Staffing: Post-acute care’s pain point

Low wages, demographics add up to post-acute staffing shortages

A recently released report points to a crisis in the direct care workforce, that is, nursing assistants, home care workers and residential care aides.

Long-term-care employers are struggling to recruit and retain enough workers to fill vacant positions, while existing workers are shouldering the burden of growing demand without enough resources or support, according to the report, “It’s Time to Care: A Detailed Profile of America’s Direct Care Workforce,” by Bronx, New York-based advocacy firm PHI.

Meanwhile, consumers are struggling to access the care they need, piecing together support from family and friends; waiting months or even years to receive formal services; moving into nursing homes sooner than necessary; or simply going without.

Some facts from the report:

  • Nearly 20 million adults in the United States require assistance completing self-care and other daily tasks due to physical, cognitive, developmental, and/or behavioral conditions. This number includes about 17 million individuals living in the community, 1.5 million residing in nursing homes, and nearly 1 million in residential care.
  • Individuals with personal assistance needs rely first and foremost on family members, friends, and neighbors – an estimated 43 million caregivers. But for those with limited local caregiving networks, or with more complex needs, paid direct care workers are a lifeline.
  • The direct care workforce is expanding rapidly as our population grows older, as people live longer with disabilities and chronic conditions, and as the supply of potential family caregivers dwindles. The workforce has already nearly doubled within a decade, from 2.9 million workers in 2008 to almost 4.5 million in 2018. In fact, the long-term care sector is expected to add 1.3 million direct care jobs, primarily personal care aide positions, from 2018 to 2028. That’s more new jobs than any other occupation in the U.S. economy.

Yet retaining qualified people in all those positions is challenging, according to the researchers. Part of the reason is direct care workers don’t get paid much.

The median wage for all direct care workers is $12.27 per hour, according to the Bureau of Labor Statistics. Due to high rates of part-time employment as well as low wages, median annual earnings are just $20,200.

Among direct care workers, home care workers earn the least, at $11.52 per hour and $16,200 per year; residential care aides earn $12.07 per hour and $20,200 annually; and nursing assistants in nursing homes earn $13.38 per hour and $22,200 annually.

Little relief in sight

The report suggests that the need for direct care workers will only increase in the next few decades:

  • From 2016 to 2060, the number of adults in the United States aged 65 and over will nearly double, from 49.2 million to 94.7 million, and the number of those aged 85 and over will triple, from 6.4 million to 19 million. During the same period, the number of adults aged 18 to 64 is projected to increase by only 15%.
  • Population aging is significant because the need for personal assistance and formal long-term service support increase with age. More than 21% of adults in the community who are aged 85 years and above require assistance with activities of daily living, compared to 8% of those 75 to 84, just under 4% of those 65 to 74, and just 3% of those 18 to 64.
  • The caregiver support ratio (that is, the ratio of those aged 18 to 64 years old, who are most likely to provide care, to those aged 85 and above, who are most likely to need care) is projected to fall from 31 to 1 in 2016 to only 12 to 1 by 2060.

The researchers point out there are numerous ways to improve job quality and thereby build the direct care workforce, but the bottom line is, workers must be better compensated, in line with the value of their contribution. If they are not, the long-term service and support sector will continue to struggle to recruit and retain a strong workforce, especially given the fierce competition for entry-level workers across the labor market.

Editor’s note: “It’s Time to Care: A Detailed Profile of America’s Direct Care Workforce” is the first in a year-long series that will provide a current-day analysis of the direct care workforce and its role in the long-term-care system of the United States. It was made possible through support from the W. K. Kellogg Foundation and the Woodcock Foundation. To view the first report, go to