The Home Care Aide Association of America

Position Paper:
National Uniformity for Paraprofessional Title, Qualifications, and Supervision

The paraprofessional home care worker is a key component of both acute and long-term home care programs. Two elements are essential to the success of the paraprofessional: appropriate training and supervision. Supervision should include a strong worker support system. The paraprofessionals' support system includes competent administrative leadership and the potential for interaction and sharing of experience among workers.

The Home Care Aide Association of America (HCAAA) developed these standards for home care paraprofessional titles, qualifications, and supervision as a conceptual model for paraprofessional services. A uniform system must be agreed on before policymakers will provide adequate funding to cover the costs of implementing increased training and supervision. Adoption of this approach will result in greater uniformity and accountability, improved quality in home care services and public policy decisions, and enhanced consumer understanding. It will allow the industry to improve current home care services funded by the Older Americans Act, Medicare, Medicaid, the Social Services Block Grant (Title XX), insurance programs, and consumers. Most important, it will enable the industry to develop a comprehensive long-term care policy.

This position paper is based on the premise that uniform titles, qualifications, training, and supervisory standards for the paraprofessional in home care must be agreed on and that the financial resources to meet the standards must be made available simultaneously with the imposition of those standards. These standards should apply to all paraprofessional home care services regardless of payment source. The policies outlined in this paper are not intended to supersede, preempt, or otherwise affect existing state scope of practice laws regarding the provision of care in the home.

The core services around which a long-term care strategy should be forged are those cost-effective services that are performed by home care paraprofessionals. NAHC and other organizations have called this work category homemaker-home health aide. This worker is a paraprofessional with training and competence in both home management and personal care skills. Individuals perform these tasks under a variety of titles, each with different training requirements, standards of supervision, and funding sources, for example, the home health aide within the Medicare model and the homemaker under Title XX. This lack of uniformity in title, function, and standards for training and supervision for the home care paraprofessional has resulted in considerable fragmentation and no clear perspective on the continuum of long-term care services provided by this important segment of the home care community.

Without uniform standards and definitions, long-term care policymakers will be pressured to accept what exists, rather than to promote an improved classification system.

Uniform Title

To facilitate long-term care planning and legislation, the HCAAA Advisory Board has proposed the use of a generic title for paraprofessionals in home care. It will cover many manifestations and leave room for the growth and development of classifications and specializations as they become appropriate. That title is home care aide. The term encompasses the essential components of the job. Care is being provided in the home by someone who has received training and is working under professional supervision with the goal of assisting the client with independent living. HCAAA's Advisory Board is proud to advocate the term home care aide.

Levels of Preparation and Responsibilities for the Three Classifications of Home Care Aide

To prevent or delay institutionalization, clients will need a range of services that extend from basic housekeeping to complex personal care. The home care aide must be prepared to adapt to client differences. The three classifications of home care aide defined below address a range of client needs and the attendant needs for training and supervision. HCAAA proposes that experienced home care aides bypass training if they are able to demonstrate their ability to perform required tasks through a competency evaluation. Any long-term home care program must provide funding for this training and supervision to meet client needs.

Delineating three classifications of home care aide will provide the flexibility needed to design a system that maintains appropriate standards for appropriate levels of care. It is inefficient to discourage provision of these services if the only available personnel are overqualified and more costly than needed. It is essential that those clients who need environmental services or minimal personal care services must receive help from people who are fully qualified to meet their needs.

The environmental and personal care needs of the client can be met by the same person. The Class III home care aide is prepared and competent to perform tasks of the Class I and Class II home care aide, as well as tasks for which he or she has had more advanced training. Similarly, the Class II home care aide can perform the duties of both home care aide Classes I and II. No home care aide is to perform tasks with clients (1) for which he or she has not received appropriate training or (2) without proper supervision.

It is also important to note that this classification system allows individuals to work their way up a career ladder or path. Such verification of the value of this role will enhance job satisfaction and thus improve patient care.

The following descriptions of Home Care Aide I, II, and III address these issues.

Home Care Aide I

The home care aide I (HCA I) assists with environmental services such as housekeeping and homemaking services to preserve a safe, sanitary home and enhance family life. The HCA I should encourage the client and/or family to assume as much responsibility as possible for care and environment in accordance with the plan of care. The HCA I is not to provide any personal care.

Examples of duties: housekeeping; shopping; laundry; essential errands; basic meal preparation and meal planning (not for special diets); maintaining a safe environment; observing, monitoring and reporting on a client's condition; and teaching of those tasks to the client that will increase client independence and that the HCA I is qualified to teach.

Training: The following training units, based on the National HomeCaring Council's "A Model Curriculum and Teaching Guide for the Instruction of the Homemaker-Home Health Aide," should be completed before assignment.

Section I. Orientation to Home Care Aide* Services, 4.5 hrs.

Section II. Understanding and Working with Various Client Populations

Unit A. Communication, 2 hrs.
Unit B. Understanding Basic Human Needs, 2.5 hrs.

Section III. Practical Knowledge and Skills in Home Management

Unit A. Maintaining a Clean, Safe and Healthy Environment, 4.5 hrs.
Unit D. Portion on Infectious Diseases and Infection Control, 1.5 hrs.

Section IV. Practical Knowledge and Skills in Personal Care

Unit G. Emergency Procedures, 1 hr.

Subtotal 16 hrs.)
*The model curriculum refers to homemaker-home health aide duties; it is anticipated that future versions of the curriculum will refer to home care aides to reflect the change in title recommended by HCAAA and NAHC.

The following units should be completed within six months of the first assignment or prior to the HCA I working in any situation where the content of a unit would be appropriate to the home care aide's duties:

Section II. Understanding and Working with Various Client Populations

Unit C. Understanding and Working with Children, 3 hrs.
Unit D. Understanding and Working with Older Clients, 4 hours
Unit E. Understanding and Working with Clients Who are Ill, 2 hrs.
Unit F. Understanding and Working with Clients with Disabilities, 2.5 hrs.
Unit G. Mental Health and Illness, 2 hrs.
Unit H. Understanding Dying and Death, 1 hr.

Section III. Practical Knowledge and Skills in Home Management, 7 hrs.
(all remaining hours in Section III except 1-1/2 hours of modified diets-see HCA II)

Section V. Application of Knowledge and Skills-The Practicum, 2.5 hrs.
Subtotal 24 hrs.
Six month total 40 hrs.

Supervision: Supervision of the HCA I shall occur at least every 62 days in at least one home while the HCA I is on duty. Supervision may be performed by staff such as nurses, social workers, and home economists. An experienced HCA III may also supervise a HCA I if the HCA III has received additional training in supervision and is under the direct supervision of a professional.

Inservice: The HCA I shall be required to complete at least six hours of inservice training per year on topics relevant to appropriate clients and duties and meet applicable state laws.

Home Care Aide II

The home care aide II (HCA II) assists the client and/or family with home management activities and with non-medically directed personal care. The HCA II is not to perform duties under a medically directed plan of care and is not to be assigned duties related to assistance with medications or wound care.

Examples of Duties: All the duties of a HCA I plus: assistance with ambulation, bathing, hair care/grooming, dressing, toileting, transfer activities, special diets, activities of daily living, and appropriate client teaching consistent with training.

Training: The HCA II is to complete all the training units required of the HCA I (40 hours) prior to any assignment to a client involving the provision of care.
The following additional units are to be completed within six months of the first assignment as HCA II. However, no HCA II shall be assigned to provide services for which the HCA II has not been trained and for which the HCA II has not demonstrated competency.

Section III. Practical Knowledge and Skills in Home Management

Unit B. Modified Diets, 1.5 hrs.

Section IV. Practical Knowledge and Skills in Personal Care

Unit A. Body Systems, Disorders, and Diseases, 3 hrs.
Unit B. Observing Body Functions, 3 hrs.
Unit C. Care of the Client in Bed, 8.5 hrs.
Unit D. Care of the Client not in Bed, 1.5 hrs.

Section V. Application of Knowledge and Skills-The Practicum

Unit F. Supervised Application of Knowledge and Skills, 2.5 hrs.

Additional Training (beyond HCA I requirement), 20 hrs.total training required within six months of first assignment is 60 hrs.

Supervision: Supervision of the HCA II shall occur at least every 62 days in at least one home while the HCA II is on duty. Supervision must be performed by appropriate professionals.

Inservice: The HCA II shall be required to complete at least 10 hours of inservice education per year that are relevant to appropriate clients and duties and meet applicable state laws.

Home Care Aide III

The home care aide III (HCA III) works under a medically supervised plan of care to assist the client and/or family with household management and personal care.

Examples of Duties: All duties of the HCA I and HCA II plus those delineated under a medically directed plan of care. These would include: nonsterile wound care, assistance with self-administered medications, assistance with prescribed exercises and rehabilitation activities, simple procedures, help with assistive devices, and appropriate client instruction consistent with training.

Training: The HCA III will complete 75 hours of training and pass a competency evaluation. Training beyond the HCA I and HCA II requirements must be completed within the first six months of assignment as an HCA III. However, no HCA III shall be assigned to provide services for which he or she has not been trained and has not demonstrated competency. Units to be completed beyond the requirements for HCA II are:

Section IV. Practical Knowledge and Skills in Personal Care

Unit E. Observations about Medications, 1 hr.
Unit F. Rehabilitation, 2 hrs.
Unit G. Health Procedures, 2 hrs.

1. Dry, nonsterile Technique Dressing
2. Simple Procedures

Section V. Application of Knowledge and Skills-The Practicum.
Supervised Application of Knowledge and Skills, 10 hrs.

Additional training (beyond HCA II requirement), 15 hrs.total 75 hrs.

Supervision: Supervision of the HCA III shall occur at least every 62 days in at least one home while the HCA III is on duty. Supervision must be performed by appropriate professionals such as nurses.

Inservice: The HCA III shall be required, at a minimum, to meet current HCFA inservice requirements for home care aides under the Medicare program.

Special Needs

As this field continues to advance, special needs must be addressed. Specifically trained paraprofessionals are the ones to address these needs. As these needs evolve, new types of aides will be developed with specialized training and supervision requirements. Possible examples of future specialty areas include pediatric HCAs, mental health HCAs, HIV HCAs, and HCAs who are trained to help individuals with Alzheimer's and developmental disabilities.

With basic uniformity and consistent definitions, redefinitions and progress in the field of paraprofessional home care services will be facilitated and this crucial role in home care developed to its utmost.

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