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Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis

Publication Date

U.S. Department of Health and Human Services

Who Will Care For Us?
Addressing the Long-Term Care Workforce Crisis

Executive Summary

Robyn I. Stone with Joshua M. Wiener

The Urban Institute

May 2001

This report was prepared under contract #HHS-100-97-0010 between the U.S. Department of Health and Human Services (HHS), Office of Disability, Aging and Long-Term Care Policy (DALTCP) and The Urban Institute. For additional information about the study, you may visit the DALTCP home page at or contact the ASPE Project Officer, Andreas Frank, at HHS/ASPE/DALTCP, Room 424E, H.H. Humphrey Building, 200 Independence Avenue, SW, Washington, DC 20201. His e-mail address is:



The paraprofessional long-term care workforce--nursing assistants, home health and home care aides, personal care workers, and personal care attendants--forms the centerpiece of the formal long-term care system. These frontline workers provide hands-on care, supervision, and emotional support to millions of elderly and younger people with chronic illness and disabilities. Low wages and benefits, hard working conditions, heavy workloads, and a job that has been stigmatized by society make worker recruitment and retention difficult.

Long-term care providers report unprecedented vacancies and turnover rates for paraprofessional workers. Increasingly, the media, federal and state policymakers, and the industry itself are beginning to acknowledge the labor shortage crisis and its potentially negative consequences for quality of care and quality of life. These shortages are likely to worsen over time as demand increases. This paper, developed with support from the Office of the Assistant Secretary for Planning and Evaluation (ASPE) in the U.S. Department of Health and Human Services (HHS), and the Robert Wood Johnson Foundation (RWJF), provides a broad overview of the long-term care frontline workforce issues.

The Long-Term Care Frontline Workforce

Most paid providers of long-term care are paraprofessional workers. After informal caregivers, these workers are the most essential component in helping older persons and younger people with disabilities maintain some level of function and quality of life. According to recent U.S. Bureau of Labor Statistics (BLS) data, nursing assistants held about 750,000 jobs in nursing homes in 1998, while home health and personal care aides held about 746,000 jobs in that same year. Like informal caregivers, the overwhelming majority of frontline long-term care workers are women. About 55 percent of nursing assistants are white, 35 percent are black, and 10 percent are Hispanic. Most workers are relatively disadvantaged economically and have low levels of educational attainment. While these paraprofessional workers are engaged in physically and emotionally demanding work, they are among the lowest paid in the service industry, making little more than the minimum wage. National data on the number of these workers with health benefits is lacking, but state and local studies suggest the rate of uninsured is high.

What Is the Problem?

The severe shortage of nursing assistants, home health and home care aides, and other paraprofessional workers is the primary trend influencing the current wave of concern about the long-term care workforce. National data on turnover rates show wide variation, depending on the source of the data: One source suggests that turnover rates average about 45 percent for nursing homes and about 10 percent for home health programs, while other data place average annual nursing home turnover at over 100 percent per year. High rates of staff vacancies and turnover have negative effects on providers, consumers, and workers: The cost to providers of replacing workers is high; quality of care may suffer; and workers in understaffed environments may suffer higher rates of injury.

The future availability of frontline workers does not look promising. There will be an unprecedented increase in the size of the elderly population as the “baby boom” generation ages. BLS estimates that, in response to this rising demand, personal and home care assistance will be the fourth-fastest growing occupation by 2006, with a dramatic 84.7 percent growth rate expected. The number of home health aides is expected to increase by 74.6 percent and that of nursing assistants by 25.4 percent. While these projections suggest that the demand for workers will increase, the actual number of jobs may be tempered by the rate of economic growth and the extent to which purchasers are willing or able to pay. At the same time, as baby boomers approach old age, the pool of middle-aged women who have traditionally provided care will also be substantially smaller. Finally, with very low population and labor force growth, even a “normal” business cycle recession would likely yield only a modest increase in the number of unemployed who could become part of a frontline worker pool.

Factors Affecting the Supply and Quality of Workers

The success of efforts to recruit, retain, and maintain a long-term care workforce is dependent on a variety of interdependent factors. One important influence on individuals’ decisions to enter and remain in the long-term care field is how society values the job. Frontline worker jobs in long-term care are viewed by the public as low- wage, unpleasant occupations that involve primarily maid services and care of incontinent, cognitively unaware old people. This image is exacerbated by media reports that feature poor quality care by providers.

Conditions in the labor market are also important influences on the decision to join the long-term care workforce. Several studies have identified the strength of the local economy as a major predictor of turnover rates in long-term care. A study conducted in North Carolina found that fewer than half the individuals trained as nursing assistants in that state over the last decade were currently certified to work in that occupation, with most “leavers” working at higher-wage jobs.

Health and long-term care policies also significantly affect workforce recruitment and retention. Medicare and Medicaid account for almost three-fifths of long-term care expenditures and therefore play a substantial role in determining provider wages, benefits, and training opportunities. Regulatory policy on long-term care focuses primarily on protecting consumers, rather than on responding to workers’ concerns. Regulation tends to emphasize entry training, with limited attention to continued career growth or development. One major policy issue for workforce development is the extent to which states allow nursing assistants to perform certain tasks currently performed by nurses (e.g., administering medications or providing wound care). Giving frontline workers added responsibility and autonomy may motivate them to remain in the job or encourage others to seek these positions. Program design features, such as whether consumer-directed home care is provided, can also affect the size of the labor force by making it easy or hard for relatives and friends to be paid for care provided.

Labor policy plays an important role in determining the size of the pool of frontline long-term care workers. The federal government invests more than $8 billion annually to prepare primarily low-income and unemployed individuals for new and better jobs. Ironically, state and federal employment agencies indirectly prevent the long-term care industry from participating in training support programs by requiring that program graduates secure wages that are higher than typical frontline worker salaries. While these policies are designed to protect trainees from being shunted into poverty-level jobs, they essentially preclude graduates from entering the paraprofessional long-term care labor force. The federal Work Investment Act of 2000 does not include the same requirements, but the effects of the new law are unclear.

Federal welfare initiatives are particularly relevant to the development of this workforce. The federal Personal Responsibility and Work Opportunity Reconciliation Act of 1996 (PRWORA) created the Temporary Assistance for Needy Families (TANF) program, which replaced the cash welfare system with a new block grant program and provides flexibility to states in developing job opportunities. Many states follow a “work first” strategy that discourages skill-based training; although such policies are designed to get recipients into the work force, they conflict with federal nursing home and home health aide training requirements.

Given the current labor shortage and gloomy projections about the future pool of workers, many providers have expressed interest in immigration as a tool for expanding the potential labor pool. But immigration of low-wage workers would have to substantially increase to keep pace with population aging and new long-term care demands. Policymakers must recognize that having low-skilled immigrants fill entry- level jobs in the long-term care industry would likely mean a sharp cultural discontinuity between the client and the caregiver.

The confluence of the above factors and individual employer and employee decisions are played out in the workplace. Organizational arrangements, social factors, physical setting, and environment and technology all affect the successful development of the frontline workforce. A review of the literature reveals that little empirical research on workplace interventions has been done. Most of the research has been conducted in nursing homes and tends to be descriptive, rather than empirical, describing various management/job redesign efforts, training activities, and financial and nonmonetary reward programs. In the 1980s, several small, qualitative studies of nursing assistants identified the organization’s management style (e.g., supervisors with “good people skills,” promotion of worker autonomy) as the most important predictor of higher job satisfaction and lower turnover rates. A later study examined factors determining nursing assistant turnover, and found that local economic conditions had the strongest effects on turnover rates. One of the latter study’s most important findings was that homes in which nurse supervisors accepted nursing assistants’ advice or simply discussed care plans with the aides reported turnover rates that were one-third lower than those without these practices. Other studies have underscored the importance of including nursing assistants in care planning and providing feedback to help assistants understand the connection between interventions and resident outcomes.

Research on home care workers has been more difficult to conduct because it must be carried out in individual homes. The most comprehensive study of home care worker satisfaction and turnover, conducted over a decade ago, assessed the impact of salary increases, improved benefits, guaranteed number of service hours, and increased training and support on worker retention. In the aggregate, the interventions reduced turnover rates by 11 to 44 percent. The study found that while financial rewards were important to worker satisfaction, motivation, and retention, job qualities such as good personal relationships between management and workers and between the worker and the client were more important. Disappointingly, when research funding terminated, agencies reverted to their former practices.

Public and Private Efforts to Develop a Qualified, Stable Frontline Workforce

As noted previously, recruiting and retaining frontline long-term care workers have become a priority for many states. State initiatives have included the following options:

  • Establishing “wage pass-throughs,” in which a state designates some portion of a public long-term care program’s reimbursement increase to be used specifically to increase wages and/or benefits for frontline workers.

  • Increasing worker fringe benefits, such as health insurance and payment for transportation time.

  • Developing career ladders by establishing additional job levels in public programs, training requirements, or reimbursement decisions.

  • Increasing and improving training requirements.

  • Developing new worker pools, including former welfare recipients.

  • Establishing public authorities to provide independent workers and consumers ways to address issues about wages and benefits, job quality, and security.

Providers, too, are experimenting with a range of interventions. The literature contains numerous descriptions of programs in nursing home and home care settings that have attempted to address recruitment and retention (although few such programs have been evaluated). For example, the “Pioneer Homes” approach to changing nursing home culture does not focus specifically on recruiting and retaining workers, but it tries to link the facility to the outside world and create a community: Plants and animals abound, children interact with residents, and workers are respected as an essential part of the care team. Evaluations of this model have not been completed.

The Wellspring model of quality improvement is another approach to changing nursing home workplace culture. Wellspring is a consortium of 11 freestanding nursing homes whose top management have made a philosophical and financial commitment to a continuous quality improvement initiative. The three-pronged approach includes intensive clinical training, periodic analysis of outcomes data to monitor quality, and a management change/job redesign effort, in which nursing assistants become essential members of care teams and are empowered to make certain decisions.

Cooperative Home Care Associates, a worker-owned company located in New York, Boston, and Philadelphia, is staffed overwhelmingly by former welfare recipients. After three months’ employment, a worker can purchase shares in the company. Wages are higher than the average for home care aides, and workers receive fringe benefits as well as guaranteed hours. Workers are encouraged to advance their careers and earn higher pay and status as associate trainers or by assuming administrative positions.

Many frontline long-term care workers have developed their own initiatives to improve their status, compensation, and job opportunities. These include the Iowa Caregivers Association, the National Network of Career Nursing Assistants, and the Direct Care Alliance. Unions, particularly the Service Employees International Union (SEIU), have made major inroads in organizing both nursing home and home care workers in selected states across the country.

Developing a Research and Demonstration Agenda

This broad overview of long-term care frontline worker issues has identified a number of knowledge and information gaps that need to be addressed to further the development of a qualified, sustainable workforce: We need a better understanding of the sources of the problem, the effects of policy interventions, and which elements in different approaches succeed and fail. We need an updated profile of the frontline workforce in all long-term care settings that describes their demographic characteristics, wages and benefits, geographic distribution, levels of education, and health literacy. Policymakers need to better understand the magnitude of the long-term problem so that they are more motivated in developing this workforce, the barriers to doing so, and the possible consequences of different policy interactions. Research is needed to assess the effectiveness of state strategies’ in ameliorating the short-term crisis, as well as to determine whether such strategies as wage pass-throughs could be replicated successfully. Finally, we need to develop and test creative ways of developing new pools of workers to meet the demand for services in the future.

Federal and state agencies and private foundations have begun to invest in applied research that will help provide some solutions. ASPE is collaborating with the RWJF to develop a research and demonstration agenda on this issue, and other private foundations and agencies of the federal government are also supporting similar research efforts.

The future of the frontline long-term care worker is, in many ways, a barometer for the health of our aging communities. Stakeholders at the federal, state, and local levels and in the public and private sectors must come together to find creative solutions to this problem.

The Full Report is also available from the DALTCP website ( or directly at The Urban Institute also published a version of this Full Report, which can be viewed by going to [The Urban Institute's version of the Full Report is in the Portable Document Format (PDF). You will need a copy of the Acrobat Reader in order to view it.]