A new training program in North Carolina will help personal and home care aides (PHCA) move more easily between care settings during their careers.

The state established its training program with help from the federal Personal and Home Care Aide State Training (PHCAST) Demonstration Program. Six states used funds from the 3-year federal demonstration program to develop, implement and evaluate competency-based curricula and certification programs to train qualified PHCAs.

PHCAST was authorized by the Affordable Care Act (ACA) and administered by the Health Resources and Services Administration (HRSA). The LeadingAge Center for Applied Research is helping to conduct an ACA-mandated evaluation of the program

Worker Mobility 

A broad-based partner team—consisting of advocacy groups, state agencies, employer associations, community colleges and high schools—designed North Carolina’s PHCAST program to help reduce turnover rates that can be as high as 80% in some of the state’s residential care settings.

The 4-phase training program provides an integrated career lattice for PHCAs, says Jennifer Craft Morgan, the program’s lead evaluator.

“There is recognition of the permeable boundaries between health care settings,” she told an audience at the PEAK Leadership Summit. “We know that these workers move around settings and they move between nursing homes and home care and home health over a career. If we can integrate the training, then they don’t have to go back and start all over again if they want to work in another setting.” 

A 4-Phase Training Program 

The first phase of the North Carolina PHCAST program is a 16-hour training module that teaches basic job readiness skills and provides a realistic preview of a PHCA’s job.

“This was important to us because we knew that there was high turnover right after training,” says Morgan. “A lot of folks invest 120 hours in the Certified Nursing Assistant (CNA) program. Then they get out into the workforce and within a week they’re gone because they haven’t had a good preview of what that job entails and whether or not they matched that job. So now they can develop that realistic job preview and only invest 16 hours.”

The 3 additional training phases include: 

  • Phase 2: Direct Care Basics. This 60-hour training introduces the personal care tasks that a trainee would need in order to work in home care or in assisted living. It also includes soft skill development.
  • Phase 3: Nurse Aide I. North Carolina’s existing nurse-aide training was enhanced using an adult learning curricular design, says Morgan. “We rewrote the curriculum to make sure it was facilitative rather than didactic,” she says. This phase takes approximately 120 hours to complete.
  • Phase 4: Home Care Nurse Aide Specialty. North Carolina already had advanced curricula for medication technicians and geriatric aides. The PHCAST team added a 100-hour training for home care nurse aides. The training teaches clinical and soft skills.

Multiple Points of Entry

The multi-phase PHCAST program was designed to appeal to a variety of workers who are at different stages in their lives and their careers.

“Not everyone is the same when they come in the door for an education,” says Morgan. “We have got unemployed workers who are looking to see if this direct care work is a possibility for them as a second career. We have older workers. We have incumbent workers looking to upgrade their skills.”

Not all trainees will begin the program with Phase 1, says Morgan. In fact, trainees have the option to begin the PHCAST program with either phase 1, phase 2 or phase 3.

“If you want to be a CNA and you know you want to be a CNA, of course you can go right into Phase 3,” says Morgan.

Trainees cannot enter Phase 4 without completing Phase 3, however. That’s because Phase 4 is an add-on to the nurse aide training. 

Working with High Schools and Community Colleges

Twelve community colleges and 5 high schools helped North Carolina pilot its PHCAST program. The state’s community colleges have already embedded the first 2 phases of the program—the job readiness phase and the Direct Care Basics training phase—into their course offerings.

Embedding the program at community colleges “allows us to take advantage of the tuition waivers offered to the unemployed and underemployed workers,” says Morgan. “So we have a sustainable way of paying for most of that training if the workers qualify. Unemployed workers enter through those portals and are able to find out if they want to do direct care work.”

Early Outcomes: Three Months After Training

The PHCAST training appears to spur participants to pursue new jobs and additional training. Three months after the training concluded: 

  • 56.3% of the trainees had enrolled or planned to enroll in a training program that would increase their job skills.
  • 48.2% had enrolled or planned to enroll in an education program that would lead to a college degree.
  • 45.9% had enrolled or planned to enroll in another health care occupation training program.
  • 37.9% had applied or planned to apply for a new direct care job. Morgan pointed out that this figure does not include the many trainees who were already working in the field and planned to stay in their current job.

A new training program in North Carolina will help personal and home care aides (PHCA) move more easily between care settings during their careers.

Members Only: 

The fall 2013 edition of HUD's Evidence Matters (a journal put out by the U.S. Department of Housing and Urban Development (HUD) Office of Policy Development and Research) hits close to home for many families as they or their relatives age and consider their evolving needs.  Although aging in place was once the norm in U.S. society, modern land use trends and housing stock design make this goal increasingly difficult to achieve today.

The issue introduces the demographic trends and preferences of seniors to age safely and comfortably in the homes and communities of their choice. It outlines several of the strategies that seniors, local officials, and policymakers are pursuing to promote aging in place, with special attention to community-centered efforts in Atlanta, San Diego, and Newton, Massachusetts. 

The issue also surveys research efforts to measure the cost, health, and wellness benefits of aging in place.  

This edition highlights research underway  in conjunction with LeadingAge's Center for Applied Research, and models of achieving aging in place in non-subsidized settings as well.

The feature article, "Aging in Place: Facilitating Choice and Independence," reviews the trends underpinning the issue and looks at the federal, state, and local programs and policies for the elderly that are accommodating a shift away from institutional living and toward aging in place with supports.

The Research Spotlight article, "Measuring the Costs and Savings of Aging in Place," examines efforts to measure the potential health cost savings (as well as

improvements in well-being) to families and the government when individuals are able to age in their homes with assistance, reinforcing the argument that housing matters.

Finally, grassroots efforts to aid the elderly in their communities and provide practical solutions for the supportive services necessary to age in place are examined in the In Practice article, "Community-Centered Solutions for Aging at Home." 

Key Findings

  • Economic and demographic shifts are creating a rising need for affordable, age-appropriate housing options for seniors wishing to remain in their homes and communities as they age.
  • Homes can be modified, communities can be adapted, and seniors can be better connected to supports and services to facilitate aging in place.
  • Naturally Occurring Retirement Community Supportive Services Programs and Villages have shown promise in helping seniors remain in their homes with a high degree of independence and social engagement.
  • Research suggests that aging in place initiatives may yield cost savings to families, governments, and health systems as well as health, emotional, and social benefits to aging seniors and the broader community.

In this Issue:  

HUD held a briefing January 9, 2013 (Visions for Aging in Place: Challenges for the Future) with panelists including Alisha Sanders from the LeadingAge Center for Housing Plus Services to discuss elements of this report. Presentations were quick and informative. 

The webcast should be available shortly in the HUD webcast archives.



This edition highlights research underway in conjunction with LeadingAge's Center on Applied Research, and models of achieving aging in place in non-subsidized settings as well.

Members Only: 

Before the call, the members knew that they were all attempting to bring supportive services into affordable senior housing communities. They also were aware that each had received $25,000 from the LeadingAge Innovations Fund, which received a matching contribution from the NewCourtland Foundation, to support those initiatives.

But during the call, which was facilitated by the LeadingAge Center for Housing Plus Services, the grantees were surprised by how many common experiences they shared, in spite of the fact that their individual projects are so varied. Now, they are anxious to learn as much as they can from one another’s successes and challenges.

“We wanted to make all the grantees aware of each other’s projects,” says Alisha Sanders, manager of the Center for Housing Plus Services. “We hope that when they are struggling with common issues or hitting common barriers, they can serve as a resource to one another.”

Innovations Fund Grantees

The 4 Innovations Fund grantees were profiled recently in LeadingAge magazine:

  • Jewish Association on Aging (JAA) in Pittsburgh, PA is implementing a HomeMeds program through which a nurse and social worker use Internet-based software to catalog the medications of housing residents and flag issues that need attention from the residents’ physicians. 
  • Jewish Community Housing for the Elderly (JCHE) in Brighton, MA is working with the Alzheimer’s Association to train its housing staff in habilitation therapy. The therapy is designed to help older adults who are experiencing cognitive decline. 
  • Sayre Christian Village in Lexington, KY opened a primary care health clinic in one of its largest independent living communities. A part-time staff person serves as a liaison between clinic staff and housing residents.
  • Francis E. Parker Memorial Home in Piscataway, NJ is launching a social adult day program at 5 independent housing properties within a 5-10 miles radius of the home. 

Common Issues and Experiences

Research, partnerships, diversity and resident engagement were among the areas that grantees found they had in common.

Research: Several of the grantees are depending on research to ensure and measure their success. For example, JAA selected its HomeMeds software after reviewing evidence that the tool helps to reduce medication-related medical issues that can lead to hospitalization, falls and confusion. 

Parker will be looking at its measures of success when seeking charitable funding to sustain the social day program after the pilot ends. And JCHE has already arranged to have researchers at the University of Massachusetts Boston Gerontology Institute conduct a process evaluation to determine the effectiveness of its dementia training program.

“Habitation therapy has been used in nursing homes and in assisted living but it has not been used in an independent housing setting,” says Caren Silverlieb, director of strategic planning and partnerships at JCHE. “We will be testing how successfully this therapy can be applied in this setting so it can be replicated in other independent housing settings.”

Partnerships: All the grantees are working with community partners to help them implement their Housing Plus Services initiatives. JCHE is offering its dementia training program in collaboration with the Alzheimer’s Association. JAA will begin implementing its HomeMeds program in a 200-unit housing community where it already delivers home health services. 

Sayre Christian Village could never have launched its health clinic without the help of a large primary care practice. Service Coordinator Charlotte Potter attributes the success of that program to the willingness of medical partners to honor residents’ loyalty to their own primary care physicians.

“We started out and are still accepting episodic visits,” says Potter. “Anybody who has a cold or needs a Vitamin B-12 shot can come into the clinic and get that taken care of. Our clinic staff will transfer that information to their primary care physician.”

Diversity: Two grantees have found it challenging to deliver services in buildings with diverse resident populations. Just under half of the 1,500 residents living in JCHE’s 6 housing properties speak Russian while 22% speak Mandarin or Cantonese. Similarly, Francis E. Parker Memorial’s social day programs will serve a high concentration of older adults from Russia, China and Korea.

Finding qualified individuals to run these programs has been a tall order for both organizations. After much searching, JCHE found a Russian bilingual service coordinator who has dementia training and the skills to train other staff members. Parker found more candidates for its program coordinator position after changing that position from a temporary to a permanent staff slot.

“At first, we were being very cautious and referring to it as a temporary position until we could see how successful we are,” says Gloria Zayanskosky, Parker’s quality and operational excellence officer. “But we decided that it was not realistic to ask someone to sign on for a temporary position. We believe in our hearts that the program is going to be extremely successful.”

Resident engagement: Housing residents have shown universal support and enthusiasm for all the Innovations Fund-supported programs. For example, the clinic at Sayre Christian Village has become so popular during the past year that the physicians group recently doubled its on-site hours. And local housing residents are already clamoring to participate in JAA’s HomeMeds program.

“We met with residents and families a few weeks ago,” reports Mary Anne Foley, executive director for hospice and home health programs at JAA. “They were truly delighted when they heard that this program is free, that a nurse will be providing community outreach, and that this will all be done under the supervision of their physicians. We walked out of there with a long list of people who wanted to be first.”



An informal conference call on a recent Friday afternoon convinced representatives of 4 LeadingAge member organizations just how much they had in common.

Members Only: 

The Center for Applied Research is partnering as a subcontractor to the Lewin Group to provide technical assistance to states and other organizations seeking to improve the recruitment and retention of individuals who provide support services for people with disabilities. 

The National Direct Service Workforce Resource Center was created to respond to the large and growing shortage of direct service workers. The resource center offers:

  • An online searchable database.
  • Access to information from a team of direct service workforce policy professionals.
  • Technical assistance for selected State Medicaid Agencies awarded through an annual application process.   

The project was funded by the Center for Medicare and Medicaid Services.


Center for Applied Research provides technical assistance to states and other organizations seeking to improve the recruitment and retention of individuals who provide support services for people with disabilities.

Members Only: 

The 2007 National Home Health Aide Survey is the first national probability survey of home health aides. 

LeadingAge Center for Applied Research, in partnership with Social and Scientific Systems, Inc. (SSS), will be conducting analyses using this survey to provide technical assistance and policy analysis to the Office of the Assistant Secretary for Planning and Evaluation (ASPE). 

The goals of the analyses are to describe workforce characteristics and to evaluate the interrelationships among workforce characteristics, job quality, and other worker and facility characteristics and quality of care. 

The goal of analyses underpinning the "Workforce Characteristics" report is to understand the supply of workers by demand, geographic location, policy variation, agency characteristics, and recruitment strategies.

The team will prepare reports and manuscripts with results from these analyses.

This project is funded by ASPE and the Center is a subcontractor to SSS.



LeadingAge Center for Applied Research, in partnership with Social and Scientific Systems, Inc. (SSS), will be conducting analyses using the 2007 National Home Health Aide survey to provide technical assistance and policy analysis to the Office of the Assistant Secretary for Planning and Evaluation (ASPE). This project is funded by ASPE and the center is a subcontractor to SSS.

Members Only: 

Better Jobs Better Care (BJBC) was a $15.5 million research and demonstration program funded by the Robert Wood Johnson Foundation and Atlantic Philanthropies from 2003-2008. 

BJBC was designed to bring about changes in long-term care policy and practice that help reduce high vacancy and turnover rates among direct care staff across the spectrum of long-term care settings and improve workforce quality. 

The BJBC program funded grants for state demonstration and applied research and evaluation projects. As a result of the initiative, a number of resources were developed to help providers build a quality workforce. These resources, available to all providers, highlight the findings and lessons learned from the BJBC program and provide tools to reduce worker instability and improve the workforce.


A Crisis with a Solution: Tools and Resources for Transforming the Long-Term Care Workforce
Catalogue features descriptions of the tools and resources developed and tested by the BJBC research and demonstration grantees. These tools, used to reduce direct care worker turnover and build a quality workforce, are now available to all providers.

Better Jobs Better Care: New Research on the Long-Term Care Workforce July 2008
Report outlining key BJBC research findings and what they mean to providers.

Gerontologist Special Issue of BJBC
Special Issue of The Gerontologist encapsulates BJBC's research findings and includes Pennsylvania State University's evaluation of the demonstration projects. The articles cover the organizational and management interventions that attracted and kept direct care workers on the job. Available for purchase from Gerontologist Special Issue of BJBC.

FutureAge March/April 2007
The March/April issue of FutureAge magazine is dedicated to the Better Jobs Better Care findings. Each article illustrates the work BJBC has done to support changes in long-term care policy and provider practice that help improve frontline worker retention.

Better Jobs Better Care Issue Briefs

Contact Natasha Bryant about this project.


The recently completed research and demonstration program was designed to bring about changes in long-term care policy and practice that help reduce high vacancy and turnover rates among direct care staff across the spectrum of long-term care settings and improve workforce quality. The goal of the program was to improve recruitment and retention of direct care workers.

Members Only: 
Subscribe to CFAR