Daniel Bustillo, Healthcare Career Advancement Program (H-CAP): Advancing Job Quality and Racial Equity in Healthcare

Van Ton-Quinlivan: Welcome to Workforce Rx with Futuro Health where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host Van Ton-Quinlivan, CEO of Futuro Health. As we all know, the pandemic has taken a toll on the healthcare workforce. A recent national poll underscored that reality by reporting that nearly 30% of nurses, doctors, and allied professionals might leave the field. This makes programs to expand the healthcare workforce more important than ever, and also programs that upskill current health workers to both address gaps and help with retention.

Creating career pathways for the healthcare workforce is the focus of our guest, Daniel Bustillo, Executive Director of the Healthcare Career Advancement Program (H-CAP), a national organization of SEIU unions and healthcare employers that promote innovation and quality in healthcare career education and equity in the healthcare workforce. He also serves with me on the board of the National Skills Coalition. Thanks so much for joining us today, Daniel.

Daniel Bustillo: Thank you, Van. It’s a pleasure to be here with you today.

Van Ton-Quinlivan: I would love for you to start by adding to that very brief description of your national organization, H-CAP.

Daniel Bustillo: Sure. Happy to do so, Van. As you mentioned, we are a national labor-management organization that promotes innovation and quality in healthcare career education. Our work is really focused at the intersection of skills attainment, racial and gender equity, and job quality. We have a series of partnerships that include workforce intermediaries — or what we call training funds or training partnerships — that span 16 States and D.C. Overall, it encompasses about 550,000 covered healthcare workers, over 1,000 participating employers training tens of thousands of healthcare workers a year on a variety of either upskilling, re-skilling initiatives, career pathway progressions and a variety of different things.

We also have a couple of different initiatives at H-CAP that we have launched over the past few years. One, related specifically to registered apprenticeships, we lead the work of the National Center for Healthcare Apprenticeships which is part of that work. We have worked with a variety of different stakeholders, states, and partners all over the country and we have an exciting new initiative that I hope I’ll get a chance to talk a little bit about — we just launched a new Center for Advancing Racial Equity and Job Quality in Long-Term Care as well.

Van Ton-Quinlivan: Wonderful. So, if H-CAP is covering 16 states and DC, you probably have a good feel for what’s going on in the healthcare workforce. What’s your reaction to the poll number I cited at the beginning, that 30% of health workers might leave the profession? What are you hearing about the wellness and retention of this important workforce?

Daniel Bustillo: Those are really sobering figures, Van, when you think about what we’ve been through with the pandemic over the past year and a half, and think about the essential role that caregivers have played in making certain that people are provided with the best possible care under really difficult circumstances. Sadly, I can say I’m not surprised to hear those figures. We work across all sectors of healthcare, so we have partnerships with acute care, with ambulatory care, skilled nursing facilities, as well as in-home care. We’ve been aware of some of the difficulties within healthcare, and some of the difficulties faced by the healthcare workforce in particular, which if anything have been severely exacerbated by what’s going on during the pandemic. Healthcare workers have rightly been lauded as heroes during the pandemic, but have frequently faced really challenging situations and oftentimes have been treated differently than heroes as well.

So as I said, I’m not surprised to hear those figures. I think I’m really concerned about the longer-term implications from both the physical and mental health perspective for healthcare workers, and we have certainly been hearing about individuals leaving the profession and a need for new individuals to come into the profession. So, I think 30% is a sobering figure, but my concern is that it may end up being greater than that. Hopefully not.

Van Ton-Quinlivan: Oh my. That will be really troublesome if it’s greater than 30%. So, Daniel, you mentioned H-CAP is working in a role to innovate the healthcare workforce development world. What are the biggest changes that you’re seeking to make? What are the problems you’re trying to solve, and how is H-CAP going about it?

Daniel Bustillo: That’s a big question, right? I think in fully answering this question, I do need to take just a little bit of a step back. I really think we need to take into consideration the multiple interlocking mechanisms and ecosystems that comprise not only the healthcare workforce development system with the healthcare delivery system, but I’ll focus on just a few.

First, I would say I think that just writ large, there is a level of introspection that is needed from a workforce development perspective within the field of workforce development itself — healthcare or otherwise — which I believe really needs to reckon on a much deeper level with some of the dominant principles and narratives that have governed the field for some time. I would contend that sometimes they have perpetuated some misconceptions, unsupported by evidence, related to things such as individual or group deficits, skills gaps, etcetera. So, that’s one I think, just contextually.

Second, the healthcare industry itself — in addition to being the largest industry for employment in this nation with current projections indicating that 6 of the 10 fastest-growing occupations over the next decade are healthcare-related — is a highly regulated and credentialed industry. Oftentimes, there are different training requirements for the same occupation across different states which is a particular issue that we face when we talk about working across geographies and across states as well.

So, to meet this demand, healthcare workforce development I think also needs to grapple with multiple issues, and amongst these are things such as: reimagining ecosystems, models, and partnerships to facilitate the delivery of critically needed, and more nimble and responsive skills attainment of re-skilling initiatives for entry into the field; progression for incumbent workers who may already have deep experience in the field — and when you heard me talk about our partnerships initially upfront, those partnerships primarily serving incumbent workers; and quality care delivery because frankly, that’s what we’re all in this business for as well. I think also educational provider responsiveness, capacity, some of the predatory practices of some for-profit entities in certain locations, and there’s much, much more beyond the scope of what we have time to discuss today.

In addition to everything I just mentioned in healthcare, I think if we’re truly invested in reimagining systems for better outcomes, there are specific systemic issues related to the racialized and gendered role of caregiving in our society that need to be addressed. In healthcare, we do have this severe over-representation of primarily black and brown workers in the lower wage, entry-level occupations, and an under-representation of those same workers as we move up the occupational ladder. The quality of jobs and the difficulty accessing options that facilitate career mobility beyond the first rung or two are all issues that we have to account for.

So at H-CAP, at the national level, we really are an association so we work with partners around the country. We attempt to deal with these issues through participatory policy and programmatic initiatives that are really situated, as I said initially, at the intersection of skills attainment, racial and gender equity, and job quality. These initiatives all take a sectoral supply and demand-side approach that, as a differentiator, I think equally centers the needs of workers and directly takes into account the voice of workers and adult learners as well. They are obviously important and critical components who too often have, I think, limited agency and are not part of the development process even though if you think about them as end-users, they often times have a great deal of untapped experience and expertise.

So, we work across all sectors of healthcare to really create strong ecosystems and partnerships that influence policy change and provide quality outcomes but with intensive services and supports that we all know help facilitate adult learner success beyond just access to funding — which is important — but there are a variety of other parts of the equation that are equally important in facilitating adult learner success.

Van Ton-Quinlivan: Well, the things that you’re saying are just music to my ears because, as you know, we really appreciate meeting people where they are in terms of bringing them into this workforce. So, Daniel, 65% of the healthcare workforce is in allied health roles. Which workforce development models work really well in allied health? I’d love to get your perspective because you get to see them across the board.

Daniel Bustillo: I think there’s an entire set of potential options under the rubric of work-based learning models that clearly have a great deal of efficacy within allied health. Models with robust mentorship components or peer-to-peer components I think are particularly important when you think about the transition to practice and caregiving responsibilities. H-CAP and our partners have a long history also of supporting competency-based education. In addition, our network partners across the country have a long record, and have had an excellent success, with models that are informed by and take into account the needs of working adult learners contained along the continuum we just talked about. These models really do provide the necessary intensive wraparound services and supports that may be localized to a variety of languages, because if we think about the health care workers that we serve, we are talking about many immigrants and many different languages depending upon geographic location, etcetera. An entire suite of services is really required to facilitate optimal success, which is what we’re all working towards in conjunction with each other.

Van Ton-Quinlivan: One of the “earn and learn” models proven around the world is the apprenticeship. For those in our audience who may be less familiar with it, tell us a little bit more about the merits of the apprenticeship model and where there’s been traction, because it’s relatively new in healthcare.

Daniel Bustillo: It certainly is and I’m happy to talk about this as well. I think apprenticeships, in particular registered apprenticeships, are a model that nationally we’ve invested in as one mechanism to in some way ameliorate the issues that we’ve previously talked about, at least in part. We’ve had good success in embedding the model in certain locations. We have almost twenty different competency-based occupations registered under our national program. We’ve supported the registration of thousands of apprentices with partners around the country, whether it’s at the state level or at the national level. But I think the healthcare sector, as you talked about — even though it has a long history of apprenticeship-like training models — does not have a strong history of uptake for the formal registered apprenticeship model. That’s clearly the case.

Oftentimes, when I have this conversation, I think we need to be realistic about people who love to talk about scale and things of that sort related to registered apprenticeship because we are embedding a new model. Many stakeholders might have an interest initially, but there’s a concern that ‘you’re changing my entire sourcing model for talent’ or you’re talking about doing so. I think there are some common misconceptions, but I think we need to be realistic about what traction, application, and scale mean for registered apprenticeship in healthcare right now and build upon the good success that folks such as ourselves and others have had over the past few years.

All that being said, if you look at the core components of registered apprenticeship models in healthcare: earn and learn; structured on-the-job learning; mentorship from an experienced health care provider — that, importantly, is formally trained to be a mentor because just because you are good technically in your profession does not mean that you are a good mentor; robust supportive services; pre-apprenticeship model options…I think it can oftentimes be a particularly elegant solution to some of the challenges in our sector for certain occupations.

Van Ton-Quinlivan: Daniel, could you clarify the role of wages in this type of model?

Daniel Bustillo: Yes. It’s actually where I was going to next. So, in a formally registered apprenticeship model, there is a requirement to have at least one — you can have more than one – but at least one formal wage progression. It is different than what many folks would categorize as the traditional model — the sort of “train and pray” model — where you access some training and then it is incumbent upon you as an individual to attempt to find the job. This is a job from the beginning. This is a real commitment. This is a job that provides real wages with at least one wage progression built-in.

Speaking to your point, one of the things that is oftentimes unspoken but certainly true, is that apprenticeships — primarily due to the elements we referenced — certainly function for workers and adult learners, and the evidentiary base continues to build regarding better outcomes for investment on the demand side. We’ve seen an uptick over the last intervening few years. Since the pandemic, ironically, for certain occupations in certain locations, we have definitely seen an uptick. We’re now almost seven years into this federal investment in expanding registered apprenticeships into nontraditional sectors like healthcare.

Van Ton-Quinlivan: Well, I’m curious…can this apprenticeship model be of help to some of the low-wage occupations in healthcare that are so vital — especially the ones that provide care to the home — where the individuals make such low wages that the workforce is somewhat unstable? All of us need more care as our parents age or our family members have needs. What do you think?

Daniel Bustillo: I appreciate that question. Working with partners in particular locations such as Washington State and New York, we have a pretty robust registered apprenticeship program for Home Health Aides or Advanced HHAs that, importantly, has a variety of different specializations built into it in terms of separate tracks that are targeted towards disease-specific conditions. Dementia is an example. I think that we’ve had good success with that.

Speaking to your question more broadly, Van, when looking at national occupational projections to 2029 by far the largest number of projected new jobs needed is for home health and personal care aides. That’s more than double the next occupation on the list, and five times the next healthcare-related occupation. Ideas for how to break that cycle are not training-related. Training plays an important role, but it’s not solely a function of training. It’s important to acknowledge that this cycle for that particular sector is really caused by history: the racialized and gendered nature of caregiving. It’s really a direct result of a history steeped in intentional and exclusionary policy practice, such as exclusion from labor law, which really does require social policy solution.

As I’m sure you’re aware, we have an exciting opportunity right now to shape a historic moment in our nation around the future of home and community-based services with caregivers around the country calling on Congress to pass President Biden’s plan which would invest multiple hundreds of billions of dollars in the home care workforce. As I mentioned upfront, at H-CAP we’re really excited about our newly launched Center for Advancing Racial Equity and Job Quality in Long-Term Care which will take an intersectional approach that nests training in the broader social policy and narrative change work that is being led by so many advocates around the country to advocate for important improvements for this really critical workforce.

Van Ton-Quinlivan: I’m looking forward to seeing what results. Thank you for your leadership in this area. We definitely need some rethinking on the social structures and the human infrastructure that all of us will need in the future.

Daniel Bustillo: Absolutely. We all will.

Van Ton-Quinlivan: I want to dive in a little bit. You mentioned dementia, the training of a home health aide, and the connection to an apprenticeship. Is the thought that someone begins work first — you’re hired into the home with some baseline level of training — and then if the individual that you’re caring for has dementia, you would then add on dementia training? Talk to us a little bit more about how that model works.

Daniel Bustillo: It depends, because there are many differences depending upon which state you are in, but in a consumer-directed care system if you are going to provide the best possible care to a consumer or client with a specific condition, you would want to be robustly trained in the provision of that care particularly if you’re in someone’s home. There are six different potential specializations at the moment. Dementia is just one of them, and I mentioned that because it is obviously critically important. It involves providing the necessary competencies to those caregivers for the particular clients that they are working with. If it is in a hospital setting, patients. If it’s in a nursing home setting, residents.

Van Ton-Quinlivan: Is the curriculum for the six areas of specialization already developed out there, Daniel?

Daniel Bustillo: Yes, it is for most of the tracks. This is not necessarily new. We’ve been doing this for a number of years now. It keeps getting expanded. There’s a lot of iteration that takes place as it expands to new locations depending upon the particular needs, but we have a good basis of occupational frameworks and curricula in apprenticeships.

Van Ton-Quinlivan: Terrific. Much work has been done to improve how healthcare is delivered with a lot of emphasis being placed on primary care. How has that influenced H-CAP’s work, and what do you see happening in that trend?

Daniel Bustillo: I appreciate this question as well. I think it’s a long-standing conversation. I know it’s something that you’re right in the midst of in California, Van. I think we certainly have some leading-edge states in healthcare like California and Washington and some other locations. At the national level, we’ve been discussing changes in the site of care delivery for some time and that’s greatly influenced us. That being said, I think it’s important to note when you’re talking about working across different locations that as we disaggregate by geography, there’s a great deal of variation in the state of play as relates to this emphasis.

As an example, I think there are varying levels of interest in serious investments for certain occupations. I’ll bring up community health workers as one example. In particular states, there are serious levels of investment in that as an occupation, potentially. That is not necessarily the case everywhere for a variety of reasons, I think mostly related to a lack of billable services. I think that’s important to take into account.

There’s also great variation in standards and training requirements, oftentimes for the same occupation. I would say very similar to some of work that you’ve done, we’ve had partners that have had serious programs focused on things such as care coordination and community-based care occupations for some time now. I really do anticipate this trend continuing, but I just want to point out that — speaking to many of the things I talked about earlier — it is really important to take into account that we shouldn’t just think about this in a vacuum. The occupational growth in these areas in some places is being accompanied by lower wages. So, it’s important to have that context while working towards training initiatives and infrastructure.

Van Ton-Quinlivan: Good things to think about. Let’s end on a personal note. I would love for you to tell us what led you into this field of work and why you wake up every day to do the work that you do.

Daniel Bustillo: (laughs) It’s a great question. In many ways it’s a bit of happenstance, which I’m sure is true for many of us, right? It was never a specific intention of mine to end up in the field of workforce development. But once upon a time, a long time ago, I was a healthcare worker myself in a large health system in New York City. I have both an immediate and extended familial history in healthcare as well.

As we’ve increasingly heard during the COVID-19 pandemic, caregiving is an essential infrastructure in this nation. It’s an essential infrastructure for families. Caregivers, as we’ve talked about, have rightfully been lauded as heroes but not frequently treated as such historically. It’s oftentimes difficult but really rewarding work that happens to be undervalued in our society.

You’ve heard me talk quite frequently about the racialized and gendered nature of caregiving and the occupational segregation issues endemic to the healthcare sector. If we can make change in this sector, which is so important to the livelihoods of so many communities, there could potentially be cascading multiplier effects. Beyond this, I’m personally privileged to be able to at times have direct interaction with caregivers around the nation — no longer as much as I would like — but I really do cherish and value those opportunities.

So, for me, the question is how can we not envision and do everything we can to work towards a different future than what exists right now? I wake up every day hoping to utilize whatever platform I may have available to me to play some small role in supporting moving these efforts forward for caregivers.

Van Ton-Quinlivan: Well, Daniel, I certainly learned a lot today and hope that Futuro Health can be a part of your multiplier effect.

Daniel Bustillo: Well, we certainly anticipate that, Van.

Van Ton-Quinlivan: Thank you very much for being with us today. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.