Preface

Nursing aides and home health aides are two of the major occupations responsible for providing patient care of a paraprofessional nature to chronically ill, disabled, and elderly persons in nursing homes and other institutional or community-based settings as well as at home. The challenges faced by long-term care facilities in recruiting and retaining these workers have been increasing in recent years, resulting reduced services for many Americans.

Recognizing the importance of this segment of the health workforce in meeting the care needs of an increasing percentage of the population, the National Center for Health Workforce Analysis (NCHWA) in the Health Resources and Services Administration's (HRSA) Bureau of Health Professions (BHPr) has commissioned and directed this study. The study concludes that informed workforce planning is needed to document the extent of existing shortages in these occupations and thereby assist states and institutions in addressing them, as well as to assess the impact of present and future initiatives to balance supply and demand.

The comprehensive assessment presented in this report was based on a review of eight key Federal datasets, certified nursing aide registries in 45 states, and fieldwork in four states (California, Illinois, New York, and Wyoming). The fieldwork included interviews and focus groups with long-term care providers and State officials to assess both their current data collection activities and the data needed for future program and policy development. The project was guided by an expert advisory panel and interviews with leaders in the long-term care field. These efforts, along with a review of the literature, resulted in (a) confirmation that there exists a widespread shortage of long-term care paraprofessionals and (b) affirmation that the shortage is likely to be far more severe in the future. The report concludes with a series of suggested strategies for improving data collection relating to these occupations, building on existing datasets and data collection activities.

Executive Summary

Introduction

This report focuses on nursing aides and home health aides, two of the major occupations responsible for providing patient care of a paraprofessional nature to chronically ill, disabled, and elderly persons in nursing homes and other institutional or community-based settings as well as at home. Faced with an aging population and a material shift of patient care to non-hospital venues, the Nation is experiencing an unprecedented demand for individuals with the training and experience needed to provide such care. There is a high turnover rate associated with these occupations, the result of a variety of factors relating to job satisfaction, such as low pay, lack of a career ladder, and occasional less than ideal treatment by supervisors. As a consequence, the supply of these individuals, while continuing to grow, has been slipping relative to demand, a situation likely to continue well into the future.

Because of the importance of this segment of the health workforce in meeting the care needs of an increasing percentage of the population, the National Center for Health Workforce Analysis (NCHWA) in the Health Resources and Services Administration's (HRSA) Bureau of Health Professions (BHPr) has commissioned and directed this study. The study concludes that informed workforce planning is needed to document the extent of existing shortages in these occupations and thereby assist states and institutions in addressing them, as well as to assess the impact of present and future initiatives to balance supply and demand. Current data systems were found to be limited in their ability to assist in such planning efforts. They do not, for the most part, accurately estimate the supply of individuals working in these occupations, including their numbers, locations, characteristics, and qualifications.

The comprehensive assessment presented in this report was based on a review of eight key Federal datasets, certified nursing aide registries in 45 states, and fieldwork in four states (California, Illinois, New York, and Wyoming). The fieldwork included interviews and focus groups with long-term care providers and State officials to assess both their current data collection activities and the data needed for future program and policy development. The project was guided by an expert advisory panel and interviews with leaders in the long-term care field. These efforts, along with a review of the literature, resulted in (a) confirmation that there exists a widespread shortage of long-term care paraprofessionals and (b) affirmation that the shortage is likely to be far more severe in the future. The report concludes with a series of suggested strategies for improving data collection relating to these occupations, building on existing datasets and data collection activities.

Nature of the Problem Across the United States, there is growing concern about current and projected shortages of frontline, direct care workers who provide care and services to the elderly, chronically ill, and disabled. National studies cite annual turnover rates in nursing homes ranging from 45 to 105 percent (Stone, 2001). In 1999, Ohio's nursing assistant turnover rate ranged from 88 to 137 percent while in Florida, only 53 percent of the state's certified nursing aides (CNAs) were working in a health-related field one year after certification. Long-term care provider organizations have either reduced services due to shortages of permanent staff or, alternatively, hired temporary replacement staff at significantly higher hourly rates (Forschner et al., 2001). In areas where levels of service have been reduced, elderly or chronically ill persons deprived of access to care must either remain in more restrictive, more costly environments (notwithstanding the Supreme Court Olmstead decision affirming the right of nursing-home-eligible people to live in the "least restrictive" setting) or seek care from family or friends. Both quality of care and quality of life suffer as people are denied services, or services are provided by persons less qualified or experienced.

Over the next several decades, as population aging and advances in medicine increase the number of persons living with chronic medical conditions, the need for long-term care workers will continue to grow. The Bureau of Labor Statistics (BLS) projects that between 2000 and 2010, an additional 1.2 million nursing aides, home health aides, and persons in similar occupations will be needed to (a) cover the projected growth in long-term care positions and (b) replace departing workers. This rapid increase in demand -- over half the year 2000 supply -- can be expected, for similar reasons, to continue well beyond 2010. The pool, however, from which such workers have traditionally been drawn -- largely women between 25 and 50 without post-secondary education -- continues to shrink. It is questionable, therefore, whether the Nation will have an adequate supply of workers in these occupations to meet the expected increase in demand.

Nursing aides and home health aides provide much of the care in long-term care settings, both in nursing homes and in the community. Policymakers and the health care community have sought to understand the problems in maintaining an adequate supply of such healthcare workers. While some studies have led to an improved understanding of these occupations and the causes of the shortages, they have tended to rely on case studies, focus groups, and data that are incomplete. The lack of system-wide data has weakened efforts to understand the scope of the problem and to develop programs and policies that could address it.

Characteristics of Long-Term Care in the United States

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., 1995

Source: Kaiser Commission on Medicaid and the Uninsured, 1999

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:

• 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:

Nursing aides, orderlies, and attendants 1,262,000
Home health aides 577,700
Personal and home care aides 366,600
Total 2,206,300

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

Table ES-2. Paraprofessional Workers by Industry Group: 2000

Source: BLS Occupational Employment Survey

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".

Shortage Issues

Factors affecting supply

The high turnover and vacancy rates associated with these occupations are consistently found to be the result of job dissatisfaction stemming from the following:

• Jobs are physically and emotionally demanding. Many nursing home injuries consist of back problems resulting from lifting or transferring residents, a high rate of injury corroborated by data from the BLS Survey of Occupational Injuries and Illnesses (BLS, 1999). Patient load in many nursing homes is excessive; the consequent pressure to "speed up" results in increased job stress (Wilner, 1994; Foner, 1994; Diamond, 1992).
• Wages and benefits are generally not competitive with other available jobs (Case et al., 2002; Himmelstein et al., 1996).
• Jobs are often not well designed or supervised (Kopiec, 2000), with few or no opportunities for advancement. Workers perceive a general lack of respect from management.

Factors affecting demand

Factors responsible for the increased demand for long-term care include:

• Aging of the population as baby boomers advance to the ranks of the elderly.
• Technological advances that extend the lives of those with chronic ailments.
• The greater availability of services in less restrictive, less costly community settings.

Population aging, in and of itself, might present less of a problem if the supply of care providers were growing at approximately the same rate. Unfortunately, it is not. It is growing at a significantly lower rate -- not only are providers leaving the field for reasons of job dissatisfaction but the pool from which such providers have typically been drawn in the past has been dwindling compared to the growth in demand due to aging. In 2000, there were 1.74 females between the ages of 25 and 54 for every person 65 and older; by 2030, that ratio is projected to drop to 0.92 (calculations based on Census Bureau National Population Projections). Since women provide the majority of both paid and family-provided long-term care, this "care gap" will increase. Families unable to care for their loved ones by themselves will find, when they turn to the formal system for assistance, relatively fewer paid staff available.

Data Issues

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.

Making Workforce Data More Useful

The limitations noted above apply not only to the present study but also to future attempts to achieve a comprehensive assessment of the long-term care paraprofessional workforce at national, state, and local levels. To assure the accurate, comprehensive, timely data needed to support workforce planning in this area and offset possible future shortages, the following options are identified:

Upgrade and augment existing CNA registries.
Possible options in this area include:
Expanding the occupational categories included in the registries beyond nursing aides to include home health aides and personal care aides, with agreed-upon definitions.

• Expanding the recorded data elements to include demographic characteristics, educational background, and current job status, among others.

Maintaining data timeliness and accuracy by requesting employers to submit annual lists of individuals currently employed, including hours worked and other non-sensitive information.

Adopt and implement state-level workforce data collection systems for nursing aides, home health aides, and related health care occupations.
Such systems, using standard definitions and terminology, would permit useful totals and subtotals to be collected from facilities and agencies, to be shared and compared across states. A proposed data collection instrument of this form is shown in Appendix B of this report.

Involve long-term care provider organizations and professional associations in data collection efforts.

Such groups would be a valuable source of information. Organizations that collect and maintain informative workforce data report fewer recruitment and retention problems than their relatively data less counterparts.