Creating an Adequate, Well-Trained Workforce for Long-Term Services and Supports


The care provided in long-term services and supports (LTSS) settings is only as good as the personnel who provide it. Indeed, workforce challenges abound in the LTSS industry and need to be addressed swiftly if the nation is to respond to the growing need for high-quality care. Lack of staff, inadequate training, and an insufficient number of bilingual workers and workers sensitive to different cultures are all serious problems. So are workers who have committed abuse or have criminal backgrounds.

Registries—all states are required to have registries with information on nurse aides eligible to work in nursing facilities. Some states have expanded their registries to include other direct service workers, including medication aides, home health aides, and developmental disability aides.

Criminal background checks—because no national registry of abusive workers exists, people who have a record of abuse or serious crimes in one state can simply travel to another state to find work. They can also move from working in nursing facilities to home health agencies or supportive housing without ever undergoing a criminal background check.

Although the federal government does not require criminal background checks of LTSS workers, increasing numbers of states do. Certain states require statewide or national criminal background checks for certified nursing assistants (CNAs) and assisted living staff. In addition states that require statewide criminal background checks may also mandate a national background check under certain circumstances, such as when applicants have recently relocated from other states. Some states bar employment if certain offenses are found. A 2011 study by the US Health and Human Services Office of the Inspector General reported that 43 states required nursing facilities to conduct a Federal Bureau of Investigation (FBI) or a statewide criminal background check on prospective employees; ten required FBI and statewide checks. State laws vary considerably in terms of who is screened and exempted, what convictions preclude employment and for how long, what provisional employment is permitted while checks are conducted, and who pays for screening. Some state laws have an exemption clause for workers hired directly by the care recipient.

Worker retention and vacancies—many types of qualified LTSS workers are in short supply; notably, registered nurses, licensed practical nurses), and direct service workers, such as home health aides, personal care attendants, and CNAs. These shortages are cause for serious concern (see this chapter’s section Quality and Consumers’ Rights Across Settings—Nursing Facilities and Other Settings).

Direct service workers provide most paid LTSS, yet people who can afford home-care services often have difficulty locating competent, trained people to do the job. In 2015 the median hourly wage for home health aides was $10.54. Low wages (and few benefits) contribute to high staff turnover and low-quality care. Historically, federal regulations excluded home-care workers from the minimum wage and overtime protections mandated by the Fair Labor Standards Act (FLSA). However, in 2013, the Department of Labor promulgated a rule that covers most home care workers under the FLSA’s minimum wage and overtime provisions—an important step in recognizing the value of these workers in helping older adults and people with disabilities to continue living independently in their own homes.

In addition, broadening the scope of clinical responsibilities may help attract and retain direct-care workers. Finding ways for all professionals to provide services to the full extent of their current training, experience, and skills could go a long way toward easing access-to-care issues caused by personnel shortages (see Chapter 7, Health for information on scope of practice).

Training for direct-care workers—home health aides (HHAs) in Medicare and Medicaid provide personal care and some clinical care under the direction of nurses or other licensed medical staff. CNAs, who generally work in long-term care facilities, and home health aides, who are employed by Medicare-certified home health agencies, are required by federal law to have at least 75 hours of training and/or pass a competency exam. At least 16 hours of this training must be “hands-on clinical care” under the supervision of a registered nurse (see Chapter 7, Health: Workforce and Education: Financing, Education, and Training for additional information and policies on training).

Personal care workers, who provide help with activities of daily livingActivities of daily living (ADLs) include: bathing or showering, dressing, getting in and out of bed or a chair, walking, using the toilet, and eating. and instrumental activities ofIADLs include preparing meals, managing money, shopping for groceries or personal items, performing light or heavy housework, and using a telephone. daily living, cannot by law provide the clinical care that CNAs and HHAs provide. These workers (also called personal assistance workers, home-care aides, and personal care attendants) include independent providers, people hired through agencies, and family members who provide services in participant-directed programs. Unlike agency workers, individual providers are hired, screened, trained, and supervised by consumers (see this chapter’s section Creating a Participant-Directed Long-Term Services and Supports System for more about participant-directed programs).

At the federal level, the CMS National Direct Service Workforce Resource Center developed a set of core competencies for the direct service workforce. These core competencies can help states develop a more comprehensive and standardized approach to training and performance improvement practices. Having a competent direct service workforce will improve the quality of life for care recipients.

Gerontological/geriatric nurse practitioners (GNPs)—evidence consistently shows that GNPs improve the quality of care for older people across health care settings. Care provided by advanced practice registered nurses (APRNs), such as GNPs, results in fewer falls, fewer hospital admissions and readmissions, and higher patient, family, and physician satisfaction. GNPs excel in chronic-care management and care transitions. They diagnose and treat a wide range of health problems and serve as advocates and role models for nursing staff in all LTSS. This group should receive stronger financial and professional incentives to enter the LTSS field.

Creating an Adequate, Well-Trained Workforce for Long-Term Services and Supports: Policy

Qualified workers

In this policy: FederalState

Federal and state governments should support programs to increase the supply of health care personnel with geriatric training.

States should work with state nursing associations and regulatory agencies to allow nurses to delegate and teach certain health-related tasks to direct-care workers and family caregivers. Nurses must ensure that the direct-care worker or family caregiver demonstrates competency to perform the specific task for that consumer. State nurse practice acts should provide adequate consumer protections including appropriate follow-up and appropriate liability protections for nurses.


In this policy: FederalState

Federal and state governments must ensure that Medicaid and other public reimbursements, as well as reimbursements paid by private contractors with government agencies (such as Medicaid-managed care plans), are sufficient to pay wages that will attract and retain long-term services and supports (LTSS) workers.

Living wages and salaries should be commensurate with others in the region and with the time, skill, and effort required to render high-quality services and supports.

Medicaid reimbursement rates should be rebased and updated regularly to take into account relevant economic and financial information, including provider costs.

Federal and state governments should require pass throughs (i.e., using additional LTSS funding) or other mechanisms to increase compensation for direct-care workers.

There should be adequate accountability procedures, such as audits, to ensure that reimbursement increases designated for staffing costs are used for that purpose.

Employee benefits

In this policy: FederalState

Federal and state governments should support payment reform and the provision of adequate health and retirement benefits, educational opportunities, and career ladders to encourage recruitment and retention of LTSS workers.

Identifying workforce shortages

In this policy: FederalState

Federal and state governments should document the shortage of workers and their training needs, and support research to identify effective ways to address these problems.

The federal government should offer matching funds or incentives and technical expertise to help states collect data and annually assess the supply and competency of LTSS workers.

Education and training

In this policy: FederalState

Funds should be provided for education and training for LTSS workers, especially those in short supply, such as certified nursing assistants.

Federal and state governments should encourage education and training programs to require gerontology courses and practical experience for all appropriate health professions.

Schools should be encouraged to include LTSS-related specializations in the curricula for nurses and physicians.

States should establish competency-based training requirements for personal care workers in home- and community-based settings hired through agencies. However, when requested by the beneficiary, states may allow exceptions for family caregivers and other nonagency providers when hired through self-directed programs—as long as competency, established by state standards, is demonstrated.

Workers who are paid to provide care in home and community settings should meet state-established competency-based training requirements, be evaluated for competency, undergo a period of probationary supervision, and fulfill annual continuing education requirements.

Training and certification

In this policy: State

The core training competencies needed by personal care workers—those who are agency-hired as well as those hired by consumers—and the means by which such competency-based training should be provided, should be evaluated in state demonstrations.

State-approved training and certification should be competency-based and include a core curriculum covering the needs of people who require LTSS.

Training should include both classroom instruction and practical experience, such as simulations and real-person or clinical training.

Training should include the concept of participant-directed care.

Training should also convey the interpersonal aspect of culture change, teaching the personal rewards and positive outcomes associated with culture change.

States should require home-care agencies and community care providers to be responsible for regular training, supervision, and documented performance evaluations of aides and other workers.

Quality assurance measures must include participant preferences and satisfaction as key quality measures and should evaluate whether a participant is receiving all the services in his service plan and whether there are unmet needs.

Goals of state training programs

In this policy: State

Training should be completed before staff begins working independently with consumers.

Training and continuing education also should focus on maximizing quality of care while supporting the independence, autonomy, dignity, and privacy of consumers.

States should provide training in dealing with dementia and in personal assistance for all direct-care workers in nursing facilities and assisted living residences, and for staff employed by home-care agencies.

In participant-directed programs, states should be required to allow participants to train their workers, and participants should retain the right to hire workers who meet qualifications based on the participants’ needs and preferences. Each person’s needs are highly individualized, and a standardized training curriculum may not address the specific needs of a particular individual. However, states should make available training opportunities for those participants who prefer that their workers receive standardized training.

Criminal background checks

In this policy: FederalState

Policymakers should require nationwide criminal background checks prior to employment on all workers who provide LTSS or who are employed in LTSS settings. Although people in self-directed programs may request background checks, background checks should not be required for parents, spouses, partners, close relatives, or close friends when hired through self-directed programs.

Individuals who have been convicted of burglary, larceny, violent crimes, or crimes involving abuse or neglect of vulnerable individuals should be prohibited from employment in LTSS settings.

The national background checks should be affordable and conducted in a timely manner prior to employment, and should include a fingerprint check.

States should require that providers notify appropriate state licensing or registration boards of all employees convicted of a felony, resident abuse, or having knowledge of but failing to report abuse.

After due process, the state board should consider suspending or revoking the employee’s license, registration, or certification.

National registry of LTSS workers

In this policy: FederalState

The federal government should create a national registry of certified nursing assistants and home health aides that documents training, lists references, and includes findings of abuse, neglect, misappropriation of individual property, and other criminal conduct.

The federal government should consider broadening the registry to include other unlicensed workers who provide LTSS, including staff in assisted living and other supportive housing settings.

Providers should be required to clear potential employees through the registry before hiring them.

In the absence of a national registry of LTSS workers, states should ensure that ombudsmen have access to the registry and develop a national clearinghouse for sharing information.

Bilingual workers

In this policy: State

State governments should offer incentives for providers to hire bilingual workers, when appropriate, to assist non-English-speaking consumers and train all staff to be culturally competent.

States also should establish incentives for providers to ensure that workers not proficient in English get training in English as a second language.

Recruiting and retaining direct-care workers

In this policy: FederalState

Policymakers should improve labor standards for home-care and home health aides, including minimum wage and overtime pay protections, meal breaks, sleep time, and time off. So as not to place an undue burden on LTSS consumers and family caregivers, however, these standards must be appropriately tailored to address the realities of LTSS: Services are provided in private homes, services are often arranged by a family caregiver living in another home or another city, services are provided under different models (including participant-directed models that allow family caregivers to be paid), and services are provided to individuals with physical, mental, and/or cognitive impairments.

Federal and state governments should initiate efforts to promote changes in the work environment that encourage staff recruitment and retention.

Such changes could include:

  • expanding roles for direct-care workers commensurate with their demonstrated competency to take on additional roles with greater compensation;
  • requiring adequate staffing;
  • providing adequate salaries and benefits;
  • dedicating staff to specific units;
  • encouraging workers’ participation in decisions on resident care;
  • offering training in accordance with government standards;
  • ensuring appropriate supervision and in-service training;
  • providing programs, career ladders, and educational incentives to facilitate advancement; and
  • providing day care for children of staff.

AARP supports increasing the flow of immigrants who could serve as direct-care workers.

Gerontological/Geriatric nurse practitioners (GNPs) and other APRNs in LTSS Settings

In this policy: FederalState

Policymakers should remove barriers to the effective use of advanced practice registered nurses (APRNs), such as GNPs, in all LTSS settings. APRNs should be permitted to certify people for home health and hospice services and should be eligible to perform the admission physical for skilled long-term care. Arbitrary restrictions on APRN care, such as not permitting nurse practitioners to serve as medical directors of skilled-nursing facilities, should be removed.

Current state nurse practice acts and accompanying rules should be interpreted or amended where necessary to allow APRNs to fully and independently practice as defined by their education and certification.

APRNs such as GNPs should be reimbursed directly by Medicare or Medicaid for their services in all LTSS settings.