LeadingAge's Policy on Long-Term Services and Supports Workforce

Long-Term Services and Supports Workforce
The salaries nursing homes and other long-term services and supports providers can pay are inadequate to attract and keep workers. The hours that must be worked include nights, weekends, and holidays. The work itself is physically, psychologically, and emotionally demanding. Direct care workers are at the bottom of the staff pyramid and frequently do not feel respected for the work they do.

70% of the cost of long-term services and supports is paid by public programs, primarily Medicaid. In most states, Medicaid grossly underpays the actual cost of services. States’ moves to managed long-term care under their Medicaid programs and Medicare bundling and other alternative payment models pose further challenges.

The population group from which long-term services and supports providers traditionally have drawn – young and middle-aged women – is falling in proportion to the growing elder population. This trend will become even more pronounced as the baby boomer generation first retires, then ages into needing long-term services and supports. It is also a particular challenge in rural and frontier areas in which the population is disproportionately older.

The population from which we draw workers has its own obstacles to employment. Direct care workers often are single mothers who need affordable child care. They may have difficulty arranging transportation to work. They should not work with elders if they themselves are sick, but without paid sick leave, they cannot afford to stay home.

Long-term services and supports is high-touch. 60-80% of the cost of services relate to our workforce, rather than to technology. Long-term services and supports require different skills, education, and training than acute care. Furthermore, there are insufficient numbers of RN educators and RNs typically are not trained in the supervisory skills they need to manage direct care workers effectively.

Potential Solutions

  • Holistic Education/Universal Workers: In the small home, “Green House” model, all staff are trained to perform a variety of tasks, blending roles, and responsibilities. Experience indicates that this staffing model results in better job satisfaction and increased efficiency in the provision of services. Minnesota has an apprenticeship program built on the universal worker model.
  • Better Financing for Long-term Services and Supports: There cannot be any more unfunded mandates. We could consider supporting more requirements on staffing levels in nursing homes if there are provisions for adequate reimbursement and flexibility for rural areas where workers are harder to recruit. Bundling and other alternative payment models must include specific language and provisions related to adequate pay and benefits for direct care workers.
  • Employment Benefits: The health insurance exchanges established under the Affordable Care Act and the expansion of Medicaid may give direct care workers better access to health care coverage.
  • Incentives Necessary: Existing healthcare workforce programs, such as those under the Health Resources and Services Administration (HRSA), should be expanded to apply to direct care workers as well as to physicians and RNs.
  • Ongoing Training and Education: This needs to be provided to direct care workers so that they have the competencies needed to care for a growing population of frail elders. There needs to be special training in dementia care and communication. Problem-solving skills should be developed for all levels of the long-term services and supports workforce. We may need to consider whether regular re-certification would be either beneficial or overly burdensome for direct care workers. Recertification should be accompanied by wage differentials and growth in responsibilities. Federal grants should be available for direct care worker education and training.
  • Recognize Complexity of the Workforce: Policymakers and payors must recognize the importance of all of the staffing positions that are essential to high-quality long-term services and supports, including dietary, social work, and housekeeping.
  • Non-traditional Workers: The long-term services and supports field needs to figure out ways to bring in workers from population groups not previously tapped, including older workers. Immigration preferences should be established for direct care workers.
  • Technology: Applied technology can help to leverage skilled and professional services that may be difficult to find in some geographic areas. Direct care workers should be trained in the use of technology for tasks such as medication management.

Proposed Principles

  1. Long-term services and supports providers must commit to best practices in managing terms and conditions of direct care workers’ employment. Wages and benefits must be optimized, career growth opportunities provided, and direct care workers recognized for their unique skills and relationships with nursing home residents and clients.
  2. Financing for the long-term services and supports field must improve. Public programs on which many individuals rely to cover the cost of the long-term services and supports they need must reimburse providers at levels that allow for appropriate wages and benefits for direct care workers. A better system of financing long-term services and supports would bring new revenues into the field that could go toward improved wages and benefits for direct care workers.