For more than a decade, analysts have sounded the alarm about the growing shortage of front line workers throughout the U.S. health care system. This sector of the health care industry—essential personnel such as nursing assistants, home health aides, respiratory therapists and many others who provide initial, direct patient care —accounts for more than half of the 12 million professionals engaged in health care and related services. Further, demand for these workers is growing faster than all other health care occupations, largely driven by the needs of an aging population of baby boomers, turnover and looming retirement of many of these employees.

Most experts agree that traditional recruitment practices won't be enough to reverse the severe labor shortage among this segment of direct care workers. The question then becomes, how will health care providers address this workforce challenge?

One organization, the Baltimore Alliance for Careers in Healthcare, has been at the forefront of this issue and its work is quietly having an impact throughout the Baltimore region and elsewhere.

Three years ago, BACH staff began looking at data that showed a growing demand for front line workers, both in the short term, as measured by rising turnover and vacancy rates, and in the long term, as indicated in high projections of job growth. In addition, they realized that local talent was insufficient to sustain a city in which health care drives its economy and captures nearly one-quarter of the state's health-related jobs. The solution: provide workforce strategies leading to worker mobility and wage gain while building capacity for the employer. The method: bridge the gap between unskilled, entry-level incumbents and skilled care jobs through custom-tailored training.

"With turnover rates near 30 percent at some hospitals and 3,000 new entry-level health care jobs anticipated for Baltimore by 2012, we knew we had to be innovative in our approach to reversing the turnover/vacancy trend as well as find a way to get qualified workers into the pipeline," explained Ronald Hearn, BACH's executive director.

The result was the introduction of 1st Span, a work-based learning program that combines class work, career coaching, peer mentoring and on-the-job training to help low-skilled workers become certified nursing assistants and progress into higher-paying patient care jobs.

BACH launched the program in 2007 with a $434,208 grant to be used over three years. The organization became one of nine recipients nationwide to participate in the Jobs to Careers initiative funded by the Robert Wood Johnson Foundation and the Hitachi Foundation. Jobs to Careers educates and advances front line health care workers across the country.

BACH partnered with two Baltimore hospitals—Good Samaritan and University Specialty— with an initial goal of training 64 certified nursing assistants. The idea was to put nonclinical hospital employees who aspire to acute care positions on a career path to achieving their first skilled patient care job. The plan also focused on reducing obstacles that typically prevent low-wage, inexperienced incumbents from career advancement.

After two-and-a-half years, the outcome has exceeded expectations. Five cohorts were enrolled across the two hospitals with the first beginning in 2007. The fifth cohort concluded last spring and a sixth is currently under way at USH.

So far, some 83 participants enrolled in the program, with 74 completing the training—50 as CNAs and 24 as nurse extenders or patient care technicians as they are called in some hospitals. One cohort had a perfect 100 percent completion rate and all 24 trainees went on to pass the national certification exam—a requirement for employment.

The CNA designation is the initial rung on the direct care career ladder, often used as a stepping stone to higher-paying acute care jobs that require additional skills and training (thus giving rise to the program's name—1st Span). Two students successfully completed both CNA and nurse extender programs and many have built on the confidence gained through their training experience by enrolling in college. Fourteen 1st Span completers are currently enrolled in two-year colleges and four are attending four-year institutions.

Other measures also demonstrate the program's initial success. Of the CNAs who completed the training, 82 percent remained employed by their home hospital. Similar figures for nurse extenders will not be available until August 2009. Fifty-three individuals advanced to a new job and 52 increased their wages, on average, nearly $2 an hour.

"We were very pleased with the results," said Joanne Eich, director of nursing education and staff development at Good Samaritan Hospital. She says the learning model has contributed to a recent reduction in turnover rates at her hospital and the initiative is also improving the overall number of frontline workers in Baltimore's health care system. "We have enjoyed a wonderful relationship with BACH. We couldn't have done it without them," she said.

This kind of cooperative investment has had a profound impact on workers and the quality of care they provide by raising morale and creating a greater sense of employee loyalty. "It was a life-changing experience. They invested in me," explained Natalie Elliott, a 28-eight-year-old mother of three who was an emergency room transporter at Good Samaritan before getting into the program in 2007.

Jerome Price, a laundry worker at Good Sam for four years, completed the CNA training in 2008 and is now working with patients in the rehab unit. He says he's earning more and he intends to advance his career further by enrolling in community college classes this fall. "It was the best decision I've made in my life. This is my second home. I love what I'm doing and the patients love me," said the 25-year-old Baltimore resident.

1st Span is also creating a new model for the future where hospitals are able to "grow their own" workforce as needs dictate. BACH ensured the program conformed to state and workforce standards, but allowed a great deal of flexibility in its implementation. "They have been incredibly flexible. We changed things as needed without any bureaucracy," said Rhyannon Potter, career coach at USH. A group from each hospital meets regularly to discuss challenges and share experiences. Potter said the meetings have provided a great support system for her and other career coaches.

Both hospitals recruit workers from within their own employee ranks to enroll in the program. Those who successfully complete the training are guaranteed a position contingent upon national certification and licensure by the State of Maryland. Potter said USH also requires a six-month probationary period similar to all new hires. Good Sam works slightly differently, according to Eich, who says trainees are hired up front as CNAs when they enroll which helps the hospital support the various departments by allowing vacated positions to be filled quickly to avoid interruption in service and undue hardship on other staff.

Good Samaritan President Larry Beck has embraced the BACH model. "If he didn't value this, we wouldn't be here. He believes that everyone deserves a chance and that patient care is number one," explained Eich. Good Sam's work-based education efforts have paid off. The hospital has shown solid increases in employee retention, significant reductions in staff turnover and it scored above "world class" in employee satisfaction, according to a 2008 hospital survey.

"It's all about investing in human capital, raising employees up and helping hospitals become learning organizations," says Hearn. "The challenge of refocusing an entire hospital infrastructure to be able to provide reward and mobility to a critical segment of its workforce can be a complicated task. We were fortunate to find two fine hospitals committed to a common goal and poised to partner with us," he said.

An added benefit, Hearn pointed out, is the knowledge all partners gained from one another about developing and retaining a front line workforce. "As a workforce intermediary, it is critical for us to learn how to work together. Collaborating with interested parties toward a shared goal of improving the delivery of health care is the most important role we play," he explained.

The program is designed to remove personal and financial barriers which often limit the career mobility of low-wage, entry-level workers. Students are immersed 40 hours a week for six weeks. They are shuttled by bus to classes at the Community College of Baltimore County and split the rest of their time between the nursing lab and working at their home hospital.

With input from the hospitals and the Maryland Board of Nursing, CCBC developed a unified curriculum. "We wanted to be able to make training portable," said Mickey Jancewski, director of Health, Allied Health and Workforce Development at CCBC.

Transportation to the college was covered by BACH as well as textbooks and supplies. In addition to training costs, BACH was able to underwrite half the cost of each career coach and provide a stipend for most students to buy shoes and scrubs. Eich said that BACH's share of coach funding has been reduced each year to allow Good Sam to eventually become self- sufficient in this area.

Two of the most valuable components of the work-based learning experience have been career coaching and a tracking database called Efforts to Outcome. Barbara Hopkins, who adapted the ETO software for BACH, says that the organization has found a way to translate critical elements into a model that is helping hospitals improve retention rates and provide career mobility for workers.

A centralized database allows personnel who oversee the program at each hospital and at BACH to record information seamlessly. The data are then analyzed by Hopkins and used to track individual student performance and overall program progress. Configuration of the database aids Hopkins in reporting program outcomes to BACH's funding organizations in a specific format called Results-Based Accountability. She says RBA addresses a number of elements related to workforce challenges such as retention, job advancement and wage increases. Coordinators at both hospitals admit the system got off to a bumpy start, but over time the kinks have been ironed out and the process is now fully integrated into the program.

Most everyone involved with 1st Span agrees that career coaching has been the backbone of BACH's work-based learning success. "It is at the center of the grow-your-own philosophy and needs to be institutionalized," Hearn emphasized. Coaches, usually nurses, who are assigned to the program provide a variety of support services to students ranging from goal setting to conflict resolution. "Coaching is a very important piece. [Coaches] develop trust with each individual, act as intermediaries and reduce barriers," says Eich.

"My coach was wonderful," exclaimed Natalie Elliott referring to Good Sam's Joy Burke. "She cares and she's there for you." Even after completing the program Elliott says she can still pick up the phone and talk to her coach about a problem.

Coaches strive to bring out the best in their trainees and help them realize their own potential. "I'm so proud of them," says Potter, referring to her students who completed the program at USH. She wishes more hospitals would replicate the practice of "growing your own."

Johanna (JoJo) Romero de Slavy, also a career coach at Good Sam, described successful CNA trainee Jerome Price this way, "I knew he was a good soul, good-hearted. He just needed a chance," she said.

BACH's reputation in the area of workforce development is attracting interest from around the country. Health care organizations from Detroit to D.C. want to borrow from BACH's methods and gain similar success in their own communities. Locally, officials at MedStar Health, Good Sam's parent company and one of the region's largest employers, are in preliminary discussions with BACH about replicating the model throughout its entire system of eight hospitals in the Baltimore-Washington area. In Baltimore County, Genesis Health Care recently partnered with BACH to offer work-based training to its employees.

Students who have successfully completed their training see its value far beyond providing them with a required credential. "I gained so much confidence. This program is so great, I wish they would offer it all over the State of Maryland," said Angie Goings who recently completed requirements to become a patient care technician at USH and is awaiting the results of her score on the national exam.

When asked about the future of 1st Span in the face of current economic conditions, BACH's Hopkins believes that the present conditions will be short lived, but the need for front line workers will continue to exist.