This chapter presents an overview of the project and includes the following sections:

• Problem Definition
• Paraprofessional Workforce
• Study Objectives
• Study Methodology
• Report Contents

Problem Definition
The U.S. health care system provides an incredibly wide array of health care services to millions of Americans every day. While this often involves highly complex and sophisticated medical interventions in some of the most advanced medical centers in the world, it also involves basic services provided by such frontline direct care paraprofessionals as nurse aides and home health aides, who provide hands-on care and services in health facilities and patients’ homes.

Although direct care paraprofessionals have historically received little public policy attention, they are critical components in the health care system. In fact, according to the Bureau of Labor Statistics (BLS), there are more than 2.5 million aides and assistants employed in health care. More than a million of these workers are in skilled nursing facilities, home health agencies, and other settings.

Direct care paraprofessionals are at the heart of America’s health care system. They assist millions of Americans who face physical and mental challenges brought on by chronic illness, age, or disability. Assistance can include such daily tasks as bathing, toileting, eating, and moving from bed to chair. Some aides monitor medications, assist in physical rehabilitation, or change the dressing on wounds. All provide comfort and companionship to individuals who may be isolated, depressed, disoriented, disabled or aged, offering a lifeline to the outside world.

Until recently, policymakers and long-term care providers largely ignored direct care paraprofessionals, despite their central role in both long-term and acute care. A seemingly infinite supply of poor women who had few other employment opportunities composed the labor pool, and though turnover was high, there were enough workers to fill vacancies.

Recently, however, the situation has changed drastically. Long-term care providers across the country report they are unable to attract and retain sufficient numbers of workers. Nursing home aides work “short”—i.e., with fewer workers on a unit than necessary—on a regular basis, while home health agencies are literally turning away clients in need of care. The shortage of direct care paraprofessionals is starting to receive as much attention as the more widely publicized shortage of nurses.

Paraprofessional Workforce

Table 1-1 identifies the types of workers and the broad types of services and health care settings that are the primary concerns of this study. The paraprofessionals in these settings hold titles like certified nurse aide (CNA), home health aide (HHA), personal care aide (PCA), personal care attendant, and psychiatric aide.

Table 1-2 illustrates confusion surrounding the terminology used to classify different levels of these workers. Until terms are standardized across the different types and levels of organizations, there will continue to be difficulty reconciling different data systems.

Table 1-2. Alternative Labels

Study Objectives
This study of the long-term care paraprofessional workforce had a number of objectives. They were to:

• Identify and assess current datasets and data collection activities related to long-term care paraprofessionals
• Identify the workforce data needed for effective program and policy development
• Identify model data collection practices
• Suggest possible initiatives for State and Federal agencies to improve paraprofessional data collection

Study Methodology
The study had several inter-related components. Each examined the collection and quality of long-term care paraprofessional data from a different perspective. They were:

• Review and assessment of Federal sources of data. The study identified and reviewed seven systems with data on the long-term care paraprofessional workforce.
• Compilation of illustrative data from several of the Federal sources. Because not all users of data have the same objectives, sample data was compiled from several of the sources to clarify the nature of the data they contain.
• Special inquiry about CNA registries in the 50 states. This inquiry was conducted to help assess the potential of the registries to serve as a basis for more effective data collection.
• Discussions with long-term care providers and workers in four states. These fieldwork discussions helped us confirm the nature of the issues facing the long-term care workforce planners and policymakers and gather first-hand insights about especially effective systems and practices.
• Interviews with national leaders in long-term care. These interviews provided important insights and perspectives on the broader issues related to the long-term care workforce.
• Expert advisory committee. The project advisory committee assembled for the study provided invaluable assistance in redefining the scope of the study as originally proposed. Committee members were an important source of contacts with other experts around the country.

Report Contents
This report addresses its objectives by focusing on data related to CNAs, HHAs, and comparable paraprofessionals across the U.S. It has several components that, taken together, provide a sound basis for understanding the scope and scale of the issues related to direct care paraprofessional data collection. The components are:

• Paraprofessional Workforce Supply and Demand
• Paraprofessional Data
• Existing National Data Sources
• Occupation and Industry Classification Systems
• Current Data Collection Practices: CNA Registries
• Conclusions
• Appendices

Paraprofessional Workforce Supply and Demand

Chapter 2 describes the supply of and demand for direct care paraprofessional workers in the U.S. and includes a variety of statistics that summarize the size and characteristics of the workforce. It provides a conceptual frame of reference that informs the rest of the study, linking the different factors and summarizing the various issues. The paraprofessional labor shortages that Chapter 2 describes underscore the need for accurate and timely data collection.

Paraprofessional Data
Chapter 3 summarizes fieldwork with the long-term care workforce with stakeholders in four states: California, Illinois, New York, and Wyoming. The focus of the fieldwork was on data sources and data initiatives, with an emphasis on existing State resources and programs. The availability, accuracy, and accessibility of data were of primary concern. This research confirmed that because existing systems are designed primarily to support other programs, the data they collect are not adequate to support policymaking related to direct care paraprofessionals.

Staff also contacted several other states to compare their situations with those from the four fieldwork states. The study identified a number of factors necessary for forecasting the supply of and demand for workers and defined the kinds of data necessary for effective workforce planning. It also helped identify several states that have systems and procedures that might serve as models for other states.

Existing National Data Sources
Chapter 4 describes the seven Federal systems that collect, compile, and develop data related to the direct care paraprofessional workforce. It details the strengths and limitations of each.

Occupation and Industry Classification Systems
Chapter 5 describes the Federal occupational and industry classification systems. This system is the basis for a number of different data systems related to the long-term care paraprofessional workforce.

Current Data Collection Practice: CNA Registries
Chapter 6 describes an analysis of the 50 State CNA registries. This effort involved reviewing the characteristics and capabilities of the registries and exploring the feasibility of using them as a foundation for more effective paraprofessional workforce data systems.

Conclusions
Chapter 7 describes proposals for improving direct care paraprofessional data collection.

Appendices
The report also has eight appendices. Appendix A lists the members of the advisory committee. Appendix B presents a possible State data collection instrument. Appendix C provides definitions of the occupational and industry categories used in Federal data systems. Appendix D shows sample data compiled from the Federal data sources. Appendix E describes the issues and insights brought to light in the fieldwork in the four states. Appendix F includes details regarding the CNA registries. Appendix G is an annotated bibliography of important documents and articles related to the long-term care paraprofessional workforce. Appendix H lists references compiled during the project.