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Building a High-Quality Long-term Care Paraprofessional Workforce

Scope of the Problem


Robyn Stone, Dr.P.H., Executive Director, Institute for the Future of Aging Services, American Association of Homes and Services for the Aging, Washington, DC.

Edward Salsberg, M.P.A., Director, Center for Health Workforce Studies, School of Public Health, State University of New York, Albany, Rensselaer, NY.

As the population ages, the demand for long-term care (LTC) is expected to grow rapidly throughout the next decade. In the year 2000, 12.5 percent of the U.S. population was age 65 or over. This percentage is expected to increase to almost 17 percent by the year 2020. More than 25 percent of people age 65 are expected to survive to age 90. The majority of these people will require LTC at some point in their lives.

LTC includes the broad range of services needed by individuals with a chronic illness or disabling condition over a prolonged period of time. LTC settings may include:

  • Nursing homes.
  • Assisted living facilities.
  • Home care.
  • Adult day care.
  • Hospice care.

Services provided in LTC settings include assistance with activities of daily living (ADLs) such as eating, bathing, and dressing; and instrumental activities of daily living (IADLs) such as housework and transportation. Medical services include intravenous drug therapy, ventilator assistance, and rehabilitation therapy.

Although families are the primary providers of LTC in the United States, there is a need for qualified and prepared paraprofessional workers, which include:

  • Certified nursing assistants.
  • Home care aides.
  • Personal care aides.
  • Mental health aides.

These front-line workers, or direct caregivers, form the centerpiece of the formal LTC system. They provide care that is intimate and personal, as well as physically and mentally challenging. The typical worker is a middle-aged, single mother with a low level of education, living at or near the Federal poverty level. Although a large proportion of these workers are black, Asian, or Hispanic, the majority of the workers are white.

There are many causes of paraprofessional workforce shortages. From the worker perspective, causes include:

  • Low wages and benefits.
  • Difficult working conditions.
  • Lack of career opportunities.
  • Lack of recognition.
  • Gaps between training and real job demands.

From the provider perspective, the causes include:

  • Too little reimbursement.
  • Government regulations and oversight.
  • Poorly prepared and unmotivated workers.
  • High turnover.
  • Low unemployment rate.
  • Growth in the total number of jobs.

Regardless of the perspective, turnover and retention problems can potentially erode quality of care.

Research has found that local economic conditions have the strongest effect on turnover rates. Other interventions that have significantly reduced turnover rates include:

  • Involving nursing assistants in care-planning meetings.
  • Improved wages and benefits.
  • Guaranteed service hours.
  • Increased training and support.

Forty-two States report paraprofessional recruitment and retention as a major workforce issue, regardless of unemployment rate. At least 30 States have taken action to address this issue, primarily by implementing wage pass-throughs by means of Medicaid reimbursement. Both States and providers are engaged in additional initiatives including:

  • Career development.
  • Financial incentives.
  • Culture change initiatives.
  • Recognition programs.

The Center for Health Workforce Studies at the State University of New York at Albany has developed a conceptual framework based on State responses to address the supply and demand of the LTC paraprofessional workforce. This framework includes:

Education strategies, such as:

  • Mandates for educational programs.
  • State funding for training.
  • Scholarships.

Job-related strategies such as:

  • Increases in wages and benefits.
  • Mandates in minimum staffing.
  • Support for family and informal caregivers.
  • Career ladders.
  • Job redesign.
  • Improved working conditions.

Modified demand and improved productivity, through:

  • Regulatory changes in the scope of practice and use of workers.
  • Dissemination of best practices to improve service delivery.
  • Grants for demonstrations and technology development.

State task forces and commissions, to address the paraprofessional workforce shortage.

The Center notes that provider collaboration is critical to the success of such State policy initiatives.

More data are needed to continue research in the area of paraprofessional workforce issues. Supply-side data needs include:

  • Demographic characteristics.
  • Practice patterns.
  • Migration/job change patterns.

Demand-side data needs include:

  • Current employment.
  • Vacancy rates.
  • Future employment plans.
  • Skill needs.

There is also a need for standardized definitions for:

  • Occupational titles.
  • Turnover and vacancy rates.
  • Full-time equivalents.
  • Time rates.

State data activities should include:

  • Data collection and analysis.
  • Registry maintenance.
  • Periodic surveys of workers, employers, patients, and family members.


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Salsberg E. Long-term care workforce shortages: A conceptual framework for exploring potential solutions. The Center for Health Workforce Studies. Albany (NY): School of Public Health, State University of New York at Albany. 2000.

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