A new kind of role is emerging in nursing homes: the geriatric specialist, a certified nurse aide (CNA) who has completed an apprenticeship designed to deepen clinical knowledge, build specialized skills and take on greater responsibility in caring for older adults.

These CNA apprenticeships, which come with a pay increase, are seen to strengthen retention among a crucial group of direct care workers who often know if something is wrong with a resident days before more skilled nurses may notice, since they work so closely with their patient and their families. Now, the challenge is figuring out how to scale and sustain such programs in the years to come.

After all, there is a tremendous need for direct care workers. Between nursing homes, home care and residential care, there are 4.3 million direct care workers in these sectors as of 2024, according to a PHI National report, and the number is expected to grow by 700,000. Direct care workers are largely women, and more than 50% are people of color, while 30% are immigrants, said Alice Bonner, chair of Moving Forward.  

Job openings, meanwhile, will be close to 8 million for these care settings in the next decade, according to the PHI report.

The Moving Forward Coalition has been testing a CNA registered apprenticeship program for a year now, in partnership with the Geriatric Workforce Enhancement Programs (GWEPs), said Bonner. The Coalition recently had a multi-state convening to discuss the programs. 

Comprising over 1,600 stakeholders including nursing home residents, caregivers, advocates, and healthcare professionals, Moving Forward has been instrumental in addressing challenges outlined by the National Academies of Sciences, Engineering, and Medicine (NASEM)’s landmark report, published in 2022.

Federal grants that power GWEPs were designed to strengthen the primary care workforce by educating them and training them on geriatrics care, added Molly Carpenter, director of workforce strategy and development at LeadingAge LTSS Center @UMass Boston. One requirement for the programs is to run a registered apprenticeship program, focusing on incumbent CNAs and strengthening them in their current role.

Carpeneter likened it more to a career lattice than a career ladder, in a webinar on the apprenticeships hosted by Moving Forward on Monday.

“It’s really about developing them and specializing them,” said Carpenter. “This workforce deserves and wants this. Nursing home retention is the goal, and that’s going to result in the quality care of the nursing home.”

Talent pathways in the face of direct care churn

There are 42 GWEPs, 32 of which are for nursing homes, Carpenter said. Seven are up and running, and another 10 will be functional within the year, and the remainder are set to launch in year four or five of GWEP funding.

The Department of Labor required the programs to combine on-the-job training with a mentor, to develop “talent pathways” while the CNA is working, she added. While the federally designed model works for trade organizations like electricians and plumbers, the verdict is still out if it works in the health care world.

“We just don’t have a ton of data yet if it works in healthcare fields. This is a great opportunity to understand that. In theory, it seems like it could work in healthcare … you get some extra education hours, you get a mentor on the floor, and you have a year to complete it,” said Carpenter. “And 2,000 hours of on-the-job training really is one year of 40 hours a week.”

But at the end of the day, it’s an employer-led program, Carpenter said, and state and community partners need to get involved as well as education partners like the GWEPs to help CNAs get these credentials.

The most successful GWEPs so far have been those that created an “ecosystem” to support workforce training and solve challenges faced by direct care workers.

“They’ve brought in all the state people involved. They have brought in the right community partners involved, nursing home employers, even CNAs … they’ve brought all the right people to the table and talked about this as a community issue, not just a nursing home issue, or a state issue,” said Carpenter.

Figuring out apprenticeship scale, sustainability

Moving Forward is helping evaluate the level of success for these apprenticeship programs, support scale, spread, replication and sustainability, said Carpenter.

What the organization found was that there needs to be a better understanding of what the operator needs to make the program work, the cost involved with training time, mentor time, education time, and then the wage increases when the apprenticeship finishes, said Carpenter.

Understanding the local state workforce system is crucial too, especially when it comes to who oversees the nursing assistant and licensing requirements, which in some states like Washington could be two departments.

There has been some cross-state collaboration among GWEPs and Moving Forward to develop national standards using the apprenticeship programs and micro-credentialing programs.

In one case, Moving Forward and the GWEPs found that one operator across five states was involved in the apprenticeship programs, and so forces were combined under a common program and operator, bringing the team that much closer to a national standard.

Carpenter said this cross-state apprenticeship scale helped Moving Forward realize there was a conspicuous absence of CNA voices in the program, and in previous workforce initiatives that affected those in the role – it’s a focus the apprenticeship programs will have as they scale.

“We have got to get the CNA voice involved in this. A lot of the GWEPs have done this when they’re working on content they’re getting the voice of the CNA,” said Carpenter. “However, we still feel like this is a miss from the Moving Forward Coalition, from the work on a national level.”

And while standardization is possible for the apprenticeship programs, there’s still some wiggle room to make a program work better for a particular state, county or community with some deviation.