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Correspondence: Address correspondence to Rhonda J. V. Montgomery, Helen Bader School of Social Welfare, University of Wisconsin–Milwaukee, Milwaukee, WI 53201. E-mail: rm{at}uwm.edu
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Abstract |
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Key Words: Long-term care • Community-based care • Long-term-care workforce
In order for planners and policy makers to identify and effectively implement strategies to increase the recruitment and retention of direct care workers, particularly home care aides, it is important to establish a clear understanding of the size and characteristics of the current workforce. Detailed descriptive information about the long-term-care workforce is essential for targeting possible intervention programs. For example, knowledge of the demographic characteristics of workers may help define the target population for future recruitment efforts. Similarly, knowledge of job characteristics, such as types of employers and differential pay scales, may provide clues to strategies potentially useful to attract and retain workers in specific care environments.
The goal of our study was to provide an accurate profile of direct care aides by identifying a representative sample of workers, using the 5% Public Use Microdata Sample (PUMS) data from the 2000 Census (U.S. Census Bureau, 2003). This data set includes a large sample size (more than 14 million persons) and detailed industry and occupation codes. Numerous state and federal programs are currently underway to increase the capacity of the long-term-care workforce (Harmuth & Dyson, 2002). With these programs in mind, our ultimate goal was to provide a detailed description of long-term-care workers to facilitate the continued development of programs designed to enhance recruitment and retention of these workers to meet the increasing demands of future years.
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Methods |
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The criteria we used for creating the study sample are shown in Table 1. This table enumerates the combination of industries and occupations that we used to identify the long-term-care workforce. It is necessary to consider industries and occupations simultaneously, because some industries include occupations that we did not consider to be part of the direct care workforce (such as cooks who work in nursing care facilities). Similarly, there are occupations that may include workers who are employed in an industry that does not provide long-term-care services. For example, home health aides may work in the vocational rehabilitation services sector, which does not provide long-term-care services. The rows in Table 1 show the industries and the corresponding 2000 Census codes that we used in building the data set from the PUMS file. The columns show the occupation type along with the associated census codes. The cells of the table, therefore, contain the numbers of workers who fall into each combination of industry and occupation.
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As with occupations, the industry codes used in the 2000 PUMS are somewhat more detailed than those included in previous surveys and censuses. The industries that we used in our identification of the long-term-care workforce include the following: private households (929); hospitals (819); nursing care facilities (827); residential care facilities, without nursing (829); outpatient care centers (809); home health care services (817); and individual and family services (837). A significant difference in our sample from previous studies is the inclusion of private households. The hospital category combines several types of hospitals, including general medical and surgical hospitals; psychiatric and substance abuse hospitals; and specialty (except psychiatric and substance abuse) hospitals. Nursing care facilities include residential mental retardation, mental health, and substance abuse facilities; community care facilities for elderly persons; and other residential care facilities. Individual and family services are primarily composed of services for elderly persons and persons with disabilities.
Using these criteria, we identified 40,612 home care aides, which translates to a population estimate of 789,149 workers (using weights from the file). This is substantially more home care aides than were identified in previous studies. In addition, we identified 30,500 hospital aides and 51,703 nursing home aides. Using our selection criteria, we identified fewer hospital aides and fewer nursing home aides than in previous studies (e.g., Crown et al., 1995; Yamada, 2002). The increase in the estimate of home care aides is primarily due to the inclusion of aides working in private homes and those employed by home care agencies. In contrast, the lower numbers estimated for hospital and nursing home aides were due to our ability to exclude occupational therapist assistants and aides, physical therapist assistants and aides, medical and other health care support occupations, and ambulance drivers and attendants.
A final consideration for sample selection is whether to include only individuals currently employed in the long-term-care workforce or to select all experienced workers (i.e., persons who had worked within the previous 5 years). Because the goal of the present study was to establish a clear understanding of the size and characteristics of the current workforce, we selected only current workers (i.e., those employed during 1999). Thus, it is important to note that the present sample represents the realized demand for the long-term-care workforce, not the actual supply of potential workers.
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Results |
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The proportion of married workers is approximately the same across all three industries. The major difference occurs in the proportion of widowed and divorced or separated workers. These workers are more likely to be employed as home care workers. Nursing home and home care aides have lower levels of educational attainment than hospital aides. Although the majority of workers in all three settings have completed high school, almost 20% of hospital aides have less than a high school education and almost one third of the aides working in nursing homes or home care have not completed high school. To a large degree, the educational level of this workforce is reflected in the employment and income patterns reported in Table 3.
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Type of Employment
The PUMS–Census data include useful information about the level of workers' labor force participation. The 2000 PUMS–Census classifies individuals according to whether (a) they worked at all from 1995 to 2000, (b) they worked at all in 1999, or (c) they worked year round, full time in 1999. Table 3 provides information about patterns of labor force participation for hospital aides, nursing home aides, and home care aides in 1999. Hospital aides and nursing home aides were very similar in their levels of participation, with approximately half of these individuals working year round, full time. In contrast, home care aides were much more likely to have worked only part of the year, either on a full-time or part-time basis. Only one third (34.3%) of home care workers worked year round, full time in 1999. This difference in employment pattern is also reflected in the average number of weeks worked in 1999 and in the average number of hours worked per week. As a group, home care workers averaged both fewer weeks of employment and fewer hours of employment per week than did hospital or nursing home aides.
With respect to type of employer, home care workers also differ substantially from the other two groups. Specifically, home care workers were much more likely to be self-employed (16.8%) than either hospital or nursing home aides. In contrast, hospital workers were far more likely to work for a government agency or a not-for-profit employer than were workers employed in the other two industries. The large majority of workers in all three industries were employed by for-profit companies. More than 60% of hospital and home care aides and more than 75% (three fourths) of nursing home aides were employed by the for-profit sector.
Income
The considerable disparities in hourly and total annual wages among three health care industries underscores the need to examine separately those workers employed full time, year round, and the groups of workers employed part time or part year. In terms of median hourly earnings, hospital aides fared best, followed by nursing home aides and then home care workers. This pattern is the same regardless of whether the comparison is among year-round full-time workers, or among person employed in any capacity in 1999. A different picture emerges, however, when we examine mean hourly earnings—especially when we compare year-round, full-time workers with those reporting any employment in 1999. In particular, two points are noteworthy. First, the mean hourly earnings for year-round, full-time workers in all three industries were substantially lower than those of workers employed part year or part time. This pattern, however, was not reflected in the median incomes for each group of workers, which indicates great heterogeneity of hourly incomes for direct care workers. Second, home care workers averaged as much per hour as nursing home aides among year-round, full-time workers ($9.51/hr vs $9.50/hr), but substantially more than nursing home aides among workers reporting any employment during 1999 ($13.38/hr vs $11.46/hr).
With respect to total annual wages, a slightly different pattern emerges. When we assess total annual income by using the median, the pattern is similar to that of hourly wages: hospital aides fared best, followed by nursing home aides and then home care workers. When we assess total annual income by using the mean, however, the relative standing of the three industries depends on whether the workers were in the in the labor force at all in 1999 or whether they worked year round, full time in 1999. In the former case, hospital aides fared best ($17,144), followed by nursing home aides ($13,553) and then home care workers ($11,716). In the latter case, hospital aides still fared best ($25,294), but home care aides ($22,002) had higher mean incomes than did nursing home aides ($20,430).
It is also important to note that there is a sizeable difference in annual incomes of workers associated with their level of participation in the workforce. As would be expected, full-time workers earned substantially more than part-time workers. In the case of home care workers, those working year round, full time earned twice as much as those who worked less than full time. Not surprisingly, then, the groups enduring the greatest financial hardship, with approximately 25% living below the poverty level, are home care workers and nursing home aides who worked less than full time.
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Discussion |
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Workforce Size
With respect to the size of the workforce, estimates from the PUMS–Census data indicate four times as many home care aides than could be identified by use of the criteria employed in previous studies (Crown et al., 1995; Yamada, 2002). The findings from this analysis also indicate that there are approximately 24% fewer hospital aides and 9% fewer nursing home aides than previously identified. The larger estimate of home care workers is due to the inclusion of workers employed in private households and those working for home care agencies. Both of these groups were excluded from previous studies because they could not be uniquely identified by the occupation codes used in the available data sets. The decrease in the number of hospital and nursing home aides was due to the exclusion of occupational and physical therapists and related medical assistants, who constitute groups engaged in activities that are not comparable with the work of aides employed in the nursing home or home care industries.
Workforce Composition
Findings from this study also extend our understanding of the composition of the long-term-care workforce in a number of important ways. First, there is substantial heterogeneity among long-term-care aides in age distribution. Our findings corroborate the view that home care aides are, on average, older than nursing home and hospital aides (Yamada, 2002). It is important, however, to note the sources of these differences in average age. Specifically, the proportion of home care aides under the age of 25 is relatively small when compared with that of hospital and nursing home aides, whereas the proportion of home care workers over the age of 65 is roughly triple that of the other industries. The picture that begins to emerge is one of different populations of workers, at different phases of their working careers, who are likely to be employed in their respective industries for different reasons. Any program designed to recruit and retain long-term-care workers can be made more effective by carefully targeting the intended audience and by appealing to the specific needs and motivations of the potential workers.
Second, our analyses reaffirm the fact that approximately half of the direct care workforce is non-White. The findings also highlight substantial differences with respect to ethnicity. For example, there are proportionally more African American workers in the hospital and nursing home industries and more Hispanic and Latino workers in the home care industry. Coupled with the facts that home care workers are significantly more likely to be foreign born and less likely to be U.S. citizens (Yamada, 2002), the findings suggest that home care may represent an entry-level position for new immigrants. On the one hand, this finding makes salient a population that may be targeted to effectively recruit home care workers. On the other hand, the prevalence of Hispanic and Latino workers also raises important issues of cultural competency and training (Tellis-Nayak & Tellis-Nayak, 1989), not only to increase quality of care but also to increase worker satisfaction in a manner conducive to retaining current workers.
Third, it has been noted that the long-term-care workforce, being 80% to 90% female, is much more likely to be unmarried than the general workforce (Yamada, 2002). The present study confirms this characterization and offers additional clarification. In particular, home care workers, relative to hospital and nursing home workers, are more likely to have never married, more likely to be divorced, and twice as likely to be widowed. This suggests the possibility that home care may be an attractive work option for older women (given the proportion over the age of 65) who, as a result of widowhood or divorce, must reenter the workforce to supplement their income. Careful targeting of these individuals, many of whom are experienced family caregivers, may enhance future recruitment efforts.
Fourth, it has been suggested that, on average, the education level of home care workers has been increasing (Yamada, 2002) and that almost 30% of nursing home aides and home care aides have at least some college education. What also has to be acknowledged is that a similar proportion of workers in the home care industry never finished high school. In addition, although the proportion of home care workers who never finished high school is higher than for nursing home aides, the proportion of home care workers with college or postgraduate degrees is also higher among home care workers. This heterogeneity in the home care industry suggests that, in addition to attracting low-skill workers, the industry also attracts highly educated workers who may entertain entrepreneurial hopes. Different recruitment approaches will be needed to attract these distinct populations of workers.
Type of Employment
With respect to type of employment, the present findings also present a picture of labor force participation that is somewhat different from that which emerged from previous studies. For example, Yamada (2002) noted that estimates of the proportion of home care aides working year round, full time, was much higher in the late 1990s (46%) than in the late 1980s (29%). The present findings challenge this view. The proportion of year-round, full-time home care aides from the 2000 Census is only 34%. On the one hand, strategies to make it easier or more desirable for part-time workers to move to the full-time work force may be effective. On the other hand, even if a substantial number of part-time home care workers desire full-time employment, it is clear that the home care aide workforce is a part-time workforce. Thus, recruitment and retention strategies designed merely to increase labor force participation are likely to have limited appeal. Interestingly, for the minority of home care aides who worked full time, their mean number of hours worked per week is actually much higher (46.0) than that of nursing home aides (42.0) or hospital aides (41.8). A likely reason for this discrepancy is that significant numbers of home care aides (16.8%) are self-employed, compared with nursing home and hospital aides for whom self-employment is virtually nonexistent.
Wages
Hourly wages for the sample of workers identified for this analysis are higher than those in previous estimates. For home care aides, in 1987–1989, median and mean hourly wages were estimated at $5.81 and $7.23, respectively (Crown et al., 1995). In 1997–1999, these estimates were $6.00 and $6.69, respectively (Yamada, 2002). The discrepancy between the estimates reported here and those of earlier studies is potentially due to the differences in the composition of the samples, inflation (i.e., possible price changes), and to the distinction made between full-time and part-time employment. The sample in this study contains individuals employed by agencies, and a higher proportion of self-employed workers, both of whom are likely to be paid at a higher rate. Our estimates also distinguish between workers employed year round, full time, and those employed part time. For year-round full-time workers, median and mean hourly earnings are $7.55 and $9.51, respectively. For part-time workers, the estimates are $7.64 and $13.38, respectively. Nonetheless, all three industries (hospital, nursing home, and home care aides) are characterized by relatively low wages.
There is also a substantial difference between hourly estimates using the mean versus the median. This is particularly true for home care aides, whose mean hourly earnings were almost twice that of the median ($13.35/hr vs $7.64/hr). A similar, but smaller, disparity was observed in earlier studies as well. One possible source of this variability is the large proportion of self-employed individuals (16.8%) in the home care industry.
Interestingly, mean hourly wages for year-round full-time workers were substantially lower than those for workers employed part year or part time. This discrepancy cannot be explained directly from the available data. We might speculate that because the median hourly wages across full and part time were reasonably similar, the discrepancy in mean wages is due to a small group of highly paid workers who were likely to be self-employed or owners of the company. Another possibility is that the data reflect wages and salaries, and not total compensation. In other words, part-time workers were more likely to be contract, temporary workers who get paid more in hourly wages but do not have access to employment benefits. As a result, their total compensation may not be much different from year-round, full-time workers.
Directions for Future Research
In sum, this detailed description of the workforce provides useful information needed to support efforts to identify, recruit, and retain direct care workers, especially home care workers. It may also be of use to investigators attempting to evaluate innovations designed to achieve these ends. In particular it may serve as a baseline profile for comparison with future profiles that can be generated by using data collected in through the American Community Survey (ACS), a new program that was implemented nationally by the Census Bureau in 2005. Therefore, beginning in 2005, the ACS will collect comparable information about the direct care workforce on an annual basis. We can expect updated information to be released sometime in 2006.
The ACS replaces the decennial census long form from which we generated the information contained in this report. The occupation and industry breakdown as well as the demographic and income characteristics in the ACS are the same as the detail in the 2000 Census. The ACS is an annual survey, in contrast to the census, which is conducted every 10 years. At full production levels, the ACS will sample about 3 million addresses each year. According to current plans, there will be a public use microdata file. The size of this file is not known, but if it is comparable with the file created from the 2003 test, it could be around 1 million records. As a result, the ACS will allow for an annual update and tracking of direct care workers at a level of detail and precision that currently is available only every 10 years.
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Footnotes |
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2 Department of Gerontology, University of Nebraska at Omaha.
3 Center for Public Affairs Research, University of Nebraska at Omaha.
Decision Editor: Linda S. Noelker, PhD
Received for publication July 8, 2004. Accepted for publication May 10, 2005.
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