How will long-term care workforce demand be impacted by changes in demographics and utilization patterns?

Joanne Spetz, PhD Laura Trupin, MPH Timothy Bates, MPP Janet Coffman, PhD University of California, San Francisco

This study was supported by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (HHS) under the Cooperative Agreement for a Regional Center for Health Workforce Studies (Grant No. U81HP26494). The information or content and conclusions of this article are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the US government.

The looming long-term care crisis

By 2030: More than 70 million people 65 years and older

• 20% of the population

By 2050: Number needing long-term care will more than double

• 8 million in 2000 to 19 million in 2050

Who will care for those with long-term care (LTC) needs?

• IOM projects 3.5 million additional workers by 2030

This study examines how changing demographics and service use might affect future LTC worker demand

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Long-term care settings and workforce

Settings for LTC

• 25% institutions

‒ Nursing homes

‒ Assisted living

• 75% home and community based services (HCBS)

Workers

• Within institutions: mostly RNs, LPNs, CNAs

• HCBS: mostly unlicensed direct-care workers

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Changing patterns of LTC use?

General trend toward more HCBS use

Demographics

• Growing Hispanic & Asian populations

‒ Traditionally use fewer LTC services

• Growing Black population

‒ Traditionally uses more LTC services

New programs supporting HCBS

• ACA made $4.3 billion available through multiple programs

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Methods

1. Measure use of 4 types of LTC services by age/ethnic/gender

2. Extrapolate future use based on population projections

3. Measure employment by occupation in each LTC service sector

4. Extrapolate future worker demand by occupation using data from steps 2 & 3

(Yes, this is a giant spreadsheet exercise!)

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Data sources: A hunting expedition

National Health and Aging Trends Survey (NHATS) 2011

• Nursing home

• Residential care (assisted living and continuing care communities)

Medical Expenditures Panel Survey (MEPS) 2009-2011

• Home health services (ratio of users/population)

National Study of Long-Term Care Providers (NSLTCP) 2013

• Adult day care center clients/population

Census Bureau: Population estimates 2010 & projections

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Employment data

National Study of Long-Term Care Providers

• Nursing FTEs for RNs, LPNs, and nursing assistants

• Data reported for each type of setting

BLS National Employment Matrix

• Matched to settings using NAICS codes

• Combined home health aides & personal care aides

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Jobs/FTEs in long-term care

181,527

236,109

784,006

1,345,100

328,400

250,400

173,600

131,100

128,000

123,800

0 400,000 800,000 1,200,000 1,600,000

RN (FTE)

LPN (FTE)

Nursing asst. (FTE)

HHA/PCA

Food prep/serving

Office/admin support

Building/grounds maint.

Comm & soc serv workers

Managemnet

Counselors & social workers

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Use of services by women 75-84 years

0

200

400

600

800

1000

1200

1400

1600

1800

2000

Nursing homes Residential care Home health Adult day care

White

Black

Hispanic

Other

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Women use nursing homes, residential care, and home health at higher rates than men.

Users of LTC service per FTE worker

0

20

40

60

80

100

120

140

160

180

Nursing homes Residential care Home health Adult day care

RN

LPN

Nursing Asst.

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Other patterns of employment

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Home health & personal care aides

• More in residential care, home health, adult day care

Food prep & serving, Building & grounds maintenance

• More in nursing homes & residential care

Office & administrative support, Community & social services workers, Counselors & social workers, Management

• More in adult day services

Projected job/FTE growth: 2010-2030

Occupation New jobs Growth

RN (FTE) 132,869 73%

LPN (FTE) 166,242 70%

Nursing assistants (FTE) 534,548 68%

HHA/PCA 1,188,897 88%

Food prep & serving 219,457 67%

Office & admin support 196,416 78%

Building & grounds maint. 119,715 69%

Comm & soci serv 121,700 93%

Management 99,827 78%

Counselors & soci work 116,171 94%

Total (jobs+FTE) 2,895,842 79%

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Alternate scenarios

1. Demographic scenarios

A. Hispanics at same rates as Whites

B. Hispanics at same rates as Blacks

C. Blacks at same rates as Whites

2. LTC settings

A. Nursing home use is 10% lower, shifts to home health

B. Nursing home use is 20% lower, shifts to home health

C. Nursing home is 10% lower, shifts to residential care

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Demographic scenarios

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Total RN LPN Nursing asst

Baseline

Hispanic=>White

Hispanic=>Black

Black=>White

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Demographic scenarios

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HHA/PCA Food prep/serv Maintenance

Baseline

Hispanic=>White

Hispanic=>Black

Black=>White

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Demographic scenarios

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Office/admin Management Comm/socserv

Counselor/socwrk

Baseline

Hispanic=>White

Hispanic=>Black

Black=>White

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Utilization scenarios

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Total RN LPN Nursing asst

Baseline

10% NH=>HH

20% NH=>HH

10% NH=> RC

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Utilization scenarios

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

HHA/PCA Food prep/serv Maintenance

Baseline

10% NH=>HH

20% NH=>HH

10% NH=> RC

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Utilization scenarios

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Office/admin Management Comm/socserv

Counselor/socwrk

Baseline

10% NH=>HH

20% NH=>HH

10% NH=> RC

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Limitations

Not a microsimulation model

• Not a dynamic model

Only considered older population

• Young adults and children are 1/3 of LTC population

Some services are not measured

• Unlicensed home health agencies

Could not disaggregate Asians & “other” ethnic groups

Had to estimate some age-gender-ethnicity cells

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Policy implications

Demographic change could affect job growth for specific occupations, but overall job growth for LTC doesn’t change much

Greater use of home health (and less of nursing homes) will have small effects unless the shift in setting is large

Expansions of HCBS will be needed – ACA investments are not enough

Need to consider:

• Training requirements for PCAs and HHAs

• Strategies to reduce turnover

• Making sure these are not poverty-level jobs

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