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Photo: Guntar Kravis

In early June, Metcalf invited Jodi Sturgeon to join our 2018 Toronto Sector Skills Academy as a guest faculty member. Jodi is President of PHI, America’s leading authority on the direct care workforce. In the United States, direct care workers, home care aides, and certified nursing assistants perform a role similar to personal support workers in Canada.

Based on her experience at PHI, Jodi presented a unique case study to Toronto Sector Skills Academy (TSSA) members on how to improve employment opportunities for marginalized workers and elevate standards across an entire industry. Her insights are valuable both for professionals in the workforce development sector and also for all of us dealing with the implications of North America’s aging population. In the U.S., 10,000 people turn 65 daily and the number of people living past the age of 85 is expected to triple over the next 10 years. In Ontario, currently 16.4% of our population is over the age of 64. By 2041, that percentage is expected to double to almost one third of the Ontario’s population or 4.6 million seniors. The direct care field is rapidly growing and is projected to add more jobs than any other single occupation in the United States. At the same time, because working conditions are difficult and the pay is low, there is a chronic shortage of trained staff.

PHI is a remarkable organization. Not only has it had success in moving individuals out of poverty through its training programs, it has improved standards of care and achieved reforms in health care and labour policy through its research and advocacy, including contributing to the Affordable Care Act. It is active across the U.S. and has provided service to some 400,000 long-term facility care staff, direct care workers, and clients.

PHI, short for Paraprofessional Healthcare Institute, works with a variety of long-term care facilities, including nursing facilities, nursing homes, assisted living spaces, and private homes. Training of direct care workers is provided either in its own classrooms or in consultation with existing home care providers. Through its close partnership with Cooperative Home Care Associates (CHCA), a worker-owned home care agency in the Bronx, PHI is able to leverage its on-the-ground understanding of the realities of home care delivery to improve its curriculum and policy work.

PHI’s training focuses on moving some of the most marginalized workers out of poverty. Prior to entering direct care training programs, most applicants have been living well below the poverty line. They are overwhelmingly female and very often immigrants, with English as a second language. On average, they are around 38 years old, possess limited formal education, and rely on public benefits to make ends meet. Many have childcare responsibilities as well.

In our wide-ranging conversation with Jodi, she began by talking about how providing opportunity is integral to PHI’s organizational culture.

Metcalf: PHI is focused on moving people out of poverty by building sustainable careers for them. What does this look like on an individual level?

Jodi: Many women who start with us are living on $5,000 a year. After they complete their four-week training to become direct care workers, they can earn an annual income of $13,800 USD. This increase in earnings has a huge impact not just on the worker but also on her family. One woman talked about how consistently working full time affected her kids. Their behaviour got better. Their schoolwork got better. They started to talk about their aspirations in a way that they never had before. It’s an incredibly powerful story. And you begin to think about the number of people that we impact directly – what it means exponentially given their families.

Metcalf: Is creating an aspirational culture key to the success of PHI?

Jodi: Yes. We learned early on that in order to maintain the job satisfaction of direct care workers, we needed to provide the opportunity for advancement. And this meant creating it within our own organization – leaving the labour market to go to college to become a nurse is not something everyone has the time or resources to do. So we looked at our training and asked: how can we modify this to allow people to move up the career ladder? This led to the creation of a variety of different roles, from receptionist, to senior aide, a position which has a salary of around $28,000 a year. With each level comes new and different responsibilities and higher salaries.

When we did this, we discovered that it isn’t only the money that is important to transforming the lives of these women. For example, we had a home care worker who advanced into an administrative role. When the senior aide program got rolled out, she witnessed how the clinical staff listened to senior aides, how they were respected, how what they thought mattered. This inspired the receptionist – who was going to stay as a receptionist – to ask us, “Can I become a senior aide?” Now, that doesn’t sound like a big story. But being as disenfranchised as this workforce is can affect confidence, and a trainee may not feel like they could or want to do a higher-level role until they see it in action.

Metcalf: The fact that they’re listened to. That’s huge for people.

Jodi: I would say that the biggest impact for these women that we train and who move up the ranks is that people actually start listening to them. They have made life-changing decisions based on the feeling of confidence that being listened to has given them, along with the financial security. Their lives have significantly improved.

Metcalf: Through your work at PHI, you’ve been able to shine a light on a sector, a group of workers, that is almost entirely ignored by the media.

Jodi: They are absolutely invisible and to the extent that anybody reports on them, they are often blamed for problems in the healthcare system. We have incredibly successful direct care workers who love their work despite the challenges. If you were to sit down with a group of direct care workers, you would hear largely very positive things. They love what they do. Their work matters to them.

Metcalf: You mentioned that the workers face challenges. What are they?

Jodi: Direct care work is a very low-wage job and very rarely has fringe benefits. It is largely a part-time workforce – in this industry 30 hours a week is considered full time. And it often has very inconsistent hours; workers don’t have the same schedule every week. Workers are isolated in homes and lack the support of, say, an onsite supervisor when they need help.

Metcalf: I would imagine that workers also face conditions, which because of the medical conditions of their patients, such as dementia, are violent or abusive?

Jodi: I think that is absolutely true. The prevalence of things like dementia have made what was one of the most dangerous jobs in the country an even more dangerous job. As a result, we at PHI are highly focused on addressing the fact that folks are sicker and that direct care workers have to manage patients with these types of chronic conditions. The severity of what workers in the home are facing in terms of disease and illness has dramatically increased. This situation requires ever-increasing skills and knowledge on the part of the care workers.

Metcalf: The scenarios that you have outlined are systemic. How does PHI work to improve standards across the board or “raise the floor”?

Jodi: We do this in several different ways. We improve training, recruit the right people, and advocate for standards that are sustainable. And by sustainable I mean both regulated and reimbursed. And that’s one piece. But if you were to talk to a home care worker about why they would leave their job, most of the time wages wouldn’t be the first thing that they say. Usually, what they talk about is that they don’t feel confident or prepared to deal with what they see in the home. Or they don’t feel like they have anyone to support them. So at PHI, the importance of creating curriculum and training programs and working with provider organizations around their systems is one aspect of our work, but that alone would not be as impactful if we didn’t also work to impact policy, research, and advocacy.

Metcalf: What kind of advocacy does PHI undertake?

Jodi: We advocated for the federal government to change the federal laws around home care. We worked with other nonprofit groups on everything from minimum wage to overtime protections to family leave to increased benefits. We also contributed to the Affordable Care Act, for example. We believe that it is important to look at all the policy levers available to improve job quality measures, while at the same time focusing on improving the existing day-to-day job quality of the practitioner on the ground.

Metcalf: So PHI provides and consults on training and works on policy. And you also have a social enterprise component with your sister agency Cooperative Home Care Associates, which is very active in ensuring good job quality.

Jodi: Cooperative Home Care Associates is a worker-owned home care agency. This is part of our strategy: we use our existing enterprise at CHCA as a learning lab to test and create best practices in home care training and employment that we then disseminate to other employers.

Metcalf: And with an aging population, you are going to see an increased need for your services.

Jodi: Oh it’s absolutely a growth industry. The population is aging and there’s a shortage of workers. It’s a significant challenge and it will happen in Canada as well.

Metcalf: Is there a shortage of workers because you can’t train people fast enough?

Jodi: It used to be that if there was a challenge finding workers, it was in large part because of the job quality. Still, there were enough workers in the system writ large. Now unemployment is low and so the competition for labour is high. People are making different choices and if they can go into a job that pays the same, why would they do a harder job? So along with our focus on improving working conditions, we recently launched the #60caregiverissues campaign, which among the issues it tackles looks at attracting nontraditional workers to this field. We’ve begun to think about who else could and should be doing this job. Like older workers. Working keeps an older person engaged as well as giving them an income and benefits.

Metcalf: It must be incredibly rewarding to work with a group of people whose lives change so dramatically.

Jodi: My favourite part of my work is when I actually get to be with folks who are being impacted by PHI. There’s nothing more energizing. And it’s not just the short-term impacts. The long-term impacts are incredible. It moves through families, across generations.

Metcalf: What would you say to anyone contemplating a career in workforce development?

Jodi: Every day I get to be a part of positive change. The work PHI does lifts people out of poverty and it has an impact in the community as well. You can see it in a neighborhood like the South Bronx where our office is. Workers are now economically contributing to the community, where they weren’t able to before. So you can measure both the trajectory for the worker and the impact of the worker investing in her own community, buying food and other things. Knowing we are also building better individual patient care, helping people find ladders out of poverty, and strengthening the local economy, is incredibly rewarding.

To address the growing interest and need for sector-focused workforce development in Toronto, in 2016 the Metcalf Foundation established the Toronto Sector Skills Academy in partnership with the highly regarded Aspen Institute. This leadership program is the first of its kind in Canada. Participants in the Toronto Sector Skills Academy become Aspen Economic Opportunity Fellows and work with peers from a variety of organizations. Fellows attend three retreats and three workshops over a 10-month period. Led by experts drawn from across North America, participants engage in experiential learning with practical applications, acquiring new skills to explore and enable innovative workforce strategies. Partnerships are strengthened and networks broadened. You can find out more about the TSSA here.

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