Nursing Aides, Home Health Aides, and Related Health Care Occupations -- National and Local Workforce Shortages and Associated Data Needs

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Chapter 1. Project Overview | Chapter 2. Paraprofessional Workforce Supply and Demand | Chapter 3. Important Data Issues | Chapter 4. Existing National Data Sources | Chapter 5. State-Level Data Issues | Chapter 6. Occupation and Industry Classification Systems | Chapter 7. Current Data Collection Practice: CNA Registries | Chapter 8. Conclusions | Appendix A. Project Advisory Committee | Appendix B. Proposed State Data Collection Instrument | Appendix C. Occupational and Industry Definitions | Appendix D. Sample Data | Appendix E. Issues from Four States | Appendix F. CNA Registry Details | Appendix G. Annotated Bibliography | Appendix H. References

Chapter 7. Current Data Collection Practice: CNA Registries

This chapter describes the CNA registries and includes the following sections:

• Introduction
• Characteristics of Registries
• Key Findings
• Best Practices
• Conclusions

Introduction
OBRA 87 mandated the training and registration of nurse aides working in nursing homes and the training of home health aides working for certified home care agencies as a condition for reimbursement under Medicare. As a result, all states and the District of Columbia register nurse aides who are eligible to work in nursing homes. Collectively, these registries represent the only source of names and data on CNAs across the country. For this reason, this study comprehensively assessed them to determine whether or not they contain data that would be helpful to policymakers and planners and whether or not they are a potential source for a national database on the direct care paraprofessional workforce. The assessment included a review of the structure, function, content, and operation of the registries from forty-five states and the District of Columbia.

The registries’ primary purpose is to help nursing homes ensure that they hire only individuals who have completed an approved training program that meets Federal requirements. Before hiring a CNA, a nursing home must check with the registry to confirm that the individual has completed the required training.

The assessment found that many states have expanded their registries beyond the original Federal mandate to include additional paraprofessionals and, in some cases, additional information on each person in the database. A few states have even been able to use the data in their registries to inform policymaking and planning activities. While this variation would make it difficult simply to aggregate all of the registries into a single national database, it also provides a variety of models for developing a state-based direct care paraprofessional database.

Since the majority of direct care paraprofessionals do not work in nursing homes, many are not regulated in any systematic way, and many do not have any formal training, the expansion of the registries to include aides and other similar workers in settings other than nursing homes would offer additional protections to patients. They could also provide a valuable source of data on all direct care paraprofessionals.

Clearly, policymakers and the public would like to know more about this workforce in order to provide additional safeguards to protect the vulnerable populations whom they serve. While the primary goal of the registries is administrative not for planning, it would be relatively easy and cost effective to design the nurse aide registries to feed into a comprehensive database on the paraprofessional workforce.

Characteristics of Registries
The comprehensive assessment of the State registries focused on:

• Structural characteristics
• Information in the registries
• Use of the registries
• Access to the registries
• Funding for the registries
• Future plans for the registries

The following is a summary of the assessment’s findings. Appendix F offers additional detail on a state-by-state basis.

Structural Characteristics
In most states, registries are operated and administered by agencies and departments of State government. In seven states and the District of Columbia, operation of the registries is outsourced to a private for-profit corporation that manages the technical aspects of registration while maintaining an interface with the State agency responsible for oversight.

Some states have established multiple registries within a variety of State agencies, depending on the type of worker. For instance, nurse aides are in one registry while medication aides are in another.

Information in the Registries
The information in the registries varies from State to State. It can include birth date, gender, race, training and certification information, employer information, and criminal background indicators or legal judgment information. Some registries include comprehensive demographic information; others contain only enough information to permit basic registrant identification. Table 7-1 presents the scope of the occupations and data included in each state’s registry.

Worker types vary considerably across states. In some states, nurse aide is an exclusive category; in others it is inclusive. In one state, a nurse aide may be defined as simply a certified paraprofessional direct care worker who is employed in a skilled nursing setting. In another, a nurse aide may be defined as any direct care worker who performs health care tasks as delegated by a licensed or registered nurse in any setting where health services are provided.

Per OBRA 87 mandate, all registries include information about certified, licensed, or registered nurse aides working in skilled nursing facilities. However, some State registries have expanded registration to include a variety of other direct care paraprofessionals including medication aides, home health aides, and developmental disability aides.

This variation is a source of concern when attempting to aggregate data from registries or compare the workforce across states. The variation in who is included in each registry makes it difficult to use existing registry data to measure and compare the supply of workers, the demographic characteristics of the workforce, the settings in which they are providing services, and the training and certification requirements across states.

Another concern is that many registries only update information on a biennial basis, and others do not purge their systems at all. In some states, databases include information about all nurse aides registered since the establishment of the registry. Other states update information as frequently as yearly.

Some states efficiently tie registration to employment so that when a nurse aide leaves an employer, it is noted in the registry. This makes counts of nurse aides who are active in the workforce possible.

Use of the Registries
There is also significant variation in how the states use their registries. The registries’ primary function is to track individuals’ eligibility to work as nurse aides. Eligibility includes, at a minimum, completion of the required training. It also generally includes information regarding misconduct as an aide.

Many states use their registries as a clearinghouse for background checks. Some registries are actively involved in performing criminal background checks. Others only note the findings of other State agencies in the registry records.

In a few states, registries are functioning as data sources for long-term care planning. Some states have mandated in law the collection of data about the long-term care workforce.

Access to the Registries
Although registries contain “public” information, how public is defined differs across states. Public access to the information may be limited. Some registries contain sensitive information about criminal backgrounds. Some states consider the private nature of the information and feel the need to disseminate it only to those who require it for protection of their constituents. Some states require formal authorization to use their registries, while others make registry background information available only to those who pay a fee. Yet, other states permit universal access to information, though access may require a social security number or a certification number. However, access to some states’ registries is possible simply by providing the name of the paraprofessional who is being checked.

Table 7-1. Type of Worker and Information in State Registries

* Home Health Aides with documented findings of abuse are included in Kentucky CNA Registry.
** Unlicensed direct care providers with substantiated findings of abuse are included in the Massachusetts CNA Registry.
*** Missouri and Nebraska maintain separate medication aide registries.
**** North Carolina maintains a Health Care Personnel Registry which lists all aides with allegations or findings of abue.
***** Rhode Island lists all aides in healthcare facilities.
****** Texas maintains a separate abuse registry for direct care staff working in long term care facilities.

The information is available through diverse media, and content may be limited depending on how it is accessed. Some states provide information by telephone, some by Internet, and some by written request. Limited information may be available on-line, with expanded information available only through personal contact with registry personnel. For instance, an Internet inquiry might reveal that a particular worker has been disqualified for employment. However, further direct inquiry by telephone would be necessary to ascertain the details of that disqualification.

Funding for the Registries
All registries receive funding through a memorandum of agreement between the Federal government (CMS) and the appropriate State agency. Federal regulation limits the fees that registries can collect from nurse aides. However, many registries with expanded functions generate revenue from registration of those other than the federally mandated workers.

This study’s assessment revealed that, due to budget restrictions, many registries are limited by a lack of resources for new or expanded technology that could improve registry data, data availability, and functionality. Providers suggest that reimbursement methodologies prevent them from assuming costs of registries. The registered workers, who are paid at or near minimum wage, are unable to assume higher registration costs.

Future Plans for the Registries
Many states are interested in creating a more comprehensive means of tracking the paraprofessional workforce and are considering expanding existing registries. Much of this is prompted by emerging concerns for accurate information about the background of workers who care for vulnerable populations. Additionally, some states are anticipating statewide long-term care planning that will require data from registries to support their understanding of the workforce.

Key Findings
Key findings were as follows:

• Nurse aide registries collect data on certified nurse aides in every state.
• There are great variations in the structure and content of registries across states.
• With some limited modifications, nurse aide registries could be an excellent source of data on the paraprofessional workforce. Key modifications that would increase the usefulness of the registries include:
  • More consistent, core data elements
  • Greater consistency in the types and definitions of workers included in the registries
  • Regular updates of the files on current activities
  • Maintenance of some historical data for active and inactive paraprofessionals
• Several states have registries that collect data on all direct care paraprofessionals in a manner that protects patients, assists providers, and contains valuable data for planning and policymaking. These states could be models for other states.

Best Practices
The comprehensive assessment of the State registries revealed several states with registries that protect patients, assist providers, and obtain valuable data that contribute to effective policies and programs for the direct care workforce.

Kansas’ registry is a good example of a registry that meets regulatory needs and provides data for planning and policymaking. It includes information regarding all direct care paraprofessionals in facilities and organizations that provide health services. Per State requirement, all in-State health care employers must register their workers by a specific date each year. This allows annual background checks on all workers regardless of direct care provision. It also provides an accurate snapshot of the types of workers in health care settings since registration is linked to job codes. Kansas has also invested in new technology that permits an efficient interface between various State agencies, which has resulted in more efficient dissemination of appropriate workforce information to registry users.

Conclusions
This study’s assessment of the registries suggests that they are an important potential resource upon which to build future data collection efforts. They provide an existing structure that, with expanded and more uniform data collection, could meet the data needs of local users, State regulators, and policymakers at all levels.
Establishing consistent criteria and core data elements would facilitate creating a national database that houses worker training and background information. Such a database would:

• Permit paraprofessionals to move across states more easily.
• Speed entry of experienced workers into the delivery system through certification by endorsement.
• Allow states to access comprehensive background information about abuse, inappropriate behavior, or any legal judgments on file.

Presently, many providers are limited to state-specific information, which technically allows a disqualified worker to move across State lines and obtain work in another jurisdiction. The great variation that now exists across states also makes cross-State comparisons inappropriate.

Developing more uniform and functional registries may evolve through the implementation of the Health Insurance Portability and Accountability Act (HIPAA) legislation that requires State enumerators to register health care providers and issue national provider identifiers. Although the HIPAA legislation’s primary goal is to provide a consistent single identifier to those seeking or providing payment for health services, establishing a registry mechanism is critical to achieving its objective. Although their initial focus will be on meeting HIPAA standards, future planners should consider the HIPAA enumerators potential as registries for the paraprofessional workforce. They would provide a consistent platform for implementation of our recommendations.