Cooperative Home Care Associates (CHCA) is a for-profit, worker-owned cooperative located in the South Bronx, New York -- one of the most distressed inner-city areas in the United States. The cooperative provides home health care aides on a contract basis to large health-care providers such as the Visiting Nurse Service and major hospitals. CHCA is an example of a sectoral program that has attempted to restructure poor-quality jobs for the benefit of the worker as well as the industry.
Founded in 1985 by Rick Surpin and Peggy Powell, CHCA now employs more than 300 women of color, and successful replication projects employing a total of 120 women of color have been established in Philadelphia and Boston.
The cooperative was established on the premise that by aggressively intervening as an employer in the home health care industry, the entry-level occupation of home health aide -- which is already accessible to women with low skills and education -- could be improved for the benefit of the worker.
Home care services, although technically not temporary work, are nonetheless organized in much the same manner as other temporary industries. Cases assigned to home care papaprofessionals vary in schedule by number of hours, time of day, day of week, and duration of case. Most home care agencies fill their rosters with as many part-time aides as they can hire, train them to minimum required standards, and assign work with little regard for the aides' need for full-time hours or other professional treatment. As a result, turnover in the industry is high, care provided is erratic, and both home care aides and home care clients suffer.
CHCA leadership believed that by changing the nature of the home care job, the industry could be shown that a strategy of investing in the front-line worker could provide both better jobs and better patient care. In an industry characterized by part-time work, low wages, and high turnover, CHCA currently pays workers between $7 and $8 per hour with health insurance and paid vacation time. Seventy percent of CHCA employees are employed full-time, and turnover is just 20 percent annually (compared to the industry average of 40 to 60 percent).
All CHCA home care aides are first trained by the Home Care Associates Training Institute (HCATI), a nonprofit organization housed in the same offices as CHCA and funded by public (33 percent) and philanthropic (67 percent) sources. Trainees must be low-income -- 85 percent were dependent upon public assistance immediately before entering the training program. All CHCA home care aides are minorities; all but two are women. Only 40 percent of workers have completed high school or a GED, and most test at 5th- to 8th-grade levels in reading and math.
The CHCA model has three essential components:
A participatory organizational culture, combined with a commitment to a worker-ownership structure, gives employees a voice, encourages commpany loyalty and keeps both turnover low and patient care high.
In 1993, HCATI initiated a replication program to introduce the CHCA model into other inner-city home care markets. The first replication site was started in Philadelphia in 1993 and now employs 75 home health aides; the second was started in Boston in 1994 and now employs 45 aides. Two more sites are slated for the Midwest by 1999.
CHCA was created in an effort to improve the quality of jobs for low-income women in the home health-care industry. The home care industry has been growing for the past 10 years and the paraprofessional home care aide position is one of the few jobs still available to inner-city women.
However, these jobs are typically poor-quality jobs offering part-time work, low pay, few benefits, inadequate training, and little or no career upgrading opportunities.
In addition, hospitals and home nursing agencies that contracted for home care services also complained of poor service and problems with patient care. CHCA's founders felt that these concerns over poor quality were directly related to the poor quality of home care jobs. They thus sought to create a new context that recognized this relationship.
CHCA today is a model employer in the industry with wages and benefits 20 percent over industry average, 34 to 35 hours or employment per week for the typical aide, and an annual turnover rate that is half the industry average. The worker-ownership structure essentially acts as a guarantor to ensure that the firm remains committed to being "built around the front-line employee."
At the same time, contractors have acknowledges that CHCA's home care aides are more desirable that those of other companies. They deliver a higher level of reliability and responsiveness, and have raised standards of expectations industrywide about what a home care aide is capable of doing. The linking of quality of job to quality of care is what CHCA attributes its success to on two fronts: first, the original mission to create good jobs for low-income people, and second, becoming a valued and integral player in the home care sector.
Since the home care industry in larger cities is structured with private companies funded primarily by public agencies, CHCA's strategy has been forced to address both private industry practice and public funding and regulatory policies. Although highly regulated, home care agencies are nonetheless market-driven. They constantly look to one another for standards -- both of "best practice" and of what is minimally acceptable. Over time presumptions settle into all home care providers within a given area, shaping perceptions as to what works best and what does not work at all.
CHCA's leaders decided that the most effective way to influence practice within the home care industry was to demonstrate what changes are possible. Over time, CHCA's contractors sought similar innovations from their other sub-contractors (CHCA's competitors), improving the practices of the home care industry throughout New York City.
Therefore, CHCA was established as a new, competitive, for-profit business in the industry to lead as a model, proving to the rest of the industry that workers who are better trained, who receive better wages and benefits, and who have a voice in their company would provide better care.
After CHCA had established legitimacy with both its contractors and its competitors, the company was then well-positioned to achieve a public policy labor-market impact. CHCA is now perceived as a "yardstick corporation," one that is respected by various local stakeholders -- from patient advocates to labor leaders, and from agency managers to regulators -- for balancing employee and client needs while remaining a profitable business. In coalition with these stakeholders, CHCA has been able to encourage improved reimbursement rates and regulatory reform throughout the New York City home care market.