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How will long-term care workforce demand be impacted by changes in demographics and utilization patterns?
Joanne Spetz, PhD Laura Trupin, MPH Timothy Bates, MPP Janet Coffman, PhD University of California, San Francisco
This study was supported by the Health Resources and Services Administration (HRSA) of the Department of Health and Human Services (HHS) under the Cooperative Agreement for a Regional Center for Health Workforce Studies (Grant No. U81HP26494). The information or content and conclusions of this article are those of the authors and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS, or the US government.
The looming long-term care crisis
By 2030: More than 70 million people 65 years and older
• 20% of the population
By 2050: Number needing long-term care will more than double
• 8 million in 2000 to 19 million in 2050
Who will care for those with long-term care (LTC) needs?
• IOM projects 3.5 million additional workers by 2030
This study examines how changing demographics and service use might affect future LTC worker demand
3
Long-term care settings and workforce
Settings for LTC
• 25% institutions
‒ Nursing homes
‒ Assisted living
• 75% home and community based services (HCBS)
Workers
• Within institutions: mostly RNs, LPNs, CNAs
• HCBS: mostly unlicensed direct-care workers
4
Changing patterns of LTC use?
General trend toward more HCBS use
Demographics
• Growing Hispanic & Asian populations
‒ Traditionally use fewer LTC services
• Growing Black population
‒ Traditionally uses more LTC services
New programs supporting HCBS
• ACA made $4.3 billion available through multiple programs
5
Methods
1. Measure use of 4 types of LTC services by age/ethnic/gender
2. Extrapolate future use based on population projections
3. Measure employment by occupation in each LTC service sector
4. Extrapolate future worker demand by occupation using data from steps 2 & 3
(Yes, this is a giant spreadsheet exercise!)
6
Data sources: A hunting expedition
National Health and Aging Trends Survey (NHATS) 2011
• Nursing home
• Residential care (assisted living and continuing care communities)
Medical Expenditures Panel Survey (MEPS) 2009-2011
• Home health services (ratio of users/population)
National Study of Long-Term Care Providers (NSLTCP) 2013
• Adult day care center clients/population
Census Bureau: Population estimates 2010 & projections
7
Employment data
National Study of Long-Term Care Providers
• Nursing FTEs for RNs, LPNs, and nursing assistants
• Data reported for each type of setting
BLS National Employment Matrix
• Matched to settings using NAICS codes
• Combined home health aides & personal care aides
8
Jobs/FTEs in long-term care
181,527
236,109
784,006
1,345,100
328,400
250,400
173,600
131,100
128,000
123,800
0 400,000 800,000 1,200,000 1,600,000
RN (FTE)
LPN (FTE)
Nursing asst. (FTE)
HHA/PCA
Food prep/serving
Office/admin support
Building/grounds maint.
Comm & soc serv workers
Managemnet
Counselors & social workers
9
Use of services by women 75-84 years
0
200
400
600
800
1000
1200
1400
1600
1800
2000
Nursing homes Residential care Home health Adult day care
White
Black
Hispanic
Other
10
Women use nursing homes, residential care, and home health at higher rates than men.
Users of LTC service per FTE worker
0
20
40
60
80
100
120
140
160
180
Nursing homes Residential care Home health Adult day care
RN
LPN
Nursing Asst.
11
Other patterns of employment
12
Home health & personal care aides
• More in residential care, home health, adult day care
Food prep & serving, Building & grounds maintenance
• More in nursing homes & residential care
Office & administrative support, Community & social services workers, Counselors & social workers, Management
• More in adult day services
Projected job/FTE growth: 2010-2030
Occupation New jobs Growth
RN (FTE) 132,869 73%
LPN (FTE) 166,242 70%
Nursing assistants (FTE) 534,548 68%
HHA/PCA 1,188,897 88%
Food prep & serving 219,457 67%
Office & admin support 196,416 78%
Building & grounds maint. 119,715 69%
Comm & soci serv 121,700 93%
Management 99,827 78%
Counselors & soci work 116,171 94%
Total (jobs+FTE) 2,895,842 79%
13
Alternate scenarios
1. Demographic scenarios
A. Hispanics at same rates as Whites
B. Hispanics at same rates as Blacks
C. Blacks at same rates as Whites
2. LTC settings
A. Nursing home use is 10% lower, shifts to home health
B. Nursing home use is 20% lower, shifts to home health
C. Nursing home is 10% lower, shifts to residential care
14
Demographic scenarios
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Total RN LPN Nursing asst
Baseline
Hispanic=>White
Hispanic=>Black
Black=>White
15
Demographic scenarios
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HHA/PCA Food prep/serv Maintenance
Baseline
Hispanic=>White
Hispanic=>Black
Black=>White
16
Demographic scenarios
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Office/admin Management Comm/socserv
Counselor/socwrk
Baseline
Hispanic=>White
Hispanic=>Black
Black=>White
17
Utilization scenarios
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Total RN LPN Nursing asst
Baseline
10% NH=>HH
20% NH=>HH
10% NH=> RC
18
Utilization scenarios
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
HHA/PCA Food prep/serv Maintenance
Baseline
10% NH=>HH
20% NH=>HH
10% NH=> RC
19
Utilization scenarios
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Office/admin Management Comm/socserv
Counselor/socwrk
Baseline
10% NH=>HH
20% NH=>HH
10% NH=> RC
20
Limitations
Not a microsimulation model
• Not a dynamic model
Only considered older population
• Young adults and children are 1/3 of LTC population
Some services are not measured
• Unlicensed home health agencies
Could not disaggregate Asians & “other” ethnic groups
Had to estimate some age-gender-ethnicity cells
21
Policy implications
Demographic change could affect job growth for specific occupations, but overall job growth for LTC doesn’t change much
Greater use of home health (and less of nursing homes) will have small effects unless the shift in setting is large
Expansions of HCBS will be needed – ACA investments are not enough
Need to consider:
• Training requirements for PCAs and HHAs
• Strategies to reduce turnover
• Making sure these are not poverty-level jobs
22