By Geralyn Magan

Most providers of long-term services and supports (LTSS) struggle to address high turnover rates and growing job vacancies within their organizations. A recent article by Robyn Stone, co-director of the LeadingAge LTSS Center @ UMass Boston, warns that those struggles are likely to escalate over the next two decades unless policy makers take six actions.

“The current direct care worker shortage … is simply a bellwether of things to come over the next 20 years as Baby Boomers age and the life expectancy of younger people with disabilities increases,” writes Stone in the Public Policy and Aging Report.

As the need for services and supports increases, the LTSS sector will also experience declines in the number of working-age women most likely to be employed as direct care workers, predicts Stone. In addition, several demographic trends—such as increases in childlessness and rising divorce rates among Baby Boomers—will reduce the number of family members who are available to provide care to aging relatives.

“These trends portend a grim future for LTSS consumers and their families and call for policy makers, providers, and other stakeholders to aggressively work together on solutions to this workforce challenge,” writes Stone.

The effects of worker shortages will have far-reaching consequences, predicts Stone. Rising turnover and vacancy rates have been associated with poor quality care in nursing homes, she reports. In addition, the economies of local communities around the country could suffer if the LTSS workforce crisis is not addressed.

“Between 2014 and 2024 alone, home care occupations are projected to add more jobs to the economy than any other occupation,” writes Stone. “In many areas of the country … these are the jobs of the future and have the potential to contribute substantially to the economic development of disadvantaged communities throughout the United States.”

Solutions For Development a Quality Direct Care Workforce

Stone identifies several barriers to developing a quality direct care workforce, including low worker compensation; inadequate training, education, on-the-job supervision, and career mobility for workers; the uncertain future of immigration; and the perception among policy makers, providers, consumers, and their families that direct care jobs are not valuable.

Despite these challenges, writes Stone, policy makers could address the workforce crisis if they took the following steps:

Increase Medicaid and Medicare reimbursement. Adequate reimbursement plays a critical role in helping LTSS providers pay certified nursing assistants, home care aides, and personal care workers more than a minimum wage, writes Stone. In addition, she recommends that states explore ways to use Medicaid reimbursement strategies to encourage nursing homes and providers of home and community-based services (HCBS) to “create more supportive workplaces that train, empower, and offer professional development opportunities to their direct care workers.”

Protect Medicaid benefits. Recent Congressional attempts to cap federal funding for the Medicaid program would have jeopardized state investments in HCBS programs that support direct care worker jobs. Because these proposals were not adopted, Medicaid is not in jeopardy at this writing. However, Stone writes, any future efforts to reform the Affordable Care Act must ensure that investments in HCBS are preserved.

Implement training standards and programs. Stone supports 2008 recommendations from the Institute of Medicine that called for adopting federal training standards for direct care workers across all settings, increasing the required number of training hours to 120 for nursing assistants and home health aides, and introducing required training for home care and personal care workers.

Implement nurse delegation. Federal policy makers should follow the State of Washington in allowing nurses to delegate certain roles and responsibilities—such as administering prescription medications and performing blood glucose testing—to aides who have appropriate training and supervision. “Delegation provides opportunities for direct care workers’ professional growth, contributes to increased retention, and saves money for public payers by reliance on less expensive labor,” writes Stone.

Develop state and local economic development demonstrations. These demonstration programs could address the need for new jobs and the demand for services in geographic areas with high unemployment rates or a large population of older adults, writes Stone. Demonstration programs could also explore ways to create quality direct care jobs for high school students, displaced workers, and older individuals who need to work past retirement age.

Gather better data. The Centers for Medicare and Medicaid Services has improved nursing home data reporting on turnover and retention, but similar efforts are needed in the home health and home care sectors, writes Stone. “These data are essential for identifying worker shortage areas that need special attention, for tracking direct care worker trends over time, and for helping policy makers identify the most fruitful areas for job development,” she concludes.