Trends In Home Care Versus Nursing Home Workforce Sizes: Are States Converging Or Diverging Over Time?

Implications of Rebalancing Home-Based Care for Family Caregivers to Older Adults

Over the last several decades, Medicaid has been "rebalancing" services from institutions to the community, increasing support of home- and community-based services (HCBS). These services could potentially substitute for care typically provided by family members, replacing or reducing care from kin. Leveraging one of the most recent Medicaid rebalancing programs, the Balancing Incentive Program (BIP), and using data from the 2008-2016 Health and Retirement Study on 953 Medicaid beneficiaries ages 65 and over with at least one functional limitation, we examined the relationship between exposure to BIP and family and professional caregiving. BIP exposure was not associated with receipt of care or total hours of care. It was, however, associated with more hours of professional care and fewer hours of family care from non-spouse kin. These findings suggest that recent Medicaid rebalancing programs, while intended to meet the desires of older adults, could have implications for their families.

Tracking long-term services and supports rebalancing through workforce data

OBJECTIVE

To understand trends in the long-term services and supports (LTSS) workforce and assess workforce data as a measure of progress in shifting LTSS resources from institutional to community-based settings.

DATA SOURCES/STUDY SETTING

Workforce data from the American Community Survey from 2008 to 2022.

STUDY DESIGN

Measures of LTSS rebalancing and institutional and community workforce supply per 1000 persons with LTSS needs were constructed. After showing national trends over the study period, state fixed effects regressions were used to evaluate the within-state relationship of these measures with existing measures of LTSS utilization. Workforce supply measures were compared to the percentage of state Medicaid LTSS spending spent in the community to assess their utility for across state comparisons. Each state's progress in LTSS rebalancing over the study period was then shown using workforce data.

DATA COLLECTION/EXTRACTION METHODS

A sample of 336,316 LTSS workers and 3,015,284 people with LTSS needs over the study period was derived from American Community Survey data.

PRINCIPAL FINDINGS

From 2008 to 2022, the percentage of the LTSS workforce employed in the community rose from 44% to 58%. Thirty states saw more than a 10 percentage point increase. From 2008 to 2013, the size of the community workforce expanded dramatically but has since stagnated. In contrast, the institutional workforce entered a long-term decline beginning in 2015 that accelerated during the COVID-19 pandemic. State fixed effects regressions showed that measures of workforce supply have a strong relationship with LTSS utilization measures for older adults, but not for younger people with disabilities.

CONCLUSIONS

Workforce data can serve as an effective measure of changes in LTSS utilization for older adults. This offers researchers and policymakers a useful alternative to administrative claims, bypassing threats to comparability from coding changes and the shift to managed care. Additional data is needed on workforce trends in services for younger LTSS consumers.

Change in Caregiving to Older Adults During the COVID-19 Pandemic: Differences by Dementia Status

We use a nationally representative study of 3451 adults who provided assistance to a relative or friend age 50 or older immediately prior to the Coronavirus Disease 2019 (COVID-19) pandemic to explore changes to care provisions, use of services, and support networks. While we see turnover in assistance during a retrospectively assessed 12-month time period, respondents exited or adopted caregiving roles primarily for reasons unrelated to the pandemic. About two thirds of caregivers' social networks remained unchanged and, of those that did change, only half lost network members without gaining others. Changes in care settings and use of support services were uncommon. Caregivers to persons with dementia may have been more adversely affected than other caregivers as they were more likely to experience loss of social ties, potentially performing more care activities without the full support system they had in place prior to the pandemic.

Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas

Using the 2021 Occupational Employment and Wage Statistics (OEWS) dataset, we calculate the ratio of direct care workers relative to the population of older adults (ages 65+) across rural and urban areas in the US. We find that there are, on average, 32.9 home health aides per 1000 older adults (age 65+) in rural areas and 50.4 home health aides per 1000 older adults in urban areas. There are, on average, 20.9 nursing assistants per 1000 older adults in rural areas and 25.3 nursing assistants per 1000 older adults in urban areas. There is substantial regional variation. Greater investment needs to be made in improving wages and job quality for direct care workers to attract workers to these critical occupations, especially in rural areas where the need for direct care is greater.

The effect of nursing home closure on local employment in the United States

OBJECTIVE

To estimate the effect of nursing home closure on local employment, overall, and by rurality.

DATA SOURCES AND STUDY SETTING

We obtained 2008-2018 county-level data from the Quarterly Workforce Indicators, Medicare Provider of Services, Area Health Resource, and Urban Influence Codes files. From 2008 to 2018, 878 counties experienced at least one nursing home closure, and 2055 counties did not experience a closure.

STUDY DESIGN

Using a difference-in-difference study design, we compare the changes of total employment, health sector employment and non-health sector employment over time between counties with and without a nursing home closure. We utilize the variation in the year and quarter of nursing home closures to estimate subsequent employment changes as well as employment trends before closure. We also account for contemporaneous events including nursing home entries and hospital entries and closures, and evaluate heterogeneity by rurality.

DATA EXTRACTION

We include data on nursing home closure from the Medicare Provider of Service file. Quarterly county-level employee counts were obtained from the Quarterly Workforce Indicators provided by the Census Bureau. County-level demographic data were obtained from the Area Health Resource Files. We use Urban Influence Codes from the Economic Research Service, Department of Agriculture, to classify metropolitan, micropolitan, and rural (noncore) counties.

PRINCIPAL FINDINGS

Health sector employment decreased by about 3.2%-4.1% (p < 0.01) in counties with a nursing home closure. The reduction was largest in rural counties (approximately 7.2%-9.4%, p < 0.01). The reduction in health sector employment persisted over time, particularly in rural counties. Overall, there was no discernable effect on non-health sector employment.

CONCLUSIONS

Nursing home closure is associated with a persistent decline in health sector employment, particularly in rural counties, suggesting a reduction in the health care workforce and in the ability to sustain health care services supply, particularly in rural areas.

A Qualitative Description of Direct Care Workers of Lesbian, Gay, Bisexual, Transgender Older Adults

Purpose: The aim of the study was to examine direct care worker (DCW) perceptions of lesbian, gay, bisexual, transgender (LGBT) older adults living in long-term care, assisted living, and home health settings. DCWs provide the closest interaction with LGBT older adults in these settings. The perceptions DCWs have toward LGBT older adults is important because the quality of care can be influenced by negative attitudes. Methodology: Qualitative description was used to synthesize what is known about DCWs' perceptions toward LGBT older adults. Results: The overarching theme, "Care is Different, but Not my Care," was supported by the categories Cues of Stereotyping, Cues of Prejudice, and DCWs' Social System and Reported Care. Application: Specific implications for practice (i.e., training, recruitment, retention strategies) and policy (i.e., mandated staffing ratios, pay) are explicated to guide future interventions to ensure equitable, quality care in health care.

Growth of Private Pay Senior Housing Communities in Metropolitan Statistical Areas in the United States: 2015-2019

Older adults needing assistance with activities of daily living can receive support in various settings. Senior housing communities, such as independent living, assisted living, and continuing care retirement communities, are an increasingly popular option for adults not requiring nursing home-level care. However, limited research exists due to a dearth of data on these types of communities. We use a proprietary data set to describe the market of private pay senior housing and community-level characteristics in 140 metropolitan statistical areas, from 2015 to 2019. Although the number of senior housing communities increased substantially, the supply of senior housing options supporting the continuum of care has not necessarily kept up with population growth. Describing the supply of senior housing communities across the spectrum of levels of care provides a more complete description of the formal noninstitutional long-term care supply among the 140 most populated metropolitan statistical areas.