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From the Entry Level to Licensed Practical Nurse: Four Case Studies of Career Ladders in Health Care

• Community College of Denver

• 1199C Training and Upgrading Fund

• Workforce Alliance and Hospital Corporation of America

• WorkSource Partners

By Susan Goldberger

Part of a series of reports onAdvancement for Low-Wage Workers

S E P T E M B E R 2 0 0 5

Table of Contents

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Community College of Denver: CNA-to-LPN Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4

1199C Training and Upgrading Fund:LPN Career Ladder Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Workforce Alliance and Hospital Corporation of America:LPN Career Advancement Program. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10

WorkSource Partners:Regional Advancement Centers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

From the Entry Level to Licensed Practical Nurse: Four Case Studies of Career Ladders in Health Care

Introduction: Strategies for DesigningLPN Programs for Low-Skill/Low-Income Workers

Fueled by government funding and increasedemployer investment in “grow your own” strategies toaddress the severe shortage of nurses, a handful ofinnovative Licensed Practical Nurse training programshas arisen to serve low-income adults working inentry-level health care. These programs share severalfeatures that set them apart from traditional LPNtraining programs and account for their success inhelping low-income working adults with limited edu-cation enter and complete demanding LPN trainingprograms:

• They provide intensive academic remediation inmath, reading, and writing to prepare students forcollege-level work and pass program entrance exams.

• They offer part-time or evening/weekend schedulesso that participants can continue working while theyare in school.

• They provide formal tutoring and counseling sup-port to students once they enter the program to helpthem meet the demands of school, work, and family.

Most important, they incorporate their programsof study into well-defined steps of employer-sponsoredcareer ladder programs that offer financial support,classes at or near the worksite, and clear rewards in payand promotion for successful completion of each step.Sponsoring employers typically pay tuition costs inreturn for the student’s commitment to continue towork for them for a period of time upon graduation.

While the programs profiled here share many simi-larities, they vary in the types of educational providersthey use and the nature of program sponsorship. Twoprograms use community colleges to provide training,another uses a non-profit vocational school, andanother runs its own vocational LPN program.Program sponsors include a large nursing homeemployer, a jointly administered union-managementtraining fund, a community college-initiated partner-ship with local nursing home employers, and aWorkforce Investment Board-initiated partnershipwith local area hospitals.

The research for these case studies was conductedin conjunction with the preparation of The Right Jobs:Identifying Career Advancement Opportunities for Low-Skilled Workers. This guide for workforce developmentpractitioners is available on the Jobs for the FutureWeb site at: www.jff.org/jff/kc/library/0261.

From the Entry Level to Licensed Practical Nurse

Jobs for the Future: From the Entry Level to Licensed Practical Nurse 3

Overview

Community College of Denver, in partnership withthe City of Denver’s Division of WorkforceDevelopment and local health care employers, hasdeveloped a part-time, evening and weekend worksiteprogram to prepare Certified Nursing Assistants andother entry-level workers to become Licensed PracticalNurses (LPN). The program begins with a nine-hourNursing Success Course in which students receivecounseling on life skills, time management, and studyskills. Customized to meet the needs of each student,the program provides a Learning Lab that offers up tothirty weeks of remedial instruction in math, reading,and writing to prepare students for college-level coursework. This accelerated remedial instruction, deliveredin three ten-week modules, can take students with aslow as a third- to fifth-grade math, English, or readinglevel up to the eleventh-twelfth grade level required forentry into the LPN program. Tutoring is provided inall Learning Lab courses, and students have access toadditional tutoring support at the college campus.

Once students complete the Learning Lab, theytake all prerequisite courses required for entry into theLPN program, including nutrition, medical terminol-ogy, English composition, and anatomy and physiol-ogy. After completing the prerequisite courses, stu-dents move into the nursing classes required forlicensure. All courses are delivered at the worksites ofparticipating employers, who provide classroom spaceand coordinate work schedules for employees. Coursesmeet two evenings per week and are offered consecu-tively, so students are only enrolled in one class at atime. In addition, students complete five clinical rota-tions over fifty-five weeks, with rotations taking placeone to two days a week, depending on the specialty. Tothe extent possible, clinical rotations are scheduled forSaturdays, and the first rotation is done at theemployee’s worksite.

This worksite LPN training program is designedto meet employer needs for skilled nurses while pro-viding a career advancement ladder for dedicated,frontline caregivers. As such, it relies upon employersupport for its success. Employers adjust work sched-ules of participating employees to accommodate pro-gram demands. In addition, most employers providefunding to help pay for tuition and fees; some providepaid release time.

Program Design and EntryRequirements

To be eligible, employees must meet their employer’scriteria for program participation—such as a mini-mum period of employment at the facility, exemplaryperformance evaluations, and the recommendation ofsupervisors. While there are no minimum academicrequirements to enter the program, all participantshave tested at a sixth-grade reading level or higher.However, many have scored in the third- to fifth-graderange in math. In order to take prerequisite nursingcourses, participants must raise their reading, writing,and math skills to an eleventh- to twelfth-grade level.

To accomplish this goal, the program begins withan intensive academic remediation component, theLearning Lab. This is divided into three ten-weekmodules customized to the entering skill levels of par-ticipating students. It is designed to enable incumbentCertified Nursing Assistants and other entry-level staffto advance from the lowest development skill levelinto college-level courses in half the time required intraditional development education. Each ten-weekmodule consists of ten hours of instruction a week:two three-hour classes after work, and a four-hourSaturday morning learning lab. The first ten-weekmodule is reserved for those who are at the lowestdevelopmental math level (i.e., third- to fifth-gradelevel). Those assessed at a sixth-grade or higher readingand math level skip this first module. The second ten-week module covers math, reading, and writing; it is

FROM THE ENTRY LEVEL TO LICENSED PRACTICAL NURSE:

Community College of DenverCNA-to-LPN Program


designed to move students who start at a sixth- toeighth-grade level in these subjects up to a ninth-gradelevel. Employees who initially test at a ninth-gradelevel or above may skip the second module. The finalten-week module moves students from a ninth-gradereading, writing, and math level to college-ready stan-dards (grade eleven or twelve).

In addition to offering classes at the worksite, theprogram provides several layers of support: counselingfrom a case manager, on-site tutoring throughout theLearning Lab, and peer support, which is encouragedby grouping employees from the same facility togetherfor classes. Students also have access to all CommunityCollege of Denver support services. Tutoring and peersupport are not the only ways the program promotesacademic success. The program also makes the aca-demic content more accessible by using health careexamples as the context for teaching math and literacyskills. Class sizes average 12 to 15 for modules deliv-ered at the worksite.

Entry into LPN Program

Employees who complete the Learning Lab modulesmove on to take four college courses required for entryinto the LPN nursing courses. These prerequisitesinclude medical terminology (1 credit), nutrition (1credit), English composition (3 credits), and anatomyand physiology (4 credits). Once employees pass thesecourses, they can enroll in the nursing courses.Participants can bypass the general waiting list forentry into the college’s LPN program because thispart-time, employer-supported program is speciallydesigned and funded to serve employees of participat-ing facilities. All Learning Lab, prerequisite, and nurs-ing courses are offered at the worksite.

The entire program takes about two and a halfyears to complete:

Learning Lab 30 WeeksPrerequisite Courses 23 WeeksNursing Courses 74 Weeks

127 Weeks

Description of ParticipatingEmployees and Employers

Since 2002, when the city’s Division of WorkforceDevelopment asked the Community College ofDenver to develop a nursing career ladder program forentry-level health care workers, the program has part-nered with 10 health care organizations, most with


multiple facilities, to serve 230 workers at 26 nursinghomes, hospitals, and outpatient facilities. Mostemployers support the financing of the program sev-eral ways, including providing classroom space, com-puters, and tuition reimbursement. Participants arelow-income employees working as Certified NursingAssistants and clerical, dietary, laundry, and house-keeping staff.

The program provides tangible benefits to employ-ers, making it worth their investment. In addition tohelping them fill critical nursing positions with staffwho understand the culture of the institution andhave previously demonstrated their abilities as care-givers, the program also helps employers to retainthese proven employees. Employers are virtually guar-anteed that program participants will stay in theiremploy for the duration of the program. Also, partici-pants are typically high-caliber employees who arehappy with their jobs and see the program as a job-related benefit.

From the student’s point of view, the “cohort”model, in which employees from the same facility aregrouped together for classes, provides important peersupport. Additionally, they appreciate their employer’stangible support and encouragement. Both sides wishto see the students continue in their employ as LPNsafter they complete the program and pass the licensureexam. However, it is also realized that employers maynot be able to absorb all LPNs at one time.

Costs and Financing of Program

The cost of the preparatory or Learning Lab portionof the program varies by the number of modules that astudent is required to take based on his or her enteringACCUPLACER math, reading, and writing scores.The cost for a student who places at the lowest levelon the test, and therefore requires the full 30 weeks ofpreparatory coursework, is $3,044. Students whoplace at the highest level (ninth and tenth grade) onlyneed to take the final 10-week module; the cost forthem is $1,500 each. The cost for students whorequire 20 weeks of instruction is $2,226. These costfigures all include tuition, fees, supplemental instruc-tion (tutors), and textbooks.

The total cost of the LPN program for studentsrequiring the full 30-week of Learning Lab courses is$8,252. This includes the costs of Learning Lab, pre-requisite, and nursing courses and all other costs,except for required immunizations and backgroundchecks.


U.S. Department of Labor grant funds secured bythe Division of Workforce Development, along withgeneral city funds and WIA funds, helped finance theprogram during its first two years. Typically, DWDgrants covered half of the costs of delivering the work-site LPN program, with employers providing the otherhalf in cash and in-kind contributions. Employeesusing DWD or WIA funds had no obligation to con-tinue working for the employer after completion ofthe program. However, the employer did have theright to terminate funding contributions should theemployee leave the facility during the course of theprogram. If a student qualified for a Pell Grant, he/shewas expected to use that as a “first source” of payment,with DWD/WIA paying the remainder. Typically onlya small portion (15 to 20 percent) of students quali-fied for Pell Grants as most were gainfully employedwithin the facility.

With the end of the federal grant in 2004, thetuition burden shifted to the students and theiremployers. Arrangements vary with these newercohorts. In some cases, employers are providingtuition reimbursement; in other cases, it is theemployee’s responsibility. A small portion of employ-ees can secure Pell Grants to finance their education;those who are not eligible for Pell Grants are often eli-gible for low-interest student loans and other forms offinancial assistance from Community College ofDenver. The college strives to help employees find away to finance their education.

The Community College of Denver has expandedits personnel to accommodate the site-based LPN pro-grams. Two full-time employees are assigned to theseprograms (a program manager and case manager).Funding for the two program positions is provided bythe college’s general budget; it is not included in thetuition costs charged to employers and employees.Program faculty are part-time and added as needed.

Program Results

The program began in 2002 with one cohort oftwenty students. Since then, thirteen cohorts havebegun the program, four of which have graduated.

Despite the low incoming reading and math levelsof participants, the program has achieved a remarkableretention and completion rate. Seventy-seven percentof the participants who began the program have eitherearned their LPN diploma or are still enrolled. As ofFebruary 2005, 230 individuals had started the pro-gram, 42 had graduated as LPNs, and 136 were stillenrolled in Learning Lab, prerequisite, or nursingcourses; 52 left before completing the program.

In examining early attrition data, program man-agers realized that the original Learning Lab design(twenty-four weeks, in three eight-week modules) wastoo fast-paced for students who entered with seriousacademic deficiencies. As a result, the programextended the modules to ten weeks each, or thirtyweeks total. The program continues to monitor andtroubleshoot areas where students are having prob-lems. For example, within the Learning Lab compo-nent, the highest rate of attrition appears to occur dur-ing the last module, as students move into moredifficult material. Among the prerequisite courses,anatomy and physiology poses the greatest academicchallenge to students. The program is in the process ofidentifying additional ways to support students inthese gatekeeper courses to improve their chances ofsuccess.


Overview

A Philadelphia-based Practical Nursing program oper-ated by a union-employer training fund is providing aroute to LPN positions for hundreds of nursing assis-tants and other entry-level health care workers. One ofonly a handful of part-time nursing programs gearedto the needs of working adults, it is also the onlyunion-sponsored nursing program in the country.

The program is operated by the District 1199CTraining and Upgrading Fund. The fund is jointlyadministered by District 1199C of the NationalUnion of Hospital and Health Care Employees—which is part of the American Federation of State,County, and Municipal Employees—and representa-tives of the approximately 50 contributing health careemployers. The fund opened the Practical Nurse (PN)training program in 1999, two years after the SchoolDistrict of Philadelphia closed its Practical NursingProgram. Since opening its doors with 31 students,the new program has grown steadily and now enrolls120 students per year (60 students per class, withclasses starting every 9 months). The program isapproved by the Pennsylvania State Board of Nursing.


The 18-month program is structured to accommodatethe needs of working adults, with classes and otheractivities held part-time in the evening and on week-ends. Classes take place two evenings a week from 4p.m. to 10 p.m. and every other Saturday and Sunday.

Several supports help ensure student success. Eachstudent is assigned an advisor for individual counsel-ing. Group tutoring is available throughout the pro-gram, as well as individual tutoring and counselingfrom program faculty. Tutoring is also availablethrough adult literacy programs that the fund alsooperates.

The participants begin with a three-week, fifty-hour bridge program that prepares them for both the

academic and life demands of a rigorous trainingschedule on top of work and family obligations. Thecurriculum for the bridge program includes mathe-matics, medical terminology, life skills, and computerskills. The bridge program is also used to help identifyapplicants who have met the program’s entry require-ments but, after experiencing the time demands of theprogram, realize that they are not in the position tomake an 18-month commitment. Typically, about fiveto ten of the seventy students admitted to the bridgeprogram decide not to enroll in the training.

Applicants to the PN program must have a highschool diploma or GED and demonstrate that theyhave sufficient academic skills. They must pass themathematics, English, and scientific reasoning sectionsof the Nursing Entrance Test (NET); a passing scoreon this exam approximates a grade level of 11-12 inreading and math. In addition, applicants must meetthe state’s standard of having a satisfactory criminaland child abuse check required for working with chil-dren and in long-term care. (See www.pde.state.pa.us/career_edu/lib/career_edu/CRIMINAL_HISTORY_RECORD_INFORMATION.pdf )

Of the approximately 400 applicants who take theNET test each enrollment period, about one-quarterpass. Those who do not pass can enroll in free prepara-tory classes and reapply for the next session (seebelow). Once the other screens are applied (e.g., validdiploma), about ninety qualify for admission and sev-enty are selected to fill sixty slots. Five to ten studentstypically decide not to enter the program after thebridge experience.

Preparatory Classes to ExpandProgram Access

Given the weak educational backgrounds of manyentry-level health care workers, the fund designed apreparatory program to raise participants’ math andreading skills to the standards required to enter thePN program. Individuals who test at an eighth-gradelevel in math and a ninth-grade level in reading are eli-


1199C Training and Upgrading FundLPN Career Ladder Program

recipients. Approximately one-third of PN programparticipants have attended fund-sponsored prepara-tory classes in order to raise their reading and mathskills enough to pass the entrance examination.Another 25 to 30 percent attended classes elsewhere toprepare for the exam.

In recent years, a large percentage of the unionparticipants have come from local nursing homes—NewCourtland Elder Services, a nonprofit subsidiaryof the Presbyterian Foundation, which operates sixfacilities, and Golden Slipper, a stand-alone non-profitfacility. Over the past two years, seventy-twoNewCourtland nursing aides have participated in thePre-Nursing course delivered at the worksite, withforty-five subsequently enrolling in the PN program.At Golden Slipper, twenty-two nursing aides partici-pated in the Pre-Nursing course, with six subsequentlyentering the PN program.

Demographic data for the most recent class is con-sistent with previous classes. Just over 21 percent of thestudents are male, 63 percent are single, and 35 percentare single parents. At least 60 percent of the studentsindicate that they plan to work full time while inschool. Seventy-five percent are African-American.Approximately 80 percent of the students were sup-porting themselves prior to starting school, and 45 per-cent indicated that they were paying their own tuitionout of their own pocket. The average age of the class is32.8 years, with a range of 21 to 50 years.


The 2004-05 tuition for the 18-month PN program is$8,200 per student. The cost of running a 16-week,144-hour preparatory program is $650 per student,assuming that 15 students are enrolled, but studentsare not charged for taking this course

Union members whose employers contribute 1.5percent of gross payroll to the fund are eligible forbenefits, which include tuition reimbursement of upto $5,000 a year for classes taken at area colleges, voca-tional centers, and the PN program. Members areexpected to put up the first $1,850 payment for LevelI of the PN program. Upon completing each of thePN Program’s five levels, the reimbursement is rolledover to pay for tuition for the subsequent level. At thecompletion of the 18-month program, members arereimbursed in full.

For other participants (i.e., union members whoseemployers do not contribute to the fund and non-union community residents), tuition payments are


gible to attend an intensive Pre-Nursing Program.This is a sixteen-week program, with classes meetingthree evenings or mornings a week for three hours asession.

As with the PN program, classes are open to com-munity members as well as union members. Theinclusion of large numbers of non-union members in1199C fund training programs is the norm, not theexception. From its inception in the late 1970s, thefund’s mission has been to serve the broader commu-nity as well as union members. It has aggressivelysought government and private grants to underwritethe costs of extending services to non-union members.

The preparatory classes, which are intentionallysmall, averaging 15 to 20 participants, are held at thecentral Training Fund facility, as well as at the work-sites of sponsoring employers (e.g., NewCourtlandand Golden Slipper long-term care facilities).

For individuals who test below the eighth- toninth-grade level, the fund offers basic education andESL classes for both members and community resi-dents. The fund has developed four levels of basic edu-cation classes to assist students in acquiring the aca-demic competencies needed to advance into thePre-Nursing and Practical Nursing programs. Studentsare encouraged to work at their own pace in theseclasses. Practical Nursing faculty and administratorswork closely with the basic education department toensure that the curriculum prepares students ade-quately with the skills needed to succeed in thePractical Nursing program. The goal of the prepara-tory classes goes beyond helping students to pass thePN admissions examination. Faculty work on impart-ing the skills in studying, test-taking, time manage-ment, and critical thinking that are required to suc-ceed in the PN Program.

Description of Participants

Most of the students in the preparatory and PN pro-grams are low-income health care workers employedin entry-level positions, such as nursing aides in areahospitals and long-term care facilities. Almost 51 per-cent have completed a Certified Nursing Assistantprogram before enrolling in the practical nursing pro-gram. About 30 percent of the PN students are unionmembers employed in facilities represented by District1199C. The remainder includes health care workersemployed at non-union facilities, workers employed inother industries who are interested in entering thenursing profession, dislocated workers, and TANF


due at the start of each of the five levels. Differentsources of financial assistance may be available foreach level:

Level 1: (months 1 to 3): The participant pays thefirst $1,850. NewCourtland and Golden Slipper paythis for their employees.

Levels 2 and 3 (months 4 to 9): The fund hassecured U.S. Department of Labor H-IB and WIAgrant funds to cover the $3,175 cost.

Levels 4 and 5 (months 10 to 18): Employers whoare either sponsoring their own employees (e.g.,NewCourtland and Golden Slipper) or have beenrecruited by the fund to sponsor a student make thefinal tuition payments of $3,175 in exchange for thestudent’s commitment to work for the employer forone to two years following graduation.

The fund covers the cost of preparatory classes foreligible members. The costs for non-members are cov-ered through a range of government funds, includinggrants from the Pennsylvania Department ofEducation and other state funding, and throughemployer fee-for-service agreements.

Program Results

Since 1999, 396 individuals have entered the PN pro-gram upon completing the bridge experience. Ofthose, 185 (47 percent) have completed the programsuccessfully, 85 (21 percent) are still enrolled, and 126(32 percent) did not complete it; 81 percent of gradu-ates passed the LPN licensure examination on the firstattempt. Of those who entered the program, approxi-mately 60 percent needed to take preparatory classesin order to pass the entrance examination.

Employees participating in PN training under theauspices of an employer-sponsored workplaceadvancement program have had a higher-than-averagePN completion rate: 82 percent (37 out of 45) ofNewCourtland’s nursing aides who entered the PNprogram completed it; 83 percent (5 out of 6) ofGolden Slipper’s nursing aides graduated.

The success rate of students in the fund’s prepara-tory course has varied a great deal, with as few as 30percent completing the course, to a high of 80 percentor more. Fund staff say that attendance and pass ratesare much higher for people who already work inhealth care as caregivers and are more committed tothe goal of becoming nurses.

The next challenge for the Training Fund’s PNprogram is to design and implement a nursing careerladder that articulates nurse’s aide training to the prac-tical nursing program and the practical nursing pro-gram to a Registered Nursing program, with the goalof aligning the curricula and shortening the totallength of training. This will most likely involve offer-ing a combination of college credit and non-creditcourses. It will also require the fund to intensify andexpand the preparatory classes to include pre-collegecourse work.


Overview

Three Hospital Corporation of America (HCA) facili-ties, in partnership with the local WorkforceInvestment Board (The Workforce Alliance), havedeveloped an LPN career ladder program for low-income employees and other low-income residents ofWest Palm Beach, Florida. Geared to the needs ofworking adults, the two-year LPN program meets twodays a week at the worksite for nine hours a day, withan optional third day for individual tutoring andremediation. Participants can work part time on non-class days and weekends, with participating employersguaranteeing flexible work schedules that fit studentneeds.

Florida’s Career Advancement and RetentionChallenge Initiative (CARC), a state-sponsored grantprogram designed to advance TANF (i.e., welfare)recipients and other low-income working adults intowell-paying jobs, has served as a catalyst for the cre-ation of the program. Funded through state TANFdollars and administered through the BetterJobs/Better Wages Committee, CARC has underwrit-ten approximately 55 percent of the cash costs andabout 40 percent of the overall costs of the HCA-sponsored LPN Career Advancement Program.Employer tuition payments and federal Pell Grants arethe other major sources of program funding.Employers and The Workforce Alliance provide sub-stantial in-kind contributions in terms of staffing andthe use of facilities.

While CARC has been an indispensable source offinancial support for the LPN Career AdvancementProgram, its requirements have restricted participationto employees who meet TANF family income guide-lines of less than 200 percent of the federal povertylevel. This restriction has created some difficulty foremployers who seek to make educational opportuni-ties available to all entry-level staff. Employers haveresponded by informing all non-income eligible

employees about tuition reimbursement benefits aswell as other on-site adult basic education and college-level course opportunities. In addition to servingTANF-eligible employees at participating facilities, theprogram also serves TANF recipients; upon acceptanceinto the program, they are offered part-time jobs withparticipating employers.

The program contracts with several nonprofit ven-dors to deliver different services. The Academy forPractical Nursing and Health Occupations(APNHO), an accredited, not-for-profit postsec-ondary training institute that specializes in servingless-formally educated, low-income adults, delivers theLPN training program. ACS State and Local Solutionsprovides case management services to students, andthe Palm Beach County Literacy Coalition providesremedial reading, writing, ESL, and math instructionto help candidates prepare for entrance exams.

The program enrolled its first class of 36 LPNtrainees in January 2002; 23 (or 64 percent) of themsuccessfully completed the LPN training. Since then,the program has launched two additional classes, onein December 2003 and another in December 2004,enrolling a total of 73 students. Of these, 56 (77 per-cent) are still enrolled in the program and on target tograduate in December 2005 and December 2006.


The two-year LPN program delivered by APHNOmeets two days a week, one day for classes and one dayfor clinical rotation; a third day is available for tutor-ing support. All students, not just those struggling in aparticular class, are encouraged to attend the optionalthird day.

Originally structured as an 18.5-month program,the LPN program was extended to 24 months for thesecond and third classes in order to include prepara-tory classes for the state licensure exam, a required IV


Workforce Alliance and Hospital Corporation of AmericaLPN Career Advancement Program

in South Florida, it is not surprising that manyemployees who aspire to become LPNs lack the aca-demic and English language skills to pass the entranceexams. To address this issue, the program has includeda remedial or skill enhancement component from itsinception. The program contracts with the PalmBeach County Literacy Coalition to offer worksiteskills enhancement instruction to candidates who donot pass the TABE and other employees who need toraise reading, writing, math, and English languageskills. Classes, which are offered at the hospitals andnursing home, are open both to employees and toTANF-eligible clients from the community. Basicskills instruction and English language instruction usea variety of teaching methods, including classroom-based and computer-assisted learning.

To date, over 150 students have participated inskill enhancement classes. Approximately 30 percentof participants test at the ninth-grade reading level, 55percent at the seventh- to eighth-grade level, and 15percent at fifth-grade or below. Of those students whoenrolled in one of the first two remedial sessions andattended at least 25 hours of instruction (approxi-mately 75 percent of participants), 30 percent passedall sections of the TABE test and qualified for admis-sion to the LPN program. An additional 78 studentswho attended at least 25 hours of instruction raisedtheir reading and/or math levels.

Description of Trainees and TheirEmployer Sponsors

The vast majority of students are TANF-eligible healthcare workers employed in entry-level positions such asnursing aides in one of the sponsoring facilities: thethree HCA-owned hospitals (JFK Medical Center,Columbia Hospital, Palms West Hospital) or MorseGeriatric Center. Senior human resources staff at JFKMedical Center play the lead role in organizing HCAhospital involvement in the program.

A few students are TANF recipients and/or TANF-eligible individuals recruited by Workforce Alliancestaff from the community. Each is offered the chanceto become an employee of a participating facility andwork on non-class days. Most take up this offer, butsome are already employed elsewhere and choose toremain at their current job until completing the pro-gram. Upon completion, they, too, must join the staffof the sponsoring employer that paid a portion of theirtuition in exchange for a commitment to work at thefacility for two years after getting an LPN license.


(intravenous) certification course, and a module insupervision and delegation, which is particularlyimportant for LPNs working in long-term caresettings.

Another important change from the originaldesign is the incorporation of intermediate credential-ing. All participants in the LPN program qualify asCertified Nursing Assistants and Patient CareAssistants within the first six months. These certifica-tions enable participants to earn pay increases beforereaching LPN status; they also serve as marketable cre-dentials for students who do not complete the LPNprogram, whether for personal or academic reasons.

Prior to the start of the second LPN class, theprogram added a non-HCA hospital partner. MorseGeriatric Center, a 280-bed, long-term facility,provides several levels of nursing care.

All classes are based at a worksite. Participantsfrom the three participating hospitals attend classes atJFK Medical Center (the largest of the three partici-pating HCA hospitals); employees of Morse GeriatricCenter attend classes at the nursing home. Clinicalrotations take place at participating employer sites.

Support for Students

Several levels of support promote student success.APHNO faculty provide academic tutoring. A part-time career consultant at ACS provides counseling andjob-coaching support and connects eligible students totransitional support services funded by TANF, includ-ing transportation and child care assistance and hous-ing referrals. The program also recruits LPN and RNsto serve as mentors to support and encourage trainees.Peer support is fostered by grouping employees fromthe same facilities together for classes at the worksite.

Entry Requirements

In addition to meeting the income-eligibility criteria,candidates must score at the eleventh-grade level onTABE reading and math tests. They must also pass acritical thinking and writing exam administered byAPNHO. Candidates who are unable to pass theTABE are referred to the Palm Beach LiteracyCoalition for skills enhancement instruction.

Preparatory Classes to Expand Program Access

Given the immigrant status and limited educationalbackgrounds of many entry-level health care workers



The tuition, books, and fee costs for the two-yearLPN program come to $11,500 per student. The pro-gram employs a half-time coordinator and half-timecareer consultant, which adds another $88,000, orabout $2,400 per student. The program also providesa nominal stipend of $150 a year to each of 20 LPNand RN employee volunteers who serve as mentors.

The $11,500 per student tuition costs are financedfrom three sources: employer contributions in theform of tuition benefits, federal Pell Grants, and thestate CARC grant. Employers contribute $3,500 foreach student they sponsor. In exchange, students com-mit to work at the facility for two years after earningtheir LPN license. Pell Grants cover an average of$3,500 per student; the state CARC grant finances theremaining $4,500 per student, as well as the cost ofprogram staff.

The state CARC grant also funds the worksiteremediation classes delivered by the Palm BeachCounty Literacy Coalition. Costs for those classes runabout $700 per participant.

Employers make other important financial contri-butions to defray program costs, including classroomspace, computers, and senior management time tocoordinate their facility’s participation. Employers alsoprovide flexible work schedules to their employees toallow them to work on their off-class days and week-ends. And they offer employment to TANF recipientswho enter the program.

Program Results

• Of the 36 students who began the first two LPNclasses, 23 students successfully completed the pro-gram. As of July 2005, 21 of the students who grad-uated had passed the state licensure exam on theirfirst attempt.

• Of the 38 students who began the second LPN classin 2003 and 35 who began the third LPN class in2004s, 58 are still enrolled and on target for gradua-tion.

• Across the three classes, over 150 employees haveparticipated in remedial literacy and math instruc-tion. Of those who attended at least 25 hours ofinstruction, 30 percent subsequently passed theTABE and qualified for admission into the LPNprogram. An additional 78 students raised theirreading and math levels.

• In 2003, Workforce Alliance received the First Place“Best Practices” award for this program fromWorkforce Florida, the state’s Workforce Board.


Overview

WorkSource Partners, a workforce development firmthat designs and implements career development andeducation programs for entry-level workers, hashelped long-term care employers and their communitycollege partners develop comprehensive CNA-to-LPNcareer ladder programs to fill nursing vacancies. Bybringing pre-college and college education to theworkplace in conjunction with career counseling andcase management support, WorkSource has helpedemployers design, implement, and expand a “growyour own” career advancement model: the RegionalAdvancement Center. The RAC, currently in opera-tion in three regions of Massachusetts that have clus-ters of nursing home sites, creates sufficient scale tomake it feasible for community colleges to deliver edu-cation and career counseling services at the worksiteand to tailor nursing home programs for the long-term care industry.

The impact of the strategy for addressing the LPNshortage has been especially significant at the two sitesthat are further developed: the five facilities inWestern Massachusetts owned by Genesis HealthCare,one of the nation’s largest providers of long-term careand rehabilitation therapy, and the eleven independentnon-profit facilities in Worcester that comprise theIntercare Alliance. WorkSource has partnered withGenesis HealthCare since the inception of the RAC,and it has worked closely on the program’s design andimplementation. Even before joining forces withWorkSource, the Intercare Alliance had demonstratedits commitment to workforce development by part-nering with Quinsigamond Community College todevelop the school’s initial evening LPN program.WorkSource then assisted Intercare in developing anursing career pipeline: it set up career counselingservices, remediation, and college prep classes, all ofwhich made the LPN program more accessible toentry-level workers.1

Since 2003, 69 Genesis and Alliance workers haveentered the evening LPN training programs designedfor them; 31 have graduated and 29 students are fin-ishing up in the summer of 2005. Only 9 students (13percent) have failed to complete the program. Anadditional 350 Genesis employees have received careercounseling and education services since 2001, includ-ing 74 who enrolled in pre-college classes to preparefor the LPN program. In 2004-2005 alone, 141CNAs employed in Alliance nursing home facilitiesattended a career ladder class through the RAC.

This grow-your-own strategy has yielded signifi-cant financial benefits to employers, as well asimproved patient care as a result of reduced staffturnover and vacancy rates. Genesis HealthCare hasended its use of agency nurses to fill LPN vacancies atits five Agawam facilities—saving $500,000 per yearover January 2001. The model has also helped Genesissignificantly reduce turnover of nursing assistants. TheAlliance facilities have enjoyed similar benefits fromreduced agency fees and reduced staff turnover andvacancy rates. CNA turnover rates have dropped by 30to 40 percent at Alliance facilities in the past two years.

Seed funding for developing the Genesis andAlliance programs has come from an innovative stateprogram designed to help the long-term care industryupgrade the skills of their entry-level workers: theExtended Care Career Ladder Initiative.2 ECCLI grantshave provided approximately $100,000 a year at each ofthe sites to help cover program development costs aswell as the costs of career counseling and pre-collegeclasses. Employers have covered their employees’ LPNtuition and fee costs through tuition benefits plans.


The CNA-to-LPN programs sponsored by GenesisHealthCare and the Intercare Alliance offer a sequenceof educational steps coupled with counseling and sup-port services to prepare workers to enter and succeed


WorkSource PartnersRegional Advancement Centers

demanding schedule: students are in class from 4 p.m.to 10 p.m., with additional clinical rotations everyother weekend from 7 a.m. to 3:30 p.m. All remedialand prerequisite courses are held at the EducationalBridge Center and the college campus.

Genesis HealthCare contracts with Holyoke todeliver a similar sequence of educational courses, cul-minating in a ten-month evening and weekend LPNprogram. The students are in classroom instructiontwo or three days per week from 4 p.m. to 10 p.m.,and the clinical rotation days are twice per week from4 p.m. to 11 p.m., with no weekend instruction. Allremedial and prerequisite courses are offered at thecompany’s five-facility campus in WesternMassachusetts.

Employers at both RACs contract withWorkSource Partners to provide a comprehensive set ofemployee outreach and counseling services. Staff fromWorkSource conduct outreach sessions at all facilitiesto communicate the employer’s commitment to careerdevelopment and to solicit employee interest in partici-pating in the CNA-to-LPN program. A WorkSourcecareer development specialist then conducts a one-on-one session to help each interested employee develop acareer plan based on an assessment of his/her academicskill level, career interests, and life circumstances.Employees who enroll in CNA-to-LPN careeradvancement courses (from pre-college prep throughthe pre-nursing program) receive ongoing academicand “life” coaching to help them juggle the conflictingdemands of family, work, and school.

To help employees meet the demands of a full-time education, Alliance employers limit the workschedule of students in the LPN program to no morethan 24 hours a week, and they provide flexible workschedules, especially around exams. All full-timeemployees who enroll in the LPN program agree toreduce their work hours until they graduate. AtGenesis, the negotiation of work schedules is informaland conducted on a case-by-case basis. Managersacross the Genesis Campus are committed to this pro-gram and have been supportive and flexible in thisprocess.

Description of ParticipatingEmployees and Employers

The first class of 24 students entered the IntercareAlliance-Quinsigamond Community College LPNprogram in 2002. All have been CNAs in one of the11 member nursing homes. Each Alliance facility had


in community college-sponsored LPN programs. Bothsites contract with a local community college partnerto deliver a full sequence of preparatory educationalcourses as well as a customized evening LPN program.Genesis partners with Holyoke Community College,and the Intercare Alliance partners withQuinsigamond. At both Regional AdvancementCenters, employees receive counseling and supportservices on each step of the ladder.

The career ladder sequence begins with pre-collegecourses at the worksite in math and English foremployees who need additional academic skill devel-opment to qualify for college-level coursework.Intercare Alliance employers have created a separatespace for this part of the RAC: the Notre DameEducational Bridge Center, owned and managed byone of the Alliance Members, Notre Dame Long TermCare Center.

Workers who complete the pre-college courses orwho test directly into college-level work by passing theCollege Placement Test can enroll in the prerequisitecollege courses required for entry into the LPN pro-gram. The three prerequisite courses to enter theHolyoke Community College program are an intro-duction to psychology, human development, andhuman anatomy and physiology. Intercare Allianceemployees selected for the program must take fourprerequisite courses to enroll at QuinsigamondCommunity College: two psychology courses, biology,and “Math for Meds.”

To promote financial sustainability, the Genesis-Holyoke Community College evening LPN program isbuilt on a community satellite model—that is, coursesare part of college’s regular catalog and open to thecommunity at large. This approach makes it possible tosplit program costs between community residents andthe employer, and it also allows the college to tap intorelevant state subsidies/FTE payments that may becomeavailable. For each cycle of the program, Holyoke holdsa certain number of seats for Genesis employees, andthose individuals who pass the prerequisite courses arethen eligible to enter the program. Community mem-bers who wish to enroll for the other seats in the pro-gram must also complete the prerequisites.

The Alliance facilities collectively contract withQuinsigamond to provide an LPN program that canaccommodate 24 students each year. After passing theprerequisite courses, students can enroll in the cus-tomized ten-month, evening and weekend, LPN pro-gram. The program is full time and has a very

The costs per person for the Genesis-HolyokeCNA-to-LPN program are as follows:

• Approximately $700 for pre-college reading/writingand math classes;

• Approximately $300 for each of three prerequisitecourses;

• $7,997 for tuition and fees for LPN program; and

• Approximately $120 per person for counseling serv-ices provided by WorkSource.4

Employers cover the bulk of program costs at bothsites. Alliance members and Genesis pay all LPN pro-gram tuition and fees. In exchange, Alliance employ-ees are required to “pay back” this tuition benefit bycommitting to work at their facility for two years afterearning the LPN license. Genesis employees arerequired to make a similar commitment: they payback the benefit at a rate of one hour for each dollar oftuition they use.

Employers also contribute toward the cost of pre-college and prerequisite courses. For the Alliance, theprerequisite costs are paid by Intercare. The costs ofthe pre-college classes can be paid by the student (whomay get financial aid), ECCLI, or the facility (throughtuition reimbursement programs). At Genesis, thesecourses have been paid for primarily through ECCLIand tuition reimbursement. Genesis offers a tuitionassistance program: employees can apply for funds tocover most of their LPN program costs. A major partof career counseling is identifying the types of finan-cial aid that the employees might qualify to receive viascholarships and grants. In addition, each employeecan get assistance in applying for financial aid throughFree Application for Financial Student Aid (FAFSA)forms.

Federal Pell Grants help to offset employer tuitioncosts for eligible employees. To take advantage of thisfunding source, Alliance employers now requireemployees who enroll in the LPN program to fill outthe FAFSA forms. Ten of the twenty students in theclass of 2005 received Pell Grants ranging from$1,000 to $1,800.

Employers make other important financial contri-butions to defray program costs. Alliance employersprovide flexible work schedules and continue to payfull medical and dental benefits for participatingemployees who work a reduced, 24-hours-per-weekschedule. Genesis front-line managers work withemployees on a case-by-case basis to provide flexible


up to three slots to fill in the program. For the secondclass, entering in 2004, the Alliance allowed a local,non-member nursing home to fill six of twenty-fourslots. The Alliance anticipates a similar mix of memberand non-member homes filling slots in the next class,due to start fall 2005.

After being selected to participate in the program,candidates take the College Placement Test to deter-mine if they are eligible for the prerequisite collegecourses. The first year of the program, only nine offorty-eight candidates passed the CPT, forcing theprogram to delay its start for six months so that thosewho did not pass could take remedial math andEnglish courses. Based on this first-year experience,the Alliance, with help from WorkSource, set up a for-mal “Bridge program” that provides remedial mathand English instruction to employees interested inenrolling in the LPN program or other college-levelcourses.

The Genesis HealthCare-Holyoke CommunityCollege LPN program enrolls a mix of Genesisemployees and community members in theevening/weekend LPN program. The inaugural 2004class of twenty-five students included fourteen Genesisemployees; eight of the twenty-four students whobegan the 2005 program were Genesis employees.Almost all the Genesis employees are CNAs.

The vast majority of Genesis employees who enrollin the LPN program need to take remedial Englishand math courses to qualify; fourteen of the twenty-two employees in the first two LPN classes completedremedial courses prior to enrolling. Genesis offersboth adult basic education and pre-college math andEnglish courses to any interested employees at thecompany’s Western Massachusetts campus. So far, 74have taken pre-college courses towards nursing.


The costs per person for the Alliance-QuinsigamondCNA-to-LPN program are as follows:

• $400-$450 for pre-college classes (includes bookcosts);

• $450-$500 for each of the four required prerequisitecourses (including book costs);

• $5,896 in tuition and fees for the LPN program(excluding $775 in estimated book costs); and

• Approximately $65 per person for counseling serv-ices provided by WorkSource Partners staff.3


work schedules to accommodate the LPN program,enabling employees to maintain benefits. Employersalso contribute classroom space, computers, and a por-tion of the costs of a director to manage the program.Genesis also contributes the time of its RNs to serve asadjunct faculty to the Holyoke LPN program. For theIntercare program, all LPN instructors are from thecollege partner. However, staff development coordina-tors from the Alliance teach the Math for Meds pre-requisite course.

State ECCLI funding has supported programdevelopment costs, including program design andplanning assistance provided by WorkSource and thepartial salary of a program director at the Genesis andAlliance RACs. ECCLI funds have also paid for theemployee outreach and counseling services providedby WorkSource and a portion of the tuition for pre-college courses and prerequisite courses.

Program Results

The retention and completion rate for CNA-to LPNprograms have been outstanding at both locations:

Seventy-five percent of the Alliance employeeswho enrolled in the first LPN class completed the pro-gram. Seventeen of the eighteen graduates passed thelicensure exam on the first try. Twenty-three of thetwenty-four students who enrolled in the 2004-2005program passed the first semester.

Thirteen of the fourteen Genesis employees whoenrolled in the first class completed the program. Sixof the eight employees who entered the second class inthe fall of 2005 are still enrolled and near completion.

An additional 17 Genesis employees and 29Alliance employees were enrolled in the pre-collegesegment during 2004-2005.

Endnotes

1 For the third cluster, WorkSource is in the process of replicat-ing the Regional Advancement Center concept with a clusterof four Genesis nursing facilities in Lowell, Massachusetts.

2 The ECCLI grant program, which has distributed $11.6 mil-lion to long-term facilities in Massachusetts, has not cost thestate a dime. Through an innovative funding arrangement,the state leverages federal Medicaid matching funds tofinance the program. Ostensibly, the ECCLI program isfunded through a “bed tax” or a user fee that the state assessesnursing homes on their non-Medicare bed days. The statecollects approximately $145 million from this fee. It thengives the fees back to the nursing homes in the form ofincreased Medicaid payments. In the process, the state candouble the funds it returns to the nursing homes (i.e., from$145 million to $290 million) because the increase inMedicaid nursing home rates funded through the bed tax ismatched by the federal government, which provides 50 per-cent reimbursement to states for federally approved Medicaidexpenditures. The bulk of new funding secured for nursinghomes through this innovative arrangement has been used toraise the wages of nursing home staff. About two dozen statesuse this “bed tax” to leverage federal funds and help financestate Medicaid payments to nursing homes; no other state hascreated a program like ECCLI, but the funding mechanismexists to do so.

3 This cost is calculated by dividing $61,750 that Worksourcereceives to provide outreach and counseling services by a baseof 950 Alliance employees.

4 This cost is calculated by dividing $48,000 that Worksourcereceives to provide outreach and counseling services by a baseof 400 Alliance employees.


Appendix

List of Interviews

Community College of Denver: CNA-to-LPN Program

Elaine Baker, Director of Workforce Initiatives,Community College of Denver

Linda Merkl, Site-based Healthcare Program Manager,Community College of Denver

1199C Training and Upgrading Fund:LPN Career Ladder Program

Cheryl Feldman, Director, District 1199C Trainingand Upgrading Fund

Workforce Alliance and Hospital Corporation of America:LPN Career Advancement Program

Terry Eggenberger, RN, MSN, Workforce andOrganizational Program Director, JFK Medical Center

Debora Kerr, former Vice President, ResourceDevelopment, Workforce Alliance

Marsha Thrower, Vice President, ResourceDevelopment, Workforce Alliance

WorkSource Partners:Regional Advancement Centers

Shawntsi Baret-Stone, Vice President, WorkforceDevelopment, WorkSource Partners

Patricia A. Campbell, Manager Training andDevelopment, WorkSource Partners

Neil Silverston, President, WorkSource Partners

Jobs for the Future seeks to accelerate the educational and eco-

nomic advancement of youth and adults struggling in today’s

economy. JFF partners with leaders in education, business, gov-

ernment, and communities around the nation to: strengthen

opportunities for youth to succeed in postsecondary learning

and high-skill careers; increase opportunities for low-income

individuals to move into family-supporting careers; and meet

the growing economic demand for knowledgeable and skilled

workers.

Acknowledgements

The author and the entire JFF family would like to thank themanagers and educators from the four programs featured inthis publication who generously shared their experiences andinsights: Elaine Baker, Shawntsi Baret-Stone, Patricia A.Campbell, Cheryl Feldman, Terry Eggenberger, Debora Kerr,Linda Merkl, Neil Silverston, and Marsha Thrower. Theyresponded quickly and meticulously to every question abouttheir program’s operation and outcomes and carefullyreviewed each draft. Their commitment to creating high-quality programs that provide a supported route for nursingassistants and other entry-level health workers to advanceinto well-paying, practical nursing positions is matched onlyby their desire to help others replicate their success. A specialthanks as well to Amy Robins at JFF who helped research andwrite the WorkSource Partners case study.

About the Author

SUSAN GOLDBERGER, Director of New Ventures at JFF, is

responsible for promoting the development, testing, and scaling

up of new educational and workforce program designs to help

low-income youth and adults achieve academic and career suc-

cess. Previously, she directed JFF’s youth development and edu-

cational reform efforts, including a multi-city, urban high school

reform initiative. Prior to joining JFF, Dr. Goldberger founded

and directed several community-based organizations that advo-

cated for improvements in health care, child care, and economic

opportunity for low-wage workers. She holds a Ph.D. in social

policy from Brandeis University and a B.A. from Brown

University.

Jobs for the Future88 Broad StreetBoston, MA 02110617.728.4446www.jff.org

Advancement for Low-Wage Workers:A Series of Reports from Jobs for the Future

Jobs for the Future develops models, strategies, and policies that enable adults to advance toward eco-nomic self-sufficiency for themselves and their families. Drawing on innovative workforce developmentefforts around the country, our publications, tool kits, and other resources respond to the challenges toadvancement for low-wage workers. With the series Advancement for Low-Wage Workers, JFF seeks to ele-vate discussion of this critical issue within and outside the workforce field. Elaborating upon the themesin the series introduction, The Next Challenge, these occasional papers address public policy and on-the-ground practice.

Titles in the series include:

From the Entry Level to Licensed Practical Nurse: Four Case Studies of Career Ladders in Health Care (2005)

The Right Jobs: Identifying Career Advancement Opportunities for Low-Skilled Workers (2005)

Career Ladders: A Guidebook for Workforce Intermediaries (2003)

Earning While Learning: Maintaining Income While Upgrading Skills (2004)

The Next Challenge: Advancing Low-Skilled, Low-Wage Workers (2004)

Reinventing Workforce Development: Lessons from Boston’s Community Approach (2004)

Workforce Intermediaries and Their Roles in Promoting Advancement (2004)

Employer-Led Organizations and Career Ladders (2003)

Getting Ahead: A Survey of Low-Wage Workers on Opportunities for Advancement (2003)

Opportunity in Tough Times: Promoting Advancement for Low-Wage Workers (2003)

Low-Wage Workers in the New Economy (Urban Institute Press, 2001)

Public Views on Low Wage Workers in the Current Economy (2001)

A National Survey of American Attitudes About Low-Wage Workers and Welfare Reform (2000)

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