Long-Term Care Workforce: Better Information Needed on Nursing Assistants, Home Health Aides, and Other Direct Care Workers
Published: 2016-08-16T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Millions of elderly individuals and persons with disabling conditions rely on LTSS to help them perform routine daily activities, such as eating and bathing. Direct care workers are among the primary providers of LTSS. Reported difficulties recruiting and retaining direct care workers and the anticipated growth in the elderly population have fueled concerns about the capacity of the paid direct care workforce to meet the demand for LTSS. Despite these concerns, policymakers lack data to help assess the size of the problem.
GAO was asked to provide information on direct care workers who deliver LTSS. This report examines (1) federal and state data available on the paid direct care workforce and (2) actions HRSA has taken to develop information and projections on this workforce. GAO analyzed the most recent data available from the Census Bureau and Bureau of Labor Statistics on paid direct care workers' demographics, compensation, and benefits and reviewed efforts to collect data on direct care workers in four states, selected in part for geographic variation. GAO also reviewed HRSA documents and interviewed agency officials about HRSA's previous, ongoing, and planned efforts to improve data.
section_title: What GAO Found
paragraphs: Federal data sources provide a broad picture of direct care workers—nursing assistants and home health, psychiatric, and personal care aides—who provide long-term services and supports (LTSS), but limitations and gaps affect the data's usefulness for workforce planning. Some states have collected data in areas where federal data are limited, but these have been one-time studies. Federal data show that direct care workers who provide LTSS numbered an estimated 3.27 million in 2014, or 20.8 percent of the nation's health workforce. Federal data show that wages for direct care workers, while differing by occupation, are generally low, averaging between approximately $10 and $13 per hour in 2015. However it is unclear to what extent these wage data include direct care workers employed directly by the individuals for whom they care. The number of these workers, often referred to as independent providers, is believed to be significant and growing. Some states, in coordination with the federal government or on their own, have conducted studies about direct care workers and collected detailed information. These studies showed that a majority of independent providers worked for a family member or someone else they knew.
The Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA), which is responsible for monitoring the supply of and demand for health professionals, has developed some information on direct care workers. However, HRSA has not produced projections of this workforce or developed methods to address data limitations, which is in line with one of the goals in its strategic plan. HRSA's actions include sponsoring research and issuing a 2013 report that summarized federal data on different occupations, including direct care workers. While HRSA has recognized the limitations of existing data and cites these as reasons it has not developed projections for this workforce, the agency has not developed methods to address data challenges. Unless HRSA takes steps to overcome data limitations in order to make projections of supply and demand for direct care workers, policymakers will continue to be hampered in their ability to identify workforce trends and develop appropriate strategies to help ensure a sufficient number of qualified direct care workers.
section_title: What GAO Recommends
paragraphs: GAO recommends that HRSA take steps to produce projections of direct care workforce supply and demand and develop methods to address data limitations in order to do so. HHS concurred with GAO's recommendation, stating that developing projections for the direct care workforce is timely and important.

section_title: Letter
paragraphs: Millions of Americans, including the elderly and people with disabling  conditions, rely on long-term services and supports (LTSS) to help them  perform routine daily activities, such as eating, dressing, bathing, and  making meals. LTSS can be provided in institutional or home- and  community-based settings and comprise a broad range of health care,  personal care, and supportive services to help individuals with limited  ability for self-care maintain their quality of life. Direct care workers— home health aides, psychiatric aides, nursing assistants, and personal  care aides—are the primary providers of the paid, hands-on care received  by these individuals. High reported attrition rates and persistent  challenges recruiting and retaining direct care workers, however, have  fueled long-standing concerns by experts and policymakers about the  capacity of this workforce to meet LTSS demands. These concerns are  heightened by the large increase expected in the number of people ages  65 and older, who are projected to comprise one-fifth of the U.S.  population by 2030.
While policymakers and other stakeholders are aware of the challenges in  recruiting and retaining direct care workers, their ability to develop  relevant, targeted policies addressing these challenges has been  hampered by gaps in data. For example, the Congressional Commission  on Long-Term Care reported in 2013 that a number of states have  experienced shortages and high attrition of direct care workers but lack  data to help them assess the size of the problem. The Commission  recommended that an appropriate federal agency, such as the Health  Resources and Services Administration (HRSA), initiate a process to  collect detailed data about the direct care workforce and launch  comprehensive data collection efforts. HRSA, within the Department of  Health and Human Services (HHS), is responsible for ensuring that  Americans have access to a skilled health workforce. Within HRSA, the  National Center for Health Workforce Analysis helps build a body of  knowledge about the health workforce by projecting the supply of and  demand for U.S. health workers and developing methods to inform health  workforce decisions.
Given the concerns about the ability of the direct care workforce to meet  current and future demands for LTSS and the reported lack of data  needed to estimate the size and characteristics of this workforce, you  asked us for current information about direct care workers who provide  LTSS, such as their wages, hours, and attrition rates.  1.  available federal and selected state data about the direct care  2.  actions HRSA has taken to develop information, project supply and  demand, and overcome data limitations related to the direct care  workforce.
To examine the available federal and selected state data about the direct  care workforce, we reviewed data sets collected by the Census Bureau,  the Bureau of Labor Statistics (BLS) in the Department of Labor, and  selected states. We used the Census Bureau’s 2014 American  Community Survey (ACS) to estimate the number of direct care workers,  their demographics, and hours worked. We used the BLS’s 2015  Occupational Employment Statistics and 2015 National Compensation  Survey to report data on direct care workers’ wages and benefits,  respectively. For each source, we used the most recent data available at  the time we conducted our work. In addition, while direct care workers are  employed in both long-term care settings and acute care settings, such as  hospitals, we limited our analyses to certain industries in which LTSS are  likely provided. (For detailed information on our analysis methods and  federal data sources, see app. I.) We assessed the reliability of ACS and  BLS data by interviewing knowledgeable officials, reviewing relevant  documentation, and comparing the results of our analysis to published  data, as appropriate, and determined that these data were sufficiently  reliable to inform our objectives. We also gathered information about state  efforts to collect data on their direct care workforce by focusing on four  states—Arkansas, Maine, Minnesota, and Oregon—that had conducted  comprehensive surveys about their direct care workforce since 2012.  Three of the states—Arkansas, Maine, and Minnesota—conducted their  surveys as part of a multistate study funded by the Centers for Medicare  & Medicaid Services (CMS) and were selected because they had  achieved the highest survey response rates for their geographic regions.  Oregon collected data about direct care workers through its own survey  initiative and was selected for geographic variation and its high survey  response rate. For each state, we obtained copies of the survey  instruments used and documentation of the states’ summary survey  results to the extent available, and we interviewed state officials about  their experiences collecting these data. The survey results for the four  states are not generalizable to other states. We did not verify the results  of states’ data collection efforts but considered them reliable for the  purpose of illustrating the range of data these states had collected about  direct care workers.
To identify HRSA’s efforts to develop information, project supply and  demand, and overcome data limitations related to the direct care  workforce, we analyzed agency documents that contain details about  HRSA’s strategic plan, health workforce efforts, assessment of available  direct care workforce data, and related workforce data needs. We also  interviewed HRSA officials to establish the agency’s previous, ongoing,  and planned efforts to provide information on the health workforce and to  develop and employ approaches to monitor, forecast, and meet health  workforce needs.
We conducted this performance audit from April 2015 to August 2016 in  accordance with generally accepted government auditing standards.  Those standards require that we plan and perform the audit to obtain  sufficient, appropriate evidence to provide a reasonable basis for our  findings and conclusions based on our audit objectives. We believe that  the evidence obtained provides a reasonable basis for our findings and  conclusions based on our audit objectives.
subsections: section_title: Background
paragraphs: Federal census data show that an estimated 12.3 million Americans age  6 years and older needed LTSS in 2010. LTSS are a distinct set of  services that are critical elements of support for people with functional  limitations due to health conditions. Individuals’ needs for LTSS are often  measured in terms of their need for assistance with activities of daily  living (ADL) and instrumental activities of daily living (IADL). ADLs include  bathing, dressing, eating, getting into and out of chairs, walking, and  using the toilet; IADLs include using the telephone, doing housework,  preparing meals, shopping, and managing money.
subsections: section_title: LTSS Expenditures
paragraphs: According to the Congressional Research Service, U.S. expenditures for  LTSS in 2014 totaled an estimated $337 billion, representing 13 percent  of personal health expenditures. Nearly two-thirds of LTSS spending is  financed by the federal and state governments, primarily through  Medicaid and Medicare. Medicaid is the largest payer of LTSS,  accounting for 42 percent of LTSS spending followed by Medicare, which  pays an additional 22 percent. Private funding (e.g., out-of-pocket  spending and private insurance) accounts for less than one-third of LTSS  spending.
section_title: Direct Care Workers
paragraphs: A number of job titles are used in the long-term care industry to refer to  direct care workers. Often, workers’ job titles vary by state or by the  setting where they provide care. For example, direct care workers as a  group are also referred to as paraprofessional workers, direct support  professionals, or direct service workers. Specific job titles for direct care  workers include home care aides, personal assistants, home attendants,  homemakers, companions, personal care staff, and resident care aides,  among others. For this report, we examined data for the four occupations  often used to categorize direct care workers:
Home health aides monitor individuals’ health statuses; provide  routine individualized health care, such as changing bandages,  dressing wounds, and applying topical medications; and assist with  ADLs. Home health aides are generally hired through a home health  agency and assist individuals in their homes or in residential care  facilities.
Psychiatric aides, under the direction of nursing and medical staff,  assist people who are mentally impaired or intellectually and  developmentally disabled with ADLs, educational and recreational  activities, or accompany them to and from medical examinations and  treatments. They may also be referred to as mental health orderlies,  psychiatric orderlies, or psychiatric nursing aides. Psychiatric aides in  long-term care industries are primarily employed in residential care  facilities for the intellectually and developmentally disabled, residential  mental health and substance abuse facilities, and state facilities.
Nursing assistants, also known as nurse aides, provide basic patient  care under the direction of nursing staff. They also perform clinical  tasks, such as taking blood pressure readings and performing range- of-motion exercises, in addition to assisting with ADLs and IADLs.  Nursing assistants work primarily in nursing home and residential care  facilities.
Personal care aides assist individuals with ADLs, not including  medical care, at a person’s home or in a residential care facility.  Personal care aides are often employed through an agency or hired  directly by an individual to provide assistance with both ADLs and  IADLs.
While many direct care workers are employed by traditional business  establishments such as nursing homes and home health agencies, some  work directly for the individuals they care for or their families under a  variety of arrangements. Often referred to as independent providers,  these workers are believed to comprise a large and growing portion of the  direct care workforce, although their exact numbers are unknown.  Independent providers can be employed by individuals under  government-funded programs, such as Medicaid, that allow individuals to  hire their own workers, including family members; or hired by households  under private arrangements; or sometimes hired by both, even for the  same client. Most private arrangements are thought to be unreported,  constituting what some refer to as a “gray market” of providers.
Federal law requires states to certify nurse aides and home health aides  who provide LTSS for nursing home facilities and home health agencies  that accept Medicaid and Medicare reimbursement. A state-approved  nurse aide or home health aide certification program must require a  minimum of 75 hours of training, including at least 16 hours of supervised  practical training. While federal law also requires states to maintain a  registry of nurse aides who are certified, no such requirement exists for  other direct care workers.
section_title: Workforce Planning
paragraphs: The goal of workforce planning, the systematic process of identifying and  addressing the gaps between the current workforce and the workforce  needs of the future, is to ensure that an adequate supply of appropriately  trained workers is available to meet demand—either for a particular  employer, position, or industry. Workforce analysis requires an  understanding of the characteristics, capability, and distribution of the  current workforce to model the workforce and project how it may change  in the future.
In the last 15 years, a number of reports have highlighted the need for  direct care workforce planning and called for more data about direct care  workers. In addition to the Congressional Commission on Long-Term  Care report, HRSA reported in 2004 that informed workforce planning is  needed to document the extent of shortages in direct care occupations so  that states and institutions can address them and assess the impact of  present and future initiatives to balance supply and demand. A 2009  study funded by CMS reported that information about the long-term direct  care workforce is essential for understanding workforce issues and  developing appropriate policy responses to plan for the future  workforce. The study also recommended that states collect a minimum  dataset about their direct care workforces that includes three elements:  (1) the number of direct care workers; (2) workers’ compensation (wages  and benefits); and (3) workforce stability measures (attrition and vacancy  rates).
One of HRSA’s primary goals is strengthening the health workforce. In its  fiscal year 2016-2018 Strategic Plan, HRSA specifically aims to  strengthen the health workforce by developing and employing  approaches to monitor, forecast, and meet long-term health workforce  needs as well as providing policymakers, researchers, and the public with  information on health workforce trends, supply, demand, and policy  issues. Within HRSA, the National Center for Health Workforce Analysis  helps build knowledge about the nation’s health workforce through data  development, projections of supply and demand, and serving as a focal  point for health workforce data.
section_title: Federal Data Provide Broad Picture of the Direct Care Workforce but Contain Limitations and Gaps; Some States Have Collected Data in These Areas
subsections: section_title: Federal Data on the Number, Characteristics, and Compensation of Direct Care Workers Exist but Have Limitations, and Data about Workforce Stability Are Unavailable
paragraphs: Federal data from the Census Bureau’s ACS show that in 2014, the direct  care workforce that provided LTSS totaled an estimated 3.27 million  workers, about 20 percent of the total U.S. health workforce that year.  Personal care aides made up over 46 percent of all direct care workers,  and in the last decade their numbers have more than doubled. Over the  last decade, the estimated total number of direct care workers increased  over 44 percent, in part due to growth in the number of personal care  aides. Our analysis of projections from the BLS shows that the number of  jobs for direct care workers providing LTSS is expected to increase to  4.56 million in 2024. At the same time, growth in the number of women  between the ages of 25 and 64, who comprise the vast majority of direct  care workers, is expected to remain flat through 2024.
While the ACS provides information on the number and characteristics of  direct care workers, these data are subject to limitations, which affect  their usefulness for workforce planning. While the ACS separately  identifies personal care aides, it combines data for home health aides,  psychiatric aides, and nursing assistants into one occupational grouping,  so separate estimates for these occupations are unavailable. Another  limitation is that the number of these workers employed as independent  providers is unclear, because the ACS data do not separately identify  independent providers from other direct care workers. In addition, since  the ACS inquires only about the job where individuals work the most  hours, direct care workers who provided LTSS part-time as a secondary  job are not included in these data. The ACS data also include individuals  identified as direct care workers who have not been employed in the last  12 months but were employed as direct care workers in the previous 5  years. Finally, the ACS data are self-reported, so individuals choosing not  to identify themselves as direct care workers are not picked up in the  data.
Federal data from the BLS also provide information on direct care  workers’ compensation, including wages and benefits. In 2015, direct  care workers in long-term care industries received an average hourly  wage of $11.21, which is in the bottom quarter of all U.S. wages,  according to BLS’s Occupational Employment Statistics. The average  hourly wage in the United States across all occupations was $23.23,  more than double direct care workers’ average wage. Personal care aides  in long-term care industries had the lowest hourly wage of direct care  workers at $10.42, while psychiatric aides had the highest at $12.62.  According to data from the ACS, 48.8 percent of personal care workers  and 37.6 percent of nursing, psychiatric, and home health aides worked  part-time (less than 35 hours per week) in 2014. In addition, data from  BLS’s National Compensation Survey showed that direct care workers’  access to employment benefits varied depending on whether they were  employed full-time or part-time. Over 90 percent of full-time direct care  workers received paid vacation, paid holidays, and health insurance in  2015; fewer workers were provided paid sick leave, life insurance, and  retirement benefits. In contrast, less than half of part-time direct care  workers had access to any of these benefits.
BLS data on wages and benefits also have limitations. According to BLS  officials, due to the National Compensation Survey’s small sample size,  benefits data are limited to direct care workers in all industries and cannot  be broken down by occupation or specific industry. Also, data on both  wages and benefits exclude some direct care workers working as  independent providers. Both the Occupational Employment Statistics and  the National Compensation Survey collect information from employer- based surveys that do not capture individuals employed by private  households, such as independent providers working under private  arrangements. The data may include some independent providers funded  by government programs, such as Medicaid; however, the extent to which  these providers are included in the data depends on their employment  relationship with the government program, which can vary. (See app. II  for more detailed information about direct care workers’ numbers,  demographics, wages, and other characteristics.)
We were unable to identify federal data sources on workforce stability  measures, which are often used for workforce planning. BLS conducts the  Job Openings and Labor Turnover Survey, which provides data on job  openings and separations for broad industries, such as all health care  and social assistance establishments. However, due to the small sample  size, this survey does not determine attrition for specific occupations,  such as personal care aides. BLS officials informed us that filling the  data gaps of attrition rates at the occupational level would require major  changes in their surveys and would be costly to implement.
section_title: Some States Have Collected Detailed Data in Areas Where Federal Data Are Lacking
paragraphs: The four states we reviewed (Arkansas, Maine, Minnesota, and Oregon)  each conducted one-time studies to obtain more detailed information  about direct care workers who provide LTSS in those states. Three of the  states (Arkansas, Maine, and Minnesota) collected data on direct care  workers in 2012 as part of a CMS initiative called the National Balancing  Indicators Project (NBIP). The seven states that participated in the NBIP  collected data using two standardized surveys—one for employer  organizations and one for independent providers—designed by CMS’s  National Direct Service Workforce Resource Center, in coordination with  the participating states. The surveys were designed to collect data  about the number of workers, their hours, worker compensation, and  measures of workforce stability. Each survey incorporated these required  variables, and states included additional variables at their discretion.  See table 1.
The fourth state we reviewed (Oregon) collected data in 2014 on direct  care worker compensation, attrition, and the relationship between  workers’ wages and Medicaid payment rates over time. Oregon’s survey  of Medicaid-participating LTSS providers also captured many of the same  variables included in NBIP’s employer survey. Both NBIP’s and  Oregon’s surveys asked about direct care workers as a group as opposed  to asking about each separate direct care worker occupation.
The four states obtained data that federal sources have not, such as  information describing the characteristics of independent providers and  attrition rates. We obtained summary results from independent provider  surveys for Maine and Minnesota, which showed that most responding  independent providers worked for a family member, a neighbor, a friend,  or someone else they knew. The data also showed large differences  between the two states in the education, income levels, and hourly wages  of independent providers. Appendix III provides more detailed information  on the NBIP and the survey results for independent providers.
Arkansas, Maine, and Oregon also surveyed employer organizations  providing LTSS to calculate attrition. In Arkansas and Maine, the  average attrition rate across all employment settings was close to 30  percent, and in Oregon, the rate was about 64 percent, although rates  varied widely across settings in all states. The NBIP states and Oregon  calculated attrition differently, which could explain in part why Oregon’s  attrition rate was more than twice the rates of Arkansas and Maine;  research on attrition in nursing homes has shown that definitions of  attrition can vary substantially, making it difficult to make comparisons  across studies.
Officials in all four states said that the data they collected provided helpful  information about direct care workers. Despite the usefulness of the  survey data, none of these states continued data collection after the study  ended; some state officials noted the significant resources required to  collect data on this workforce. Each of the three NBIP states received  $200,000 to conduct their workforce studies while Oregon spent about  $299,800, according to a state official.
Officials from the NBIP states said they appreciated the opportunity to  use a standardized survey, emphasizing the value of being able to make  cross-state comparisons. The National Direct Service Workforce  Resource Center, which carried out the NBIP study, had planned to  disseminate a data collection toolkit to states for collection of information  on direct care workers. The toolkit was to include guidance about data  collection methods and versions of the employer and independent  provider survey instruments. Although the toolkit was completed by the  end of the NBIP contract, CMS’s contractor for the study said that the  National Direct Service Workforce Resource Center was not funded to  disseminate the toolkit or help states use it, and it was not widely  disseminated or posted on CMS’s website.
section_title: HRSA Has Developed Some Information on the Direct Care Workforce but Has Not Projected Supply and Demand or Overcome Data Limitations
subsections: section_title: HRSA Has Developed Some Information about the Direct Care Workforce
paragraphs: We identified two reports that HRSA issued in the last 12 years that have  provided information about the direct care workforce. First, in 2004,  HRSA issued a report on workforce shortages of nursing assistants and  home health aides and the associated data needs for workforce  planning. The report provided a comprehensive assessment of data  needed for program and policy development as well as the extent and  limitations of available data, including eight federal data sets; 45 state  registries of certified nursing assistants; and 4 states’ data collection  activities. The report concluded that informed workforce planning was  needed to document the extent of shortages and to assist states and  other stakeholders in addressing them. The report also included options  for making existing data sources more useful, such as expanding state  registries of certified nursing assistants to include information on other  direct care workers.
Second, in 2013, HRSA’s National Center for Health Workforce Analysis  issued a chart book summarizing national data on different health  occupations. Personal care aides and the occupational grouping titled  nursing, psychiatric, and home health aides were among the 35  occupations included in this report. Using data from the ACS for 2008  through 2010, the chart book estimated the number of workers for each  occupation and presented figures showing their geographic distribution,  workplace settings, and demographic characteristics.
HRSA has also supported academic institutions in conducting research  and providing information about health workers, including long-term care  workers. HRSA provides funds to seven Health Workforce Research  Centers at universities to conduct research and help federal, state, and  local decision makers better understand health workforce needs. One of  the research centers located at the University of California, San Francisco  focuses on the long-term care workforce. This center has examined  several topics related to direct care workers, such as training  requirements for personal care aides across states; long-term care  service use trends and workforce demand predictions; and the entry and  exit of workers in long-term care.
In addition, HRSA has taken part in the Office of Management and  Budget’s Standard Occupational Classification Policy Committee, which  works to ensure that the occupational classifications used by the  government are updated to reflect changes in the economy and nature of  work. The Policy Committee, which comprises representatives of  several federal agencies, formulates recommendations for revisions to  occupational titles and definitions. The Standard Occupational  Classification system has been revised several times to reflect changes in  the economy and how work is accomplished; the next scheduled revision  is 2018. HRSA officials reported that the occupational definitions for home  health aides, nursing assistants, and personal care aides are being  considered for modification in the 2018 revision to more closely reflect the  tasks workers perform.
section_title: HRSA Has Not Produced Projections of Supply and Demand for the Direct Care Workforce or Developed Methods to Address Data Limitations
paragraphs: HRSA’s strategic plan includes a goal to enhance focus on workforce  assessment and policy analysis through developing and employing  approaches to monitoring, forecasting, and meeting long-term health  workforce needs. According to HRSA’s website, the National Center for  Health Workforce Analysis conducts projections of the supply of and  demand for the U.S. health workforce and works to overcome inherent  data challenges in making these projections by improving available data;  HRSA has not yet done this for direct care workers. Previously, the  National Center for Health Workforce Analysis developed projections of  the supply of and demand for workers in a number of other health  occupations, including, but not limited to, chiropractors, podiatrists,  respiratory therapists, dietitians, pharmacists, and health technicians. Not  having such projections for direct care workers is significant because the  Center’s projections for health professions by discipline help set the  national agenda for the health workforce and inform HRSA and HHS  programs. According to HRSA officials, HRSA utilizes the information  provided in the projection reports to assess changes in the national  workforce, and these reports guide the strategic direction of both HRSA  and HHS programs. Officials further explained that HRSA sends the  workforce projections to HHS agencies to initiate awareness and visibility  of workforce issues and to inform budget requests, program planning, and  performance management activities. These activities, undertaken as part  of the strategic planning and budget development processes, are HHS’s  main health workforce planning activities.
HRSA officials stated that the agency has not developed projections of  the supply of direct care workers, because the available data are  insufficient. To project the direct care workforce, HRSA officials stated  that they would need basic, uniform, aggregate data that counts the  number of workers, but no federal, state, or external body collects data  specifically about these workers across all settings. While HRSA  considers projecting supply to be problematic, officials told us that  projecting demand for direct care workers is possible. However, they  have no specific plans to project demand for this workforce, at this time.
In spite of finding the data insufficient, HRSA has also not developed  methods to overcome data limitations in projecting the direct care  workforce. HRSA officials told us that because of its large sample size,  the ACS is currently the best source of information about health workers  and provides reliable estimates of the direct care workforce, but noted  that there are significant limitations. Officials stated that they can use  ACS data to estimate the supply of personal care aides, but that it is not  possible to develop estimates for the other individual direct care  occupations because they are combined into one occupational group— nursing, psychiatric, and home health aides. We asked HRSA officials  whether the occupational grouping in the ACS data could be  disaggregated to estimate the supply of each direct care occupation  separately. Officials responded that when analyzing data, they use the  standard data set as supplied by the data sponsor, and they had not  asked the Census Bureau whether further disaggregation or special data  collection were possible now or in the future. We asked HRSA officials  further whether the supply of home health aides, psychiatric aides, and  nursing assistants could be estimated from ACS data using data from  other sources. For instance, BLS estimates the number of workers in  each direct care occupation for its National Employment Matrix by  determining the proportion of that occupation that is found in one survey  and applying these proportions to data from another survey. When we  suggested that similar methods could help develop direct care worker  supply estimates from ACS data, HRSA officials responded that they  prefer to use direct data rather than making assumptions to derive  estimates.
Although HRSA officials said they prefer to use primary data in making  projections, the agency has not been proactive in identifying and  improving primary data about the direct care workforce. It has been over  10 years since HRSA last produced a comprehensive assessment of the  available data on direct care workers, despite the advent of new data  sources since that time; some of these new data sources were unknown  to HRSA officials. For example, at the time we interviewed HRSA  officials, they were unaware that CMS planned to begin collecting staffing  data from nursing homes that participate in Medicare or Medicaid  beginning July 1, 2016, pursuant to a requirement in the Patient  Protection and Affordable Care Act. These new data will include  information on direct care worker attrition, tenure, and the number of  hours of care per resident per day that could potentially fill current data  gaps. In addition, HRSA officials were unaware that CMS’s NBIP initiative  had developed a set of standard survey instruments that were used by  seven states to collect direct care workforce data. HRSA officials told us  that state-collected data are often not uniform from one state to another  and this limits the data’s usefulness. However, HRSA noted in its 2004  report that data collected by states could potentially fill existing data gaps  and the NBIP initiative represents a significant effort to develop and  standardize state data.
Given the limitations with direct care workforce data, new approaches for  overcoming these limitations would help improve projections and  monitoring of this critical workforce. Developing new approaches would  be consistent with HRSA’s strategic goal to enhance workforce  assessment and analysis. But HRSA has not taken actions to project  supply and demand or to overcome the data limitations it cites as  challenges to doing so. Without HRSA developing projections of supply  and demand, the information on direct care workers will remain limited,  and opportunities may be missed to improve the information upon which  other HHS agencies and policymakers rely to guide their workforce  development efforts.
section_title: Conclusions
paragraphs: Direct care workers are responsible for providing the majority of paid  hands-on care to millions of elderly and individuals with disabilities  needing LTSS. However, reported high attrition rates and problems  recruiting and retaining these workers, along with the anticipated rise in  the elderly population, have fueled concerns about shortages. The  importance of the direct care workforce and the potential for shortages  underscores the need for informed workforce planning. The success of  such planning will depend in part on having current and reliable estimates  of the direct care workforce, and future projections of the supply of and  demand for direct care workers. While existing federal data sources  provide a broad picture of the direct care workforce, gaps exist, such as  the lack of information on independent providers and attrition. Unless  HRSA takes actions to overcome data limitations in order to make  projections of supply and demand, the ability of policymakers and other  stakeholders to develop appropriate workforce strategies to ensure a  sufficient number of qualified direct care workers will continue to be  hampered.
section_title: Recommendation for Executive Action
paragraphs: To improve available data about the direct care workforce, we  recommend that the Acting Administrator of the Health Resources and  Services Administration  take steps to produce projections of direct care workforce supply and  demand and develop methods to address data limitations in order to  do so.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided a draft of this report to HHS and the Department of Labor for  review and received written comments from HHS, which are reprinted in  appendix IV. HHS and the Department of Labor also provided technical  comments, which we incorporated as appropriate.
In its comments, HHS concurred with our recommendation that HRSA  take steps to develop projections of direct care workforce supply and  demand, stating that developing such projections is timely and important.  Congruent with the message of our report, HHS stated that given the  growth in the aging population and the challenges in recruiting and  retaining direct care workers, having clear information on this workforce is  critical for workforce planning. To that end, the department stated that  HRSA is developing demand projections for certain direct care workforce  occupations and will explore ways to develop additional information  needed to provide comprehensive workforce trends. Given the challenges  with the underlying data on the direct care workforce, HRSA will likely  need to develop methods to overcome data limitations to produce this  information.
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If you or your staff have any questions about this report, please contact  me at (202) 512-7114 or kingk@gao.gov. Contact points for our Offices of  Congressional Relations and Public Affairs may be found on the last page  of the report. GAO staff who made key contributions to this report are  listed in appendix V.
section_title: Appendix I: Scope and Methodology
paragraphs: This appendix describes the methods and federal data sources we used  to examine the direct care workforce. In total, we analyzed data from  three different surveys—one by the Census Bureau and two conducted  by the Bureau of Labor Statistics (BLS)—as no one data source  contained information about all aspects of the direct care workforce (see  table 2). In conducting our analyses, we made some adjustments due to  the data sources’ differing structures. In addition, to focus our analysis on  direct care workers providing long-term services and supports (LTSS) (as  opposed to those providing any type of care, including acute care), we  used Census Bureau and BLS data to identify the industries and workers  most likely providing LTSS. We assessed the reliability of the data by  interviewing knowledgeable officials, reviewing relevant documentation,  and comparing the results of our analysis to published data, as  appropriate, and determined that these data were sufficiently reliable to  inform our objectives.
subsections: section_title: Data Sources
subsections: section_title: Census Bureau Survey
paragraphs: To report on the number of direct care workers, their demographic  characteristics and their hours worked, we used 1-year estimates from  the Census Bureau’s 2014 American Community Survey (ACS), a  monthly household survey that collected data from approximately 3.54  million addresses in 2014, including both housing units and group  quarters. The ACS provides broad, comprehensive information on social,  economic, and housing data across the United States. We obtained 2014  ACS 1-year estimates using the DataFerrett tool provided by the Census  Bureau. We narrowed the data to include only the occupations identified  as direct care and industries that provide long-term care. We then  selected the demographic variables of interest and downloaded the data.
For comparison, we also downloaded data using the same demographic  variables for all U.S. occupations and industries.
One limitation of the ACS is that it collects information about the job  where an individual works the greatest number of hours, or an individual’s  primary job. This would likely exclude direct care workers who provide  LTSS part-time as a secondary job, according to Health Resources and  Services Administration (HRSA) officials. While many direct care workers  work part-time, we do not know how many do so as a secondary job.  Another limitation of the ACS data is that individuals who are currently  unemployed are classified into the occupational group in which they were  most recently employed, which can be as far back as 5 years. This results  in counting approximately 472,000 currently unemployed individuals as  direct care workers even though they have not been employed in the past  12 months. The ACS data are also self-reported, so individuals choosing  not to identify themselves as direct care workers would not be included in  the data.
section_title: Bureau of Labor Statistics (BLS) Surveys
paragraphs: To report on direct care workers’ wages, we used BLS’s May 2015  Occupational Employment Statistics. The Occupational Employment  Statistics measure jobs and wage rates by occupation for all full- and  part-time wage and salary workers in nonfarm industries. Over a rolling 3- year cycle, BLS gathers semiannual probability samples of approximately  200,000 business establishments for a total of 1.2 million businesses.  These establishments are selected from a list of nonfarm establishments  that file unemployment insurance reports to state workforce agencies.  Self-employed workers, owners and partners in unincorporated firms,  household workers, unpaid family workers, and government workers in  the military and legislative and judicial branches are excluded. We  obtained the data through BLS’s online Occupational Employment  Statistics database by searching for the direct care occupations of interest  and long-term care industries. To calculate the mean hourly wage for an  occupation, across all long-term care industries, we multiplied the number  of workers employed in each industry by the industry’s mean hourly  wage, summed these numbers, and then divided by the total number of  workers.
To report on direct care workers’ benefits, we used BLS’s National  Compensation Survey published in March 2015. The National  Compensation Survey collects a range of compensation data along with  detailed worker characteristics, such as benefits, union status, and part- time or full-time work schedules. This information is obtained from  approximately 10,100 business establishments per year in private  industries and state and local governments. The National Compensation  Survey excludes workers in federal agencies, quasi-federal agencies,  agriculture, and private households as well as military personnel, self- employed workers, unpaid workers and volunteers, individuals receiving  long-term disability compensation, and those working overseas. Since  National Compensation Survey data on the BLS website is provided by  industry sectors, we requested that BLS provide us with data on a range  of employment benefits, such as vacation, sick leave, and retirement,  specific to direct care occupations for the long-term care industries we  identified. Because the National Compensation Survey is administered to  a relatively small sample of business establishments, BLS officials stated  that they were unable to limit the data to only long-term care industries or  provide data for each direct care occupation separately. As a result, the  benefit data provided in this report are for all direct care workers in all  industries.
One limitation of the BLS surveys we reviewed is that the extent to which  they include direct care workers working as independent providers is  unclear. According to BLS officials, the Occupational Employment  Statistics and National Compensation Survey include some independent  providers paid for by government programs, such as Medicaid. Their  inclusion in the data, however, depends on their employment  arrangement with the government program, which can vary. BLS officials  explained that, in contrast, independent providers working under private  arrangements are not included in the data because these data sources do  not include private household workers and self-employed workers.
section_title: Occupational Classification
paragraphs: The job titles of direct care worker can vary, but they are often classified  into four categories according to the Office of Management and Budget’s  Standard Occupational Classification system. We selected four Standard  Occupational Classification categories equivalent to the direct care  occupations: home health aides (code 31-1011), psychiatric aides (31- 1013), nursing assistants (31-1014), and personal care aides (39-9021).  One difference between BLS and Census Bureau data is that Census  Bureau data use fewer detailed occupational codes. Specifically, Census  Bureau data classify direct care workers into two groups: personal care  aides (occupational code 4610) and one broad grouping that includes  nursing, psychiatric, and home health aides (occupational code 3600).  The broad occupation referred to as “nursing, psychiatric, and home  health aides” also includes orderlies. While orderlies are generally not  considered direct care workers, BLS Occupational Employment Statistics  data suggest that they comprise a small portion of all workers in this  occupational grouping. The ACS uses this grouping that includes  orderlies, as shown in table 3.
section_title: Identifying Long-Term Care Industries
paragraphs: Because direct care workers can also work in non-LTSS settings, such as  hospitals, we used the Office of Management and Budget’s North  American Industry Classification System (NAICS) industry definitions to  narrow our scope just to those direct care workers employed in long-term  care settings. We considered an industry to provide LTSS if the industry,  as defined by NAICS, (1) primarily served the elderly or those living with  chronic health conditions (i.e., physical, cognitive, or mental disabilities)  who need assistance with activities of daily living on an ongoing basis; (2)  provided services that help individuals perform everyday activities,  including health care, personal care, and supportive services, such as  feeding, bathing, administering topical medication, and supported  employment; and (3) provided the services and supports in institutions  (e.g., nursing homes) or home- and community-based settings. In  addition, we included direct care workers employed by private households  and government. The industries we identified and their associated NAICS  and Census codes are shown in table 4.
In some cases, industries are classified differently between BLS and  Census Bureau data, with Census data generally using less specific  industry classifications. For example, one of the industries we identified  as long-term care related from BLS data was Services for the Elderly and  Persons with Disabilities. The Census Bureau, however, does not use  this specific industry and instead utilizes the broader industry Individual  and Family Services—the aggregate of Services for the Elderly and  Persons with Disabilities and two other industries: Child and Youth  Services and Other Individual and Family Services. In addition, BLS data  classifies public administration entities into one of three industries based  on the level of government—federal, state, and local, whereas Census  Bureau data divide government employees among public administration  settings based upon work activities. For instance, direct care workers  employed by all levels of government are captured in Census data in the  industry titled Administration of Human Resource Programs.
section_title: Appendix II: Federal Data on the Number of Direct Care Workers and Their Compensation
paragraphs: This appendix contains figures and tables presenting data about direct  care workers obtained from federal sources. The data include information  on the percentage of direct care workers out of all health workers, and  direct care workers’ demographics, wages, hours, and benefits.
section_title: Appendix III: National Balancing Indicators Project and Selected Results from the Study’s Surveys to Independent Providers
paragraphs: The Centers for Medicare and Medicaid (CMS) funded the National  Balancing Indicators Project (NBIP) from 2010 through 2014 to develop  and test the feasibility of implementing a set of national indicators to  assess states’ efforts toward attaining and maintaining a balanced and  person-centered long-term services and supports (LTSS) system. As part  of the NBIP, CMS funded seven states (Arkansas, Florida, Kentucky,  Maine, Massachusetts, Michigan, and Minnesota) to collect data on direct  care workers as a demonstration to see how states could measure the  strength and stability of their home- and community-based LTSS  workforce. We selected three NBIP states—Arkansas, Maine, and  Minnesota—to review because of their geographic diversity and because  they had achieved higher response rates in comparison with other states  in their geographic region.
CMS’s National Direct Service Workforce Resource Center, in  coordination with the participating states, designed two surveys to collect  uniform minimum data sets from employer organizations and independent  providers in each of the states. The survey templates were designed to  collect a minimum data set that included measures of workforce volume  (the number of full- and part-time workers), workforce stability (attrition  and vacancy rates), and worker compensation (average hourly wage and  benefits). Each survey incorporated these required questions, and states  included additional questions if they wished.
The NBIP states selected which groups of employers participating in their  Medicaid home- and community-based services programs to survey.  Non-Medicaid participating providers were not included in the NBIP study.  Otherwise, states selected which providers to survey, such as providers  serving certain populations. Of the states we reviewed, Arkansas and  Maine together surveyed 490 employer organizations and obtained  response rates of 38 and 54 percent, respectively. Minnesota elected not  to survey employer organizations, as the state had conducted previous  surveys of these providers. All three NBIP states fielded a survey to  independent providers. Working with financial management services  vendors or community partners, the states together identified over 11,900  independent providers and achieved response rates ranging from 44 to  51 percent.
The information collected by the NBIP from independent providers was of  particular interest, since detailed information on these providers is not  available through federal data sources. We obtained summary results  from independent provider surveys for two states—Maine and  Minnesota. Together these states surveyed a total of 7,209 direct care  workers working as independent providers for consumers in Medicaid  home- and community-based programs. Overall response rates achieved  were 46 and 44 percent for Maine and Minnesota, respectively. The  results for these states showed, among other things, that the vast majority  of responding independent providers worked for a family member,  neighbor, friend, or someone else they knew. The data also showed large  differences in the education and income levels between independent  providers in the two states. For example, a little over one-third of  responding providers in Maine reported having had some college or  higher education, compared with over 60 percent in Minnesota, and over  half of responding providers in Maine reported having annual household  incomes of less than $22,000, while over 40 percent of independent  providers in Minnesota reported incomes over $50,001. Wages also  differed between the two states, with responding independent providers in  Maine reporting an average wage of $9.51 per hour, compared with  $15.40 per hour in Minnesota. (See table 10 for selected results for  Maine’s and Minnesota’s surveys to independent providers.)
section_title: Appendix IV: Comments from the Department of Health and Human Services
section_title: Appendix V: Contact and Staff Acknowledgments
subsections: section_title: GAO Contact:
section_title: Staff Acknowledgments:
paragraphs: In addition to the contact named above, Christine Brudevold, Assistant  Director; Linda McIver, Analyst-in-Charge; Dee Abasute; Elizabeth  Morrison; and Lisa Opdycke made key contributions to this report. Also  contributing were Vikki Porter, Merrile Sing, and Emily Wilson.