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. 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. 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. 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. 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.