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By Robyn I. Stone, DrPh, Executive Director, Institute for the Future of Aging Services (IFAS) and Denise Clemonds, CEO, Missouri Association of Homes for the Aging

Meeting the long-term care needs of America’s chronically disabled older population will become ever more challenging as the Baby Boom generation ages. Both the financing of such care and service design have received much attention, but until recently less thought was given to another key component: recruiting, training and retaining the long-term care workforce. (Stone, 2006).

Fortunately, about five years ago workforce concerns began receiving more scrutiny. More than 35 state commissions and task forces have examined workforce issues and possible solutions.[1] The National Commission for Quality Long-Term Care's 2006 report, Out of Isolation: A Vision for Long-Term Care in America, made the case for long-term care reform, including confronting workforce problems.

In addition, the Institute of Medicine (IOM) and the U.S. Departments of Health and Human Services (HHS) and Labor (DOL), the National Commission on the Nursing Workforce for Long-Term Care, the Citizens for Long-Term Care, and the National Alliance for Caregiving (the Alliance) have become involved.

These organizations concur that:

1. The professionals and paraprofessionals who manage, supervise and provide long-term care services already are in short supply.
2. The problem goes beyond mere numbers. There is now a dearth of qualified, competent, appropriately trained and educated caregivers even among the available workforce.
3. Lack of competencies and workforce instability result in:
   • Problems accessing needed services. This has, in some cases, compromised safety, quality of care and quality of life;
   • Higher costs due to the need to continuously recruit and train new personnel and/or employ higher-cost contract staff;
   • Extreme workloads for nurses and paraprofessional staff, inadequate supervision, less time for new staff training, as well as employee accident and injury rates exceeding those in construction and mining.
4. Growing demand from aging baby boomers, coupled with shrinkage of the traditional caregiver labor pool, could make a bad situation significantly worse unless decisive action is taken.
5. Workforce shortages do not exist in isolation but are related to all other aspects of long-term care reform, from financing to technological innovations.

There is no “silver bullet” that can solve today’s problems, much less tomorrow's. Rather, it will require a multifaceted approach. How the United States chooses to meet the growing demand for long-term care will significantly impact those in need of care and their loved ones.

The Make-up of the Long-Term Care Workforce

According to the Bureau of Labor Statistics (BLS) as of December 2007, about 3.9 million people worked in facility-based and home care settings[2], not including informal caregivers and caregivers employed directly by consumers and their families. This report focuses on licensed professionals and direct caregivers. In Missouri in 2007, approximately 67,000 people worked in facility-based care while approximately 11,000 worked as home health aides.

Licensed Professionals
Physicians. Physicians are involved in long-term care as nursing home and home health agency medical directors and as the individuals who must sign off on nursing home and home health care plans. Some also treat their elderly patients after placement in a nursing home or assisted living facility.

Nurse practitioners (NPs). NPs are registered nurses with additional education in health assessment, diagnosis and management of illness and disease. Studies of NPs suggest they enhance the medical services available to residents and prevent unnecessary hospital admissions (McAiney, 2005). A survey of nursing home medical directors found that they perceive NPs as particularly effective in maintaining physician, resident and family satisfaction (Rosenfeld, Kobayashi, Barber, and Mezey, 2004).

Nursing home/other long-term care administrators. The federal government requires states to license nursing home administrators, although there are no national standards. States determine whether and how administrators in assisted living facilities, home health agencies and other home and community-based services agencies are credentialed. In Missouri, nursing home administrators must pass state and national licensure exams as well as demonstrating three years experience in health care administration or two years of postsecondary education in the field (Missouri Board of Nursing Home Administrators).

Of late there has been a sharp decline in the number of individuals entering nursing home administration and a high turnover rate among current job holders (National Association of Boards of Examiners of Long Term Care Administrators, 2001).

Nurses. An estimated 500,000 registered nurses (RNs) and licensed practical/vocational nurses (LPNs/LVNs) make up the vast majority of long-term care professionals (American Health Care Association, 2004). As of 2007, approximately 56,000 registered nurses were practicing in Missouri, as were 17,750 licensed practical/vocational nurses (Missouri Economic Research and Information Center).

RNs are the dominating force in long-term care, playing a major role in care assessment, planning and delivery, as well as quality assurance. RNs are relatively evenly distributed between home health agencies and nursing homes.

Most RNs in nursing homes hold administrative and supervisory positions. Their primary role is to assess resident health, develop treatment plans and supervise LPNs and paraprofessional direct care staff. Home health RNs assess patients’ living environment, care for and instruct patients and their families, and supervise home health aides. LPNs account for 46 percent of licensed long-term care nurses and are employed primarily by nursing homes. The LPN workforce is somewhat younger than the RN workforce, and shows greater racial diversity. (Seago, Spetz, Chapman, Dyer and Grumback, 2001).

Although LPN scopes of practice are more limited than that of RNs, they play an extremely important role in nursing homes, providing direct patient care including taking vital signs and administering medications. Surveys indicate that more than 60 percent of LPNs act as charge nurses or team leaders, supervising and directing the care provided by paraprofessional staffers.

Reports of high turnover and difficulty recruiting and retaining RNs and LPNs are widespread. Analysis of a 2001 survey of nursing homes conducted by the American Health Care Association (AHCA) found annual turnover among RNs averaged almost 49 percent, and LPN turnover averaged more than 50 percent.

Direct Care Workers
Direct care workers are the “hands, voice and face” of long-term care. The majority work in nursing homes and assisted living facilities, but increasing numbers provide services in-home. Women make up about 90 percent of the paraprofessional workforce. Almost half of these workers are racial or ethnic minorities.

Importantly, 50 percent of nursing home workers are employed full-time, while only about a third of home care workers are full-time. These differences have implications for developing recruitment and retention strategies.

Certification requirements for direct care workers are usually low or non-existent. Federal law requires less than two weeks of training for nursing assistants and home health aides, although most states have additional requirements. Missouri has a certified nurse assistant program (CNA) that prepares individuals for employment in various long term care settings. The state-approved course requires the individual to complete 75 hours of classroom training, 100 hours of on-the-job training and successfully complete a two-part final examination. Some of the topics include basic nursing skills, fire safety, disaster training, resident safety and rights, and social and psychological training to care for those with dementia and mental disease. [3]

Federal law does not require training for home care workers, and state requirements for these workers vary widely.

Nationally, the median annual wage in 2005 for personal and home care aides was $17,710; for home health aides, $18,850; and for nurse’s aides and orderlies, $21,480 (Bureau of Labor Statistics, 2006). In Missouri, the median annual wage in 2006 for personal and home care aides was $17,700, for home health aides was $18,220, and for nurse’s aides and orderlies, $20,320 (Missouri Economic Research & Information Center, 2007). Home Health Aides was projected to be the fourth fastest growing occupation in Missouri. Growth in this field is projected to increase by more than eight percent between 2007 and 2009 with approximately 500 new openings per year. [4]

One in four direct care workers employed in nursing homes and two in five employed by home care agencies lack health insurance. Despite high injury rates, nursing home workers are twice as likely to be uninsured as hospital personnel. (Paraprofessional Health Care Institute, 2006).

Turnover and job dissatisfaction are clearly linked to poor pay and benefits (PHI, 2004), but direct care staff who feel valued and appreciated by their supervisors have better job satisfaction and are more likely to stay (Bowers, Esmond and Jacobson, 2003; Harris-Kojetin, Lipson, Fielding, Kiefer and Stone, 2004). Also, those who stay in their jobs cite their relationships with older adults in their care as the reason.

Factors Influencing Workforce Recruitment and Retention

Many factors influence the recruitment and retention of the long-term care workforce. The impact of some factors is immediately apparent, others much less so.

Trends
The “Emerging Care Gap”. Demographers say that between now and 2015 the population aged 85 and older, those most likely to require long-term care, will increase by 40 percent. At the same time, the native-born population aged 25 to 54, the pool from which both paid and informal caregivers largely come, will not increase. After 2015, growth of the older adult population will begin to accelerate and will continue to do so until 2050.

Shift from Institutional Care to In-Home and Community-Based Care Settings. The number of older adults in nursing homes declined from 4.2 percent to 3.6 percent between 1985 and 2004. During this period, alternatives to nursing homes have rapidly emerged, particularly assisted living and home and community-based services. This shift will influence the number and types of caregivers needed, as well as regulatory requirements. According to a recently-released study from the AARP Public Policy Institute, compared to the U.S. average, Missouri allocates a greater percentage of its Medicaid long-term care spending to home and community-based services for seniors and those with disabilities.[*] The study also notes that the number of Missourians receiving home and community-based services increased by approximately 15 percent (+15,753) between 2000 and 2006 while those receiving services in nursing homes has in minimally declined (-156).

Movement to New Models of Care. The organization of tomorrow’s long-term care system will be different. Traditional nursing homes may not exist, but become primarily sub-acute facilities, with the more traditional long-term care services being provided in other types of residential settings.

Home and community-based services will dominate long-term care delivery. Consumer-directed care enables older adults, rather than professionals, to make decisions about the services they want, who they want to deliver them, and how and when they are delivered.

Introduction of New Technology. The impact of new technology on the supply and demand for personnel is promising but uncertain. Technology may reduce paperwork burdens and injury rates while improving worker efficiency. Telehealth, including electronic records that allow monitoring health and functional status and managing patient transitions from setting to setting, may help as well.

Strategies for Solving the Long-Term Care Workforce Crisis

Goal 1: Expand the Supply of Personnel Coming into the Long-Term Care Field
Clearly, new sources of caregivers must be found. To accomplish this:
Federal and state government must do a better job of tracking supply and demand and labor shortage areas.
Employers should cooperate in marketing and recruiting campaigns aimed at improving the image of long-term care. Such firms also should encourage post-secondary schools to expose students to long-term care careers.
Improved financial assistance, including scholarships and loan forgiveness, should be offered to anyone interested in such careers.

Goal 2: Create More Competitive Long-Term Care Jobs through Wage and Benefit Increases
Low wages for paraprofessional staff and direct care workers, and limited employer-based health insurance coverage for the latter, makes recruiting and retaining personnel difficult. In the long term, wage and benefit improvements are tied to fundamental reforms in how long-term care is financed and reimbursed.

In the shorter term, possibilities include:

• A federal/state working group could examine wage and benefit parity between acute and long-term care settings and recommend financing and reimbursement options for achieving parity.
• A working group of the American Association of Homes and Services for the Aging (AAHSA), AHCA, the Alliance, the National Governor’s Association (NGA) and the National Conference of State Legislators could be established to identify and disseminate strategies for raising wages and providing health insurance to direct care personnel.
• the national provider associations could investigate how temporary and contract personnel are being used and the added costs of these temporary staff.

Goal 3: Improve Working Conditions and the Quality of Long-Term Care Jobs
Higher wages and better benefits alone will not suffice to attract and retain a high-quality workforce. Most experts agree that working conditions and the quality of the job must be improved. Potential initiatives include:

• Develop effective long-term care leaders and managers.
• Increase participation of minorities in long-term care management.
• Give long-term care employers and states that improve working conditions financial incentives and regulatory relief.
• Invest in information technology to reduce paperwork.
• Promote employers’ self-assessment of working conditions.
• Create career advancement paths in all long-term care settings.

Goal 4: Make larger and smarter investments in the development and continuing education of the long-term care workforce.
The preparation, credentialing and ongoing training of long-term care workers should be redesigned in light of workforce composition and work setting changes, job dissatisfaction, high turnover and vacancy rates, and future needs. Potential initiatives include:

• Encourage government to match long-term care provider investments in workforce development.
• Request the Institute of Medicine (IOM) to review federal regulations governing the preparation and credentialing of the long-term care workforce.
• Encourage state reform of education and training requirements.
• Make education and training more accessible, particularly in rural areas.
• Improve medical directors’ performance by better preparing physicians to assume the position of medical director.
• Strengthen long-term care nurse competencies in geriatrics, administration, management and supervision.
• Reassess the scopes of practice of RNs and LPNs in long-term care.

Goal 5: Moderate the demand for long-term care personnel.
It is unlikely that the need for new long-term care personnel can be completely reconciled with the growth in demand, especially given the shrinking numbers of potential family and formal caregivers. However, other strategies that might improve the efficiency of the workforce or lessen the need for hands-on care should be pursued. Potential initiatives include:

• Identify and disseminate labor-saving service delivery strategies.
• Support government investment in technologies to reduce the demand for direct care personnel.
• Facilitate lateral transfers across health and long-term care settings.
• Create and implement education programs and preventative healthcare.

Goal 6: Encourage and support applied, evidence-based research to inform long-term care workforce policy and practice.

• Develop measures of supply, demand and workforce shortages.
• Studies of physicians, nurses and administrators should be conducted to learn why they choose or avoid long-term care careers.
• Determine how the demand for formal and informal long-term care is likely to be affected by the growing population of aging baby boomers, their economic status, their better health, and new ways to diagnose and treat chronic illnesses.
• Quantify the impact of different wage and benefit structures, and other factors, on recruitment and retention, and if such factors are different from other comparable labor markets.

Missouri Senior Report is published by the State of Missouri Department of Health and Senior Services (DHSS), MU’s Office of Social and Economic Data Analysis (OSEDA) and University of Missouri Extension.

 
For more information about the report please contact: at 573-751-6062 or info@dhss.mo.gov

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