Direct Care Workers Pathways Program : A Strategy for Seamless Academic Progression

Nationally, there is a great demand for systems that meet the needs of local employers as well as develop tools and training for their incumbent workers. Concurrently, demand for healthcare professionals is growing and projected to continue for the next decade. Worcester State University created the “Direct Care Workforce Development Program” to offer a pathway for nontraditional-aged students in direct care positions to advance to higher-level jobs with family sustaining wages. Direct care workers (DCWs) (e.g., patient care assistant) encounter challenges in a quest to continue their education. They may be non-native speakers, lack a foundation in basic numeracy skills, or lack experience with technology. Therefore, DCWs require many support services for success in professional health-studies programs. In response, a partnership emerged between an urban medical center, state university, and labor union to provide academic pathways for DCWs to progress in careers through higher education. Two cohorts of DCWs from the medical center enrolled in the program, which provided courses totaling nine college credits. Career maps, containing action steps towards goals, and individual coaching helped DCWs define their aspirations. Many workers who completed the program matriculated into two and four-year professional programs, while others plan to do so in the future.


Introduction
Nationally, the demand for direct care workers is growing rapidly.Experts expect this growth to continue for the next decade at a much faster rate than other professions (The Lewin Group, 2008;Occupational Outlook Handbook, 2017).Direct care jobs, for the purposes of this paper, are defined as certified nurse assistants, medical assistants, homemakers, personal care and home health aides, and Licensed Practical Nurses.These jobs represent the front line of health care delivery in communities and offer entry-level access points to health care careers for many adult and traditional-aged students who aspire to advance to higher-level jobs paying family sustaining wages.Students interested in healthcare careers often begin in non-credit training programs and, with a modest amount of post-secondary training, can progress along career pathways to higherlevel careers in allied health and nursing.
However, the workforce that seeks these jobs presents many challenges (Khatutsky, Weiner, Anderson, Akhmerova, & Jessup, 2011).Candidates may not be fluent in English, may lack a foundation in basic numeracy skills, and have little or no experience with the application of technology as a tool for health care delivery.A strong cultural awareness of the communities these students seek to serve can offset these deficits.Therefore, this workforce presents both challenges and opportunities, requiring an array of support services to become ready for success in job training programs.
Creating a true workforce on-ramp, benefitting both current and prospective workers in need of basic skills training, to prepare for entry into and retention in the direct care workforce, requires considerable work.It begins with forging career pathways from the local community that lead to job-training programs and on to credit-bearing degree and certificate programs at community colleges.An additional area of consideration is the high turnover rate among the direct care workforce (Bowers, Esmond, & Jacobson, 2003), which affects the quality of patient care and increases the cost of workforce acquisition and training (Brannon, Barry, Kemper, Schreiner, & Vasey, 2007).New approaches to the development of workforce pathways, transferrable credentials, consistent definitions of core competencies, and supportive leadership training are necessary to motivate and support the entry-level workforce to persist in their current jobs and progress to other opportunities in the healthcare field (Alexander, Wegner, & Associates, 2004).
Direct care jobs represent entry-level access points to higher education for many adult and traditional-age students (Institute of Medicine Committee on Future Health Care Workforce for Older Americans, 2008).Curriculum and career pathways, based on industry-validated job competencies, consistent across the taxonomy of direct care jobs and health care delivery settings, are necessary to develop and sustain the direct care workforce pipeline.Such pathways, codified in standards and regulations, can provide for portability of job competencies (knowledge, skills, and abilities) among different entry-level training programs and jobs.It may also provide for alignment of outcome expectations between education and employer partners.This framework can allow seamless progression of both traditional-age and adult learners from foundation skills training, such as English language and numeracy, through entry-level workplace skills into college-level certificate and degree programs leading to sustainable, living wage careers.It will also offer the flexibility to provide students with options for entry, exit, and re-entry points along the education/career pathway.
Development of such an aligned curriculum and career pathways system requires collaboration across community-based training organizations, higher education institutions including community colleges, employers, labor organizations and industry associations.The community college system has made considerable progress in developing stackable and accelerated programming for high demand industry sectors, including healthcare, through credit bearing certificate and degree programs.However, opportunities exist to expand the transferability of credit between non-credit and for-credit programming.
Just as credit transfer is a priority for students who progress from 2-year to 4-year programs, it is equally important that non-credit training "stack" for-credit coursework, certificates and degrees.This approach provides portable building blocks and seamless academic progression that reinforce student learning outcomes and progression to higher levels of education and careers.These clearly articulated pathways, stackable credentials, and complementary support services that align and reinforce the partnership between levels of the direct care/allied health career ladder are strategies that reinforce student retention, completion, and worker progression in direct-care careers.

Partnership and Project
Worcester State University (WSU) along with University of Massachusetts Memorial Health Care (UMMHC), the largest employer in Central Massachusetts, and the State Healthcare and Research Employees' Union (SHARE), which represents the direct care workers (DCWs) of UMMHC, collaborated to develop and implement an innovative educational program.The partnership designed this program to provide seamless academic and career pathways for DCWs to progress in their careers through higher-levels of education provided by the university on UMMHC campuses.With nearly 13,000 employees, UMMHC is the largest and most comprehensive health care system in Central and Western Massachusetts.UMMHC faces difficult challenges as a complex multi-institutional system in developing and maintaining opportunities for employment and career growth for the people of Central Massachusetts.UMMHC employs over 1,000 DCWs.
The designers of the program discussed in this paper intended to build a DCW pathway that allowed a seamless progression of students from foundation skills training through college level certificate and degree programs leading to sustainable, living-wage careers.This program offered flexibility for students, through options for entry, exit, and re-entry points along the education/career pathway.The project provided a seamless academic and career pathway for DCWs to progress in their careers through higher-levels of education.
Project objectives included: (a) plan, develop, and implement a DCW Readiness Certificate delivered by WSU on the UMMHC hospital campuses to two cohorts of 20 students; (b) develop effective academic success and retention strategies for students in the program; (c) increase the number of DCW in Central Massachusetts on a seamless pathway to career advancement; and (d) demonstrate positive impact on DCWs.This last objective would document decreased employee turnover, increased retention, increased employee engagement, increased worker commitment to quality, and improved job satisfaction.
To meet the objectives, participants developed four research questions as follows: 1. What role did support strategies implemented as part of program play in academic success and retention of first two cohorts?2. Will the increased accessibility and support provided by a worksite approach f o r DCW education promote an increase in the incumbent workforce able to advance their education?3. What are the identified barriers to enrollment and incentives to persist in the program?4. Will increased accessibility and flexibility provided by this approach combined with student-support services and advising/career-coaching promote successful completion of the program?

Major Activities
Major activities of this project included: • Development and use of new/returning students support services including intrusive advising and career coaching by WSU faculty on the UMMHC campus; • Diagnostic testing, (e.g., Accuplacer for math and reading and tutoring; • A Strategies for Academic Success (SAS) course to build college readiness skills for DCWs, establishing a positive learning environment, building supportive connections among newly-enrolled adult students, and promoting confidence in the student's ability to achieve academic success.• The project designed SAS to equip students with knowledge and resources to meet program expectations and achieve academic outcomes; • An online tutorial to assist students in gaining the needed skills for college-level writing and grammar; • HE 400: Interpersonal Communications course, which incorporates soft skills into DCW curriculum.These skills include, but are not limited, to communication, conflict resolution, communication within teams/groups, and professionalism; and • HE240 and 242: Perspectives on Writing and Learning from Experience I and II.
Through these learning activities and support systems, students were able to earn up to 27 college credits in all: nine credits earned in HE 240, 242 and HE 400, as well as up to 18 college credits through the completion of a portfolio that they could complete on their own after the course work was completed.The structure of college-credit bearing courses provided a significant savings of both time and money for the DCWs.
Throughout the program, students met regularly with their academic advisor/career coach to make academic decisions about courses, College-Level Examination Program (CLEP) tests, and to navigate the unfamiliar territory of the university.All students completing the Direct Care Worker Pathways Program developed an individualized career ladder plan or "career map" with "on and off ramps" for educational pathways leading to career goals.

Description of Cohorts
Recruitment efforts centered on distributing a brochure specifically created for this program.Initially, there were attempts made to hold information sessions, but potential students did not attend.Instead, Worcester State University staff handed out the brochures at tables set up in the cafeterias at two of the hospital's facilities.Staff scheduled dates and times with the shift times of DCWs taken into account.When individuals expressed interest after reviewing the brochure, the staff at the table asked them to complete a survey, which gathered basic contact information as well as some general background details about their educational attainments.WSU staff followed up on the inquiries.Students gained admission based on their designation as a DCW, as identified in the grant, and on whether the program would serve to benefit their career goals.The first cohort began with 18 students, of whom 10 completed the program.Students for cohort 2 won admittance in a similar manner as above.The second cohort began with 22 students, of whom 17 completed the program.

Benefits to Students
Intrusive advising showed itself to be an important aspect of the program and a benefit to all students.Intrusive advising is a proactive approach that has been shown to be an effective tool to enhance student retention (e.g., Rodgers, Blunt, & Trible, 2014;Sutton, 2016).Aspects of intrusive advising include advisors' early connection with students, frequent one-on-one meetings between a student and an advisor, and a supportive system of encouragement and guidance regarding obstacles that that may hinder a student's progress in the program.Frequent two-way communication is encouraged; it usually takes place through a combination of meetings, emails, texts, and phone calls.Intrusive advising allow students to feel comfortable with the advisor and helps the advisor anticipate the student's needs and be able to suggest strategies to address the needs.Students are encouraged to reach out to the advisor at the first sign of difficulty.In this way, advisors may address problems early, before they become insurmountable.
Each week on-site advising was available to all DCW students at their place of work.The academic advisor/career coach met with students by appointment.Students were also encouraged to call or email the advisor in between meetings if they needed additional support.If students missed consecutive classes, the advisor contacted them to encourage them to return to class and to offer assistance in resolving any barriers to attendance.Students were encouraged to discuss their courses, possible future academic plans, opportunities to obtain credit for prior learning, and issues of navigating the unfamiliar territory of academia.
During the one-on-one meetings, advisors asked the students to update their career planning maps (Appendix).The career-planning map was a tool developed to guide students through the process of figuring out their career plans and figuring out how to achieve them.Special consideration went into to figuring out work-school-family balance issues.Students learned through their participation in this program the critical importance of making time for their academic pursuits and making school an important priority in their lives.The academic advisor/career coach served as a sounding board to help students determine how to make quality time in their daily lives for their academic pursuits.
An additional benefit to students was the incorporation of a credit course that addressed soft skills development, specifically related to the development and improvement of communication skills.The students all took the Everything DiSC ® Workplace assessment and each student received a personalized profile that identified their preferences and tendencies when interacting with others.Students gained an awareness of their communication style and the ways that style could both contribute to and prevent a positive working environment.Students learned about how others have styles that are different from their own and the importance of being able to adjust to other styles.Furthermore, students learned how to be better problem solvers and apply a process to resolving conflict.Classes required the students to engage with each other and activities were created that allowed for conversations about how the topics covered played out in the workplace.Students learned to apply the concepts learned to the workplace and reflect on how situations could have resulted in different outcomes with their newly learned information.
In addition to the student-support services and customized curriculum noted above, there were also financial benefits to attending this program that DCWs would not have received in other programs.A grant from the Massachusetts Department of Higher Education provided funds that supplied the textbooks and materials for all students in this program.These funds also enabled WSU to offer a small monetary completion incentive to all students who successfully finished the program (passing all three credit-bearing courses and developing a career map).
UMMHC provided additional financial benefits to the program's students via an adjustment to their tuition benefit policy.Generally, students are eligible for a tuition reimbursement ranging from 50% (part-time employees) to 80% (full-time employees) from UMMHC upon completion of a course including a required grade of C or better.However, for this program, UMMHC agreed to pay their portion up front so that the students only incurred 50% or 20% of the cost, respective to their employment status.These financial benefits aided in reducing a potential barrier to enrollment and provided motivation for students to enroll and complete the program.

Program Evaluation
The project management team met monthly to evaluate the effectiveness of program components including, but not limited to, marketing and recruiting efforts, academic success and retention strategies, on-site advising, efficacy of academic support services, curriculum design and implementation, and student course evaluative feedback.The Direct Care Worker Pathways Program faculty met monthly with the project staff to review curriculum development and implementation, as well as formative and summative student data.This mechanism for regular review of evaluation feedback from university/employer/labor partners, as well as students, provided opportunities for ongoing continuous quality improvement.

What role did support strategies implemented as part of DCWRP play in academic success and retention of first two cohorts?
One hundred percent of survey respondents (n=27) described support strategies as either "Extremely Important" (66.66%) or "Very Important" (33.33%) in their ability to persist and complete the program.

Will the increased accessibility and support provided by a worksite approach f o r DCW education promote an increase in the incumbent workforce able to advance their education?
College enrollment data for SHARE employees in 2015 (based on tuition reimbursement request to UMMMC Human Resources) compared to 2016 enrollment trends revealed a significant increase (28%) in the number of SHARE direct care workers applying for college tuition benefits.

What are the identified barriers to enrollment and incentives to persist in the program?
Survey data of DCWs who completed the program (n=27) indicated the following as potential barriers to enrollment (respondents were asked to select "all that apply"): • Financial burden (96.29%) • Family responsibilities (81.48%)Retention in the program increased from the first cohort (Cohort 1 = 55% completion) rate) to the second cohort (Cohort 2 = 77%).This increase in retention was likely due to responses to challenges noted and discussed below in "Challenges."In addition, 26 of the 27 individuals (96%) who completed the program continued their employment at UMMMC.Finally, 24 of the 27 individuals (89%) who completed the program opted to continue their education either at WSU or at a local community college.

Challenges
Participant Recruiting: Recruitment presented an unanticipated challenge as our partner SHARE was unable to participate in recruiting in the manner that we hoped.SHARE indicated that information sessions at the hospital were not the preferable method to recruit for the program.
They instead suggested that we recruit at tables outside of the cafeteria at each of the three hospital campuses.SHARE was, in fact, correct in their recommendation as among the 12 information sessions that we held (at lunchtime and immediately after work) only one employee attended an information session.The "tabling" events were highly successful but the opportunity to communicate sufficient information to applicants was limited.While all information was very carefully detailed in the program brochure and in all written communication, we still had students who were unclear about the goals of the program at the time they enrolled.
In recruitment activities for Cohort II, after applicants indicated their interest in enrolling, each applicant had a 50-60 minute intake interview.The purpose of this interview was to assure that the applicant was clear about the goals of the program, as well as how the program could assist them to meet their own professional and personal goals.In some cases, students in consultation determined that this program might not be the best option for them.For example, we had applicants in Cohort II who had already completed all pre-requisites for admission, completed Accuplacer testing, and were already on the waiting list for Quinsigamond Community College (QCC) Nursing program.It was clearly preferable for these students to remain at QCC.
Our recruiting for Cohort II occurred at the same time that SHARE was preparing for contract negotiations.In addition, several key SHARE organizers were away for much of the summer for vacations and conferences.While we were unable to alter the timeline for our activities, UMMMC was able to provide significant support for our recruiting activities.Managing Advising Needs: While certainly predictable, Cohorts I and II consisted almost exclusively of students with almost no exposure to higher education and very significant personal issues.To meet the needs of these students, we were required to more than double the advising/coaching time dedicated to each student.Most students had no previous exposure to higher education and they did not understand that many academic majors had required courses/specific degree requirements.To emphasize the importance of meeting with the advisor and completing the career maps, some class time was set aside for the advisor to visit the class.
Other student issues ranged from childcare, family illness, indebtedness, eviction, and intimate partner violence.
Academic Abilities: The writing ability of the students varied, and was lower than expected.As a result, instructors spent significant time reviewing basic grammar requirements and the concept of application.Students required more time than expected to develop their writing skills because of the academic expectations of the college-level credit courses.Although they all write in one form or another for their jobs, academic writing brought out the limitations of their ability in this area.The instructors in each of the courses provided direct feedback to each student and spent additional time to develop the writing skills of the students so that they would be prepared for future academic courses.

Summary and Recommendations
Several key elements contributed to the success of this program.First, establishing partnerships was critical to the success of this program.All of the grant partners shared a common goal to assist the direct care incumbent workers to have the opportunity to improve their skills in order to advance professionally at their current workplaces.Once all of the partners agreed to this common mission the partnership became very united and student focused.
Second, flexibility was necessary to assure student retention and completion.Because of the many life challenges that adult learners face along with the lack of experience with and/or readiness for higher education, it was important for all partners to maximize their flexibility.The establishment of a second class illustrated one example of this willingness to adapt during cohort 2. This second class met later to accommodate students' work schedules.This scheduling issue, arising just before implementation, came as a surprise, but due to the cooperative nature of the partnership, we made changes quickly to promote the success of the participants.Another example is that as we found that students had difficulty writing at the level required, we put in place more instruction, feedback, and supports during and after the classes.
Third, intrusive advising helped students find their pathway.From the profile of the students, it clear that a standard advising model would not be sufficient.They needed a more intrusive advising model to work with them closely to guide them through both the academic and administrative processes of academia.The student advisor worked with the students at their workplace on a weekly basis.The advising sessions covered course work and career planning, creating a work/school/life balance plan, and mapping an academic success plan.We contacted and offered assistance to students who missed more than two consecutive classes.Students also were encouraged to contact the advisor by email or telephone between advising appointments as needed.During advising sessions, students worked on career maps.The career map document served as a tool to help students refine their academic and career aspirations and create a concrete plan to achieve those goals.
Fourth, all partners in the project noted the time commitment.Because of the high-touch, frequent-touch nature of this student population the time commitment for the partners was substantial.The students also needed to devote a fair amount of time per week to their studies.The academic rigor of the classes was significant and required a substantial investment of time from the students and faculty.
An additional challenge in the area of recruitment related to the start time for classes.Cohort I consisted almost entirely of PCAs.However, Cohort II had five LPNs drawn to the Worcester State University LPN-to-BS program.These LPNs work in ambulatory settings.As such, they were unable to participate in a course with a 4:30 class time most convenient to the PCA participants.The start time for the Strategies for Academic Success program shifted to 5:30pm, to enable the LPNs to participate.In addition, because we had two faculty members assigned to HE 240 and HE 242 (faculty students ratio 2:22), the decision was made to divide the class into two groups to accommodate those who were unable to arrive for a 4:30 start time.
Student Career Choices: Our program came designed with pathways and reserved seats in several health professions programs at WSU.These seats, reserved for students who had successfully completed the Direct Care Workers Pathways Program included our most selective programs: Nursing (four pre-licensure and four LPN-to-BSN); Occupational Therapy (four); Communication Science Disorders (two); and Public Health (two).However, we had no students interested in the reserved seats in any program except nursing.Rather, every student in both Cohorts had indicated their desire to study nursing or a program other than the ones with saved seats.We invited representatives from central Massachusetts community colleges to visit class and describe opportunities for continuing studies in a variety of health careers including radiologic technology, surgical technology, and respiratory care.We also worked with our longterm partners at QCC who agreed that, beginning in Spring 2017 and Fall 2017 (based on the entry calendar for each of the program listed below) QCC would save a number of spaces for students from WSU and the Direct Care Worker Pathways Program in the following programs.One place in spring and one place in the fall would go to participants in the Degree in Nursing Program.Two places would go to students in the Practical Nursing Evening Program.One place went to the Surgical Technology Program and one place to the Respiratory Care Program.