I-1163: Addressing Testing Barriers for Home Care Aides

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Long-term care supports people who need help meeting their health or personal care needs due to age or disabling conditions. However, maintaining an adequate workforce of long-term care workers has been a challenge for Washington. The COVID-19 pandemic significantly worsened the problem. Stay-at-home orders related to COVID-19 upended every aspect of the home care aide certification process. These orders resulted in nearly all state employees suddenly working from home, disrupted home care aide training programs, and prevented in-person home care aide testing for months.

A 2016 performance audit found that more than half of survey respondents who dropped out due to a barrier said they experienced a problem with the test. Reasons why applicants quit the process included problems scheduling the test and challenges getting to test sites. This follow-up audit revisited issues around the Department of Health's efforts to reduce testing barriers for home care aides.

Read a two-page summary of the report.

Report Number 1031019 Report Credits

Key findings

The audit found prospective home care aides still face a number of barriers to becoming certified. Among the most important:

  • Long delays between completing training and taking the test. The longer the wait between training and testing, the less likely applicants are to pass the tests.
  • Even fewer test sites than in 2016. Today, applicants in even some of our larger cities must travel long distances to take certification tests. For example, potential aides in Vancouver must travel more than 100 miles to Olympia to test.

In addition, we noted gaps in the Department of Health’s monitoring and accountability practices regarding the testing company.

Other states approach training and testing differently, which may offer our state some solutions. Furthermore, state laws governing the comparable profession of nursing assistants provide a model which the home care aide program might benefit from following.

Inefficiencies in the testing process have the potential to worsen the current shortage of home care aides in Washington. This performance audit offers recommendations to legislators and state leaders with the authority to remove or lessen those challenges, while continuing to ensure the state properly trains home care aides.

Background

Long-term care supports people who need help meeting their health or personal care needs due to age or disabling conditions. This type of care is important for many reasons. It can help people preserve their independence and avoid costly institutional care. They also experience the highest possible level of wellness. Home care aides help people perform activities of daily living, such as dressing, bathing, and transferring between their bed and wheelchair.

The people of Washington passed Initiative 1163 (I-1163) in 2011. The initiative increased training requirements and competency assessments for home care aides. The assessments require an applicant to pass a two-part test. The knowledge portion focuses on activities of daily living and proper treatment of clients. During the skills portion, the applicant must demonstrate correct performance of skills such as safely transitioning a client from a bed to a wheelchair and properly cleaning a catheter.

Long delays before testing

The longer applicants have to wait to test, the less likely they are to pass. Even before the pandemic disrupted testing, only one-third of applicants tested within the Department of Health’s (DOH) expected time frame – which totals almost 60 days between training and testing. The number testing within the time frame dropped further during COVID-19 restrictions. The greatest factor in testing delays was in transferring information between trainers, DOH and its testing vendor, Prometric.

Some elements are outside DOH’s control: it depends on applicants submitting complete applications and training programs sending graduation information promptly. Prometric struggled to schedule applicants in a timely manner once it received applicant information, but changing the approach to test scheduling could benefit applicants and help shorten the time frame. Prior to COVID-19, Prometric generally tested applicants as expected, but timeliness has declined over time. Overall, COVID-19 exacerbated an already delayed process.

Too few test sites

The number of regional test sites dropped 20 percent since our 2016 audit. We found applicants in many communities — including Aberdeen, Longview, Moses Lake, Pullman, Vancouver and Walla Walla — live outside a one-hour drive of a test site.

Additionally, many existing sites had fewer dates available for testing. This was due to two main reasons:

  • COVID-19 waivers resulted in fewer testers overall
  • Test sites require a minimum number of test takers to schedule a test date

Some stakeholders believe Prometric’s five-page checklist of required test-site elements also limits the number of potential sites. The list itemizes certain building structural elements plus portable items like computers, a bed and an anatomically correct manikin.

Opening additional test sites is constrained by how high Prometric can reasonably raise test fees. Applicants, or the union that represents them, pay Prometric $137 to take the test. These test fees are the only source of funding for DOH’s contract with Prometric. Low wages for home care aides effectively limit how high Prometric can set its fees. Raising them too high could result in applicants pursuing other employment. Some solutions identified in the audit may still be challenging to fund, however low the cost.

Contract management

The audit also found DOH does not track and monitor the time between training and testing. Such gaps in monitoring important features of the contract mean that the agency has less awareness of the many reasons applicants drop out. Furthermore, DOH has limited accountability mechanisms in place for the overall training-to-testing process. For example, though state law requires them, DOH’s contract with Prometric lacks some key performance measures or benchmarks.

Possible solutions

The audit identified ways to address testing issues by considering professions comparable to aides, such as nursing assistants. For example, statutes regarding testing are more prescriptive and limiting for home care aides. Nursing assistants can already take the knowledge portion of the test remotely. Home care aides, on the contrary, must test in person.

The audit looked at several comparable states to identify possible solutions to testing barriers. Some states allow their home care aide equivalents to test within or at the end of training. Other states choose to provide in-home care through nursing assistants, which could be a better path for some applicants in Washington.

Recommendations

We made a series of recommendations to the Department of Health. Recommendations included ways to address:

  • Delays between training and testing
  • The lack of test sites
  • Gaps in performance and contract management

We also recommended the Legislature give DOH similar authority and discretion in testing home care aides as the Nursing Commission has for testing certified nursing assistants.