Shoring Up the Long-Term Care Workforce

By Kate Bradford | Vol . 27, No. 28 | August 2019

Did You Know?

  • 20% of the U.S. population is projected to be age 65 or older by 2030, outnumbering children for the first time in the nation’s history.
  • Nearly 90% of this population prefers to remain in their own homes for as long as possible.
  • More home care jobs are projected to be added than any other single occupation between 2016 and 2026. Yet one in two workers leave these jobs within 12 months.

Millions of Americans rely on care provided through long-term services and supports (LTSS). These include a wide range of medical and personal care services that assist people with disabilities and older adults with routine daily activities. Demographic changes in the U.S. indicate further increases in demand for LTSS, led partly by the aging population, increased life expectancies and a higher prevalence of certain chronic health conditions.

Medicaid is the primary payer of LTSS, paying roughly 30% ($167 billion), which includes care offered in nursing facilities and through home and community-based services (HCBS). More than half of Medicaid LTSS spending currently supports HCBS rather than institutional care (e.g., nursing home care). Several factors contribute to this, including individual and family preferences and the relative cost-effectiveness of home and community-based care.

This increased demand for HCBS coincides with an increased demand for workers to deliver these services—the direct care workforce. States use various titles for these workers and often define them in statute. They can include personal care aides (PCAs), home health aides (HHAs), home care workers, long-term care aides and nursing assistants.

Each profession has a slightly different scope of practice depending on the number of required training hours or varying state regulations, and a handful are defined in the Bureau of Labor Statistics Standard Occupational Classification Manual. For example, PCAs generally assist with social supports or daily living activities such as meal preparation, dressing and bathing, shopping and other housekeeping chores. HHAs and nursing assistants share many of the same duties and perform certain clinical tasks under the supervision of a licensed professional. The distinctions between HHAs and nursing assistants often have more to do with work settings, regulations and oversight than with tasks. As of 2016, 12 states require HHAs to also complete nursing assistant training.

Together, these health care professionals play a critical role in helping older adults and people with disabilities remain in their homes and communities; however, experts see challenges for this workforce. Direct care jobs are often characterized as having low pay, poor benefits, and minimal training and advancement opportunities. Such factors can be associated with a high turnover rate for direct care workers, which ranges from 45% to 60%.

State Action

States consider various strategies to improve delivery of HCBS and to support the recruitment and retention of the direct care workforce as demand rises for home care. Some states and health plans target improved reimbursement and workforce protections such as workers’ bill of rights laws. Others focus on training programs for direct care workers to help improve skills and job and consumer satisfaction.

Benefits, Wages & Workforce Protections. Some states have looked to wages, benefits and other workforce protections to support their direct care workforce. Colorado SB 238 (2019) establishes a new hourly minimum wage for employees who provide direct care. Maryland HB 166 (2019) increases the rate of reimbursement for community service providers, including direct care staff, each fiscal year (beginning with a 3.5% increase in 2019).

Other bills passed in recent years support better benefits and worker protections. In 2017, Wisconsin increased the direct care portion of funds paid to managed care companies that go towards wages, bonuses, time off, or benefits through the general appropriations bill. Additionally, a handful of states, including Oregon, Illinois and Nevada, have passed “Domestic Workers’ Bill of Rights” laws. These generally extend workplace harassment and overtime protections to domestic workers, which often include home care workers. 

Training. Other states focus on strategies to improve the quality of the direct care workforce through training and career advancement opportunities. Research indicates direct care workers succeed when they can access high-quality entry-level training, ongoing education opportunities and defined career ladders. Some efforts may also enrich the perceived value of direct care jobs for future candidates and improve recruitment and retention.

Washington passed a 2011 ballot initiative that expanded learning objectives, increased training hours, and introduced certification requirements for PCAs. The initiative requires the state to approve all pre-service training and continuing education, and the curricula must be more relevant to the specific needs of patients, service settings and the trainees’ career development. After meeting the certification requirements, PCAs can complete condensed training to become an HHA or a nursing assistant. Arizona also addressed training by implementing a uniform, statewide and state-funded training system in 2012, following recommendations from their Direct Care Workforce Committee.

Other policies focus on specific curricula to meet the unique needs of certain populations. Illinois enacted SB 2301 (2016), establishing minimum training requirements for employees of home health agencies providing services for people with Alzheimer’s and related dementias. Similarly, Oregon’s HB 3359 (2017) outlined specific training on dementia care to direct care workers.

Other Strategies. A few states are looking at alternative policies that help address their workforce needs. The Texas Health and Human Services Commission issued a 2018 report as mandated by the legislature) to improve recruitment and retention among state Medicaid-funded personal care aides.

Some states, including Maine and New Mexico, have convened stakeholder task forces to consider ways to support and strengthen the direct care workforce.

In 2018, Minnesota launched Direct Support Connect, a statewide job board that helps consumers find direct care workers and helps workers find the right employment fit. The Minnesota Department of Human Services created this resource to help address the shortage of direct support workers in the state.