Training, Recruitment, and Retention

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What are Registered Apprenticeships?

Registered apprenticeships are high-quality career pathways and “earn-and-learn” models that have been verified by the U.S. Department of Labor or a State Apprenticeship Agency. Registered apprenticeships meet industry and federal standards that ensure jobseekers can become skilled in a trade or profession leading to a nationally-recognized credential and/or career in a specified field. They can be a useful strategy and accessible pathway, especially in direct care fields, as the learner gains a blend of education and hands-on experience while healthcare employers shape their talent pool by playing an active role in their training. In the healthcare workforce registered apprenticeship programs for nursing assistants and social and human service assistants, for example, have been successful pathways to careers in healthcare and there are increasing opportunities to build programming for other direct care roles.

How can you establish a registered healthcare apprenticeship program in your state?

1. Select the occupation for your apprenticeship program. The first step in establishing a registered healthcare apprenticeship program in your state is identifying an appropriate and needed occupation. Think about where there is a current or future healthcare workforce need and determine whether it can be appropriately administered in an apprenticeship format.
2. Identify a sponsor(s) and a partner(s).
3. Determine the appropriate registration level. All apprenticeship programs have a set of standards that must be approved by federal and/or state registration agencies. Which approval is needed will be based on the apprenticeship occupation and state policies, but federal approval takes precedence over state approval - thus, if an apprenticeship program has already met the standards for national approval, it does not need to be registered by the state as well. If the apprenticeship program will involve multiple states, it requires national approval. If the program is limited within a state with a state approval agency, that is the only level of approval/registration required.
4. Develop core components of your apprenticeship program.
5. Launch and manage your program.

Additional resources to support establishing a registered healthcare apprenticeship program are available at: U.S. Department of Labor: Updated Guidance - Minimum National Program Standards for Registered Apprenticeship Programs

Overview of Workforce Development

Workforce development is a way to approach economic growth and opportunity within state and local communities. The goal is to provide workers with information, advice, job search assistance and training so that they develop into the type of employees that get and retain good jobs. The approach of workforce development is personnel focused rather than business focused, and will provide workers with tools to overcome barriers to job acquisition as well as creating skills within the talent pool. Workforce development is generally applied in two ways within a given community: place-based approaches focus on the needs of a population within an area, while sector-based approaches address coupling workers' skill sets to needs in an industry.

State-based Workforce Development Approaches

When identifying occupations of focus for the application of their WIOA funds, states often rely on partnerships formed between employers and educational entities, such as a school or post secondary institution. This is due to the fact that work-based learning programs include a continuum of activities that comprise everything from career exploration to registered apprenticeship. When identifying sectors of focus for their funds, states with existing WBL partnerships referenced multiple best practices to consider when partnering with stakeholders including:

• Using asset mapping and gap analysis’ to identify target stakeholders that can help fill existing gaps in student participation or industry representation
• Co-creating and co-branding programs, policies, and resources whenever possible
• Building in a feedback loop so necessary adjustments can be made to address under represented sectors and populations

Partnerships Between the State, Employers, and Training Providers

Work-based learning provides potential employees with authentic work experiences where they apply and develop employability and technical skills that support success in careers and postsecondary education. Work-based learning activities culminate in an assessment and recognition of acquired knowledge and skills. Governors and state policy makers can encourage strong partnerships between education and business through holding regular convenings with both parties, incentivizing partnerships through funding or other avenues, and creating resources to help interested stakeholders form strong partnerships and programs. Examples of potential government partners include state departments of education and/or higher education, two- and four-year colleges, and school districts. These government partners can form relationships with community-based organizations, non-profits, individual employers, and industry associations to enhance worker training. For additional information about state approaches for industry-level coordination of workforce strategies related to health workforce, see the Health Resources and Services Administration’s Health Workforce Strategic Plan from 2021.

Alignment of Earn-and-Learn Strategies with Stackable Credentials

Stackable credentials focus career and technical education programs on building the critical skills needed for students to advance in growing sectors of the economy. By awarding credit for a range of education, training, and workplace learning and skill building experiences that "stack," toward associate degrees, stackable credential programs help working students develop the skills they need to advance on the job and earn credentials that enable further study – at the same time. This accelerates credit attainment and may increase the likelihood of degree completion. By allowing workers to stack credits, states can increase the job pool with skilled workers and use their partnerships to place applicants in fields desperately needing their services.

Other State-based Workforce Development Opportunities

• Pre-apprenticeships: Pre-apprenticeship is a program or set of services designed to prepare individuals to enter and succeed in a Registered Apprenticeship program. A pre-apprenticeship program, by definition, has a documented partnership with at least one Registered Apprenticeship program. Quality pre-apprenticeship programs are a starting point toward a successful career path for under-represented job seekers (such as disadvantaged women and men, individuals with disabilities and others) who may not be aware of this approach to obtain good jobs with opportunities for advancement. Pre-apprenticeships help individuals meet the entry requirements for apprenticeship programs and ensure they are prepared to be successful in their apprenticeship.
• Youth apprenticeship: Youth apprenticeship programs are for high school students who combine academic and technical classroom instruction with work experience through a Registered Apprenticeship Program. It provides the foundation for students to choose among multiple pathways after high school – to enroll in college, to enter an apprenticeship program, begin full-time employment, or a combination.

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Variations in education and skills requirements can make navigating or transitioning to a career in healthcare difficult for job seekers. Many of the direct care jobs in the healthcare industry require limited training and education, but the path towards them is unclear or otherwise under communicated at critical transition points in a person’s work or education journey. At the other end of the spectrum, highly trained healthcare professionals can struggle to find meaningful opportunities for upskilling. For jobseekers who are underrepresented in the healthcare field, this lack of clarity serves to weaken an already meager health workforce.

Income share agreements and other workforce development strategies can be effective in retaining and attracting workers to the healthcare field. However, more deliberate and aligned efforts across states are needed to fill the workforce gap and develop a more future-ready healthcare workforce. Having a healthcare workforce system that aligns career pathways and workforce development strategies and clearly maps a viable career trajectory for jobseekers ensures individuals have a clear understanding of career opportunities for roles. This comprehensive career pathway creates more opportunities for workers while sustainably meeting a need for healthcare workers that is expected to worsen in the coming years. Healthcare career pathways that are better aligned with workforce development strategies also allow individuals to understand their skills gaps and ensure that individuals have a clear understanding of career opportunities that lead to careers with family-sustaining wages and satisfy the workforce needs of the healthcare field.

What is a career pathway?

Career pathways are defined by the Workforce Innovation and Opportunity Act (WIOA) as: a combination of rigorous and high-quality education, training and other services that meet the following criteria:

1. Aligns with the skill needs of industries in the economy of the State or regional economy involved;
2. Prepares an individual to be successful in any of a full range of secondary or postsecondary education options, including apprenticeships;
3. Includes counseling to support an individual in achieving the individual's education and career goals;
4. Includes, as appropriate, education offered concurrently with and in the same context as workforce preparation activities and training for a specific occupation or occupational cluster;
5. Organizes education, training, and other services to met the particular needs of an individual in a manner that accelerates the educational and career advancement of the individual to the extent practicable;
6. Enables an individual to attain a secondary school diploma or its recognized equivalent, and at least 1 recognized postsecondary credential; and
7. Helps an individual enter or advance within a specific occupation or occupational cluster.

The term “career pathway" is defined in the same way in WIOA as well as Perkins V pointing to the alignment between career and technical education and workforce paths. Healthcare workforce careers are often at the center of aligning those paths as many healthcare careers that are experiencing the highest workforce shortages span CTE education and workforce education programs.

State examples of processes for mapping career pathways for a health sector

Several states have built out career pathways in the health sector. See below for examples on how those pathways were developed, who were the partners, and other helpful information.

• Example: Georgia Board of Health Care Workforce
  • Who: The Georgia Board of Health Care Workforce (Board) is a 15-member body appointed by the Governor and confirmed by the state Senate. The Board includes practitioners, health system representatives, and consumer members.
  • What: The Board meets quarterly to identify health workforce needs (through production of health workforce data reports) and support development of programming to meet those needs (such as loan repayment programming or directing medical education funding).
  • Mechanism of Formalization: The Board receives an appropriation from the General Assembly to execute its functions (including separate appropriations for administrative activities and funding for programming). The Board is outlined in statute and has associated rules and regulations.
  • Example of Outcome: The Board produces an annual report which outlines activities completed that year, with financial reporting how funds were directed.
• Example: My Colorado Journey
  • Who: The Colorado Workforce Development Council is a Governor-appointed  public-private partnership formed under the Federal Workforce Investment Act of 1998. The council is currently made up of employers, workforce representatives, government representatives, postsecondary leaders, and corrections office representatives.
  • What: The council is made up of committees that focus on aligning the council with the Colorado Blueprint, the WIOA state plan, Colorado Rises, and other talent development priorities; aligning efforts throughout the state with the development and implementation of career pathways; advising on sector partnerships and support to workforce development boards and industry intermediaries, and evaluating and communicating policy and legislation that will impact workforce issues.
  • Example of Outcome: Each year the Council adds career pathway information to My Colorado Journey. Currently, their healthcare career pathway includes 14 pathways.

Marketing of career pathways

The existence of healthcare career pathways may not be immediately obvious to interested jobseekers. Information about healthcare career opportunities can be hidden on websites or only known by the people who operate them, and this creates a barrier to entry, especially for jobseekers who are new to the healthcare field. It is not enough just to have created the career pathway – the marketing of the pathways should also be considered. For them to be feasible and attractive options to jobseekers, they have to be marketed to the interested jobseeker. Below are things to consider in your marketing strategy for career pathways:

Accessibility: Consider how jobseekers and career counselors learn about the healthcare career pathway in your state and what information is provided at a glance. Providing useful and enticing information up front such as additional education requirements needed, credentials earned, expected and potential wages, and employment outlooks, can entice a job seeker and move them towards enrollment in a program or prompt them to seek out more information about the pathway.

Potential Partners: States should also consider potential partners for dissemination of healthcare careers marketing materials. There are a range of workforce and education partners that play a key role in recruiting potential healthcare workers and attracting them to the field.

Which audiences should be partnered with for dissemination?

States have different approaches and options for partners in disseminating information about healthcare career pathways to jobseekers and students. Depending on the length and breadth of the pathway, a range of partners at every career pathway touchpoint should be engaged in marketing the career pathway. Along with major employers, state and local partners include, but are not limited to, higher education agencies, career schools, hospitals, primary care associations, and adult basic education providers. Dissemination by the governor’s office and local elected officials can also be helpful.

Incentivizing career pathways

Career pathways require a combination of state resources and buy in from employers and postsecondary institutions to be successful. Though employers ultimately benefit from workforce development, it can be a costly investment, especially for small and medium-sized employers who often have fewer resources to contribute to workforce training for future employees. For small institutions and community colleges, it can be costly to train faculty and bring in the necessary technology to meet the demands of a changing healthcare system. Some states have taken to better aligning themselves with postsecondary and employer networks to remove recruitment, training, and hiring barriers. Still many stakeholders are requiring other incentives to ensure the longevity of their workforce development programs.

Assessing career pathways in healthcare

States are positioned to assess healthcare pathways using administrative data. (State Sources of Health Workforce Data is available on the Data & Planning page of the toolkit.) The healthcare sector is highly regulated and its workforce is no exception. Many healthcare occupations/professions are regulated by the state, either through licensure or certification. Career pathways among healthcare occupations, such as within nursing professions, are well documented. Quantifying the number of individuals that have taken specific healthcare career pathways and understanding characteristics of individuals on these pathways can be helpful to inform state policy making.

• Indiana linked licensure records for Certified Nurse Aides (CNAs), Licensed Practical Nurses (LPNs), Registered Nurses (RNs), and other licensed healthcare occupations using social security numbers to quantify healthcare career pathways of Indiana CNAs. Simply by linking these records, the state was able to identify more than 10,000 individuals that held CNA certifications and went on to obtain licenses as LPNs and/or RNs. Further linkage of licensing information to demographic data identified significantly greater diversity among Indiana nurses that had held a CNA. As a direct outcome from this work, Indiana community college approved a bridge program, which awards five credits toward nursing education for individuals who have CNA certification.

Resources

Building Industry-Driven Career Pathway Systems in Colorado: A Step-by-Step Guide, Colorado Workforce Development Council, 2016

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Definitions

• Racial concordance refers to a shared identity between two people with regards to their race. In the case of healthcare workers, racial concordance refers to a shared identity between a healthcare worker and patient regarding their race.
• Racial discordance refers to two individuals having different identities with regards to their race. In the case of healthcare workers, racial discordance refers to a healthcare worker and patient having different racial identities.
• Cultural Competence refers to the ability of a person to effectively interact and work with people of different cultures and belief systems than their own. 
• Cultural Responsiveness refers to the ability of a person to respond respectfully and effectively to people of all cultures, languages, classes, races, ethnic backgrounds, disabilities, religions, genders, sexual orientations, and other diversity factors in a manner that recognizes, affirms, and values their worth.
• Culturally Anticipatory refers to the ability of a person to proactively anticipate and respond in a manner that that recognizes, affirms, and values the worth of people of all cultures, languages, classes, races, ethnic backgrounds, disabilities, religions, genders, sexual orientations, and other demographic factors.

Why is this important?

Research has long demonstrated the important role of race and culture in the relationship between healthcare workers and their patients. Having healthcare workers that understand, value and respect the identity of diverse populations improves healthcare access, quality and outcomes. Personal knowledge of a race and culture or appropriate training can prepare healthcare workers to provide person centered care.

Racial concordance between healthcare workers and patients has been associated with improved healthcare. Having a workforce that reflects the population can enhance the opportunity for racial concordance between healthcare workers and the patients they serve. Enhancing diversity and representation within the healthcare workforce is a priority for many states and organizations.

While the information related to diversity in the health workforce contained in this tool is focused on racial and ethnic diversity, it is important to note that diversity extends to numerous other characteristics. For example, underrepresentation by gender, sexual orientation, disability status, and geography are common among certain health professions. Strategies presented herein may be targeted to meet state diversity goals set for any population.

What can Governors and states do?

1. Keep a finger on the pulse of diversity and representation within the healthcare workforce.

As described in the Health Workforce Data and Planning page of the toolkit, states are strategically positioned to use existing data sources or collect supplemental data on the demographic characteristics of healthcare workers. Demographic information, such as race, ethnicity and gender, can be used by states to assess representation within various healthcare professions/occupations.

Consideration:

• Measuring Diversity: Demographic data on healthcare workers can be used to determine the proportion each race, ethnicity, or gender represents of an overall profession/occupation. For example, there are 100 Nurses in state XYZ and only 12 of them identify as Black or African American. In this case, Black or African American Nurses represent 12% of all Nurses. Tracking such data over time can be useful to monitor the effectiveness of policies and programs seeking to increase diversity and representation.
• Comparing the Workforce to the Population: Demographic data on the healthcare workforce provides an understanding of representation in the workforce, but comparing workforce demographics and representation to that of the overall population provides states with insight on the extent to which concordance exists (or does not exist). This type of information can be used to understand the extent of underrepresentation as compared to the population.  For example: In state XYZ, Black or African American Nurses individuals account for 28% of the total population within the state, but only 12% of Nurses within the state. As compared to the state’s population, Black or African American individuals are significantly underrepresented in the Nursing workforce. State XYZ may use this information to set targets and inform the development of programs which support the recruitment of BIPOC individuals into nursing.
  • Additional information: Depending on the data available, diversity and representation assessments can be done at the state level, or within smaller areas, such as counties. Smaller area assessments can be used to identify and target geographic areas where the greatest underrepresentation exists.

State Examples:

• Indiana collects demographic data from healthcare professionals during the biennial license renewal process. These data are used to monitor trends in diversity and representation. Aggregated data are made available in various formats: Data Reports, Brief, Interactive Dashboards.
• Minnesota also monitors health workforce demographics through data collected from healthcare professionals during license renewal. An interactive dashboard is available to quickly compare demographic characteristics across health workforce types.
• The Oregon Health Authority released a report exploring the Diversity of Oregon’s Licensed Health Care Workforce which explored race, ethnicity, gender, and languages spoken of healthcare professionals.
• Virginia Department of Health Professions collects demographic data from health professions biennially as part of the license renewal process. Aggregated data by reporting year are publicly available via an interactive dashboard.

Resources

• The George Washington University Fitzhugh Mullan Institute for Health Workforce Diversity hosts a Health Workforce Diversity Tracker which presents a state level diversity index for 10 health professions.

2. Targeted workforce development opportunities

Pipeline programs

• Secondary Career and Technical Education (CTE)
  Secondary career and technical education programs remain a viable on-ramp for careers in STEM fields, especially healthcare. They can also be a starting point for equitable recruitment and retention initiatives that lead to sustained health workforce diversity. In October 2022, the Project on Workforce brought together Harvard’s policy, business, and education graduate school fellows to develop an analysis of best practices to advance equity in secondary CTE. The culminating report details specific state strategies that target performance equity gaps, and data quality and collection systems with the aim of diversifying the workforce pipeline. The report includes recommendations for state and federal policymakers and leaders to bolster their workforce through equity and data quality in CTE.

• Area Health Education Centers (AHECs)
  The AHEC program is a federal program administered by the Health Resources and Services Administration focused on developing and enhancing education and training networks within communities, academic institutions, and community-based organizations. These networks aim to increase diversity among health professionals, broaden the distribution of the health workforce, enhance healthcare quality, and improve healthcare delivery to rural and underserved areas and populations. Many states have federally funded AHEC Networks. Some states seek to enhance the reach of their AHEC programs and support diversity initiatives through targeted state appropriations.

• HCOP
  National HCOP Academies are federally supported initiatives administered by HRSA to assist individuals from disadvantaged backgrounds to enter a health profession through the development of academies that will support and guide them through the educational pipeline.

Incentive Programs

See the Recruitment and Retention sections for additional information about incentive programs that have been developed and implemented by states.

Continuing education in cultural competence and/or cultural responsiveness

Cultural competency and responsiveness training has been demonstrated to be effective in generating knowledge and skills related to a culturally competent practice.

• Some states (such as Oregon) require cultural competence training for health professionals as a part of continuing education requirements for license renewal.
• New Jersey has similar continuing education requirements for physician licensure and also requires cultural competence training to be incorporated into medical school programming.
• The U.S. Department of Health & Human Services tracks cultural competency training requirements in states and territories for healthcare providers; see here for more information.

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Retaining healthcare workers is a top priority. There are a number of professional and social factors influencing retention of healthcare workers. Financial incentives are among the factors that have an important role in retaining workers. Healthcare worker compensation varies widely by profession, practice type/specialty, geography, and various other characteristics. Among some health workforces, such as direct care workers, low wages threaten retention of workers who may pursue higher paying jobs with fewer requirements in other sectors.  Other health workforces, such as the licensed healthcare professions, require at least a baccalaureate degree to qualify for licensure, and many require a master’s or doctoral degree. Upon completion of an academic training program, many healthcare professionals graduate with a debt burden. There are a number of strategies that have been explored, both within states and by states, to support healthcare workforce retention.

Loan Repayment

Loan repayment is a common strategy to incentivize healthcare professionals to practice in areas of need. Loan repayment programming exists at the national level for many health professions through the National Health Service Corps and Nurse Corps, administered by Health Resources Services Administration. In addition to national programming, states have invested in loan repayment strategies to support strategic recruitment and retention of health professionals. One such strategy is the State Loan Repayment Program through NHSC which requires a state match commitment and adherence to federal requirements. States may also develop additional state-level loan repayment strategies where the state has more autonomy over program design and implementation. Generally, state-operated loan repayment strategies are appropriated funding through the legislature and are designed to address a specific state workforce need.

Additional Information

• National Health Service Corps loan repayment opportunities
• Nurse Corps Loan Repayment Program
• Federal match State Loan Repayment Program

Examples of state-operated loan repayment programs:

• Comprehensive Loan Repayment Programming: Nebraska has created a suite of loan repayment programming for healthcare professionals, and published an evaluation of this programming which reported that the overall fiscal impact on communities was 72 times the loan repayment funds invested by the state.
• Broad Loan Repayment Programming: Colorado operates a Health Service Corps Program which includes a large number of eligible professions at various approved sites throughout the state.
• Addressing Behavioral Health Needs: New Jersey established the Behavioral Healthcare Loan Redemption Program which offers $50,000 to behavioral healthcare providers in exchange for two years of service at an approved site (an additional $5,000 is available for professionals working primarily with children or adolescents).
• Addressing Nursing Faculty Needs: Colorado has established a Nurse Faculty Loan Repayment program to support recruitment and retention of nurses with master’s degrees to serve as faculty.
• Supporting Retention in Rural Communities: Minnesota operates a suite of Health Care Loan Forgiveness Programs, including programs targeting recruitment and retention in rural communities. Separate programs are in place to support rural healthcare professionals in the following profession types: 1) Dental Therapists/Advanced Dental Therapist, 2) Mental Health Professionals, 3) Advanced Practice Providers, 4) Pharmacists, 5) Physicians, and 6) Public Health Nurses. In a similar vein, Kansas operates a Residency Bridging Loan Agreement, which is funded through appropriation, and is used to provide a payment to residents agreeing to establish a practice in certain non-metro counties. Colorado also offers a Rural Essential Access Provider Loan Repayment Program to support rural providers.

Tax Incentives

States may consider tax incentives, such as Tax Credits, as a strategy to retain healthcare workers. A tax credit is an amount of money that a taxpayer can subtract, dollar-for-dollar, from the income tax owed. State tax credit strategies may focus on providing retention incentives to specific professions or for professionals working in specific geographies.

• Colorado and Maryland have established an Income Tax Credit for Preceptors to support individuals that serve as an uncompensated preceptor in shortage areas.
• New Mexico has established a Rural Health Care Practitioner Tax Credit Program which allows certain healthcare providers who provide care in rural and underserved areas to be eligible for an income tax credit of $3,000 or $5,000.
• Georgia and Oregon have established a $5,000 tax credit for physicians who practice and reside in a rural county or a county contiguous to a rural county.
• Oregon has also established a Rural Volunteer EMS Provider Tax Credit whereby qualifying volunteer providers may receive a $250 personal income tax credit for their service.
• Utah has established a $10,000 tax credit for qualifying mental healthcare practitioners renewable for up to 10 years.

Housing Support

The United States Department of Agriculture offers a number of programs to provide housing support for both single family and multi-family housing for first time home buyers in rural America. While multi-family opportunities are accessible to applicants directly through the U.S. Department of Agriculture at the federal level, single family housing support programs are administered through the state rural development office. Both programs offer support in the form of no downpayment, low rates, relocation, and/or construction support for qualifying individuals seeking housing in rural communities.

In addition to state-level approaches, healthcare employers are also working to address housing challenges. A recent report by the American Hospital Association presents several examples of healthcare employer housing assistance programs.