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. Workforce challenges, including recruitment and retention of LTSS workers, are prevalent in the LTSS 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 workers: The direct service workforce includes many in LTSS 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 Medicare-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 under 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 for additional information and policies on training). 

Personal care workers, who provide help with activities of daily living and instrumental activities of daily living, cannot by law provide the clinical care that CNAs and HHAs provide. These workers are personal-assistance workers, home-care 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 Medicare & Medicaid Services. A competent direct service workforce will improve the quality of care and the quality of life for individuals who need LTSS. 

Private providers often provide the bulk of the training that LTSS 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 practitioners (GNPs): Research demonstrates that GNPs improve the quality of care for older people across health care settings. Care provided by Advance Practice Registered Nurses, 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 settings. 

Worker recruitment, retention, and shortages: All LTSS 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 LTSS. Yet, people who can afford home-care 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 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 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 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 addressing access-to-care issues caused by personnel shortages (see also Health for information on scope of practice). 

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 LTSS 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 exemption 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. 



Education and training

Funds should be provided for education and training for long-term services and supports (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. 

States should provide direct-care workers across all LTSS settings competency-based training, including but not limited to: 

  • specialized training in providing services for older adults, people with dementia, and people with different types of disabilities; 
  • training in person-centered approaches that are responsive to individual needs, preferences, cultural and religious practices; and 
  • training in infection prevention and control. 

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 include LTSS-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 workers in home-care settings to help ease the burden on family caregivers. All states should require, by 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. They 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 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. 

In participant-directed programs, participants should be allowed to train their workers and hire workers who meet qualifications based on 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 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 and other Advanced Practice Registered Nurses (APRNs)

Policymakers should remove barriers to the effective use and hiring of APRNs, such as nurse practitioners, in all LTSS settings. APRNs should be permitted to certify people for hospice services and provide clinical care. They should be eligible to perform the admission physical for nursing facilities. Arbitrary restrictions on APRN care, such as not permitting nurse practitioners to serve as medical directors of nursing facilities, should be removed. 

Nursing homes should also hire qualified, licensed clinical social workers to support the psychosocial needs of residents. 

Medicare and Medicaid should directly reimburse all these providers for their services in all LTSS settings. 

Gerontological/geriatric nurse practitioners should receive stronger financial and professional incentives to enter the LTSS field. 

Qualified LTSS workers

Federal and state governments must ensure that Medicaid and other public program reimbursements are sufficient to pay wages and benefits that will attract and retain LTSS workers. During a public health emergency, LTSS staff who do not already have sick leave should be granted it. 

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

Policymakers should improve labor standards for the direct-care workforce, including home-care and home health aides. Labor standards should address 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, these standards must be appropriately tailored to address the realities of LTSS provision. It should be taken into consideration that services are provided in private homes. Services are often arranged by a family caregiver living in another home or another city. And services are provided under different models, including participant-directed models that allow family caregivers 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 LTSS 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 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. 

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. 

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. 

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. 

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 workers 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 LTSS 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 LTSS 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 LTSS 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 LTSS 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 LTSS workers.