The direct care workforce comprises about 4.8 million workers, including nearly 2.8 million home care workers; over 718,500 workers in residential care homes; about 448,000 nursing assistants employed in nursing homes; and nearly 1 million workers employed in other settings, such as hospitals.
DIRECT CARE BOOM
Between 2021 and 2031, the direct care workforce is projected to add more than 1 million new jobs, which represents the largest growth of any job sector in the country. During the same timeframe, nearly 9.3 million total direct care jobs will need to be filled, including new jobs and job vacancies that are created as existing workers leave the field or exit the labor force.
AN AGING AMERICA
From 2016 to 2060, the population of adults aged 65 and over will almost double, from 49.2 million to 94.7 million, and the number of adults aged 85 and older will nearly triple over the same period, from 6.4 million to 19 million. The growing number of older adults and increased longevity are two primary factors spurring demand for long-term services and supports.
SHRINKING AGING SUPPORTS
Over this same period, the population of adults aged 18 to 64 will remain relatively constant. Currently, there are 31 adults aged 18 to 64 years old for every adult aged 85 and over. By 2060, that ratio will drop to 12 to 1.
WHO ARE ‘DIRECT CARE WORKERS’?
Direct care workers include personal care aides, home health aides, and nursing assistants, as formally classified by the Bureau of Labor Statistics. Direct care workers assist older adults and people with disabilities with daily tasks, such as dressing, bathing, and eating. Personal care aides may also help clients with meal preparation, housekeeping tasks, errands, appointments, employment and/or social engagement. Home health aides and nursing assistants perform some clinical tasks, such as wound care, blood pressure readings, and/or assistance with range-of-motion exercises, under the supervision of a licensed professional.
IN WHAT SETTINGS ARE DIRECT CARE WORKERS EMPLOYED?
Direct care workers are largely employed in private homes, community-based residential care settings, skilled nursing homes, and hospitals. In our research, PHI focuses on three groups of direct care workers: home care workers, who work in private homes; residential care aides, who are employed in group homes, assisted living communities, and other residential care settings; and nursing assistants in nursing homes.
WHAT IS AN ‘INDEPENDENT PROVIDER’?
Independent providers are direct care workers who are employed directly by consumers through publicly funded consumer-direction programs. Although it is difficult to accurately estimate the number of independent providers due to the wide variation in methods used to quantify this workforce, data on enrollment in consumer-direction programs suggest that there are at least 1.2 million Medicaid-funded independent providers across the United States.
WHAT IS THE ‘GRAY MARKET’?
The so-called “gray market” refers to home care workers who are hired directly by individuals or households using private funds, i.e. outside of a consumer-directed services program and not through any type of home care agency. PHI’s estimates of the size of the direct care workforce do not capture the gray market, which is very difficult to measure.
HOW MUCH TRAINING IS REQUIRED FOR DIRECT CARE WORKERS?
Home health aides and nursing assistants are federally required to complete at least 75 hours of training, including 16 hours of supervised practical training, and pass a competency exam—while personal care aides have no federal training and competency requirements. Training requirements for each of these occupational roles vary by state and can be compared on our website (under the “Advocacy” section). PHI works closely with a wide spectrum of providers to create feasible training approaches that equip workers with the necessary skills and competencies to provide quality care.
What are key challenges facing direct Care workers?
Despite their essential role, direct care workers struggle to achieve quality jobs, which impedes recruitment and retention efforts across long-term care settings. The median wage for direct care workers was just $15.43 per hour in 2022, with variability by occupational role and geographic location (among other factors), and median earnings were only $23, 688 per year in 2021. As a result, 39 percent of this workforce lives in or near poverty and 46 percent rely on public assistance programs to make ends meet. Beyond low wages, direct care jobs are physically and emotionally demanding and often characterized by heavy workloads, scheduling challenges, inadequate supervision, and limited training and career advancement prospects.
WHAT IS THE TURNOVER RATE FOR DIRECT CARE WORKERS?
Median annual turnover for nursing assistants in nursing homes was nearly 100 percent in 2017-2018 and turnover in home care was about 64 percent in 2021, according to the most recent research in each case. Unfortunately, a large-scale, comprehensive assessment of turnover across the full direct care workforce does not exist. Turnover is difficult to measure without systematic processes to collect workforce data at the provider and state levels, and most studies have measured turnover for only a subset of the workforce (e.g. by occupation, payer, population served, or geographic area).
WHAT’S THE SIZE OF THE WORKFORCE SHORTAGE IN DIRECT CARE?
Ever-greater demand for long-term supports and services—along with the sustained impact of COVID-19 on this sector, slow labor force growth, and a tight labor market overall—is placing intense pressure on direct care workforce employment. Reports from the field indicate devastating workforce gaps across long-term care settings, but unfortunately, there is no national estimate of the workforce shortage (and few state-level estimates) due to data-collection limitations. In our research, PHI describes the workforce shortage by combining data on workforce trends and projections with evidence on current workforce turnover and job vacancy rates. Other researchers have hypothesized about the future workforce shortage, however, by relying on broad assumptions about population growth and care utilization patterns. As one example, in 2017 MIT Professor Paul Osterman estimated that there will be a national shortage of 151,000 direct care workers by 2030 and 355,000 workers by 2040.
WHAT ARE THE SOURCES FOR PHI’S DATA ON DIRECT CARE WORKERS?
Our wage and employment trends are sourced from the Bureau of Labor Statistics (BLS) Occupational Employment and Wage Statistics (OEWS) program, and our employment projections are sourced from the BLS Employment Projections (EPP) program. For other workforce characteristics, we primarily rely on data from the American Community Survey and Current Population Survey conducted by the U.S. Census Bureau, as well as other public data sources.
WHY DO PHI’S estimates of THE NUMBER OF DIRECT CARE WORKERS DIFFER FROM DATA FROM THE BUREAU OF LABOR STATISTICS?
The Bureau of Labor Statistics (BLS) provides data by industry, occupation, and both industry and occupation. Occupations are defined by skills, training, education, and on-the-job responsibilities, while industries are defined by primary business activities. Whenever possible, PHI uses the BLS data that combines these two classifications (which produces different estimates than when looking at industry or occupation data alone).
For example, we define “home care workers” (described above) as those who fulfill a particular set of on-the-job responsibilities in private homes and certain community-based establishments. To analyze this segment of the workforce, we combine data on three occupations (personal care aides, home health aides, and nursing assistants) in two industries (Home Health Care Services and Services for the Elderly and People with Disabilities). Separately, we analyze personal care aides, home health aides, and nursing assistants who work in other long-term care industries.
DOES PHI’S DATA ON IMMIGRANT WORKERS INCLUDE UNDOCUMENTED WORKERS?
Yes, but not all undocumented workers. Our statistical snapshot of immigrant direct care workers uses data from the American Community Survey, which only distinguishes between naturalized citizens and non-citizens (without specifying the legal status of non-citizens). Our workforce estimates certainly undercount undocumented immigrants, who are more likely to be employed in the “gray market” (see above).