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By Lora Perry, MS, BCBA

Last week I wrote about the high cost of paraprofessional turnover, both in terms of dollars, and in terms of diminished quality of care (see The High Costs Of Paraprofessional Employee Turnover – Sizing Up The Challenge). It is clear that no behavioral health care organization will withstand the transition to more in-home and community-based care without successfully tackling the challenge of recruiting and retaining the paraprofessional work force. How to do this?

As a behavior analyst, I look at staff performance challenges in terms of “response effort” and “contingencies of reinforcement.” In other words – how difficult is it to do this job? (Very.) And what’s the payoff for doing it? (Low, in terms of compensation.) Paraprofessionals are asked to help consumers achieve goals, objectives, and care standards in manners that are physically strenuous, may be intimate in nature, and require authentic and agile interpersonal skills – for little “payoff” in terms of wages and benefits.

What to do? According to the Paraprofessional Healthcare Institute (PHI), a direct care workforce association and advocacy group, improving the recruitment and retention of paraprofessionals is tied to three factors – compensation, opportunity, and support (see Paying The Price).

Compensation – Health care paraprofessionals are members of the low-wage work force. PHI notes that in 2012, the median hourly wage for all direct-care workers was $10.63 – personal care aides earned $9.57, home health aides earned $10.01, and nursing assistants earned $11.74 (see America’s Direct-Care Workforce). The low-wage market for labor is one in which the labor pool has choices – compensation being relatively equal, and benefits for many being non-existent, workers choose the employment option that is most attractive in terms of working conditions. When provider organizations can streamline operations (cut costs) to direct more revenue to wages, a pay differential over the competition can make an enormous difference in the lives of a low-wage worker, and therefore go a long way toward staff retention. PHI noted an interesting example of this situation, “San Francisco personal care workers voted to form a union in 1996 and over the next several years significantly increased wages and benefits. In a study of how these wage increases affected annual retention rates, researcher Candace Howes found that the near doubling of wages over 52 months increased annual retention from 39% to 74%.”

Opportunity – Many in the low-wage work force don’t want to remain there, so positions that offer growth opportunity improve recruitment and retention. Most direct care positions do not require specialized education and training, so without additional professional development and careful planning, opportunities to qualify for more senior positions are limited or non-existent. Provider organizations can overcome this by carving out positions and defining a technical career track that brings value to the organization while offering opportunity to the employee. For example, many paraprofessionals can become trainers of behavioral de-escalation techniques; serve as team leaders for groups of peers; oversee scheduling of staff to meet client needs; or serve as a safety officer during group consumer activities. Employees who move through these stretch assignments and concurrently obtain additional educational qualifications or certifications can be further positioned for growth – and more likely to stay.

Support – Paraprofessionals require ongoing support in the form of supervision by licensed or certified practitioners, and this is required by most payers and regulations. For example, paraprofessionals working under the supervision of a Board Certified Behavior Analyst (BCBA) are required to have one hour of supervision per month for every 10 hours the paraprofessional works with clients. This then provokes the question of how many paraprofessionals a BCBA is supervising—and for that, there is no clear answer. My rule of thumb is it really has a lot to do with the complexity of the care plan the paraprofessional has a role in implementing; a more complex group of consumer needs will result in a lower number of BCBA supervisees, in order to ensure all aspects of the care plan are being addressed with quality and treatment fidelity. Other important ways to supervise paraprofessionals?

  1. Allocate the necessary time to provide support, including ongoing training in all domains necessary for the worker to continuously improve technical and interpersonal skills essential to their roles.
  2. Manage the logistics of unstable paraprofessional work schedules.
  3. Document the impact (positive or negative) support has on the quality of consumer care and regulatory compliance.
  4. Link this low-wage work force to public benefits, if needed, to stabilize families at home, thereby reducing the likelihood of missed shifts due to personal urgent needs.

For more, check out my session, Talent Management: Getting the Most from Your Human Capital, from The 2015 OPEN MINDS Executive Leadership Retreat. And for more, check out these resources from the OPEN MINDS Industry Library:

  1. Talent Management: Getting The Most From Your Human Capital
  2. Keeping Pace In The Race To Change: Workforce Development In The New Health & Human Services Landscape
  3. “Employer of Choice” Models as a Retention Tool: Seven Strategies for Behavioral Health & Social Service Organizations
  4. Assessing & Building Your Organizational HR Competencies: Using HR as a Strategic Partner in Human Service Capacity Development
  5. Strategic Human Resource Management: Tackling the Issues of Employee Recruitment & Retention

Implementing these organizational strategies begins with the collection of baseline data to pinpoint exactly what challenges your organization faces in turnover. What percentage of paraprofessional new hires separate within 30 days? Within six months? If this is a significant, it indicates your on-boarding needs an overhaul. What percentage of staff separate within one, two or three years? The answer to this will guide you toward more robust compensation packages, training, supervision, career development, and support system. These are simple fixes, but they’re not easy.


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