Prepared for the Community Campus Partnership at UNC-Chapel Hill and the Workforce Investment Network at RHA Howell, Inc.
Ashley Yingling Ben Houck
RHA Howell, Inc. Community Campus Partnership
University of North Carolina at Chapel Hill
Table of Contents
Table of Contents 2
Fastest Growing Healthcare Occupations: Eastern Carolina Region 3
Median Income and Required Education 5
Available Training Programs 7
Report from the Field: Interviews with Local Employers 9
Conclusions and Recommendations 11
Building Healthcare Career Ladders in Lenoir County is a short-term research initiative funded through the Community-Campus Partnership Small Grants Program of the University of North Carolina at Chapel Hill. Recent graduates of the University’s Department of City and Regional Planning crafted the research as a follow-up to findings from an earlier workshop regarding the direct support workforce in Lenoir County.
The workshop – a Masters-level capstone course of 10 students convened in the 2010 spring semester – examined the county’s entry-level direct support workforce, including such data as wages, employment trends, and demographics. Understanding the direct support workforce is important as these professionals provide a high amount of patient care for vulnerable individuals. Efforts to reinforce the stability and professional satisfaction of these workers can have a significant impact on their patients’ quality of life (Hewitt, Edelstein, Hoge, Morris, & Seavey, 2007). The growing demand for direct care workers due to a growing and aging population is, by now, well understood.
Examining the direct support workforce in Lenoir County is of special interest as it creates an entry point into a healthcare industry which has buffered the area’s decline in manufacturing employment. As patient care decentralized from institutional to community settings, employment opportunities have dispersed among many smaller service providers. Despite this trend, the Caswell Center continues into its 100th year of service as the county’s largest employer, providing over 1,600 jobs (Lenoir County Economic Development, 2009). Lenoir County’s location within eastern North Carolina is important as well. Kinston’s proximity to approximately 100,000 veterans within a 50-mile radius paid dividends in its selection as the site of a new 100-bed skilled nursing facility for veterans (Lavender, 2009).
A few of the main findings from the workshop include:
The wages of local and state direct support professionals lag well behind the aggregated averages for all occupations, and this gap has grown over time.
Approximately 4 out of every 5 nursing and residential care facilities in Lenoir County employ less than 50 workers. These employers often have “flat” organizational structures with limited opportunities for internal advancement.
Among occupations with a high tendency for female employment, the direct support profession has a higher frequency of workers who are single mothers.
These findings depict a health care industry which, despite its rise to the leading source of employment in Lenoir County, remains inhibited in its ability to provide living wages and advancement opportunities. On a positive note, however, the students involved in the workshop identified several workforce interventions intending to strengthen the direct care workforce in Lenoir County. One form of intervention, career ladders, serves as a support system for incumbent workers to realize occupational advancement.
Lenoir Memorial Hospital, a prominent healthcare employer, provides career support through several means, including the Grow Our Own career advancement program. RHA Howell, a provider of services for developmentally-disabled individuals, also created a career advancement program known as Workforce Investment Network. The Caswell Center, the county’s largest employer and a long-standing provider of services for developmentally-disabled individuals, also supports career advancement without the structure of a formal program.
The findings discussed above formed the basis for the Community-Campus Partnership research. To begin, this project broadened its lens to the entirety of the healthcare workforce, examining not only entry-level occupations but mid-level and senior positions as well. We deemed it necessary to speak with facilities directly given the difficulties of relying upon secondary data sources. Utilizing national and regional data, we encountered common problems. First, labor data tends to be too general. For example, the direct care workforce is difficult to distinguish as it is spread out across three standard occupational codes. Second, secondary data does not encompass the promotional opportunities we were trying to identify.
In addition to a wide range of interviews, we utilized the available regional data in order to identify broader trends in the healthcare labor force. Presented in this report is our analysis, which intends to identify the fastest growing occupations and characterize them with regards to required training and income potential. Training data was also utilized in order to identify any training gaps in the region. Our goal was to identify possible causes of staffing difficulties, as well as potential targets for a career ladder initiative. Our analysis has yielded the following major findings:
Nearly all healthcare occupations are growing in the Eastern Carolina Workforce Development Board Region (Carteret, Craven, Duplin, Greene, Jones, Lenoir, Onslow, Pamlico and Wayne Counties), with most growing at a rate faster than the regional rate of growth. Entry level home health aides, nursing assistants and personal aides, which includes direct support professionals, are among the fastest growing occupations.
These entry level positions are very low paying positions, much below the area median income level and the poverty line. Many fast growing positions only require one to two years of training, and offer wages at or above the area median income level.
Employers report similar challenges, the main challenges being: high turnover in entry level positions, and difficulty recruiting high level licensed professionals. Many employers are utilizing similar strategies to reduce turnover—assisting with education and promoting from within their organizations.
Two external training gaps were identified: a lack of standard training for direct support professionals, and gaps in high school education. These gaps can increase turnover, increase turnover costs, and limit individuals’ career advancement opportunities.
Based on these findings, as well as the results from a local stakeholder meeting, we have concluded that there is potential for collaboration among local employers to establish a career ladder program. We recommend targeting both nursing and technical positions, which often overlap among employers and can provide the entry level workforce career advancement options with local training opportunities. We also recommend providing intermediate steps and advancement opportunities within the entry level fields (particularly nursing assistants and direct support professionals), which can reduce turnover and lift individuals out of low wage, dead end positions.
Fastest Growing Healthcare Occupations: Eastern Carolina Region
The following table lists the fastest growing healthcare occupations by estimated annual openings, providing potential occupations to target through a career ladder initiative. These figures are based on the North Carolina Employment Security Commission’s estimates for occupational growth through 2016, and the Bureau of Labor Statistics’ average replacement rate. Thus, the annual openings include openings from those leaving the profession due to career change or retirement, as well as increased demand for healthcare services. The majority of job openings are expected to be from industry growth rather than career change and retirement. Occupations included in this analysis were those defined by the Occupational Information Network as being part of the healthcare cluster (Occupational Information Network, 2010), as well as additional occupations identified by healthcare employers in Lenoir County.
These estimates, based on the Bureau of Labor Statistics and Employment Security Commissions’ methodologies, assume that historic growth trends will continue. Not included in these estimates are changes in the healthcare system due to the Affordable Care Act of 2010. Major reforms will be enacted in 2014, with many of the uninsured gaining access. As of 2005, 19.8% or 9,691 of Lenoir County’s population under 64 were uninsured (Holmes & Ricketts, 2005). With nearly 10,000 individuals gaining easier access to insurance and healthcare in the county, there will be a significant increase in demand for health professionals. These changes are not accounted for in the estimates of job openings, indicating that these are potentially underestimates, particularly for patient care positions.
These estimates are further limited due to the use of national replacement rate estimates. In 2000, the Institute on Aging (University of North Carolina) survey showed 100% turnover in nursing homes, 119% in adult care homes, and 53% in home care agencies (Instutute on Aging, 2000). The replacement rate is intended to capture those that retire or change careers, and thus require additional workers to be trained in the occupation. Thus, the rate is expected to be lower than overall turnover. However, the Bureau of Labor Statistics only estimates a 10% annual replacement rate for home health aides, personal assistants, and registered nurses, which may not reflect local workforce conditions.
In addition to these occupations, the following occupations have above average growth in the region, though there are fewer than 15 estimated annual openings:
Dental Laboratory Technicians
Diagnostic Medical Sonographers
Medical and Public Health Social Workers
Medical Records and Health Information Technicians
Mental Health and Substance Abuse Social Workers
Mental Health Counselors
Obstetricians and Gynecologists
Occupational Therapy Assistants
Physical Therapists Respiratory Therapists
Physical Therapy Aides
Physical Therapy Assistants
Social and Community Service Managers
Special Education Teachers (Middle School)
Substance Abuse and Behavioral Disorder Counselors
Special Education Teachers, Preschool, Kindergarten, and Elementary School*
Emergency Medical Technicians and Paramedics
Medical and Health Services Managers
Source: (U.S. Bureau of Labor Statistics, 2010)
In summary, the above estimates provide a general list of high growth positions in the healthcare industry. These occupations have will require among the highest number of new employees, and should be considered for training, recruitment and retention efforts. These figures do not take into account the aging population and the anticipated increase in healthcare demand after the Affordable Care Act takes effect in 2014. Thus, this list of occupations may be viewed as potential occupations to target with career ladder initiatives, but job opening estimates for occupations demonstrated to have high turnover should be viewed as the low end of a range of possible employment needs.
Median Income and Required Education
Most of the fast growing positions (11 of 16), as well other high growth healthcare positions, require some amount of postsecondary training. Often they require a one year diploma or two year Associate’s degree in order to meet state requirements for the position. Occupations that do not require postsecondary education, such as home health aides and nursing aides, are the lowest paying occupations, with all but one being below the area median income. These income levels cause significant housing stress, with an individual needing to work over forty hours a week just to afford rent for a studio apartment in Lenoir County. Additional information regarding the housing stress and poverty levels faced by those in these occupations can found in the report completed by the spring workshop (Davis, et al., 2010).
Overall, the region has lower wages than state median wages. On average, the median wage for a healthcare professional in the Eastern Carolina Workforce Development Board region is 94.6% that of the median wage for the profession in the state (U.S. Bureau of Labor Statistics, 2010). For occupations for which data was available, the County wages further lagged behind the state at 91% of state median wages. Of note, the median wage for home health aides in Lenoir County is only 75% of the median wage for the state. Also below 80% of median wages in the state are: Pharmacists (52%), Radiologic Technologists and Technicians (77%), Medical Records and Health Information Technicians (75%) (U.S. Bureau of Labor Statistics, 2010). Many other healthcare occupation wages are unreported at the county level. While these differences are in part due to cost of living differences, significantly lower wages may result in the high turnover and recruitment challenges that have been reported by employers in the region.
While the highest paying occupations require doctorate degrees, there are several growing occupations that offer above average pay with only one to two years of postsecondary education required (North Carolina Area Health Education Center, 2010). These one to two additional years of training can significantly improve the annual income of individuals who enter the healthcare field without a degree, diploma or certification. This point is further illustrated on the accompanying career maps, which show the associate’s degree level as being the entry point for many technical and patient care positions. The available associate’s degrees and diplomas in the region provide access to numerous positions with above living wages. These opportunities are a natural target for a career ladder initiative, as they offer brief, flexible and inexpensive training that allow for a significant improvement in living standards.
Table 2. 2010 Median Income and Required Education by Occupation, Eastern Carolina WDB
Median Income Level: Region
Median Income: State
Required Education Level
Home Health Aides
High School/GED or Certificate, depending on position
Personal and Home Care Aides
High School or GED
Social and Human Service Assistants
Based on position
Licensed Practical and Licensed Vocational Nurses
One year diploma
High School or GED, Certification optional
Nursing Aides, Orderlies, and Attendants
High School/GED or Certificate, depending on position
Child, Family, and School Social Workers
Bachelor’s or Master’s Degree
One year diploma
Based on position
Special Education Teachers, Preschool, Kindergarten, and Elementary School*
Bachelor’s or Master’s Degree
Emergency Medical Technicians and Paramedics
Certificate or Associate’s Degree
Medical and Health Services Managers
Associate’s or Bachelor’s Degree
Note: Highlighted cells indicate wages are significantly below the area median income of $25,800.
Source: (North Carolina Area Health Education Center, 2010) (U.S. Bureau of Labor Statistics, 2010)
Available Training Programs
The North Carolina Community College system provides extensive training opportunities in this region at five community colleges, covering all but one of the fastest growing occupations at five community colleges (Craven, James Sprunt, Lenoir, Pitt, and Wayne Community Colleges) serving the region. The following table compares the degree/certificate completions to the estimated annual job openings. The available numbers show that if historic completion numbers continue in a similar manner, regional job requirements should be met by community college graduates in the region.
The average annual opening estimates are intended to provide the minimum number of individuals that need to be trained in this profession. By this standard, the community college system will likely continue to meet most employment needs for the region, and graduates will be able to find positions in their field.
While the region is well-served, interviews with local employers have revealed a significant training gap. Subcategories of two of the fastest growing occupations—home health aides, personal and home care aides—do not have public training available to them. While those hired for these occupations receive state mandated training on the job, no public education program or certification exists to serve these professionals. In the current system, a direct support professional (a subgroup of these occupations) would be required to be retrained as they move between employers. Currently, local and statewide employers are working to standardize this training, closely working with the College of Direct Support in. Addressing this gap is an important step to providing these workers with career advancement opportunities.
Further interviews with community college representatives have revealed a gap in training that is much more difficult to address. Reported in these interviews, while there is strong interest in health programs, many students do not meet the prerequisites to enter the healthcare training programs. Addressing this gap requires a much wider initiative. The Eastern AHEC has been addressing this problem through local high schools, providing students with information about the prerequisites for healthcare programs. A successful career ladder program will need to address these gaps in their existing workforce, providing continual support for those who must take remedial and prerequisite courses, as well as assistance in finding a career track that is the right fit for them.
Table 3. Available Training Programs and Average Annual Completions in the Eastern Carolina WDB Region.
Report from the Field: Interviews with Local Employers
In addition to the above labor force analysis, several interviews with local employers have been conducted to gain a greater understanding of employment needs and challenges. Much of what was learned through these interviews has been provided through the career map report. However, additional trends in recruitment and retention beyond what the labor force data provides is worth reporting.
Several institutions reported similar difficulty in recruiting highly trained licensed professionals. Specifically, physical therapists, occupational therapists, physician assistants, and pharmacists were all mentioned as requiring extra effort in recruiting and positions occasionally remain unfilled for months at a time. These positions all require training beyond a bachelor’s degree, often several years. No employers reported that assistants below these professionals (e.g., physical therapy assistants) transition to higher level position. Rather, the education requirements, several years beyond an associate’s degree, make such a transition unlikely. Thus, a career ladder program may have little impact on this recruitment difficulty unless there was a specific effort to provide assistance and intermediate career steps while employees take on the required education.
For positions that have few entry requirements, however, the challenges lie with retention. Retention problems can result from a wide range of issues. Nearly all facilities report that some workers will change positions to find a different schedule or a pay increase, particularly in the nursing and nursing aide positions. This indicates that the high turnover rates reported for nursing professions, is in part be due to changing employers rather than leaving the profession. For low wage, entry level positions turnover often results due to dissatisfaction with work conditions and pay. These positions, ranging from direct support workers to dietetic staff, have demanding jobs and receive low pay. The positions are further often considered “dead-end” jobs with limited promotional opportunities.
Nearly all employers report that they work to assist employees who return to school, and often promote these employees when opportunities arise. The most commonly cited promotions were in the nursing field, as employees became certified as Licensed Practical Nurses or Registered Nurses. One such employer commented that if they could not promote a nursing director from within, then they had done a poor job recruiting nurses. This situation is a sharp contrast to occupations requiring graduate work, which have no pool from which to promote to these positions.
In addition to scheduling flexibility and internal promotions, some employers provide scholarships, loans or other financial assistance. Many provide flexibility in scheduling to accommodate class schedules. Employers are utilizing many elements of career ladders—promotion, tuition assistance, scheduling flexibility and other supports—to serve their employees and reduce turnover.
Regional Stakeholder Meeting
On August 16th, 2010 local employers and other stakeholders were invited to a luncheon to discuss workforce development issues and the potential for collaboration. At this meeting, the research contained in this report was briefly presented, and was followed by a facilitated discussion. The discussion focused on what employers were currently doing to address workforce challenges, opportunities for collaboration and potential barriers to collaboration.
Much of what was reported in individual interviews was echoed at this meeting. Common challenges included retention of entry level workers, recruiting in a rural area, exposure to available workplaces. As shown in our career maps, many of these employers share similar entry level positions, and they reported similar issues with individuals within these positions. Participants cited the difficult work load, inconvenient shift work, and low pay as some of the reasons they must frequently replace entry level healthcare workers. With regards to recruitment, the location in a more rural setting requires heavier recruitment efforts, as employers must compete with often higher paying facilities in nearby urban areas. Less traditional healthcare providers, such as home health providers or intermediate care facilities, must also compete with more traditional employers for recruiting and retaining healthcare workers. Exposure to these work environments during training could provide more specialized skills and assist in the recruiting of highly skilled workers.
Additionally, participants mentioned specific training gaps. A representative from Lenoir County Community College mentioned that while the community college has had maximum enrollment for the past four years, they have problems with retention as students are unprepared for the required coursework. Additionally, many of the students face financial obstacles, often working multiple jobs and having parental responsibilities. A representative from RHA Howell mentioned the lack of standardized training for direct support professionals, which has proven to be a barrier their efforts to provide promotional opportunities for direct support workers.
Multiple organizations present at the meeting are currently working to address these barriers and training gaps. The RHA Howell Workforce Investment Network and the Lenoir Memorial Hospital Grow Your Own programs were specifically mentioned, both of which provide financial support for employees returning to school for additional training in a healthcare field. These programs were both formed to increase retention and improve the incomes of entry level workers. The Eastern AHEC (Area Health Education Center) is working to address retention issues at the community college, working with local high schools to ensure students are taking the right courses should they be interested in a healthcare career. The community college has also worked to address this issue through a job skills assessment program (Workkeys) and identifying transferrable skills. RHA Howell is also working on standardizing training for direct support workers, working with the internet-based College of Direct Support.
While subsets of employers have different challenges and are addressing the issues in different ways, many at the meeting agreed that there was room for collaboration. Partnerships have already formed between some of the participants, as Lenoir Memorial Hospital acts as a clinical rotation site for community college students, and has participated in some AHEC programs. There was some consensus around the idea of networks and relationships, which could provide efficiency as employees or applicants find that a specific work environment will not meet their needs. Other examples were mentioned, such as the Regional Skills Partnership in the Turning Point Workforce Development Board and the Baltimore Alliance, which could provide ideas for further collaboration in Lenoir County or the Eastern Carolina region. One participant mentioned that addressing common problems in their entry level workforce may be a starting point for collaboration. A potential barrier to this collaboration was discussed, however. Different employers require different skill sets at levels above entry level, a potential hurdle to a multi-employer career ladder.
Many questions remained unanswered—who should be included in this conversation? Should the partnership take a broad definition of healthcare, or a more narrow focus? However, many remain interested in the conversation, to be further facilitated by the Community Campus Partnership.
Conclusions and Recommendations
The goal of this analysis was to identify the causes of staffing difficulties, as well as potential targets for a career ladder initiative. We found that gaps in training, difficulty recruiting licensed professionals, as well as high turnover in entry level positions have led to common staffing challenges. Additionally, lower regional and county wages may make recruitment difficult, particularly for higher level positions. Many of these issues can be addressed through a career ladder program, much like the Workforce Investment Network established at RHA Howell or the Grow Our Own program at Lenoir Memorial Hospital.
A multi-employer initiative could brand the Lenoir County or Eastern Carolina regional healthcare employers, aiding in recruitment of both high level professionals and entry level employees. For entry level positions, having career advancement options can attract and retain employees who may otherwise seek less difficult occupations. Knowledge of career advancement opportunities can encourage high school students, or even displaced workers, to take the prerequisite courses for healthcare training programs. At higher levels, having a brand recognized as a high quality employer may allow Lenoir County healthcare providers to better compete with urban employers.
Additionally, a regional cooperation could address another training gap by utilizing standardized training for currently non-certified direct care givers within the region. Working within the existing state and national standards, adopting common training standards can allow employees to more easily move between employers. Standardized training will create a wider range of advancement opportunities for entry level direct support workers.
A career ladder initiative will be more effective if services are targeted to meet regional employment needs. Based on both the above quantitative analysis and interviews with local employers, we recommend the following:
Target nursing positions. The nursing workforce accounts for the largest segment of the healthcare workforce (Broome, 2010). All employers interviewed for this study indicated an established career pathway for the nursing staff, with additional education allowing nursing assistants to become Licensed Practical Nurses, and allowing LPNs to become Registered Nurses. There exist intermediate supervisory and leadership positions at many employers. LPN positions and RN positions both provide above median annual wages, and significant increases over certified nurse aides and direct support professionals. This occupational group has the largest overlap among the employer’s interviews for this study, making it a strong candidate for a structured career ladder program. A significant obstacle may be specialized skill needs, as the healthcare providers in the county often work to meet very diverse client needs.
Target high growth technical and therapy positions. The majority of technical and therapy positions identified in this study requires a one to two year diploma or associate’s degree, and provide a significant improvement in annual wages. The nature of the technical positions targeted through a career ladder program should be determined based on the healthcare providers included in the initiative. Among the fastest growing, however, are medical assistants, dental assistants, emergency medical technicians and paramedics, dental hygienists, diagnostic medical sonographers, medical records and health information technicians, and surgical technologists. Occupational therapy assistants, physical therapy assistants and respiratory therapists are also areas of opportunity. The short amount of training required, income potential and regional need for individuals trained in these areas makes these occupations potential fields in which entry level workers can achieve advancement.
Provide intermediate steps. The proposed career ladder for direct support professionals, put forth by RHA Howell, provides a good example of creating intermediate steps for entry level workers. As discussed at the stakeholder’s meetings, one of the main barriers to retention in community college programs is financial barriers. Creating intermediate steps, particularly in the nursing assistant and direct support professional fields, based on additional training and on-the-job experience can ease these financial barriers and provide incentives for workers to continue with their training. Even though many of these training programs are only two year programs, meeting prerequisites and working full time may increase the completion time significantly. Furthermore, providing higher level positions for nursing assistants and direct support professionals provides opportunities and rewards to those who are unable to complete an associate’s degree or chose to stay in these occupations. Leadership and advancement opportunities will create a true career ladder with smaller, more manageable, steps.
While these this initial analysis produced these recommendations, establishing clear goals for a collaborative initiative will require continued conversation among healthcare employers and institutions in the region, much like the meeting described above. It is our hope that this report may provide some common ground for further discussion as these partnerships form.
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