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News and Press: News & Views

How Can America Create the Home Care Workforce to Meet Growing Needs?

Monday, June 17, 2019   (0 Comments)

Courtesy of the National Association for Home Care & Hospice

Over two million people in the United States work as personal care aides and another 800,000 work as home health aides, both occupations among the fastest-growing in America and anticipated to grow more than 40 percent between 2016 and 2026.

Most long-term care services involve assistance with personal care – things like preparing food, cleaning the home, taking medications, bathing, dressing, grooming, and toileting – and is provided by family or paid personal care aides. Almost two-thirds of personal care aides are paid directly by the patient and/or family, with the rest funded by public programs like Medicaid or a combination of public and personal money.

As America continues to age and the “silver tsunami” (10,000 people turning 65 every day) brings demographic challenges we have never faced before, building a large, durable, reliable, and affordable workforce to care for the nation’s elderly will become more important than ever. However, there are some troubling problems we face in building that workforce, as a new Health Affairs article explored in the June 2019 issue.


One of the top challenges to building the home-and-community-based care workforce of the future is in recruitment and retention of employees. In 2017, the median turnover rate for home health aides and personal aides was almost 67 percent, mostly due to the nature of the work, compensation, poor supervision, lack of career mobility and the ability to advance, and inconsistent or insufficient work.

Researchers found that more consistent assignments lead to less turnover, while poor supervision and lack of employee autonomy increases turnover. Aides who worked part time, but wanted to work more hours were up to three times more likely to leave their jobs than those who believed their hours were “about right.”

While problems with compensation and the low value accorded to the work done by home care aides by much of society are major challenges, another is uncertainty over immigration policy. An estimated 20 percent of home care workers are foreign born, though that percentage is much higher in larger metropolitan areas. There is no data on the percentage of home care workers who are undocumented immigrants, but recent studies estimate it at less than five percent.

Anecdotes from agencies around the country lead the researchers to conclude that uncertainty with immigration policy is making it more difficult to recruit foreign born workers and that if the uncertainty continues this problem will also continue and, most likely, worsen.


“Because many of the services delivered by this workforce are funded through Medicaid and Medicare, policy makers need to recognize the role that reimbursement rates play in compensating home health and personal care aides,” reads the article. “Reimbursement simply needs to be adequate to pay this workforce more than a minimum wage.”

This is a critical point and one made by the National Association for Home Care & Hospice (NAHC) on many occasions. Wages are often low for home care aides because reimbursement from Medicaid, Medicare, and Medicare Advantage is often so low. Many agencies operate on razor-thin margins and often take Medicaid patients at cost or even at a loss. One important way to make the job of home care aide more attractive and boost recruitment and retention would be to raise reimbursement rates, thus allowing employers to increase pay and attract (and keep) the best possible workforce.

Unfortunately, as documented by the Government Accountability Office in 2017, there is very little good information on the home care workforce, thus making it difficult to craft the best policies to grow that workforce to the size it will very soon need to be. State and federal policymakers need to prioritize the gathering of better data to inform their policymaking.

The article concludes by noting that “it is clear that programs and policies are urgently needed to reduce high turnover rates, increase the economic viability of home care employment, support personal care aides and families in providing client-centered care, and provide opportunities for professional advancement of personal care aides.

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