Direct care workers and the strength of their relationships with the individuals they support are the key to both the quality of caregiving services and the quality of life for millions of Americans. Yet, employers sometimes perceive these staff members—who provide the majority of hands-on care—as unskilled laborers who can be easily replaced.

Some long term care providers are taking a different approach to employing and supporting their direct care staff. PHI, with funding from the Hitachi Foundation, issued a series of case studies profiling eight providers that are investing time, money, and other resources to improve the quality of direct-care jobs.

Each of these employers believed they could get better value from their frontline staff by improving the quality of their jobs, and each has experienced significant and measurable benefits because of their investments in these workers.

The PHI case studies found that employers are creating quality jobs by investing in three crucial areas: compensation, opportunity, and support. That is, they are making an effort to provide their direct-care staff with competitive wages and benefits, opportunities for training and career advancement, and better-quality supervision.

All the organizations profiled in PHI’s series of case studies exhibited a clear dedication to their direct-care staff, finding innovative ways to build staff loyalty and improve quality of care. One of those organizations, Benchmark Senior Living, a for-profit company that develops and manages dozens of assisted living facilities throughout New England, has developed a unique way to provide extra compensation to exemplary employees.

Through Benchmark’s Culture Compensation program, all of the company’s frontline staff can earn cash awards for performing acts that embody the company’s values and culture. Caregivers are rewarded with bonuses of $10 to $100 if a manager or department head spots them performing an action deemed to be above and beyond their job description.

The company also distributes monthly and yearly prizes of $100 and $500, respectively, to truly exceptional caregivers.

Benchmark has also supported its frontline caregivers through the One Company Fund, a separate nonprofit organization it spun off to celebrate the company’s 10th anniversary. The fund provides employees with need-based grants of up to $5,000 to cover the costs of unforeseen circumstances, such as a health emergency, a fire, or a death in the family. In 2009 and 2010 alone, the One Company Fund distributed more than $175,000 in grants to Benchmark caregivers—many to staff of Haitian descent who were directly affected by the devastating 2010 earthquake there. The fund “has been an enormously positive thing for the people affected, and also for the morale of everybody, because they know they work for a company that really cares,” said Benchmark founder and Chief Executive Officer Tom Grape.

Meanwhile, the Green House Project has restructured staffing in ways that empower direct-care workers, giving them much greater responsibility than in a typical nursing home. All Green House homes are managed by self-directed teams of direct care staff (called Shahbazim).

Nurses and other professional staff come to the home to provide services to residents, but day-to-day decisions regarding daily routines, meals, activities, and so on are made by residents and the Shahbazim who support them.

As a result, direct-care staff feel that they are truly valued, and teamwork is improved, resulting in greater satisfaction on the part of both workers and residents.

Other long term care facilities profiled by PHI provide their frontline caregivers organizational advancement opportunities via career ladders. Ararat Nursing Facility in Los Angeles, for example, maintains a five-tier ladder that allows certified nurse assistants (CNAs) to ascend to management positions. Employees secure a 50-cent wage increase for each rung on the career ladder they achieve.

Overall, the ladder has motivated Ararat’s employees to strive for better things, says Margo Babikian, Ararat’s executive director.

The career ladder tells CNAs that “if you have the ambition, if you want to grow, yes, there is an opportunity for you,” Babikian says.

One company profiled by PHI, a Philadelphia-area nonprofit that provides nursing home care, community services, and affordable housing to seniors, launched its Ladder of Opportunity in 1999 as a way of attracting and retaining quality employees. By completing a free seven-week training, CNAs can become CNA Specialists, assuming additional care and administrative responsibilities. CNA Specialists also receive a $1 increase to their hourly wage.

While training opportunities for frontline caregivers constitute an essential and obvious component of quality direct-care jobs, training programs that provide supervisors with the skills they need to support direct-care staff are equally important.

Several of the case studies showcase the PHI Coaching Approach to Supervision, skills-based training that focuses on strengthening supervisory relationships and diminishing the need to constantly “put out fires.”

In 2008, administrators at Orchard Cove, a continuing care retirement community in Canton, Mass., trained approximately 50 of its supervisors in the Coaching Approach to Supervision.

The supervisors were taught such skills as active listening, self-management, clear communication, and collaborative problem solving.

The results of the training were extremely positive, with CNAs throughout the facility reporting that they felt closer to—and better supported by—their supervisors. After the coaching training, Stare Guerrier, a CNA, said she began to see a shift in supervisors’ behavior. “They see what’s going on, and they try to help us do our jobs better,” says Guerrier.

Other organizations profiled by PHI have used peer-mentoring programs to support direct-care staff. These programs provide both better support for new employees and a professional growth opportunity for senior assistants.

At Edgewood Centre in Portsmouth, N.H., just-hired workers are shadowed and guided by a mentor for the first five to 10 days of their employment. These peer mentors are nurse assistants who have been trained in communication and problem-solving skills and receive a wage increase for their upgraded title.

Of course, a commitment to support, compensation, and opportunity means most to employers when it produces measureable improvements. PHI’s case-study series demonstrates that all of the organizations profiled have, in fact, experienced tangible, positive outcomes.

For example, Benchmark’s turnover rate is far lower than most comparable long term care organizations, averaging between 37 to 39 percent per year in a field in which an annual 100 percent turnover rate is not uncommon.

In addition to higher retention and lower turnover rates, employers who invested in their workforce also demonstrated significant improvements to their quality of care. Orchard Cove residents displayed marked improvements in several quality-of-care indicators, including decreases in falls, pressure ulcers, urinary tract infections, anxiety, depression, and reliance on nine or more medications.

Many organizations also demonstrated higher satisfaction rates for both staff and residents. At Ararat, resident and family satisfaction hovers between 98 and 100 percent year to year, while staff satisfaction consistently ranks high—around 95 percent in annual surveys.

Ultimately, organizations that make the most creative and unwavering investments in their direct-care staff are likely to see the best results in terms of the quality of care provided and the staff loyalty engendered.

“They’ve invested money in us to see us become better,” says Guerrier. “We don’t feel like we are only here to do a job. We are important, too.”