Pathway to the Future: How Workforce Development and Quality Jobs Can Promote Quality Care Conference Package. Characteristics of Long-Term Care in the United States

05/01/2004

Recipients. Long-term care recipients in the United States numbered about 12.1 million in 1995 (Kaiser Commission on Medicaid and the Uninsured, 1999). A diverse population with a wide age range and variety of service needs, the common element linking these individuals is their need for assistance with activities of daily living (ADL). Most received services at home or in community-based settings such as adult day care facilities, although about 12 percent (1.5 million) were cared for in nursing homes or other institutional residential facilities (ibid.).

As shown in Table ES-1, persons 65 or older constituted slightly over half (6.4 million) of the estimated 12.1 million long-term care recipients in 1995. Within that group, 1.3 million (20 percent) received care in nursing homes; the rest were cared for at home or in community settings. Of those receiving care at home or in the community, about two-thirds relied exclusively on unpaid caregivers, i.e., family and friends (Stone, 2001).

TABLE ES-1. Recipients of Long-Term Care in the U.S., 195
Age Group Setting in Which Care Was Received All Settings Combined
Nursing Home Home or Community
SOURCE: Kaiser Commission on Medicaid and the Uninsured, 1999
65 or Older 1.3 million 5.1 million 6.4 million
Under 65 0.2 million 5.5 million 5.7 million
All Ages 1.5 million 10.6 million 12.1 million

The dichotomy between nursing home and community-based care is even more pronounced for persons under 65. Of the nation's long-term care recipients below the age of 65, well over 95 percent--all but about 0.2 million--received care at home or in community settings. Of these, roughly three-fourths relied exclusively on family and friends for care. Long-term care recipients below the age of 65 include persons with mental retardation and serious mental illness, as well as adults living with AIDS or other chronic disorders and children with developmental disabilities.

Providers. The three major categories in the latest (1998) Standard Occupational Classification (SOC) system whose members provide long-term care of a paraprofessional nature are as follows:

The three major categories in the latest (1998) Standard Occupational Classification (SOC) system whose members provide long-term care of a paraprofessional nature
Nursing aides, orderlies, and attendants (SOC 31-1012) Provide basic patient care under the direction of nursing staff. Perform attendants duties such as feeding, bathing, dressing, grooming, moving patients or changing linens.
Home health aides (SOC 31-1011) Provide routine personal health care such as bathing, dressing, or grooming, to elderly, convalescent, or disabled persons at patient's home or residential care facilities.
Personal and home care aides (SOC 39-9021) Assist elderly or disabled adults with daily living activities at person's home or daytime non-residential facilities. Duties may include keeping house and preparing meals. May also provide meals and perform supervised activities at non-residential care facilities.

The number of individuals employed in these categories, based on year 2000 BLS data, are as follows:

The number of individuals employed in these categories, based on year 2000 BLS data
Total 2,206,300
Nursing aides, orderlies, and attendants 1,262,000
Home health aides 577,700
Personal and home care aides 366,600

Table ES-2 shows their percentage distribution by industry group in which employed.

TABLE ES-2. Paraprofessional Workers by Industry Group: 2000
Occupational
Category
Industry Group
Home Health
Care
Nursing and
Personal Care
Residential
Care
Other Total
SOURCE: BLS Occupational Employment Survey
Home Health Aides 32.9% 5.4% 22.3% 39.4% 100%
Nursing Aides, Orderlies, and Attendants 2.7% 51.9% 4.5% 40.9% 100%
Personal and Home Care Aides 30.8% 3.5% 24.1% 41.6% 100%

Approximately 60 percent of the workers in each occupational category are seen to be employed in the three industry groups most clearly associated with the delivery of long-term care (home health care, nursing and personal care, residential care). In addition, a significant portion of those in industries classified as "Other" may also be assumed to have been engaged in the delivery of long-term care. For example:

  • A substantial percentage of nursing aides, orderlies, and attendants in industries classified as "Other" work in specialty hospitals that provide long-term care for the chronically ill or rehabilitation/restorative/ adjustive services to physically challenged or disabled persons.
  • One of every five home health aides in industry groups classified as "Other", as well as one of every ten nursing aides, orderlies, and attendants in that category, work for Personnel Supply Services, i.e., temporary agencies. When employed in that capacity, they too may provide long-term direct care.

There also exists a substantial "gray market" of individuals hired directly by individuals and families, who do not show up as employed in either BLS or other government data systems. One national study found that 29 percent of workers providing assistance to the Medicare population in the home were self-employed (Leon and Franco, 1998a).

Workers in the described occupational categories earn relatively meager wages. In 2000, the median wage for each of these categories was less than $9 an hour, an annualized salary of less than $19,000 for a full work-year of 2,080 hours (BLS, National Occupational and Wage Estimates for 2000). Many of these individuals work only part-time. Long-term care paraprofessionals are reported to work only about 30 hours a week on average, reducing their annualized earnings to well below $15,000. A high percentage (28 percent) live in poverty, and are more likely than other workers to rely on public benefits to supplement their wages (Himmelstein et al., 1996). Among single-parent nursing home and home health aides, 30 to 35 percent receive food stamps (General Accounting Office, 2001). Many also rely on publicly funded health care.

Data from the BLS Current Population Survey (CPS) March Supplement indicate that over 90 percent of the two specific occupations "nursing home aide" and "home care aide" are female, with the vast majority falling between the ages of 25 and 54. A significant percentage of these individuals (12 to 23 percent) are foreign-born, of whom only about a third are naturalized. Contrary perhaps to public perception, a substantial proportion (28 to 35 percent) reported at least some college education.

Provider Organizations. Organizations that draw upon long-term care paraprofessionals to provide needed services include:

  • Nursing facilities
  • Intermediate care facilities for the mentally retarded
  • Residential facilities for adults or aged
  • Residential facilities for non-aged
  • Adult day care centers
  • Home health agencies (certified or licensed)
  • Hospice organizations (certified or licensed)

There were approximately 120,000 such organizations in the United States in 1998 (Harrington et al., 1999), of which roughly 43 percent (51,200) were residential facilities for adults or the aged and another 20 percent (23,300) were home health care agencies. Nursing facilities accounted for 15 percent (17,500) and residential facilities for the non-aged for 11 percent (13,300).

In addition to these types of organizations, there are a growing number of alternative organizational and service configurations as consumers and providers seek to expand the options for both health services and housing arrangements for the elderly and chronically ill. Many states have developed Home and Community Based Services (HCBS) options, with a sharp increase in assisted living arrangements and options. In addition, many states are promoting approaches to giving individuals more control over the selection of caregivers under programs generally referred to as "consumer-directed care".

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