Robyn I. Stone is the executive director of the LeadingAge Center for Applied Research and Senior Vice President of Research. A noted researcher and leading international authority on aging and long-term care policy, she contributed a chapter on the long-term care workforce for RSF's free e-book, Universal Coverage in Long-Term Care in the United States.
Q: Your chapter looks at the paid, formal long-term care workforce – direct care workers and registered nurses, for example. You say that many enter this profession "accidentally" – what exactly does that mean, and how does it affect the quality of the workforce?
A: For many individuals employed in long-term care, this was never their setting of choice. They were not trained to work in a nursing home, assisted living or home care and were not encouraged by their educational institutions, their peers or others to choose these occupations. Many nurses, for example, move to long-term care when they are burned out from working in the acute care sector. Physicians who become medical directors may do the job on a part-time basis because it is convenient and perceived as not very demanding. Some direct care workers view the job as a stepping stone to other occupations. What is interesting is that although they may "accidentally" fall into the job, once they get exposed, many are hooked forever.
Q: Let’s talk about the projected demand for the long-term care workforce. Why can’t we assume that family and friends – that is, the informal sector – will keep on shouldering the burden of long-term care in the coming decades?
A: Several trends influence the future availability of family and friends to continue providing informal care at the same level that they are engaged today. First, women are having fewer children than in the past or are childless, and many are having children later in life. This translates into fewer adult children available to care for their aging parents and more women who will be faced with the competing demands of child care and elder care in the future. Second, women will continue to be employed and post-recession may engage in paid employment for longer periods of time. Therefore, they may be less available to provide informal care. Third, with extended longevity, it will not be unusual to have aging children facing care responsibilities for very elderly parents. These children may be more likely to have chronic illnesses themselves, limiting their ability to be caregivers. With the increased divorce and remarriage rates, family members may be less connected to elderly parents and less willing to engage in informal caregiving. Finally, new cohorts of elderly are more likely to be comfortable with using paid services than the Depression era elderly. They also, on average, are more highly educated and interested in options than current seniors. This may increase the demand for formal, paid caregivers.
Q: You write that there is widespread consensus that the "formal long-term care workforce is already in crisis." What’s going wrong?
A: The formal long-term care workforce—from frontline high-level professionals—is not as valued in our society as those who work in other parts of the health care sector. Therefore, it is difficult to attract and retain high quality individuals to long-term care. In times of recession, turnover is less, but as local economies improve, those employed in long-term care are likely to be attracted to more competitive jobs. In addition, we are not just interested in hiring and retaining "warm bodies." We need trained competent professionals at all levels to engage in the delivery of quality care. This is particularly important as delivery and payment reforms focus more on integration and care coordination across settings, transitional care and other new models of care.
Q: One solution you propose to improve the workforce is to make the jobs more competitive. Talk about some of the conditions and wages long-term care workers face that may deter job seekers from looking at this area for employment.
A: Wages and benefits are very inadequate for direct care workers, particularly those employed in home care. But the problem applies to every profession working in long-term care. Physicians, nurses, social workers, administrators and others who work in long-term care earn far less than their peers in the acute and primary care sectors. They also have fewer opportunities for career advancement.
Q: A major concern highlighted in your chapter is the education being offered to incoming long-term care workers. Is long-term care emphasized on the curricula of nursing, medical or social work students? Do direct care workers receive enough training, in your view, before entering the sector?
A: Long-term care is currently not emphasized in nursing, medical or social work schools. There are also limited opportunities for good quality clinical placements and options for interested individuals to obtain specialty training. Through the efforts of organizations such as the Hartford Foundation and the Eldercare Workforce Alliance, more attention is being paid to improving the geriatric and gerontological content of the curricula in higher education and in-service training. The Affordable Care Act (ACA) included several provisions to expand fellowships and other training opportunities for individuals interested in working in long-term care. Currently, federal training requirements for certified nursing assistants and home health aides are very limited and there are no such requirements for personal care or home care aides; training requirements are at the discretion of each state. Furthermore, these requirements focus on hours of training, not the content. Therefore, in my view, direct care workers are not adequately prepared for the very complex, demanding jobs for which they are hired. In-service training is even less adequate. The ACA supported a 6-state demonstration to develop and test expanded competency-based curricula for these direct care workers and foundations such as SCAN have invested in the development and dissemination of better curricula for this workforce. But much more is needed if we are really committed to a competent, stable workforce that is essential for the delivery of quality care today and in the future.
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