North Carolina's direct care workforce development journey: The case of the North Carolina New Organizational Vision Award Partner Team

Background: Better Jobs Better Care was a five-state direct care workforce demonstration designed to change policy and management practices that influence recruitment and retention of direct care workers, problems that continue to challenge providers. Purpose: One of the projects, the North Carolina Partner Team, developed a unified approach in which skilled nursing, home care, and assisted living providers could be rewarded for meeting standards of workplace excellence. This case study documents the complex adaptive system agents and processes that coalesced to result in legislation recognizing the North Carolina New Organizational Vision Award. Methods: We used a holistic, single-case study design. Qualitative data from project work plans and progress reports as well as notes from interviews with key stakeholders and observation of meetings were coded into a simple rubric consisting of characteristics of complex adaptive systems. Findings: Key system agents in the state set the stage for the successful multistakeholder coalition. These included leadership by the North Carolina Department of Health and Human Services and a several year effort to develop a unifying vision for workforce development. Grant resources were used to facilitate both content and process work. Structure was allowed to emerge as needed. The coalition's own development is shown to have changed the context from which it was derived. Practice Implications: An inclusive and iterative process produced detailed standards and measures for the voluntary recognition process. With effective facilitation, the interests of the multiple stakeholders coalesced into a policy response that encourages practice changes. Implications for managing change-oriented coalitions are discussed.