time to manage all the psycho-social, emotional and medical variables involved in supporting residents’
holistic needs, Medicaid reimbursement rates are not scaled to the level of skill required. Deirdre Gilkes of the New York State
Nurses Association described that the acuity of patient needs in facilities far exceeded the capacity of nursing sta, though
she noted facilities were not attuned to the impact of patient acuity on nursing workload. She described, “it’s a disaster
waiting to happen… we are burnt out, the nurses. But the acuity is much higher. You know, we need more sta.”
Many noted the higher minimum wage for fast food workers as a discouragement to continuing with long-term care work.
Some reported that they themselves lacked health insurance. The pandemic led many managerial sta and direct care
workers to retire early or change careers, resulting in knowledge gaps and excessive burdens on the remaining sta. Workers
also emphasized that low wages for skilled nursing facility workers likely did little to produce meaningful savings in the
overall cost of care, as facilities use temp agencies to recruit workers to fill staing gaps when positions remain unfilled, and
sta sourced from these agencies are paid significantly more than the prevailing wage. Seeing facilities pay excessively for
staing through temp agencies at the same time as denying workers modest raises added to workers’ frustrations.
Job hazards: Nursing home and assisted living facility workers have an increased risk for injury compared to other direct care
workers because they are constantly on their feet, responsible for many residents at a time, and often called upon to move,
turn, or lift those in their care.
When skilled nursing facilities have too few workers serving residents with complex care needs, quality of care suers and
the consequences can be deadly. As Deidre Gilkes from New York State Nurses Association described, skilled nursing facilities’
staing ratios are directly correlated with quality of care, and cuts in Medicaid funding and state reimbursement rates are
therefore directly responsible for worsening quality of care in New York skilled nursing facilities. She also noted that the lack
of registered nurses made it diicult or impossible for skilled nursing facilities to implement eective infection control,
contributing to the extremely high COVID-19 impacts on New York’s nursing home population.
Pandemic impacts: Several workers described their fears related to COVID-19. “When workers saw their co-workers get sick
or die, many left. And today they are still afraid to come back, particularly with all the news of the Delta variant,” said
William Roe, a NYC nursing home worker. Dr. Dallas Nelson of the New York Medical Directors Association noted that the rate of
deaths among skilled nursing facility workers during the pandemic made it one of the most dangerous jobs in America.
Adding insult to injury, most long-term care workers did not receive hazard pay or “hero pay” made available to other health-
care providers who worked during COVID-19 response. One worker described receiving a t-shirt and a pen as a thank you for
continuing to work throughout the pandemic, noting that more substantive support and compensation were warranted, given
the health risks and sacrifices of front-line workers in nursing homes. The issue of chronic lack of childcare access was a
problem for skilled nursing facility workers pre-pandemic and was exacerbated due to COVID-19 school closures.
b. Home Care Workers
“We can’t be forced to always search for more hours to get a paycheck big enough to take care of our
needs. We can’t be forced to work for agencies that provide no health benefits. We shouldn’t have to look
at our paycheck every two weeks to see if the agency is paying us correctly. We’re human beings taking
care of human beings.” Jason Brooks, home health aide
“Home care work is one of the nation’s fastest-growing occupations, yet pay, benefits and working
conditions remain exploitative.” Jeanette Zoeckler (Upstate Occupational Health Clinical Center)
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Witnesses repeatedly emphasized that chronic low wages are the cause of the home care workforce shortage. While home
care workers made 150% of NY state minimum wage in 2006, wages have stagnated and today they make minimum wage or
slightly higher, often earning less than fast food and retail employees while performing skilled and emotionally intensive work.
Workers indicated that receiving a living wage would enable them to transition o of public assistance programs, therefore
reducing strain on state budgets. In addition to low pay, workers frequently reported being underpaid by agencies for the
hours they worked and having to fight to be fairly compensated. Given that 90% of the home care workforce are women and
60% belong to a racial or ethnic minority group, the devaluation of care work embodied by home care workers’ low wages is
also a racial and gender equity issue.
In addition to low wages, home care workers face additional financial challenges due to inconsistent schedules, part-time
hours, and a lack of advancement opportunities. As many consumers are only authorized to receive care for a few hours a day,
workers often travel between multiple clients in a day to get full-time hours. Home health aide Jason Brooks described the
diiculty that arose when a long-time client would die or go into the hospital, and he would suddenly be out of work until a
new client was assigned to him. He added that, as a male, he was sometimes harder to place with new clients, which could
lead to even longer gaps in employment. Home care workers are also twice as likely to be uninsured compared to the overall
population. Mr. Brooks said, “It’s been a struggle for six years for me. I’ve worked for a lot of agencies, and all of them,
non-union. ... I’ve never had health insurance through my job in all these years. Really, it’s just hard to get.”
Several witnesses focused on the “24 hour rule,” in which home care workers work 24 hour shifts to support clients with round
the clock care needs, but are paid for only 13 hours of work. Carlyn Cowen of CPC provided an in-depth analysis of the issue,
and described a 2019 New York state court ruling determining that if a home care worker receives less than five hours of
uninterrupted sleep, then the home care agency must compensate the attendant for the full 24 hours. Workers emphasized
that uninterrupted breaks and sleeping hours were not possible when clients required care through the night, and that
working 24 hour shifts was harmful to workers’ health and family relationships. Mary Lister from the Ain’t I a Woman campaign
noted that worker mistakes are more likely when shifts are longer than 12 hours, and continuing to require 24 hour shifts could
result in mistakes that harm the client or cause an injury to the worker themselves.
In many parts of the state, workers are expected to have reliable transportation to access clients’ homes. However, workers
often are not reimbursed for time on the road, and many workers must travel between multiple clients daily, which is stressful
and costly for workers. In rural areas this is especially challenging given long travel times between clients.
Workers report feeling that they lacked the skills necessary for the intensity of the work while expressing an eagerness to
learn if more learning opportunities were made available through employer-provided programs. Training practices described
were static and requirement-driven rather than dynamic and ongoing, and in some cases training was provided exclusively
online. The desire for coaching from an experienced sta member was expressed to build skills and confidence in the work
environment.
Pandemic impacts:
“The agency I worked for never provided us with PPE. We had to buy our own masks, gloves, and even
gowns… Right now I’m getting ready to go back to work, but I’m still terrified of getting sick. I feel the
agencies we work for need to do a better job of taking care of the workers and the clients.” Martha
Davila, home care worker
Lilieth Clacken of 1199SEIU United Healthcare Workers East described the experience of home care workers during COVID-19,
saying, “There are lots of reasons why home care workers left during the pandemic, but the biggest reason is the pay did not
justify the risks they faced. Fortunately, most stayed because they are incredibly dedicated to the people they care for.” Sadly,
12
Martha Davila described contracting COVID-19 after her agency Preferred Home Care sent her to a client’s home without
informing her the client was sick. The agency pressured her to continue working when she was sick and failed to provide
workers with any PPE. She was severely sick with COVID and was still recovering and unable to work six months later. Both
she and Jason Brooks described lacking health insurance, working under very stressful conditions, and consistently being
underpaid by their agencies. Martha Davila described her experience, saying, “It was a miracle if my paycheck was ever
correct. It was always missing days and hours and I always had to push to get my full hours paid. This happened to most of
the aides at this agency.”
2. Employers
a. Skilled Nursing Facility Industry
Nursing home operators expressed deep concern about the diiculty of recruiting and retaining sta. High sta turnover, they
pointed out, has adverse eects on the health and safety of sta and residents. This results in missed opportunities to notice
and address changes in residents’ health before health issues escalate and are more diicult and costly to address. Grace
Bogdanove from 1199SEIU cited the direct cost of turnover for a nurse aide as at least $2,500. She also noted that high turnover
is associated with higher injury-related medical costs for workers and increased healthcare costs for residents due to poorly
managed health issues, so the true cost of skilled nursing facility sta turnover is likely much higher.
Rather than working as a smooth health-care continuum, long-term care providers described themselves as in competition
with hospitals and medical practices for workers. Long-term care providers rely heavily on Medicaid funding, in contrast with
hospitals whose patients are mostly covered by Medicare and private insurance. As a result, hospitals have more resources
and are better able to attract and retain skilled workers than long-term care providers. This resource imbalance creates a gap
in the long-term care component of the health delivery system evidenced by worker shortages, low morale, and extremely
high turnover.
According to Jim Clancy of the Healthcare Association of New York State (HANYS), roughly two-thirds of private and non-profit
skilled nursing facilities are delivering care on negative operating margins, and the median operating margin in these homes
is negative 2.9 percent. Sarah Daly of LeadingAge NY testified that since the beginning of the COVID-19 pandemic, a number of
LeadingAge’s non-profit nursing homes across the state have closed or are for sale due to the continuing financial stresses of
the pandemic and rising staing costs. Roxanne Tena-Nelson of the Greater New York Hospital Association also reported that
loss of non-profit long-term care providers is a growing concern for New York, and in recent years there has been an annual
loss of nearly 5% of the state’s non-profit nursing homes.
Workforce recruitment and training: Individuals who testified stressed the importance of a well-functioning long-term care
sector as a critical component of the health delivery system. Dr. Dallas Nelson of the New York State Medical Directors Associ-
ation discussed a need for more geriatrics specialists to provide quality and person-centered health care to older patients.
The long-term care sector has become increasingly strained due to funding issues and worker shortages across all levels of
care, including skilled nursing, assisted living and home care services. Gaps in one area of service availability put stress on
the entire system, ultimately resulting in costly and preventable hospitalizations for individuals who lack access to high-quali-
ty long-term care to support their health and autonomy.
A lack of career ladders, programs to begin equipping future workers in high school with apprenticeships, and ongoing
workforce development for the long-term care workforce was voiced throughout the hearing. Doris Fischer of HANYS dis-
cussed the need for apprenticeship and career-ladder programs, saying “the key dierence between a job at McDonald’s and
a job at a nursing home should be a career; that you are beginning a career. And so we believe that we need to build that
infrastructure.”
One particular issue the operators noted relates to the training of certified nurse assistants (CNAs). Dr. Tara Cortes of the
Hartford Institute for Geriatric Nursing provided written testimony that the minimum training standards for CNAs were estab-
lished in 1987. Over the past 34 years resident complexity has increased dramatically without changes to the amount or type
of training required. CNAs are typically trained at skilled nursing facilities, who then draw on their CNA classes to sta the
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facility. Industry witnesses described that facilities facing sanctions or penalties from DOH are not allowed to hold CNA
training. This restriction on training impairs their ability to equip new workers and makes it diicult for facilities to address the
underlying problems for which they were cited, and a mechanism for these facilities to reach appropriate staing levels is
needed.
Witnesses made it clear that providers are looking to the legislature for solutions to long-term care workforce issues that have
historically received minimal attention from policymakers. The word “crisis” was spoken during the LTC workforce hearing
forty-nine times. In addition, the need for a more collaborative relationship between providers and the Department of Health
(DOH) was mentioned by several witnesses.
Oversight: Several witnesses expressed doubt as to the Department of Health’s ability to hold chronically poor-performing
skilled nursing facilities accountable and preserve resident’s rights and safety. Heckler (CELJ) suggested that residents of
poorly performing facilities should be given priority on waiting lists for better-performing facilities. Some witnesses indicated
that fines for violations at skilled nursing facilities were often insuicient to change behavior, and management simply
considered these fines part of the cost of doing business.
Pandemic impacts: Sta and financial losses in nursing homes and assisted living facilities have been greater during the
pandemic due to additional unreimbursed costs. These additional costs include procuring personal protective equipment,
COVID-19 testing for residents and sta, enhanced cleaning protocols, additional reporting requirements, and the cost of
recruiting and training sta who have left the workforce out of fear of contracting COVID-19. Industry testimony also described
frustration with the Department of Health, describing a lack of responsiveness and clarification when seeking guidance, and a
desire for a supportive working relationship with the Department.
b. Assisted Living Industry
Assisted Living facilities have needed additional sta to meet infection control protocols established by New York State. Sta
are required to continue to follow COVID-19 safety protocols, ensure proper visitation, and to conduct health screenings for
every person who enters a facility. These staing increases have resulted in higher unreimbursed overtime costs for Assisted
Living Facilities. Sarah Daly from LeadingAge noted that Enhanced Assisted Living Facilities have the option to assist a
resident with self-medication but do not have a Medication Technician (Med Tech) role. The Oice for People With Develop-
mental Disabilities (OPWDD) has Med Techs in their settings, and Daly suggested that the Med Tech role has been tested in
other states successfully and has the potential to alleviate some of the workload of LPN and RNs in Assisted Living facilities.
Insuicient training course availability slows down assisted living facilities’ ability to prepare potential new workers. Accord-
ing to Lisa Newcomb of Empire State Association of Assisted Living (ESAAL), “there is an extreme shortage of training
programs for certified home health aides and personal care aides,” creating additional strain on the existing workforce.
c. Home Care Industry
Home care providers and associations universally pointed to inadequate Medicaid reimbursement rates underlying lower
wages for home care workers and perpetuating the workforce shortage. Nonprofit agencies are particularly beholden to
Medicaid rates and negatively impacted by inadequate reimbursement and unfunded regulatory mandates, as Tara Klein of
United Neighborhood Houses and Carlyn Cowen of CPC discussed in their testimony. While several agencies testified in
support of raising the minimum wage for home care workers, they heavily emphasized that raising the minimum wage
without corresponding increases in Medicaid reimbursement would create a gap between expenses and reimbursements that
hurts both providers and workers. Adria Powell of Cooperative Home Care Associates explained, “for the home care sector
overall, these restrictive policies fuel sta shortages, prolong HCBS waitlists, undermine the capacity of the workforce
to meet clients’ increasingly complex care needs, and ultimately compromise care quality.”
Medicaid long-term care reimbursement rates have stagnated for over a decade. This trend is the result of the elimination of
adjustments for inflation in Medicaid rates, cuts by the Medicaid Redesign Team (MRT and MRT II) including over $1 billion in
cuts during the COVID-19 pandemic, and the 2011 introduction of the Medicaid Global Spending Cap which caps the annual
percentage growth of the state’s Medicaid spending and does not allow spending to respond to the growing number of people
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supported by Medicaid. Medicaid does not adequately account for home care costs when setting rates for Managed Long
Term Care Plans, which leads Managed Long-term Care Plans to inadequately reimburse home care agencies to cover their
costs.
Inadequate Medicaid reimbursement produces pressure for agencies to reduce costs by paying minimum wage and oering
few if any benefits for home care workers. Home care agencies discussed an increase in labor costs in recent years, citing
local minimum wage, Fair Labor Standards Act Final Rule, wage parity law, overtime and sick pay, new technology and PPE
during COVID as reasons for rising costs and a need for increased Medicaid support to cover them. High overtime costs that
agencies pay due to worker shortages are especially challenging for small agencies, as Medicaid reimbursements do not
support overtime pay, as Dana Arnone of Reliance Home Senior Services described.
Providers also discussed the high cost of sta turnover for agencies: ARISE estimated that the cost of onboarding new sta
ranges between $4,000-$6,000, meaning that the 30% annual turnover the agency experiences costs them at least $675,000 a
year. Several witnesses described agencies operating at a loss due to restricted Medicaid funding. COVID-19 costs further
exacerbated losses. Adria Powell of Cooperative Homecare Associates (CHA) reported that they were able to reduce the
turnover rate to 24% when they were able to fund 4 weeks of paid training and provide certification and advancement
opportunities for their workers. Due to Medicaid caps and lower provider reimbursement rates and distributions, they are no
longer able to do so. Providers consistently emphasized that increasing Medicaid spending was central to addressing the
home care workforce shortage and stabilizing the home care industry. According to Kevin Muir of Riseboro Homecare Ser-
vices, improving quality of care involves costly workforce training, adequate staing levels with appropriate skills and a
reliance on technology, data and information, costs which must be fully supported either through enhanced rates or govern-
ment grants.
Insuicient state funding for programs provided through the state’s aging network, including home-delivered meals and
in-home care programs, was also discussed as an issue during the hearing. Evidence supports that investing in these services
prevents Medicaid spend-down, where people qualify for Medicaid by paying out of pocket for long-term care until their
resources are below the limit for Medicaid eligibility, and also reduces preventable nursing home admissions. However, while
demand for these community-based services increased dramatically during COVID, funding has remained flat and insuicient
to support the demand for services, resulting in long waitlists and limited service for those that do receive in-home care. As
Tara Klein of United Neighborhood Houses put it, “these programs have soared in demand during the COVID-19 pandemic,
with homebound older adults discovering they can receive high-quality food delivered straight to their doors along
with case management support and regular wellness checks.”
Industry witnesses universally acknowledged the need for action to address the home care workforce shortage; Christy
Johnson of Premier Home Care described home care workforce shortages as a “full-fledged staing crisis.” Many pointed to
increasing financial and social support for workers as a key strategy for improving recruitment and retention. Several home
care agencies explicitly supported Fair Pay for Home Care to increase the minimum wage for home care workers but stressed
that increasing Medicaid reimbursements must be paired with requirements for higher wages for workers.
Several industry witnesses voiced concerns with wage mandates. Concerns included skepticism that increased Medicaid
compensation to support wage mandates would be provided, given past experiences of inadequate Medicaid support for
home care. Industry witnesses also argued that even if Medicaid funding was increased, agencies would face unsupported
cost increases for home care funded through non-Medicaid payers and out-of-pocket payments. Concern was expressed that
this would require agencies to increase hourly rates for private pay consumers, and this may drive more consumers to turn to
unlicensed caregivers. Testimony from Jeanne Chirico of the Hospice and Palliative Care Association of New York State also
noted that increasing the home care minimum wage without simultaneously increasing wages for more experienced workers
would create a compression factor, and agencies would need additional resources to provide raises for all workers. Lastly,
industry testimony discussed home care workers’ high rates of enrollment in public assistance programs such as SNAP and
Medicaid and noted that increasing wages could cause workers to lose eligibility for benefits. Testimony from Becky Preve
noted that careful planning using a regionally based pay structure would help to avert the issue of “benefit clis” which could
15
force some workers to reduce hours to avoid exceeding the income threshold for Medicaid eligibility or from receiving
material benefits from wage increases.
Duplicative annual training for workers employed by multiple agencies was identified as an ineiciency in the home care
sector. Matt Hetterich of Gurwin Home Care recommended a statewide aide registry to track home care worker training
completion, avoid duplicative annual training requirements, reduce training time demands for homecare workers, and simplify
the process for overseeing training.
Providers also testified on the disruptive impact of workforce shortages on consumers and their families. Dana Arnone of
Reliance Home Care Senior Services testified that the workforce shortage forced her agency to shift care responsibilities back
onto unpaid family members when formal services are not available, which she noted puts many families in an impossible
position of managing both their own paid employment and providing intensive care for their loved ones. Neil Heyman of New
York State Association of HealthCare Providers (NYSAHCP) highlighted that the current system of delivery of community-based
health care services places a disproportionate amount of the burden on families and loved ones who do not get paid to
perform these duties.
3. Care Recipients, Family, and Advocates
“You have people in bed all day. So it’s an accelerated decline. Bed sores. Escalating potential for blood clots.
It’s a disaster.” - Marcella Goheen, advocate and family member of a nursing home resident
Speaking about the nursing home sta shortage, Marcella Goheen expressed her concern that caregiver shortages
make it impossible to provide complex care including the specialized care her husband needed. She reported seeing
one nurse for forty-five patients and two aides for a floor of thirty people, and noted that staing levels were inadequate
to even get all facility residents out of bed.
Home care providers and consumers described the disruption, stress, expense, and health risks associated with losing home
care due to worker shortages. Tania Anderson from ARISE described a Consumer-Directed Personal Assistance Program
(CDPAP) consumer who was approved for 80 hours of support, but due to COVID workforce disruptions, he was left without
services for a week. He had a health crisis prompting a hospital stay, ultimately resulting in his admission to a nursing home.
Agnes McCray, ARISE board president and home care consumer, described the diiculty and expense of her own experience
finding home care, and noted that her son had delayed college to provide care until she was able to hire new sta. Sandra
Moore Giles testified that in spite of receiving a prescription for 20 hours a week of home care, she was not able to hire an aide
due to the worker shortage and attributed a current health crisis as a consequence of going without necessary care.
Bryan O’Malley of Consumer Directed Personal Assistance Association of NYS discussed how workforce shortages also limit
choices for consumers, and that Medicaid recipients are often the most restricted in their service options. Witnesses empha-
sized that families should be in the position of overseeing home or nursing aides rather than performing the actual care for
hours on end. As Keith Gurgui, a homecare recipient, described, “my parents are aging and I should not have to rely on
family members and unpaid volunteers to help me for weeks when an agency exists with a current contract to fill my
case. I want to be independent in my own home.”
Both Meghan Parker of Independent Living and Claire Pendergrast of the Lerner Center highlighted the diicult issue of provid-
ing home care services to people in rural communities. Meghan said that when sta earned 150% of the prevailing minimum
wage, it was easier to hire sta, but the current uncompetitive wages combined with smaller working-age populations in rural
areas produced significant staing issues. She noted that rates for “hard to sta” locations no longer exist, compounding the
challenge of rural staing.
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Carlyn Cowen from the Chinese-American Planning Council (CPC) noted that the Fair Labor Standards Act (FLSA) has not been
fully implemented in New York even though it was extended to home care workers in 2013. Lack of FLSA implementation
makes scheduling and labor issues diicult for workers and providers to manage, and also makes workers vulnerable to
situations like the 24-hour rule where they do not receive full pay for hours worked.
Many witnesses discussed the negative economic impact when families with children and/or parents needing care, are faced
with the struggle to maintain employment to support their family. Maria Alvarez of the Senior Action Council spoke of family
members who have exhausted FMLA leave who are forced to opt out of the workplace to care for a loved one when a caregiver
is not available. The family is impacted financially, no longer contributing economically and have reduced spending power.
They may require additional public benefits as a result of income loss, placing greater demand on assistance programs.
Several witnesses stressed that this common scenario is not sustainable as it leads to increased costs for New York State,
economic loss for families and a reduced tax base for state and local communities.
Melissa Wendland of Common Ground Health pointed out that older adults are staying in their homes longer, delaying institu-
tional care and increasingly relying on home and community services. The growing need for more skilled and home-health-
care nurses/aides to meet the needs of home and community service delivery exist, in addition to institutional care. Work-
force shortages contribute to long waiting lists for older adults with home care needs, creating long-term stress for family
members who are obligated to provide unpaid care for months while waiting for home care services to become available, if at
all. Several home care providers discussed the frustration of having to tell clients and their families that they were unable to
provide the services they were authorized to receive due to workforce shortages. As Rebecca Preve of the Association on
Aging in New York explained, “we really need to facilitate some type of change, not only because of the economic cost,
but because of the human cost to these individuals who are told, ‘You’re authorized for this service, but, we’re sorry,
we can’t serve you.’”
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E. Solutions
Now is the time to invest in the people of New York State and to ensure all individuals have the ability to age with
independence and dignity. This means investing in the long-term care workforce, while at the same time reforming
the delivery of long-term care services and supports. Lindsay Heckler - Center for Elder Law and Justice
Witnesses presented a range of solutions to long-term care workforce challenges. The hearing included nearly universal
acknowledgement that eorts to identify and implement holistic solutions to long-term care workforce issues were long
overdue. Ending the global Medicaid cap (introduced in legislation as S.5255 [Rivera]) and raising Medicaid reim-
bursement rates for long-term care is an essential first step to rescuing nursing homes and home care agencies. Raising
wages for long-term care workers is essential to recruiting and retaining them in the numbers required. Witnesses also
discussed the need to strengthen training opportunities and develop career pathways or ladders for diverse long-term care
roles, support promising models of community-based care, and expand research to inform data-driven policy solutions.
1. Reforming the Long-Term Care System as a Whole
Lindsay Heckler of the Center for Elder Law Justice (CELJ) described a skilled nursing facility called Safire South as an
example of the health risks insuicient nurse staing presents to skilled nursing facility residents. She described Safire South
residents developing severe pressure ulcers and receiving delayed wound treatments because of the facility’s consistent
short-staing and high use of contract staing. She and other advocates ask the legislature to work holistically on long-
term care system reform rather than thinking in silos when working to address the challenges faced.
The range of long-term care options, from skilled nursing facility to occasional in-home meal delivery, is not a constellation of
separate entities but a continuum. Individuals may transition from one care setting to another, depending on care needs and
preferences, and direct care workers may work in multiple settings. Long-term care employers may operate a nursing and
rehab facility, an assisted living facility, a PACE center, and a home care agency. If reimbursement rates fall short in one, there
is only so much they can do to make up the dierence at others. Similarly, an acute workforce shortage at one point on the
spectrum may have cascading impacts: rehab facilities cannot release residents to go home unless there is adequate home
care for their needs, and hospitals cannot release patients into rehab if the beds are full of people waiting to go home. The
result is that people don’t receive the optimal level of care, and taxpayers are on the hook for unnecessarily expensive hospital
and rehab beds.
Many witnesses spoke up in favor of the Reimagining Long Term Care Task Force Act (S.598B [May]), to bring stakehold-
ers together from the entire continuum of care to look at best practices from a holistic, statewide standpoint. The task force, if
implemented, should consider workforce supply and demand at each level on the continuum, as well as career advancement
among the dierent levels.
2. Pay and Benefits
Workers emphatically endorsed S.5374 - Fair Pay for Home Care (May) to increase the minimum wage of home care workers
to 150% of the minimum wage in the region. A living wage is projected to create 20,000 new homecare jobs per year and
create an additional 18,000 jobs with local businesses due to the workers’ own increased spending capacity. Employers are
supportive of this change, provided that they receive correspondingly higher Medicaid reimbursement rates, including at the
institutional facilities that must compete for the same labor force.
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Table 1. Recommended Wage Increases in New York State’s Three Economic Zones
Target
Level 1
Hourly
Target Level 1
Annually
Target Level
2 Hourly
Target Level 2
Annually
New York City $22.00 $40,000 $27.50 $50,000
Long Island and
Westchester
$19.25 $30,000 $24.75 $45,000
Remainder of NYS $16.50 $35,000 $22.00 $40,000
Source: The Case for Public Investment in Higher Pay for NY State Home Care Workers - Estimated Costs and Savings - CUNY
School of Labor Studies (submitted as testimony by Rebecca Preve, Association on Aging in New York)
These investments in higher home care wages are projected to yield significant returns to the state and across the
economy. This is achieved, in addition to lifting workers o of public assistance and giving them buying power, by helping
seniors avoid unnecessary stays in nursing homes and spending down all their savings, keeping them spending money in
their communities and paying property taxes, and allowing family members to stay in the workforce rather than leaving their
jobs to care for their loved ones themselves. See S.4256 Investing in Care Act (May).
Table 2. Costs and Economic Benefits of Home Care Wage Increases
Target Level 1 Target Level 2
Costs $3,965,014,000 $6,255,178,000
Economic Benets $7,632,870,000 $12,863,856,000
Net Economic Gain $3,667,856,000 $6,608,678,000
Source: The Case for Public Investment in Higher Pay for NY State Home Care Workers - Estimated Costs and Savings - CUNY
School of Labor Studies (submitted as testimony by Rebecca Preve, Association on Aging in New York)
Workers and providers emphasized the need for a legislative solution for the 24-hour rule issue, in which many home care
workers are assigned 24-hour shifts but are paid for only 13 hours. S.359 (Persaud) requires providers to cover 24-hour care
with two non-sequential split shifts of twelve hours each rather than one 24-hour shift. Several witnesses cautioned that an
increase in the home care minimum wage without such a rule, and without instituting Medicaid reimbursements for 12-hour
shifts, would provide an incentive for agencies to implement more 24-hour shifts.
Many long-term care workers described how they make ends meet by working multiple shifts or overtime. Across-the-board
wage increases would ease this problem. Often overtime is involuntary, as in the case where no one shows up to relieve a
home care worker caring for someone who needs continual care. S.359 (Persaud) would address this by limiting the
number of overtime hours a worker can be required to work without consent.
Workers who testified mentioned repeatedly the importance of being treated with dignity and respect. It is diicult to achieve
this goal through policy, other than ensuring adequate pay and benefits, but it points to the importance of according due
respect to the work we all now agree is “essential.” Lindsay Heckler (CELJ) emphasized that skilled nursing facilities’ house-
19
keeping, dietary, social work, and therapy employees play a key role in residents’ physical, social, and psychosocial well-being
and deserve adequate pay for their hard work. Hanse (NYSHFA/NYSCAL) suggested expanding the model of healthcare to
include scribes, patient navigators and expanded care coordinators. There was also discussion at the hearing of encouraging
nursing homes to develop on-site child care for their workers, as both an incentive to attract workers and a way to improve
their morale and work lives.
Matt Hetterick of Gurwin Health Services described a “Resident Care Assistant” role they utilized in skilled nursing facilities to
provide non-clinical needs such as delivering food or answering call bells from residents. According to Lindsay Heckler of
CELJ, teamwork, respect and organizational culture are key to recruitment and retention for skilled nursing facility workers.
Bogdanove of 1199 SEIU noted that including workers in management activities such as mentoring new sta also improves
worker engagement and investment in the workplace.
Individuals with more complex needs require more care hours to meet those demands. Worker stress can be reduced by
allocating an appropriate number of hours for more complex cases (accuity). Workers expressed a desire for involve-
ment in the care decision-making process. They are witnesses to subtle changes in the individuals they care for. They
expressed a desire to share their observations and contribute to discussions about care. A workplace culture where ideas are
heard, that is welcoming and supportive, where sta feel respected and appreciated leads to greater levels of retention
(Heckler).
It is a scandalous fact that many long-term care workers do not themselves have health insurance, in spite of working in
high-stress jobs that can expose them to deadly diseases. Witnesses proposed two solutions: more unionization of the
long-term care workforce, and passage of the New York Health Act (S.5474 [Rivera]), which would cover all New Yorkers
regardless of employment status or income.
3. Workforce Development and Career Advancement
“Current training standards and programs do not, for the most part, suiciently prepare nursing assistants,
residential care aides, and home care workers for their complex and challenging roles… While better
compensation is needed to attract workers to the long-term care industry, adequate training and advancement
opportunities are critical for job satisfaction, workforce retention, and high-quality care.” - Hannah Diamond, PHI
a. Professional Standards and Systems of Support
Throughout the testimony we heard about the need to reduce turnover, improve worker safety, and support the long-term care
workforce with paid training, information, and advancement opportunities. To realize these gains, New York State needs a
well-constructed long-term care workforce support system that begins with clearly defined professional standards with
mechanisms designed to achieve those standards. Doris Fischer (HANYS) referred to this as a need to build the infrastructure.
A workforce system designed to address the recommendations made in testimony would bring together all the recommended
components. It includes a career roadmap, methods for recruiting students into the profession such as apprenticeships,
identified pathways for advancement, role definitions consistent with skills required, updated training and certification
standards, development of comprehensive training and standardized curriculum, along with enhanced and specialized
learning opportunities. Addressing the need for updated professional standards and a workforce support system could be
initiated by the Reimagining Long Term Care Task Force (S598B [May]).
We heard many recommendations for improving the training and certification process and incentivizing recruitment and
retention of long-term care workers. Funding the infrastructure to support regional collaboration to benchmark eective
pilot programs, assess eectiveness, share best practices, and conduct workforce research and tracking is also recom-
mended. Jeanne Chirico of PHCANYS suggested the creation of a New York State Community Health-Direct Care Workforce
Center of Excellence to secure and dispense grants on behalf of regional and statewide initiatives to address transportation,
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career paths, and support programs such as childcare. It would also bring together stakeholders in regional coalitions to
address issues such as workforce deserts and produce recommendations to DOH and regulatory bodies.
Hanse (NYSHFA/NYSCAL) stressed the need for “more robust and broader training on geriatrics skills across the health
workforce,” that would provide “quality and eective care to cover the unique needs and challenges related to older adults.”
Legislation that would provide tuition support, stipends or loan forgiveness for nursing programs, geriatric studies and
credentialing is highly recommended to expand the pool of candidates able to enter and grow the long-term care workforce.
S.6201 (May) would create a loan repayment program for people choosing to specialize in geriatrics. Tuition support for
adult learning/certification and enhanced financial aid for nursing programs at community colleges and/or BOCES was also
recommended.
The existing pathways to training and certification of CNAs, HHAs, and PCAs is in need of reform. Current required
hours for CNAs are 100, PCAs are 40 and HHAs are 95. In addition to addressing the overarching systems issues, specific
recommendations include:
• Establishing new DOH skill classifications that reflect the acuity of care required
• Updating certification and training standards developed decades ago, to align with skills required
• Allowing multi-certification training for universal workers; eliminating duplicative training requirements
• Oering high school or technical school pre-apprenticeship programs
• Supplementing classroom training with opportunities to practice skills with an experienced trainer or mentor
• Adjusting Home Health Aide Training Program (HHATP) requirements to allow flexibility in rural areas
• Increasing the availability of enhanced skills training in areas such as mental health, Alzheimer’s, diabetes, renal
disease, hospice and palliative care, and worker safety
• Allowing LPNs to conduct training under general supervision of an RN, as provided for in Federal guidelines
• Streamlining the application process for employers/agencies to provide training. providing training for culturally
competent and trauma-informed caregiving at all levels
There are some specific eorts in place in New York State to recruit, train, and mentor long-term care workers.
• Jim Clancy of HANYS described apprenticeship programs for home care workers that include mentoring and college
credits. He noted that these programs are proven to be eective and asked the state to support the development of
additional apprenticeship opportunities.
• The Greater NY Hospital Association (GHNYHA) has a Certified Nurse Assistant Apprentice Program to recruit people
not typically exposed to the healthcare field and provide targeted educational opportunities combined with experien-
tial learning at a nursing home.
• Grace Bogdanove (1199 SEIU) spoke about LPN apprenticeships in Syracuse and Bualo, NY. With this model CNAs
continue work while they attend school to become an LPN. This eort is a collaboration between union and manage-
ment with support from the 1199 training fund. The union hopes more employers will partner with them to expand
this model.
• The Creating a Legacy of Care © Mentorship Program (New York State Association of HealthCare Providers) was
described as increasing caregiver satisfaction. This mentorship model improved cohesiveness and a sense of
connection between the home oice and the home care aides who often feel isolated in their work. The pilot program
findings showed that caregiver turnover rates (pilot vs. non-pilot agencies) for agencies without mentorship pro-
grams, had a 170% higher caregiver turnover rate in the first 90 days of employment compared with pilot agencies
21
using the program during the research period.
• Rona Shapiro of SEIU 1199 described the HUGS Aide program the union created in partnership with Healthfirst, to
create a career ladder and train home health aides to provide health coaching services for clients.
Witnesses also recommended several promising training and recruitment models in other states that may warrant
replication in New York.
• California has a senior care workforce development model that seeks to reach potential long-term care workers at an
earlier age. Partners include schools, career centers and vocational schools with programs appropriate to senior care
development. A certificate that includes rotation in assisted living residences is currently under development.
• An Ohio-based, grant-funded program, Nurse Leadership Training Program operated from 2018 to 2020. The program
helped nurses build skills in team-building and leadership. It included eective communication, managing expecta-
tions, accountability, delegation and mentorship. Based on information available, the program decreased sta
turnover by 53%, increased resident satisfaction by 17%, and increased family satisfaction by 10%.
• The Healthcare Northwest Partnership is a collaboration in Washington state between SEIU and private health-care
industries. Grace Bogdanove of 1199 characterizes it as “the nation’s first large-scale career pathway program for
home care aides.” While designed for home care, she said it applies to the aides who work in nursing homes as well.
3,000 new apprentices have completed this program over the last five years.
b. Opportunities for Advancement
Workers, employers, and advocates alike spoke to the need for career ladders and opportunities for advancement. According
to Diamond (PHI), while better compensation is needed to attract workers to the long-term care industry, adequate training
and advancement opportunities impact whether they stay.
The Centers for Medicare and Medicaid Services (CMS) developed a set of twelve competency areas named the Direct
Service Workforce Core Competencies (Appendix A). These competencies are partially but not completely covered in the
Home Care Curriculum developed in New York State, according to an assessment done by PHI. They recommend development
of core competencies and standard curricula for all roles, as well as an overarching Long Term Care career roadmap. This
could be addressed by the Reimagining Long Term Care Task Force (S.598B [May]).
According to several individuals providing testimony, the recently ended Workforce Investment (WIO) program is an
example of the type of program providers and workers need. Febraio (NYSAHCP) highlighted the success of a Peer-to-Peer
mentorship program funded through the WIO. Michele O’Connor of Argentum noted that the Advanced Home Health Care Aide
role had been created but not staed due to regulatory barriers and funding. Hannah Diamond of PHI stated, “career advance-
ment opportunities within direct-care are also critical for retaining workers, for amplifying their contribution to care, and
achieving quality outcomes and cost-savings. To develop advanced roles, PHI recommends that the legislature enact and fully
fund the Home Care Jobs Innovation Fund (S4222 [May]).”
c. Other Incentives
We heard support for maintaining and expanding upon the executive order to allow nurses from Canada and other states to
continue to work in New York State. Witnesses recommended recognizing out-of-state credentialing or participating in
multi-state credentialing to reduce redundant training requirements and expand the available workforce. Expanding loan
forgiveness for nursing programs, allowing and funding bonuses for sta, implementing incentives and tax credits based upon
length of employment were all recommended to encourage continuous learning and retention in the profession.
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4. Sustainable Financing and Support for Employers
“During budget discussions HCP and other stakeholders made clear, and we reemphasize this in the strongest
terms possible today, that any such proposal to increase wages must include minimum hourly reimbursement
rates that include wages, benefits and provider costs.” – Febraio, NYSHCP.
Employers need reimbursement to cover workforce costs, including worker recruitment, training, benefits, overtime when
needed, continuing development, safety measures including PPE and service provision. Witnesses also argued that given the
emotionally and physically demanding nature of direct care work, incentives for longevity were also recommended to retain
the skilled workforce.
Provider organizations and the Geriatrics Task Force of the NY state chapter of American College of Physicians requested
better collaboration with DOH and the Legislature to assist with improving long-term care delivery and to address the
punitive workplace culture seen in many nursing home environments, noting that this approach has been successful in
other states.
Recommendations specific to assisted living facilities are designed to support workforce flexibility. S.1593 (Rivera) authorizes
nurses to practice incidental nursing services in assisted living facilities to avoid transfers to nursing homes and hospitals. To
resolve the issue of excessive workloads for medical directors, develop legislation to allow Nurse Practitioners and
Physician’s Assistants to conduct medical evaluations for Assisted Living Facility residents.
Lindsay Heckler of Center for Elder Law and Justice (CELJ) suggested better utilization of Civil Money Penalty Reinvestment
Funds to fund some skilled nursing facility workforce development eorts. The federal Civil Money Penalty (CMP) is a
monetary penalty that CMS imposes against nursing homes for violations of federal regulatory requirements. Once CMS
collects the CMP, a portion of it is sent back to the state and must be reinvested to support projects that benefit nursing home
residents or improve their quality of care and quality of life. These funds are available through DOH-issued grants. However,
nursing home operators must apply for grants to gain access to CMP funds, and Heckler advocated for increased use of these
funds for workforce development. Since CNA certification standards haven’t been updated since 1987, there is also room for
change there.
As one means of assisting home care providers, S.2117 (Rivera) directs the Commissioner of Health to designate episodic
payments at a 10% higher rate, and to establish minimums for individual home care services paid by Medicaid. It also
provides authorization for subsequent increases to ensure that services are reimbursed adequately, which would allow home
care operators to remain viable and to provide needed services now and in the future. The Consumer-Directed Personal
Assistance Program, or CDPAP, is a Medicaid-funded program that provides chronically ill or physically disabled New Yorkers
with services from a home care worker by allowing individuals the flexibility to choose their caregiver, including hiring,
training, and supervising workers. This is a very eective model that deserves robust support in the budget and could be
emulated for senior care as well.
5. Oversight and Quality Control in Skilled Nursing Facilities
Industry witnesses also repeatedly called for simplification of the complicated process for care qualification and delivery in
skilled nursing facilities, referencing the highly regulated nature of the industry. The Washington State long-term care trust
act oers a funding approach provided by Common Ground Health.
Worker and resident advocates called for higher levels of transparency by making information about individual nursing
home performance, such as salaries, turnover rates, outcomes, violations, etc. available to the public. They recommended
restricting referrals of patients from hospitals to poor or underperforming facilities and those with insuicient staing levels.
One suggestion to improve transparency at Assisted Living Facilities is to require DOH to collect and publish staing
23
schedules.
6. Supporting family caregivers
The need for greater support for family caregivers who provide significant long-term care support to their loved ones and
reduce strain on formal long-term care providers was also discussed throughout the hearing. The Family Caregiver Tax
Credit - S.620 (May) provides a middle-class family caregiver tax credit to reduce the burden of caring for a loved one. The
tax credit can be claimed by an individual with a gross annual income of $75,000 or less and a couple with a gross annual
income of $150,000 or less. The proposed credit would not exceed $3,500, or fifty percent, of the total amount expended. These
bills are currently in committee.
7. Additional Research Needs
Many witnesses discussed the need for more robust data collection and research on the long-term care workforce.
Diamond (PHI) stated that more precise data on the state’s long-term care workforce is needed to support policymakers’
ability to quantify workforce shortages, monitor workforce trends over time, and evaluate the impact of changes in long-term
care policy and practice on the workforce. She recommended a survey of all relevant departments and agencies to catalog
existing long-term care workforce-related data collection mechanisms and to identify gaps and inconsistencies. Tara Klein
(UNH) noted that while industry trade associations and think tanks could support data collection and analysis of workforce
trends, state agencies such as the Department of Health and the Department of Labor are likely best suited to lead these
eorts, as they already have access to many relevant data sources. We heard wide ranges in estimates of basic data points:
250,000-400,000 long-term care workers, for example, or home care salaries ranging from $20,000 to $28,750 annually.
Klein also identified specific home care-related data needs, including number of clients served, number of employees,
number and percent of 24-hour cases, changes in these numbers over time, employee retention and turnover rates by role,
average length of sta vacancies, and disaggregated data by nonprofit and for-profit agencies and size of agencies. Other
specific data requests from witnesses included surveying direct care workers across occupations, care settings, and regions
to document workers’ experiences and recommendations for improving job quality, assessing sta turnover in skilled
nursing facilities to identify characteristics of facilities with high turnover and its impacts, and assessing the number of
individuals who have been approved to receive home care services but did not receive services due to workforce shortages.
More research on home care safety concerns was also discussed. Testimony from Tara Klein (UNH) noted that more systemat-
ic home care workforce data collection would support eorts by home care providers, the Department of Health, and the legis-
lature to develop a successful policy solution to the 24-hour rule. Jeannette Zoeckler of SUNY Upstate Occupational Health
Clinical Center also supported funding mechanisms to support research on health and safety issues for home care
workers.
Witnesses also discussed a need for more research on a variety of models for long-term care service provision. Zoeckler of
SUNY Upstate pointed to home care unions and worker-owned cooperatives as promising strategies for improving
outcomes for home care workers. She called for further research on challenges unions face in organizing home care
workers, including worker non-co-location and institutional hierarchies. She also noted that research is needed to under-
stand the conditions of the private pay home care workforce, who she noted are an understudied group in comparison to
publicly funded home care workers.
The importance of building an evidence base to inform eorts to improve worker training and career development was also
discussed. Zoeckler of SUNY Upstate called for further research on the potential of enhanced service delivery, such as nutri-
tional counseling or mild exercise programs, for creating career pathways for home care workers. Hannah Diamond of PHI also
recommended building in home care “advanced role” demonstration projects into New York’s Medicaid Waiver and includ-
ing provisions for thorough evaluation of these demonstration projects to build the evidence base for the impact and value of
supporting home care workers’ career advancement into roles such as “transition specialists”, “peer mentors”, and “care
integration senior aides.”
24
Witnesses also identified several specific research projects needed to inform long-term care workforce policies. Given the
potential for increased home care wages to reduce eligibility for or generosity of public assistance for home care workers,
future analyses should examine how overall take-home pay would be aected by increases in the home care minimum wage.
Hannah Diamond of PHI also recommended that the Department of Health should evaluate the impact for worker wages,
benefits, and job quality of the recent requirement that 70% of nursing home revenue be spent on direct resident
care and at least 40% on frontline sta. Sarah Daly of LeadingAge recommended that a “workforce impact analysis” be
conducted for proposed long-term care regulations to assess if the proposed requirement would divert staing resources
away from resident care. Jeannette Zoeckler of SUNY Upstate called for cost-eectiveness analyses assessing savings due to
avoided hospitalizations, Medicare/Medicaid expenditures, and the financial impacts of unpaid family caregiving associated
with investments in home care. Maria Alvarez of Statewide Senior Action Council recommended that researchers assess the
true cost of unpaid caregiving that results from inadequate home care access.
25
F. WITNESS LIST AND TESTIMONY
A transcript and recording of all spoken testimony can be found on the Senate Events website, in addition to all written
testimony. In addition, all submitted written testimonies are also available. To access this information go to - https://www.
nysenate.gov/calendar/public-hearings/july-27-2021/joint-public-hearing-nursing-home-assisted-living-and-homecare
List of Witnesses
Part I: Nursing Homes and Assisted Living
Panel 1
Meghan Parker - New York Association on Independent Living
Dora Fisher - Healthcare Association of New York State (HANYS)
Jim Clancy - Healthcare Association of New York State (HANYS)
Lisa Newcomb - Empire State Association of Assisted Living (ESAAL)
Panel 2
Stephen B. Hanse, ESQ. - NYS Health Facilities Association
Tarrah Quinlan - NYS Health Facilities Association
Lisa Volk - NYS Health Facilities Association
Panel 3
Gene Hickey - UFCW, Local # 2013 (replaced Louis Mark Carotenuto - illness)
Francine Streich UFCW, Local # 2013 (late addition)
Panel 4
Grace Bogdanove - 1199SEIU United Healthcare Workers East
William Roe, LPN, - 1199SEIU United Healthcare Workers East
Tonya Blackshear, CNA - 1199SEIU United Healthcare Workers East
Panel 5
Sarah Daly - LeadingAge New York (replaced Jim Clyne)
Michele O’Connor - Argentum/Argentum NY
Doug Wissman - Greater New York Health Care Facilities Association
Panel 6
Dallas Nelson, MD - New York Medical Directors Association
Diedre Gilkes, RN - New York State Nurses Association
Panel 7
Hannah Diamond - PHI
Maria Alvarez - Statewide Senior Action Council
Lindsay Heckler - Supervising Attorney, Center for Elder Law & Justice
Panel 8
Agnes McCray - Board President of ARISE, Human Rights Advocate & home care consumer
Marcella Goheen - Founder, Essential Care Visitor
Ian Magerkurth - Alzheimer’s Association (unable to testify due to illness)
26
Part 2: Home Care
Panel 1
Rona Shapiro - 1199SEIU United Healthcare Workers East
Lilieth Clacken - 1199SEIU United Healthcare Workers East
Jason Brooks, PCA, Healthcare Workers Rising
Martha Davila, Home Care Attendant
Panel 2
Ilana Berger - Caring Majority Panel
A reader for Sandra Moore Giles - Senior Home Care Consumer
Sandra Abramson - Family Caregiver
Mildred Garcia Gallery - Ageless Companions
Panel 3
Mary Lister - Ain’t I a Woman?! Campaign, Queen City Workers Center, Bualo, New York
Ignacia Reyes - National Mobilization Against SweatShops (NMASS)
JoAnn Lum - Ain’t I a Woman?! Campaign
Panel 4
Rebecca Preve - The Association on Aging in New York
Tara Klein - United Neighborhood Houses (UNH)
Carlyn Cowen - Chinese-American Planning Council (CPC)
Panel 5
Claire Pendergrast, MPH - Syracuse University Lerner Center for Public Health Promotion
Melissa Wendland - Common Ground Health
Jean Moore - Center for Health Workforce Studies, UAlbany School of Public Health - unable to testify
Panel 6
Bryan O’Malley - Consumer Directed Personal Assistance Association of NYS
Tania Anderson - ARISE
Heidi Siegfried - Center for Independence of the Disabled, NY
Panel 7
Jeanne Chirico - Hospice and Palliative Care
Katelyn Andrews - LiveOn
Kathy Febraio - NYS Association of Health Care Providers
Al Cardillo - Home Care Association of NYS (in place of Alyssa Lovelace)
Panel 8
Dana Arnone, RN - Reliance Home Senior Services
Hon. Christine Pellegrino - All Things Home Care, Inc. (501c3)
Faigie Horowitz - Caring Professionals, Inc.
Jim Hurley - Home Instead Senior Care
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Panel 9
Christy Johnston - NY Coalition of Downstate Homecare Agencies/Premier Home Health Care
Matt Hetterich - Gurwin Certified Home Health Agency
Veronica Charles - Maxim Healthcare
List of Written Testimony
• Bryan O’Malley, Consumer Directed Personal Assistance Assn of New York State (CDPAANYS)
• CIPA Capstone Report Oice of the Aging
• Honorable Christine Pellegrino, Civil Service Employee Association (CSEA)
• Lindsay Heckler, Supervising Attorney, Center for Elder Law and Justice (CELJ)
• Melissa Wendland, Common Ground Health
• CUNY Homecare Report
• Dr. Tara Cortes, Hartford Institute of Geriatric Nursing (HIGN), (NYU)
• Grace Bagdanove, 1199 SEIU
• Greater New York Healthcare Facilities Association (GNYHCFA)
• Greater New York Hospital Association (GNYHA)
• Matt Hetterich, Gurwin Home Health Agency
• Healthcare Association of New York State (HANYS)
• Homecare Association of New York State (HCA)
• Hospice and Palliative Care Association of New York State (HPCANYS)
• Rhonda M. Butler, EdD., Interfaith Works
• Jeanette Zoeckler, Ph.D., MPH Occupational Health Clinic Centers (OHCC) Upstate Medical University
• Amy J. Schnauber, LeadingAge New York
• Lilieth Clacken, Home Health Aide, NYC
• LiveOn NY New York State Home Care
• Long Term Care Community Coalition (LTCCC)
• Maggie Ornstein, Ph.D., MPH, caregiver and Caring Majority Member
• Martha Davilla, home care aide NYC
• Veronica Charles, Maxim Homecare Services
• Neil Heyman, Southern New York Association, Inc.
• New York Providers Alliance (NYPA)
• Colleen Downs, North Country Center for Independence
• New York Health Facilities Association/New York Assisted Living Facilities (NYHSA/NYSCAL)
• Diedre Gilkes, R.N., New York State Nurses Association (NYSNA)
• Maria Alvarez, New York Statewide Senior Action Council
• Paula E. Lester, MD, FACP, CMD Metropolitan Area Geriatrics Society (MAGS)
• Claire Pendergrast, Lerner Center at Syracuse University
• Rebecca Preve, Association on Aging in NY
• Keith Gurgui, Resource Center for Accessible Living
• Rona Shapiro, 1199 SEIU
• St. Nick’s Alliance Home Care
• Tonya Blackshear, CNA, Utica, NY
• UFCW Local #2013
• United Neighborhood Houses (UNH)
• William Roe, LPN NYC
• NY Coalition of Downstate Homecare Agencies
28
• Andrea Thomas, Sunnyside Community Services
• Margaret Lee, Ain’t I a Woman Campaign?!
• Kevin Muir, Riseboro Community Partnership and Riseboro Homecare
• New York State Association of Healthcare Providers (HCP)
• Carlyn Cowen, Chinese Planning Council (CPC)
• New York Medical Directors Association (NYMDA)
• Mary Lister, Queen City Worker Center, Ain’t I a Woman?! Campaign
• Adria Powell, Cooperative Home Care Associates (CHCA)
• PHI/Hannah Diamond Testimony
29
Appendix A - Centers for Medicare and Medicaid Services (CMS) Direct Service Workforce Core Competencies
CMS generated an initial list of direct care competencies through a comprehensive inventory of common competency lists
from across settings in long-term care. Next, CMS solicited input from consumers, family members, direct service workers,
state representatives, provider agencies, and training development experts to develop the following set of core competencies.
• Communication: use strong communication to build relationships with consumers and team members
• Person-centered practices: assist consumers to make choices and plan goals and support them in achieving those
goals
• Evaluation and Observation: Gather information on a consumer’s physical and emotional health and communicate
observations to care teams and supervisors.
• Crisis Prevention and Intervention: Identify factors that can lead to a crisis and use eective strategies to prevent or
intervene in the crisis.
• Safety: Prevent and respond to signs of abuse, neglect or exploitation and help consumers avoid unsafe situations
and keep them safe during emergencies.
• Professionalism and Ethics: Provide supports professionally and ethically, maintaining confidentiality and respecting
consumer and family rights.
• Empowerment and advocacy: assist consumers in advocating for themselves and achieving their goals.
• Health and Wellness: Support consumers in achieving and maintaining good mental and physical health.
• Community living skills and supports: Help individuals manage the day-to-day tasks that form the basis of indepen-
dence in the community.
• Community Inclusion and Networking: Help consumers maintain and expand their roles and relationships in the
community and assist individuals with major transitions that occur in community life.
• Cultural competency: Respect cultural dierences and provide services and supports in line with consumer prefer-
ences.
• Education, Training, and Self-Development: Obtain necessary training, and seek opportunities to improve skills and
work practices through ongoing learning opportunities.
Appendix B - Glossary of Acronyms Used in the Report
BOCES Boards of Cooperative Educational Services
CDPAP Consumer Directed Personal Assistance Program
CMP Civil Money Penalty
CNA Certified Nursing Assistant
DSRP Delivery System Reform Incentive Payment
EISEP Expanded In-Home Services for the Elderly
FLSA Fair Labor Standards Act
HCBS Home and Community-Based Services
HHA Home Health Aide
LPN Licensed Practical Nurse
MLTC Managed Long-Term Care
MRT Medicaid Redesign Team
PACE Program for All-inclusive Care for the Elderly
30
PCA Personal Care Assistant
RN Registered Nurse
Appendix C: Models of Care
Several promising models of care oer opportunities to support older adults across a continuum of care needs and enable
more older New Yorkers to receive appropriate services and remain independent in their homes and communities as long as
possible. Investing in access to quality models of care that align with older adults’ preferences and reduce preventable
hospitalizations and nursing home admissions benefits individuals, their families, and ultimately reduces strain on the state’s
Medicaid budget.
The Program of All-Inclusive Care for the Elderly, or PACE, is a comprehensive care model that coordinates access to health
care, services and community supports for dual Medicare- and Medicaid- eligible older adults who may otherwise be placed
in a nursing home. While PACE programs are a less costly option than nursing home care and are proven to be eective at
providing quality care, they are not available in all parts of the state and eligibility requirements restrict access to PACE for
some older adults. S6664 (May) aims to correct that.
The Expanded In-home Services for the Elderly Program, or EISEP, administered through the New York State Oice for Aging
(NYSOFA), provides non-medical in-home services for older adults who are not eligible for Medicaid. It is far less costly than
Medicaid-funded long-term care services, provides holistic person-centered care, and does not require recipients to spend
down their assets. EISEP has a long waiting list and needs increased funding in the state budget.
New York’s network of 59 county-based Area Agencies on Aging and over 1,000 local aging services providers oers a diversi-
ty of community-based services and supports to enable older adults to age in place and avoid preventable hospitalizations or
nursing home placements. Services include home-delivered meals, medical transportation, home repairs, caregiver supports,
legal services, case management, and more. Several witnesses emphasized the value of these services in addressing older
adults’ social determinants of health, reducing food insecurity, and providing social connection and supports that address
unmet needs for older adults who have less intensive care needs. While cost-eective and popular, home-delivered meals
and other aging services have been chronically underfunded.
Kevin Muir of Riseboro and Tara Klein of United Neighborhood Houses discussed the value of “settlement houses,” or neighbor-
hood-based multi-service nonprofits that oer a continuum of culturally competent social and clinical care options for older
adults, including home care, adult literacy classes, and senior centers. This model leverages additional resources such as
eviction prevention services and meal delivery to address emergent needs in an integrated and cost-eective manner.
The federal Coronavirus Aid Relief, and Economic Security Act (CARES Act) made permanent changes to federal statute permit-
ting non-physician providers, such as physician assistants and nurse practitioners, to order home care services. While this
flexibility was permitted at the federal level, state law and regulations limited applicability of non-physician practitioners’
(NPP) ordering permissions across New York home care providers and services. This created confusion for referral sources
and perpetuated access-to-care burdens. As a result, the Department of Health proposed changes to address this longstand-
ing issue to allow NPPs to broadly order home care services in New York State. Organizations such as the Home Care Associa-
tion of New York continue to advocate for changes to the rules for practitioner orders for home care.
Katelyn Andrews (LiveOn NY) discussed the importance of ensuring older adults are stably and aordably housed, as well as
oering “light-touch” supports through a service coordinator. This may include assisting residents with accessing benefits
programs or scheduling and traveling to medical appointments.
31
Sources referenced in testimony:
Center for Health Workforce Studies (2018). “The Health Care Workforce in New York: Trends in the Supply of and Demand for
Health Workers.”
https://www.chwsny.org/wp-content/uploads/2018/04/Full_CHWS_NY_Tracking_Report-2018b-1.pdf
Community Health Care Services Foundation. Creating a Legacy of Care Mentorship Program. Creating a Legacy of Care
Mentorship Program (nyshcp.org)
Cornell Program on Applied Demographics. County Projections Explorer. https://pad.human.cornell.edu/counties/projections.
cfm
Cromer, T. et al. (2021). “Modernizing Long-Term Services and Supports and Valuing the Caregiver Workforce”, Health Aairs
https://www.healthaairs.org/do/10.1377/hblog20210409.424254/full/
Farrell, C. (2021). “How Helping America’s Caregiving Workforce Can Address Diversity, Equity, and Inclusion.” Forbes. https://
www.forbes.com/sites/nextavenue/2021/05/21/how-helping-americascaregiving-workforce-can-address-diversity-equi-
ty-and-inclusion/?sh=7c38e51d533
Gandhi, A. et al. (2021). “High Nursing Sta Turnover in Nursing Homes Oers Important Quality Information.” Health Aairs.
https://www.healthaairs.org/doi/10.1377/hltha.2020.00957
Hansen Hunter & Company (2018). “Report on Shortfalls in Medicaid Funding for Nursing Center Care.” https://www.ahcancal.
org/Reimbursement/Medicaid/Documents/2017%20Shortfall%20Methodology%20Summary.pdf
Jabola-Carolus, I. et al. (2021). “The Case for Public Investment in Higher Pay for New York State Home Care Workers: Estimated
Costs and Savings.” City University of New York.
https://slu.cuny.edu/wp-content/uploads/2021/03/The-Case-for-Public-Investment-in-Higher-Pay-for-New-York-State-H.pdf
PHI (2021). “Direct Care Workers in the United States: Key Facts.” https://phinational.org/resource/direct-care-workers-in-the-
united-states-key-facts-2/
PHI (2021). “PHI Urges New York State to Renew the Medicaid Managed Long Term Care Workforce Investment Program.”
https://phinational.org/wp-content/uploads/2021/06/Discussion-Paper-April-2021.pdf
PHI Workforce Data Center
Workforce Data Center (phinational.org)
Spanko, A. (2021). “Nursing Homes Have 94% Sta Turnover Rate — With Even Higher Churn at Low-Rated Facilities.” Skilled
Nursing News. https://skillednursingnews.com/2021/03/nursing-homes-have-94-sta-turnover-rate-with-even-higher-churn-
at-low-rated-facilities/
32
Supplemental resources
AARP (2020). “Caregiving in the U.S.”
https://www.aarp.org/content/dam/aarp/ppi/2020/05/full-report-caregiving-in-the-united-states.doi.10.26419-2Fppi.00103.001.
pdf
Association for Talent Development (2015). “What’s Happening in Healthcare Talent Development.”
https://www.td.org/insights/whats-happening-in-healthcare-talent-development
Association for Talent Development (2015). “Measuring Training Success in Healthcare.”
https://www.td.org/insights/measuring-training-success-in-healthcare
Commonwealth Fund (2021). “Placing a Higher Value on Direct Care Workers.” https://www.commonwealthfund.org/publica-
tions/2021/jul/placing-higher-value-direct-care-workers
HRSG (2018). “What’s the Dierence Between Skills and Competencies?”
https://resources.hrsg.ca/blog/what-s-the-dierence-between-skills-and-competencies
National Direct Service Workforce Core Competencies. (2014). CMS Direct Care Workers Core Competency
DSW Core Final Competency Set, Appendix E (mykapp.org)
PHI (2018). “Workplace Injuries and the Direct Care Workforce.”
http://phinational.org/wp-content/uploads/2018/04/Workplace-Injuries-and-DCW-PHI-2018.pdf
Preceden. Career Roadmap
https://www.preceden.com/roadmap/career
Regional Centers for Workforce Transformation (OPWDD)
https://www.workforcetransformation.org/
SHRM. Career Paths and Ladders
https://www.shrm.org/resourcesandtools/tools-and-samples/toolkits/pages/developingemployeecareerpathsandladders.
aspx
NOTES
NOTES
SYRACUSE DISTRICT OFFICE:
State Oice Building
333 E. Washington Street, Suite 805
Syracuse, NY 13202
Phone: (315) 478-8745
MADISON COUNTY DISTRICT OFFICE:
Cornell Cooperative Ext. of Madison Co.
100 Eaton Street
Morrisville, NY 13408
Phone: (315) 684-3331
ALBANY OFFICE:
Legislative Oice Building
198 State Street, Suite 803
Albany, NY 12247
Phone: (518) 455-2838
EMAIL: may@nysenate.gov
WEB: may.nysenate.gov
RachelMayNY
Rachel May
District 53
New York State Senator
