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

Background

The care provided in long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ) settings is only as good as the personnel who provide it. Workforce challenges are prevalent in the LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. industry. They 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 insufficient bilingual workers and workers sensitive to different cultures are all serious problems. The hiring of workers who have committed abuse or have criminal backgrounds is also a problem.

Education and training for direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing.: The direct service workforce includes many in LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. settings with various job titles. Among these are certified nursing assistants (CNAs), Home Health Aides (HHAs), Direct Support Professionals, personal care workers, and peer support professionals. CNAs (who generally work in nursing facilities) and HHAs (who are employed by MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant).-certified home health agencies) are required by federal law to have at least 75 hours of training, pass a competency evaluation, or both. This is required when they provide personal care and some clinical care under the direction of nurses or other licensed medical staff.

At least 16 hours of this training must be hands-on clinical care a registered nurse’s supervision. An additional 12 annual in-service continuing education training hours are also required. Some states require CNA training beyond the federal requirements. In some states, CNAs can receive additional training to become qualified medication aides (see also Health Care Workforce Financing, Education, and Training).

Personal care workers, who provide help with activities of daily livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding. and instrumental activities of daily livingSkills necessary for daily care of oneself such as bathing and showering, personal hygiene and grooming, toilet hygiene and self-feeding., cannot by law provide the clinical care that CNAs and HHAs provide. These workers are personal-assistance workers, home-care A range of services provided in the home, including health care, personal care, and supportive services. aides, and personal care attendants. They include independent providers, people hired through agencies, and family members who provide services in participant-directed programs. Unlike agency workers, independent providers are hired, screened, trained, and supervised by consumers.

The National Direct-Care Workforce Resource Center centralized online library on the direct service workforce, hosted and relaunched by PHI International in May 2020, has resources related to workforce development including a set of core competencies developed under the guidance of the Centers for MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). & MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. Services. Having a competent direct service workforce will improve the quality of care and the quality of life for individuals who need LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. .

Private providers often provide the bulk of the training that LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers receive. It is rare for the training provided by one employer to be recognized by another employer. Thus, workers changing jobs or going to work in a different setting typically have to be re-trained. If some required training could be standardized, tracked, verified, and accepted across employers, it would be portable. This would reduce the overall cost of training that providers bear. And it would make it easier for workers to continue working in the field even if they have to leave their existing employer.

Gerontological/geriatric nurse practitionersRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. (GNPsRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. ): Research demonstrates that GNPsRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. improve the quality of care for older people across health care settings. Care provided by Advance Practice Registered Nurses, such as GNPsRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. , results in fewer falls, fewer hospital admissions and readmissions, and higher patient, family, and physician satisfaction. GNPsRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. 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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. settings.

Worker recruitment, retention, and shortages: All LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers are in short supply, including registered nurses, licensed practical nurses, and direct service workers, such as HHAs, personal care attendants, and CNAs. These shortages are cause for serious concern.

Direct service workers provide most paid LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. . Yet, people who can afford home-care A range of services provided in the home, including health care, personal care, and supportive services. services often have difficulty locating competent, trained people to do the job. Wages are low. And benefits, such as sickness and vacation pay, are often not provided. In 2019, the median hourly wage for HHAs was $12.15. Low wages (and few benefits) contribute to high staff turnover and low-quality care.

Historically, federal regulations excluded home-care A range of services provided in the home, including health care, personal care, and supportive services. 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 took effect in 2015) that covers most home-care A range of services provided in the home, including health care, personal care, and supportive services. workers under the FLSA’s minimum wage and overtime provisions. This was an essential step in recognizing the value of these workers in helping older adults and people with disabilities to continue living independently in their own homes.

Broadening the scope of clinical responsibilities may help attract and retain direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing.. 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 addressing access-to-care issues caused by personnel shortages (see also Health Care Workforce).

Registries and criminal background checks: A comprehensive background check system would review entries in all pertinent registries (e.g., sex offenders, state criminal databases) and the Federal Bureau of Investigation’s national repository of criminal history records.

All states are required to have registries that list nurse aides who meet certain requirements for working in nursing facilities. One requirement is that they must not have a substantiated finding of abuse, neglect, or misappropriation of property. Some states have expanded their registries to include other direct service workers. This includes medication aides, HHAs, and direct support professionals who assist individuals with intellectual and other developmental disabilities. No national registry of workers with serious criminal histories and records of abuse, neglect, and theft exists. As a result, workers with such a history in one state can travel to another state to apply for employment.

Although the federal government does not require criminal background checks of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers, an increasing number of states do. Certain states require statewide or national criminal background checks for 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 Department of Health and Human Services Office of the Inspector General (OIG) 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 exemptionIncome that is excluded from taxation. clause for workers hired directly by consumers.

In 2014, OIG published an evaluation of state requirements for conducting background checks on HHA employees. It found that 41 states required HHAs to conduct background checks on prospective employees. Thirty-five states specified convictions that disqualified individuals from employment, and 16 states allowed individuals who had been disqualified from employment to apply to have their convictions waived.

ADEQUATE AND WELL-TRAINED WORKFORCE FOR LONG-TERM SERVICES AND SUPPORTS: Policy

ADEQUATE AND WELL-TRAINED WORKFORCE FOR LONG-TERM SERVICES AND SUPPORTS: Policy

Education and training

Funds should be provided for education and training for long-term services and supportsLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. (LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. ) 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.

States should provide training in caring for people with dementia. Training in personal assistance should also be provided for all direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing. in nursing facilities and assisted living residences and staff employed by home-care A range of services provided in the home, including health care, personal care, and supportive services.  agencies. All direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing. should receive this training.

Required training should include behavioral management; handling of medications; cultural sensitivity; promotion of residents’ independence, dignity, autonomy, and privacy; and recognition and reporting of abuse and neglect.

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

Schools should be encouraged to include LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. -related specializations in the curricula for nurses and physicians.

All state Nurse Practice Acts should allow registered nurses to delegate certain nursing tasks to direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing. in home-care A range of services provided in the home, including health care, personal care, and supportive services. settings to help ease the burden on family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. All states should require in statute or regulation adequate training and careful supervision of staff performing delegated tasks. Statutes and regulations must follow the state’s Nurse Practice Act guidelines for delegation by registered nurses and must provide adequate consumer protections and appropriate liability protections for nurses.

States should establish competency-based training requirements for personal care workers hired by agencies to work in home and community-based settings. However, when requested by the program participant, states may allow exceptions for family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. and independent providers when hired through participant direction programs. Competency, established by state standards, must be demonstrated. The core training competencies needed by personal care workers—those who are agency-hired as well as those hired by consumers—should be evaluated in state demonstrations. The means by which such competency-based training is provided also should be evaluated.

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

States should require providers to furnish training in infection prevention and control for all direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing. in nursing facilities, assisted living residences and other residential care settings, and those employed by home-care A range of services provided in the home, including health care, personal care, and supportive services. agencies.

In participant-directed programs, participants should be allowed to train their workers and hire workers who meet qualifications based on the participants’ needs and preferences. Each person’s needs are highly individualized. 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.

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 services.

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 A range of services provided in the home, including health care, personal care, and supportive services. agencies and community care providers to be responsible for regular training, supervision, and documented performance evaluations of aides and other workers.

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

Gerontological/geriatric nurse practitioners (GNPs) and other Advanced Practice Registered Nurses (APRNs)

Policymakers should remove barriers to the effective use of APRNsAPRNs are RNs with advanced education and clinical preparation (e.g., a master’s degree, or a doctorate in nursing practice.) They include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives., such as GNPsRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. , in all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. settings. APRNsAPRNs are RNs with advanced education and clinical preparation (e.g., a master’s degree, or a doctorate in nursing practice.) They include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. should be permitted to certify people for home health and hospice services and should be eligible to perform the admission physical for nursing facilities. Arbitrary restrictions on APRN care, such as not permitting nurse practitionersAdvanced practice RNs provide a wide range of healthcare services. NPs often specialize by patient population, such as adult, geriatric, pediatric, and women’s health. They may also subspecialize in clinical areas such as oncology and dermatology. to serve as medical directors of nursing facilities, should be removed.

MedicareMedicare is the federal health insurance program for people who are age 65 or older, certain younger people with disabilities, and people with End-Stage Renal Disease (ESRD), (permanent kidney failure requiring dialysis or a transplant). and MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. should directly reimburse APRNsAPRNs are RNs with advanced education and clinical preparation (e.g., a master’s degree, or a doctorate in nursing practice.) They include nurse practitioners, clinical nurse specialists, nurse anesthetists, and nurse midwives. for their services in all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. settings.

GNPsRNs with specialized education in the diagnosis, treatment, and management of the acute and chronic conditions of older adults. should receive stronger financial and professional incentives to enter the LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. field.

Qualified LTSS workers

Federal and state governments must ensure that MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. and other public program reimbursements are sufficient to pay wages and benefits that will attract and retain LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers. During a public health emergency, LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. staff who do not already have sick leave should be granted it.

Federal and state governments should support programs to increase the supply of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. care personnel with geriatric training.

Policymakers should improve labor standards for the direct-care workforce, including home-care A range of services provided in the home, including health care, personal care, and supportive services. and home health aidesLabor standards address minimum wage and overtime pay protections, meal breaks, sleep time, and time off. So as not to place an undue burden on LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. consumers and family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. , these standards must be appropriately tailored to address the realities of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. provision. It should be taken into consideration that services are provided in private homes. Services are often arranged by a family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. living in another home or another city. And services are provided under different models, including participant-directed models that allow family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. to be paid. In addition, individuals who receive the care have either physical, mental, or cognitive impairments or some combination of the three.

Federal and state governments should support payment reform. Adequate health and retirement benefits, educational opportunities, and career ladders to encourage recruitment and retention of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers should be provided.

States that do not allow nurse delegation should work with state nursing associations and regulatory agencies to allow nurses to delegate and teach certain health-related tasks to direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing. and family caregivers People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. Nurses must ensure that the direct-care worker or family caregiver People who provide long-term services and supports to family members, relatives, friends, and neighbors. Some family caregivers are unpaid; others are paid through government programs, private funds, or long-term care insurance policies. 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.

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

MedicaidA joint federal/state program that provides health care and LTSS. However, to qualify for Medicaid LTSS, people must have extremely low assets and income, or they have to “spend down” most of their assets. 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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. funding) or other mechanisms to increase compensation for direct-care workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing..

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

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 LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers.

State governments should offer incentives for providers to hire bilingual workers as necessary to assist non-English-speaking consumers. All staff should be trained 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.

Direct-care workers

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 workersCertified nursing assistants, home health aides, personal care aides, and personal assistants, who provide hands-on help with daily activities such as bathing and dressing. commensurate with their demonstrated competency to take on additional roles with greater compensation;
  • requiring adequate staffing;
  • providing adequate salaries and benefits;
  • implementing consistent assignments;
  • encouraging worker participation in person-centered planning;
  • 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.

Criminal background checks and national registries to protect consumers

Policymakers should require a comprehensive national background check prior to employment for all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers. Individuals who have been convicted of burglary, larceny, sexual crimes, violent crimes, or crimes involving abuse or neglect of vulnerable individuals should be prohibited from employment in all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. settings.

Although people in participant-directed programs may request background checks, they should not be required for parents, spouses, partners, close relatives, or close friends when hired through participant-directed programs.

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

The federal government should create a national registry of CNAs, home health aides (HHAs), and unlicensed LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers in assisted living and other residential care settings. The registry should document training, list references, and delete any individual with a substantiated history of abuse, neglect, misappropriation of individual property, and other criminal conduct.

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

In the absence of a national registry of LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting. workers, states should ensure that ombudsmen have access to any state registries of CNAs and HHAs.

Policymakers should require nationwide criminal background checks prior to employment for all LTSSLTSS encompasses a broad range of assistance with activities of daily living and health-related tasks for people with functional limitations caused by physical or mental impairments. LTSS may be delivered in institutions or in a person’s home or a residential care setting.  workers.