Need for Data. Data that are clear, comprehensive, current, and correct are needed in the case of long-term care paraprofessionals, as they are for any other health occupation. Such data are a valuable tool for meeting the following purposes:
- Workforce planning. Providing planners and managers at all levels, especially State and local, with accurate, timely data to help them plan and effectively manage health care delivery.
- Policy formulation. Informing the process by which public policies and programs that could influence workforce supply and demand are generated, e.g., setting reimbursement policies and rates for Medicare and Medicaid, establishing licensure and regulation policies as well as policies involving employee benefits, upward mobility, etc.
- Patient safety. Promoting patient safety by ensuring that individual workers are properly trained and have no record of inappropriate activities.
- Quality improvement. Monitoring the performance of facilities and provider organizations for dissemination to patients and their families.
- Program evaluation. Monitoring and assessing program performance over time and identifying best practices.
- Informing the marketplace. Supplying education and training organizations, health providers, and the public with useful information to serve their individual needs.
Relevant Data Sources. As noted earlier, the data systems reviewed in this study, although helpful in many respects, were limited in their ability to present an accurate and timely picture of nursing aides, home health care aides, and related occupations in the United States. The datasets reviewed included six maintained by the Bureau of Labor Statistics, one on nursing homes maintained by the DHHS Centers for Medicare and Medicaid Services (CMS), one maintained by the Bureau of the Census, and 45 certified nursing aide (CNA) registries maintained at the State level. A brief summary of these datasets follows:
Bureau of Labor Statistics. The six BLS datasets cover six separate aspects of the Bureau's data collection activities:
- Occupational Employment Statistics (OES). A mail survey of 400,000 establishments per year, resulting in a total sample of 1.2 million establishments over three years.
- Current Population Survey (CPS). A monthly survey of 50 to 60 thousand households, conducted on behalf of BLS by the Bureau of the Census (personal and/or telephone interview).
- CPS March Supplement. A somewhat more detailed version of the CPS, conducted once a year on a slightly larger sample.
- National Compensation Survey (NCS). An annual compilation of data on earnings, benefits, and work hours, based on visits to some 36,000 establishments.
- Employment Projections. Projected labor force trends based on analysis of OES and CPS survey results.
- Survey of Occupational Injuries and Illnesses. An annual survey of 250,000 private sector organizations with at least eleven employees to obtain data relevant to occupational safety.
Centers for Medicare and Medicaid Services. The CMS dataset, labeled Online Survey Certification and Registration or OSCAR, consists of staffing data and associated facility characteristics for approximately 17,000 CMS-certified nursing homes. The data are self-reported and updated once a year as part of the CMS annual recertification process.
Bureau of the Census. The decennial Census collects limited data on the occupation of residents of the United States. These data, updated every 10 years, provide estimates of the numbers of persons employed in different occupations by Census tract. The data are tabulated by place of residence rather than employment.
State CNA Registries. Registries of this nature, mandated by the Omnibus Budget Reconciliation Act of 1987, are maintained by every State and the District of Columbia. Used for background checks and other relevant purposes, they contain information on certified, licensed, or registered nursing aides working in skilled nursing facilities (SNFs), although some states have gone beyond the legislative mandate to include other direct care paraprofessionals. Of the 45 State registries reviewed, nine include home health aides as well.
Data Limitations. The limitations presented by these data sources, in terms of meeting the purposes of this study, fall into three categories: data exclusions, inconsistency of definitions, and categorizations that are in some cases excessively broad.
Data exclusions. Important data exclusions are as follows:
- State CNA registries. As noted above, State CNA registries are required by legislation to cover nursing aides only; only a small percentage--less than a fourth--include health aides or other occupational categories as well. Moreover, these systems were designed--and in most cases are being used--to track eligibility (completion of mandatory training) rather than employment. While most State registries include some information of a demographic nature, about a fourth do not. Since most registries do not track the actual employment of eligible CNAs, they do not generally provide information on work setting or location.
- Online Survey Certification and Registration (OSCAR). OSCAR covers staff in nursing homes only. Nursing aides, LPNs, and RNs are the only professions/occupations for which separate tabulations are available.
- BLS Occupational Employment Statistics (OES). OES data, while disaggregated to the State and metropolitan area level as well as to industry group, provide no detail on demographic characteristics, work conditions, or setting in which services are delivered. Also, the numbers do not include self-employed or unpaid family providers of care.
- BLS Current Population Survey (CPS) March Supplement. Since the CPS March Supplement contains no State variable, the employment numbers cannot be disaggregated to the State level.
Inconsistency of definitions. Occupational and industry classifications used have differed by dataset and varied over time. However, as announced in the Federal Register Notice of September 30, 1999, all Federal agencies that collect occupational data are now required to use the 1998 Standard Occupational Classification, the largest revision to the SOC in two decades. In addition, all State and local government agencies, as well as private sector organizations, that gather occupational data are strongly encouraged to use the 1998 SOC. In the words of the announcement, "This national system ... provides a common language for categorizing occupations in the field of work."
While the Federal government has attempted to standardize classifications through the SOC, inconsistencies among state-reported data remain; this includes differing definitions of workers and different methods used to quantify the number of workers.
Excessively broad categorizations. The occupational category "nursing aides, orderlies, and attendants", retained in the 1998 SOC, includes three separate occupations, each with its own set of demographic characteristics, work settings, and job responsibilities. Similar problems exist with respect to the classification of industries: some industry codes contain work settings irrelevant to the provision of direct care, e.g., medical laboratories, youth services, crisis centers, food banks, etc.
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