This chapter describes conclusions and includes the following sections:

• Need for Better Data
• Data Collection Proposals
• Factors Important for Projecting Future Supply and Demand

Need for Better Data

When workforce issues are as clearly framed and defined as they are in this case, there are often questions about whether investments in better data systems are necessary. The temptation is to rely on anecdotes and not worry about specific data. Some would argue that better data are not necessary to know that forceful and immediate action is required.

Unfortunately, the current situation is not that easy to correct. The obvious solution, significant increases in wages of workers, would cost billions of dollars every year and have major repercussions in other industries competing for the same entry-level workers. Other solutions—improving working conditions, introducing new technologies, increasing respect for workers, and restructuring the workplace—depend heavily on local agencies and managers.

A number of states have undertaken a variety of initiatives. However, there is a concern that these initiatives are not being systematically evaluated to gauge their effectiveness. Ultimately, better data will be needed to ensure that the long-term care system is addressing the problems anecdotal evidence has identified.

Better data will help:

• Monitor patient safety and status. This should be a bottom line goal for any comprehensive information system or network of systems. We must ensure that our most vulnerable citizens—the elderly and people with disabilities and chronic illnesses—are being treated effectively and with the respect they deserve.
• Assess facility performance. It is absolutely essential that data systems permit assessing facility performance. Broad external assessments will help consumers make important life choices for themselves and their loved ones. Detailed internal assessments will also help facilities focus their resources and attention on critical problems and issues.
• Identify best practices. A corollary to facility assessment is identifying best practices. This strategy will ultimately help the entire long-term care industry to upgrade its performance and improve its cost-effectiveness.
• Estimate the supply of and demand and need for workers. To address the workforce issue successfully, clearly defining and analyzing the workforce is imperative.

Definition must start with simple counts and profiles of workers, including basic demographics, education, and certification and extend to information on why workers enter and leave the workforce. Demand for workers extends data requirements to third party reimbursement, population demographics, and basic workforce requirements for different types of facilities and services. Need for workers extends beyond this to include such topics as underserved populations and clinical problems not adequately addressed by current systems and facilities.

• Support government oversight and regulation. History has shown that some level of government regulation and oversight of the long-term care industry is necessary to protect the interests of the frail and elderly. Accurate, timely data will improve the effectiveness of such oversight. It is critical that timely assessments of the status and performance of long-term care facilities be available to federal, state, local, and facility policymakers so they can direct resources to issues requiring attention.
• Evaluate policy initiatives. When government agencies or facilities initiate new programs to address serious problems, they often do not devote resources to assessing the initiatives’ effectiveness. When that happens, they and their counterparts in other jurisdictions are not able to determine whether the initiatives have sufficient merit to warrant broader implementation. Data systems provide the basis for careful program assessments that determine what works and what doesn’t.
• Support long-range planning. Because underlying population demographics are a critical factor in the long-term care system, it is especially important to use long-range planning and forecasting to alert planners and administrators of changing situations.
• Inform education programs. Ultimately, education has to be a part of any long-term care workforce solution. It is critical to modify educational programs when quantitative or qualitative changes are necessary in workforce training. Complete and accurate data can help identify such trends in advance of actual need so the industry can respond in a timely manner.

This study has revealed that data inadequacies exist in all aspects of the long-term care industry. In fact, the problems are such that existing data systems—which were designed for other purposes—cannot support systematic assessments of any industry component: individual workers, individual facilities, classes of workers, classes of facilities, people receiving services, people needing services, organizations financing services, or policymakers overseeing the various systems. Collecting, structuring, and analyzing the data necessary for coherent planning and policymaking requires a very ambitious program to build a comprehensive database. Such an effort would represent a first step toward addressing the issues facing the long-term care industry.

Data Collection Proposals

While it is not possible, given today’s data resources and technologies, to estimate with reasonable certainty the cumulative impact of these factors on the supply of and demand for paraprofessional workers, the best judgment of the authors is that there is unlikely to be any significant change in recruiting and retaining these workers over the next decade. Only if there is a crisis in access to care for elderly and subacute care patients—a real possibility if no changes occur in the current system—will there be the social and political will to resolve this problem.

There are a number of possible responses that could address the difficulty related to paraprofessional data collection, and as previous sections of this report have stated, better quality workforce data could considerably improve policy planning. The responses fall into four broad categories:

• New standards for direct care workforce terminology
• More timely data
• Federal initiatives
• State initiatives

New Standards for Direct Care Workforce Terminology

Regardless of the choice of data system or protocol, new standards, definitions, and taxonomies for terminology are an essential first phase for improved data systems. Several steps are critical to accomplish the desired changes:

• Reorganize the current occupation categories of workers into more homogeneous groups based on the kinds of tasks, roles, and functions they perform, e.g., aides, orderlies, and attendants, and not the settings in which they work.
• Establish standard definitions for important workforce terms like turnover rates, vacancy rates, and recruiting yield.
• Incorporate the new definitions into all Federal data systems, especially the ES-202, OES, and CPS.
• Encourage State agencies to adopt the terminology and definitions in State and local data systems.

More Timely Data

Timely data is important to planners and policymakers. New or existing systems must provide faster turnaround of workforce data to users and stakeholders. Significant improvements in turnaround times for existing systems may require substantial additional resources. A sufficiently streamlined system, i.e., with minimal numbers of data elements, could probably be designed to yield fast turnaround without adding dramatically to the costs of either design or operation.

In addition, consideration should be given to collecting the following data from employers about their direct care workers:

• Hourly pay
• Percentage of full time workers
• Average number of hours worked weekly/annually by part-time workers
• Eligibility criteria for health insurance
• Percentage using employer’s health insurance
• Turnover rates
• Vacancy rates
• Other benefits offered and used
• Number of hours of initial and ongoing training
• Ratio of workers to direct supervisors
• Number of workers using public supports and of what kind
• Demographics of workers including:
  • Gender
  • Age
  • Education
  • Marital status
  • Number children at home
  • First language
  • Country of birth
  • Number of adults employed in household

Federal and State Initiatives

Because the quality and timeliness of workforce data is a national problem affecting every state, it is important that Federal and State responses be part of the solution. This is especially important to monitor the extent of problems and the impact of any initiatives undertaken to correct the problems. Several initiatives are possible:

Upgrade and Augment CNA Registries

Augmenting existing CNA registries to include additional types of facilities and workers is an important option for addressing the workforce data problems this study identified. Although this represents a major undertaking for all 50 states, if developed centrally under a federally funded initiative, development costs should be minimal. On a per patient/client basis, the operating costs should be relatively low. Part of this system should be the preparation of an annual snapshot of the long-term care paraprofessional workforce in each participating state. Improvements are possible in several broad areas:

• A minimum dataset required for effective workforce planning should be defined to serve as the basis of an ongoing master database.
• Additional categories of direct care paraprofessionals should be included in the registries, especially HHAs and PCAs.
• Additional types of long-term care facilities could be covered by the registry, especially home health agencies and assisted living facilities. It may also be appropriate to add hospices, staffing agencies, mental retardation and disability facilities, and adult residences.
• Functionality should allow developing accurate snapshot counts of all long-term care paraprofessionals in a State by type of worker and type of facility.
• Procedures should allow deleting people from the registries when they are no longer actively delivering services to clients in a nursing home or other long-term care organization.
• Periodic reports (at least annual) should document the numbers of different types of long-term care paraprofessionals working in each state, with selected demographic information, e.g., age and gender, and employment information, e.g., length of employment and number of jobs held on the census day.
• Processes for aggregating data at multiple levels should be established. The levels should include at least provider organization, state, and national totals.

This solution is even more attractive when considered in the context of the new HIPAA requirements for registering direct care workers. Implementing the corresponding HIPAA rules and regulations will require substantial resources, which could offset the costs of developing new workforce-related capabilities in existing CNA registries. At the very least, consideration should be given to workforce planning and policymaking when designing any new HIPAA registries.
There should also be consideration of coordinating databases across states to help track people with criminal backgrounds. This would greatly facilitate reciprocity agreements and mobility of workers. Perhaps more important, it would be a cornerstone in ensuring that suitable workers are employed in nursing homes, home health agencies, and other health care organizations.

Identify Best Practices

The problems identified in this study have existed in one form or other for a number of years. Although no uniform solutions have been developed for all 50 states, a number of states have developed responses, some of which deserve wider recognition and adoption. State and local programs and initiatives that have resulted in significant improvements should be sought out, identified, and shared with interested parties. Criteria should be developed with which to assess the value/performance of these procedures, and “best practices” should be identified and shared. This process would greatly speed the dissemination of effective practices, saving millions of dollars at the same time it improves practices and standardizes procedures across the 50 states.

Demonstration Projects

If there are questions about the best strategies for implementing the kinds of changes needed to improve registries and other data systems, consideration should be given to conducting one or more demonstration projects to test options and document effective state-level systems, procedures, and implementation protocols. Presentations should showcase practices and processes identified as especially effective.

Additional Workforce Components for Other Federal Systems
In general, it is important to keep workforce issues in mind when designing any modifications to Federal databases related to health care delivery. Definitions and taxonomies used for each type of facility/agency should be consistent so that workers of different types and levels can be aggregated across the entire long-term care system.

Fast Response Long-Term Care Workforce Data System
Although it is not the first choice for improving data on the long-term care paraprofessional workforce, a “Fast Response Long-Term Care Workforce Data System” could be a useful tool for any state. By using relatively simple data collection instruments, e.g., the questionnaire proposed in Appendix B, it would be possible to collect useful data from facilities and agencies using standard definitions to permit sharing and comparing of data across states. An important component of the system would be a set of standard reports and tabulations to be shared quickly with policymakers and the public to clarify the nature and extent of any problems and to assess the impact of any initiatives to correct problems.

Adoption of Standard Terminology, Definitions, and Taxonomies
Standard terminology for the long-term care paraprofessional workforce is important for both State and Federal agencies. Ideally, this will be done as part of a broader mandate to facilitate state-to-state sharing and comparisons. This will facilitate comparisons among the facilities within the State and comparisons across states adopting the same terminology, definitions, and taxonomies.

Support from Provider Organizations and/or Professional Associations
Professional associations of long-term care provider organizations are an important source of information in most states. States should encourage these organizations to collect, process, analyze, and disseminate data on long-term care paraprofessionals using standard terminology and definitions in formats that inform policy discussions and debates.

Special attention should be given to improving systems for internal use of data and reporting to government agencies. Meetings with nursing homes and home health agencies in several states have revealed that access to relevant and timely internal workforce data often results in improved recruiting and retention performance. Agencies with accurate data generally understand better the nature of their workforce problems; workforce composition and performance; and the impact of different initiatives to improve retention and recruiting. These organizations often have lower attrition and better recruiting than their counterparts without the data.

This is an area where the identification of best practices would be especially helpful. A special project funded to identify especially effective systems, processes, and projects in individual long-term care facilities would be an appropriate initiative for a State to consider. All of this can help to strengthen these facilities, so they can better serve their clients.

Factors Important for Projecting Future Supply and Demand

The task of developing accurate and reliable projections for the supply of and demand for long-term care paraprofessionals is not a trivial one. Many factors affect this segment of the workforce, and their impact has not been studied carefully. Researchers interested in developing projection models should be aware of these factors and, where possible, take them into account when designing their models.

The reaction of most of this study’s informants to the BLS projections for nurse aides and related occupations is that they need estimates of need and demand which take into account the availability of workers to fill positions. Most felt that it is highly unlikely that there will be enough workers available to come close to achieving the BLS projections for 2010. Another major concern about the BLS projections is that they are available for only large geographic units, i.e., entire states.

Given the difficulty of developing accurate projections for the future supply of and demand for long-term care paraprofessionals, it is interesting to consider some of the factors that can influence supply and demand. The discussion that follows identifies these factors and suggests the nature of their impact over the next decade or so. The factors fall into one of two categories: exogenous factors over which policymakers have little or no control [E] and policy levers over which policymakers may have significant control [P].

The Economy and General Unemployment [E]
A strong economy with low unemployment generally leads to difficulty recruiting and retaining direct care paraprofessional workers who have more employment options. The strong economy in the late 1990s made it very difficult for many long-term care organizations, especially home health agencies, to recruit aides and assistants. Many hypothesize that the recent downturn in the economy will improve the ability of nursing homes, home health agencies, and other organizations to recruit workers. Early anecdotes suggest that some improvements in recruiting have already occurred.

Compensation of Workers [P]
Many informants have concluded that a major deterrent to recruiting new long-term care paraprofessionals is compensation. Salaries of long-term care paraprofessionals are low, often just over minimum wage, and fringe benefits are rare. Compounding the problem is that these workers are much more likely than those in most industries to be part-time/part-year workers. This also results in inflated annual wage estimates in situations where standardized estimates are based on multiplying hourly wages by 2080 hours per year. Thus policymakers often base decisions on inflated wage estimates from government agencies.
Generally speaking, respondents assumed higher wages and better fringe benefits result in easier recruiting and higher retention, but research has not been done to calibrate the impact of different wage and fringe benefits structures.

Treatment of Workers [P]
Several studies have shown that, as important as compensation is for attracting and retaining workers, many believe that mature treatment of workers by supervisors is even more important for a significant proportion of workers. Retention could be improved dramatically if managers did more to respect their subordinates, especially those in the lower income groups. This is clearly a factor driven by individual facilities and managers, so it is difficult to assign a numerical score.

Over the last decade there has been a movement toward patient-centered care, parallel to the movement toward worker-centered care. Evidence is mounting that patient-centered and worker-centered care reinforce each other and that a combination of the two is the best situation for both patients and workers.

Unionization [P]
Unions have traditionally provided recourse for workers seeking to improve working conditions and compensation in their respective workplaces. There are a growing number of examples of unions helping long-term care paraprofessionals to gain wage increases relative to their nonunion counterparts. The efforts of Local 1199 in New York City and the recent unionization of thousands of home- and community-based workers in California are two examples. To the extent that these and other unions are successful in improving working conditions and wages, one can expect them to expand their membership and influence.

Population Demographics [E]
The aging of the population now underway will almost certainly result in increased demand for long-term care services and programs. The real impact of these demographic changes will not occur until after 2010, when the baby boom generation begins to reach the age of 65. This situation requires careful research to understand concurrent trends like the changing economic status of elderly, changing health status of the elderly, and effectiveness of new technologies and pharmaceuticals in diagnosing and treating illnesses and injuries.

The demographics of the long-term care workforce must also be taken into account. The groups that currently provide the largest share of services in nursing homes and home health agencies are women between 25 and 54, a population group projected to grow much more slowly than the populations they serve over the next two decades.

New Medical Technologies and Medications [E]
In the past, medical technologies and medications have been major engines for improving medical results, and they are expected to continue to be so in the future. Here, too, it is impossible to project with certainty the numerical impact of these factors on the paraprofessional supply and demand. The general expectation is that they will improve health care, which would delay the demand for some health care services. However, elderly people whose conditions improve from medical advances will eventually experience aging-related difficulties.

Reimbursement Rates and Criteria [P]
Government and third-party reimbursement is a critical driving force for the entire long-term care industry. Thus, reimbursement policies and rates are critical factors in determining both the supply of and demand for workers. On the supply side, reimbursement is based in part on, and supports the payment of, paraprofessional salaries and wages. On the demand side, reimbursement policies determine the sets of services patients and residents can receive for reduced out-of-pocket rates. It is important to keep in mind that, over time, demand for services is reduced by cost containment initiatives as both patients and their care providers stop seeking services for which adequate reimbursement is not provided.

Current government policies are driven in large part by the desire to reduce health care costs. If that trend continues, it is unlikely to have any significant impact on either the supply of or demand for workers.

Changing Illness Patterns [E]
As people live longer, the incidence and prevalence of disease can change, which can impact worker supply and demand. This is another area in which more research is necessary to estimate the impact numerically. Disease resistance to medications must also be considered. It is hard to predict the magnitude and sometimes even the direction of the impact of such epidemiological factors.

Worker Education and Training Programs [P]
Currently, direct care paraprofessionals are required to be formally trained in a variety of procedures and techniques prior to employment in a nursing home, home health agency, or other provider organization. Changes in the education requirement can have a significant impact on the availability of new workers. Increased education requirements will tend to discourage some workers from participating in the workforce. It will also add to the delay that already exists for adding new workers to the workforce, even if it improves the quality of services to the public.

Current discussions around the theme of developing better career tracks for these workers may help attract additional workers into the system. Unfortunately, without better data systems it will be difficult to test any hypotheses in this arena.

Government Regulation [P]
If the current trend toward increasing licensing and certification requirements for these workers continues, it could discourage some candidates from entering the direct care paraprofessional workforce, especially if appropriate funding is not available for additional education and record keeping requirements. On the other hand, clearer, more coordinated career tracks could attract more workers into the system. The attraction could be even greater if the new requirements increase portability of credentials and cross training of workers for different occupations.

In any case, it is not easy to quantify the likely impact of different regulatory changes on the supply of and demand for workers. This is another area that requires additional research.

New Models of Care and Service [P]
Patient-centered care is more and more common in nursing homes and home health agencies across the country. Generally speaking, the expectation is that this will make the long-term care workplace more humane for both patients and workers, which could promote increased success in recruiting and retaining workers.

Gray Market for Services [E]
The informal care system includes services provided by family members, volunteers, other unpaid workers, and paid workers outside the formal system. These gray market workers provide large amounts of service that is not well documented or understood. Two countervailing trends that will impact this situation are the smaller numbers of people positioned to help the elderly and the possibility of government reimbursement to unpaid workers in an attempt to provide incentives for greater participation in this kind of service. Neither of these situations is well understood, and both require more research.

Immigration Policies [P]
Immigrants, especially women, are an important source of paraprofessional workers in the long-term care industry. These individuals are often more acculturated to the demands of and needs for personal care services by parents than are most U.S. natives. They are also more willing to work for the relatively low wages currently paid for such services. Changes in immigration laws and rules could have a major impact on the supply of these workers.

The changes most often discussed involve relaxation of restrictions to permit easier immigration for people willing to work as long-term care paraprofessionals. It is important to keep in mind that looser immigration policies would add to the burdens on other social service programs, since immigrants tend to use these services more than U.S. natives.

Competition for Workers from Other Industries [E]
Several other industries compete directly with long-term care organizations for entry-level workers. They include fast food chains, retail stores, and financial institutions. As long as the skill and competency requirements for entry-level workers remain roughly the same or change in parallel, then this factor will probably have little impact on recruiting and retaining workers. However, should one industry decide to break from tradition by increasing wages significantly, it could have a significant impact on the workforce and the choices that recruits and workers make.

It is important to keep in mind that there is also competition for these workers within the health care industry. Hospitals, nursing homes, home health agencies, and other health care organizations are all recruiting from the same labor pool. There is also competition between for-profit and not-for-profit organizations in the same segments of the health care system.