In 2008, the ad hoc Committee on the Future Health Care Workforce for Older Americans, under direction from the Institute of Medicine (IoM), published its report concluding that the definition of this workforce must be expanded. According to the report, the definition should encompass everyone involved in a patient's care, including direct care workers (DCWs) such as nursing assistants and home care aides, and informal caregivers, referring to family and friends (IoM, 2008). The expansion of the definition is essential because DCWs and family caregivers deliver most of the hands-on care to chronically ill and impaired adults, and are regarded as the backbone of the long-term care workforce (Noelker, 2001). Hence, any efforts to improve the health care workforce must give thoughtful attention to strategies that address the needs and interests of DCWs and family caregivers. The IoM Committee proposed a three-fold approach for retooling the health care workforce aimed at the following: increasing recruitment and retention; enhancing competency through education and training; and, improving care delivery to ensure better outcomes for care receivers.
For more than 40 years, the Aging Network has helped to grow the long-term-care workforce in order to expand home- and community-based services (HCBS), thereby affording choice in long-term-care arrangements and supporting the independence of older Americans. The U.S. Administration on Aging (AoA) has led the Aging Network in these efforts. Over the years, it has taken a central role through Older Americans Act (OAA) Title IV training initiatives to improve the workforce. It also has overseen the expansion of services for family caregivers through the National Family Caregiver Support Program, funded under Title III of the OAA.
Expert Panel on the Long-Term-Care Workforce
Under a Cooperative Agreement with AoA, the Benjamin Rose Institute on Aging convened a national panel of experts on the long-term-care workforce, specifically DCWs and family caregivers, to examine ways to enhance their capacity. One basis for the AoA request was that DCWs and family caregivers are critical to the delivery of long-term services and supports for older adults and adults with disabilities. As such, they are a vital part of the health care workforce in this nation, which was acknowledged in the recent IoM report (2008) that focused on the urgent need to “retool” or strengthen this workforce.
The second basis was health care reform legislation, including the CLASS Act, that presaged a new emphasis on and expansion of health promotion, chronic disease prevention and management, and HCBS. In anticipation of the legislation's passage, AoA was seeking input from recognized experts in the field on the implications of this legislation for the long-term-care workforce, as well as possible strategies and initiatives for AoA to consider in its effort to strengthen both the direct care workforce and family caregivers.
The third basis was the pending reauthorization of the Older Americans Act and the work being done through public forums and other events to gather information from various constituencies and stakeholders related to the reauthorization. The panel was asked to consider workforce-related initiatives that AoA could carry out independently, as well as those it might do in partnership with federal and state agencies, national associations, labor unions, and other organizations. Panelists were cognizant that some long-standing and seemingly intractable workforce issues, such as low wages and the lack of health insurance for direct care workers, were not under AoA's authority or control. However, the panel did consider the extent to which AoA and the Aging Network could use their stature and experience in the long-term-care arena to explore the development of new workforce initiatives.
The expert panel was asked to address five areas of concern: 1) the supply of DCWs and family caregivers, 2) the retention of these helpers, 3) the readiness or capacity of these helpers to provide care, 4) the quality of care they provide in terms of outcomes for those in their care, and 5) the impact of the Patient Protection and Affordable Care Act, including the CLASS Act, on DCWs and family caregivers. The panel was also asked to reflect on some of the challenges regarding defining DCWs and the blurring between DCWs and family caregivers when the latter are paid to provide care to their impaired relatives.
The Panel's Work
Eleven panelists, selected in consultation with AoA staff, attended meetings of the panel with Benjamin Rose and AoA staff and/or submitted written recommendations. In advance of the first meeting, members were sent informational materials and a matrix laying out potential areas for new initiatives to strengthen the workforce. The purpose was to generate preliminary thoughts about how education and training initiatives, new or amended public policies, AoA program initiatives and demonstrations, labor pools, and potential partnerships could strengthen the supply, retention, readiness, and quality of care the workforce provides.
When the first meeting in February 2010 was canceled due to inclement weather, panel members were sent an expanded matrix and asked to submit written comments and recommendations. These were compiled by Benjamin Rose staff and distributed along with a summary document in advance of the rescheduled meeting, which was held in March 2010 in conjunction with the ASA/NCOA Aging in America conference. The discussion of the 12 persons in attendance at this meeting, including AoA and Benjamin Rose staff, was audio-taped and subsequently transcribed, analyzed, and compiled into a report incorporating all of the participants' comments and suggested approaches to date. A second meeting was held in April in Washington , DC , with 15 participants, several of whom had not been able to attend the March meeting. The discussion at this meeting was also audio-taped, transcribed, analyzed, and integrated with previous findings. The results of all the panel's deliberations are included in this report.
Challenges Defining DCWs and Paid Family Caregivers
The panel was confronted with several challenges, including different perspectives on which types of workers are included in the direct-care workforce. This challenge exists because there is little consistency or consensus across the states on the nomenclature used for classes of direct-care workers. For example, personal care attendant is a term used in federal classifications but with many different meanings across the states, where such workers may be designated as a mental health aide, respite worker, or a service aide (U.S. Department of Health and Human Services, 2004). Other nomenclatures for direct-care workers include nurse aides, orderlies and attendants; home health aides; and personal and home care aides (Harmuth & Dyson, 2005). Nursing aides are also known as nurse aides, nursing assistants, certified nursing assistants, geriatric aides, unlicensed assistive personnel, orderlies, or hospital attendants, according to the Bureau of Labor Statistics, which considers home health aides and personal/home care aides (the latter are also called homemakers, caregivers, companions, and personal attendants) to be separate occupations (U.S. Department of Labor, 2010). For these reasons, panelists had to clarify when their recommendations pertained to specific types of DCWs, such as home care workers as distinct from certified nursing assistants.
A further complication was that distinctions between family caregivers and direct-care workers have become blurred; for example, family members can become paid helpers under consumer-directed care programs and some family members perform functions that were formerly the sole responsibility of professional providers. Furthermore, a Rosalynn Carter Institute caregiver study indicates that 31% of DCWs also have family care responsibilities and function as caregivers both at work and at home (Nottingham, Haigler, Smith, & Davis, 1993). In addition, there have been attempts to enlarge the direct-care workforce by engaging former family caregivers in paid employment as direct-care workers (U.S. Department of Health and Human Services, 2009). In brief, the complexities and subtleties of caregiver designations pose challenges for their identification and categorization, which have implications when considering various strategies to enhance their recruitment, retention, training, and quality.
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