The paraprofessional LTC workforce -- over 2.4 million nursing aides, orderlies, and attendants, home health aides, and personal and home care aides (USBLS, 2004a) -- forms the core of the formal LTC system.2 Direct care workers serve as the eyes and ears of the formal LTC system and provide most of the care in this system. Even with relatively high unemployment rates, LTC providers and state agencies responsible for LTC services are reporting unprecedented vacancies and turnover rates among direct care workers, ranging from 45 percent to over 100 percent annually for nursing homes. Most states consider direct care worker recruitment and retention major issues (NCDFS, 1999; PHI and NCDHHS, 2004).
Significant societal factors are converging that will likely result in a 21st Century LTC direct care workforce crisis, or “care gap,” in the US. These dynamics include an unprecedented increase in the elderly population and those with chronic medical conditions, a decrease in the traditional pool of women available to provide formal care, fewer adult children available to provide care, and a potential increase in the need for paid care for elderly parents of dual-income and single-parent households. Policymakers and providers need to know what workforce initiatives have been shown to work to address the direct care workforce shortage.
Previously reported research (discussed in Stone, 2001 and Stone and Wiener, 2001) highlights a variety of factors associated with LTC direct care workforce recruitment and retention problems. These factors include but are not limited to: inadequate training; poor public image of the LTC direct care workforce; low pay; insufficient benefits; inadequate job orientation and lack of mentoring; little or no opportunities for continuing education and development within the position; poor supervision; emotionally and physically hard work; workplace stress and burnout; personal life stressors, such as problems with housing, child care, and transportation; lack of respect from residents’ families; and, short staffing. In the past several years, states, providers, and worker groups have developed, implemented and, in some cases, evaluated a variety of initiatives to address these challenges. This paper gives an overview of the most recent evidence base on both problems and possible solutions, to inform future investment choices and initiatives.
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