The Home Care Workforce Has Not Kept Pace With Growth In Home And Community-Based Services

Association Between Self-Direction and Personal Care Aide Wages

The supply of personal care aides (PCAs), who assist people receiving home care, is a growing concern. PCA shortages result, in part, from the low wages earned by these workers. State policies have had some effect on wages. Self-direction (SD) may be associated with wages because SD allows home care recipients to hire and manage workers, including setting wages in most states. We used wage data from the Bureau of Labor Statistics to examine the association between SD and the wages of PCAs. We found implementation of SD did not have a consistent association with PCA wages, with wages improving in some states and worsening in others. We also found little difference in PCA wages between states that allow participants to set worker wages and those that do not. SD does not seem to improve PCA wages in states, so other policy strategies will be needed.

Family caregiver lived experience matters in home- and community-based services

This editorial comments on the article by Trivedi et al.

Home Care Workers Providing Person-Centered Care to People With Dementia

Person-centered care for people living with dementia has been associated with improved functional ability and quality of life, yet little is known about person-centered care in the home settings. Our objective was to explore home care worker perspectives on providing person-centered care for their clients living with dementia. Using secondary qualitative analysis of 22 semi-structured interviews with home care workers, we identified themes related to the Dementia Initiative's person-centered dementia care framework (Initiative, 2013). We found that home care workers acknowledged their client's personhood while also advocating for their needs. However, home care workers encountered barriers to providing person-centered care, including role limitations and challenging dynamics with other home care workers and family caregivers. This analysis can inform further approaches to better integrate home care workers in person-centered healthcare teams and improve how the needs of people living with dementia are identified and met in the home.

"Too few, too far away, for what is paid": Consumer voices about the personal assistance worker crisis

BACKGROUND

The growing gap between demand and supply of personal assistance service (PAS) workers presents a significant burden to those who use services. The intensity and duration of hardship is growing, and consumer voices need to be heard and incorporated into the national dialogue.

OBJECTIVE

This paper explores how PAS worker shortages manifest themselves in the daily lives of people with disabilities using or needing PAS services in the United States.

METHODS

We used thematic coding of qualitative data from the 2022 National Survey on Health and Disability. Respondents (n = 330) provided open-ended responses to the prompt "Briefly explain the types of problems or issues you have had finding PAS or support workers."

RESULTS

Three themes emerged regarding consumer perspectives and experiences with worker shortages (1) low pay, few benefits, and undervalued work, (2) demanding working conditions and logistics, and (3) low quality workers. In combination, these themes informed a fourth theme (4) impacts for PAS consumers characterized by substandard care and additional stress and workload for those who direct their own care.

CONCLUSIONS

As a society, we have taken steps to increase opportunities for community living and created policies to uphold choice and independence for people with disabilities. In the absence of an adequate workforce to support these policies, however, we convey an empty promise. Without tangible steps to resolve these problems at the policy level, such as improved worker pay and protections, hope for resolution to these issues remains elusive.

Increasing expenditures on home- and community-based services: Do home care workers benefit?

OBJECTIVE

To examine the association of Medicaid home- and community-based services (HCBS) expenditures on the home care workforce.

DATA SOURCES/STUDY SETTING

We use two national, secondary data sources from 2008 to 2019: state-level Medicaid HCBS expenditures and the American Community Survey, in which we identify direct care workers in the home (i.e., home care workers), defined as nursing, psychiatric, and home health aides or personal care aides working in home health care services, individual and family services, and private households.

STUDY DESIGN

Our key explanatory variable is HCBS expenditures per state per year. To estimate the association between changes in Medicaid HCBS expenditures and the workforce size, hourly wages and hours worked, we use negative binomial, linear, and generalized ordered logit regression, respectively. All models include demographic and socioeconomic characteristics, the number of potential HCBS beneficiaries (individuals with a disability and income under the federal maximum income eligibility limits), indicators for minimum wage and/or overtime protections for direct care workers, wage pass-through policies, and state and year fixed effects.

DATA COLLECTION/EXTRACTION METHODS

We exclude states with incomplete reporting of expenditures.

PRINCIPAL FINDINGS

States' HCBS expenditures increased between 2008 and 2019 after adjusting for inflation and the number of potential HCBS beneficiaries. Yet, home care workers' wages remained stagnant at $11-12/h. We find no association between changes in Medicaid HCBS expenditures and wages. For every additional $1 million in Medicaid HCBS expenditures, the expected number of workers increases by 1.2 and the probability of working overtime increased (0.0015% points; p < 0.05). Results are largely robust under multiple sensitivity analyses.

CONCLUSIONS

We find no evidence of a statistically significant relationship between changes in state-level changes in Medicaid HCBS expenditures and worker wages but do find a significant, but small, association with hours worked and workforce size.

Behavioral, Cognitive, and Functional Risk Factors for Repeat Hospital Episodes Among Medicare-Medicaid Dually Eligible Adults Receiving Long-Term Services and Supports

Repeat hospitalizations adversely impact the well-being of adults dually eligible for Medicare and Medicaid in the United States. This study aimed to identify behavioral, cognitive, and functional characteristics associated with the risk of a repeat hospital episode (HE) among the statewide population of dually eligible adults in Maryland receiving long-term services and supports prior to an HE between July 2018 and May 2020. The odds of experiencing a repeat HE within 30 days after an initial HE were positively associated with reporting difficulty with hearing (adjusted odds ratio, AOR: 1.10 [95% confidence interval: 1.02-1.19]), being easily distractible (AOR: 1.09 [1.00-1.18]), being self-injurious (AOR: 1.33 [1.09-1.63]), and exhibiting verbal abuse (AOR: 1.15 [1.02-1.30]). Conversely, displaying inappropriate public behavior (AOR: 0.62 [0.42-0.92]) and being dependent for eating (AOR: 0.91 [0.83-0.99]) or bathing (AOR: 0.79 [0.67-0.92]) were associated with reduced odds of a repeat HE. We also observed differences in the magnitude and direction of these associations among adults 65 years of age or older relative to younger counterparts.

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.

Home health utilization in the Veterans Health Administration: Are there rural and urban differences?

PURPOSE

Growing numbers of older adults need home health care, yhese services may be more difficult to access for rural Veterans, who represent one-third of Veterans Health Administration (VA) enrollees. Our objective was to examine whether home health use differs within VA based on rurality.

METHODS

We examined national VA administrative data for 2019-2021 (January 1, 2019 to December 31, 2021) among Veterans ages ≥65 years. Using descriptive and multivariable analyses, we assessed whether rural versus urban Veterans differed in (1) the likelihood of using any home health and (2) for those who received ≥1 visit, number of visits received.

RESULTS

Among home health users (n = 107,229, 33.1% rural), rural and urban Veterans were similar in age (77.0 vs. 77.2 years). Rural Veterans were less likely to be highly frail (38.9% rural vs. 40.4% urban) or diagnosed with dementia (13.5% vs. 17.6%). After adjusting for Veterans' characteristics, rural Veterans were more likely to receive any home health (odds ratio: 1.10; 95% confidence interval [CI]: 1.07, 1.13). Among Veterans who received ≥1 home health visit, rurality was associated with considerably fewer expected visits (incident rate ratio: 0.70; 95% CI: 0.68, 0.72).

CONCLUSIONS

Although rural Veterans were more likely than urban Veterans to receive any home health services, they received considerably fewer home health visits. This difference may represent an access issue for rural Veterans. Future research is needed to identify reasons for these differences and develop strategies to ensure rural Veterans' care needs are equitability addressed.

Paid Caregiving in Dementia Care Over Time: Paid Caregiver, Family Caregiver, and Geriatrician Perspectives

BACKGROUND AND OBJECTIVES

As long-term care increasingly moves from facilities to the community, paid caregivers (e.g., home health aides, other home care workers) will play an increasingly important role in the care of people with dementia. This study explores the paid caregiver role in home-based dementia care and how that role changes over time.

RESEARCH DESIGN AND METHODS

We conducted individual, longitudinal interviews with the paid caregiver, family caregiver, and geriatrician of 9 people with moderate-to-severe dementia in the community; the 29 total participants were interviewed on average 3 times over 6 months, for a total of 75 interviews. Interviews were recorded, transcribed, and analyzed with structured case summaries and framework analysis.

RESULTS

Paid caregivers took on distinct roles in the care of each client with dementia. Despite changes in care needs over the study period, roles remained consistent. Paid caregivers, family caregivers, and geriatricians described the central role of families in driving the paid caregiver role. Paid and family caregivers collaborated in the day-to-day care of people with dementia; paid caregivers described their emotional relationships with those they cared for.

DISCUSSION AND IMPLICATIONS

Rather than simply providing functional support, paid caregivers provide nuanced care tailored to the needs and preferences of not only each person with dementia (i.e., person-centered care), but also their family caregivers (i.e., family-centered care). Deliberate cultivation of person-centered and family-centered home care may help maximize the positive impact of paid caregivers on people with dementia and their families.

The Impact of an Intergenerational Service Learning Program on Psychological Distress for Homebound Older Adults

This study examined the benefits of an intergenerational home-based service learning program to reduce psychological distress for homebound older adults. Multivariate regression analyses were conducted with a sample of 182 to examine the association of length of service from the program and presence of caregivers with psychological distress. Findings indicated length of service (β = -0.15, p < .05) and having a child as a caregiver (β = -0.14, p < .05) were associated with a reduction in psychological distress. Policies and practice can support a pipeline of geriatric health professionals through innovative service learning models to benefit older adults, caregivers, and students.

Proactive Care-Seeking Strategies Among Adults Aging Solo With Early Dementia: A Qualitative Study

OBJECTIVES

People living with dementia need increasing care over time, but 1 in 3 adults with cognitive impairment lives alone. The goal of this study was to explore the self-identified strengths and resources for future care needs of adults aging solo with early dementia.

METHODS

Semistructured interviews with 15 adults not living with a partner and with no children in the same state, who self-identified as having early dementia or mild cognitive impairment; hybrid inductive/deductive reflexive thematic analysis using a successful aging framework.

RESULTS

Participants placed a high value on maintaining independence and expressed concerns about preserving selfhood and becoming a burden to others. These values influenced how participants appraised financial and social resources available to address future care needs and strategies to preempt or respond to needs such as transportation, help with finances, or activities of daily living.

DISCUSSION

Adults without close family are heterogeneous and have variable resources available to address care needs associated with dementia progression. Common values of retaining independence and minimizing burden to others may be helpful in motivating adults aging solo to undertake planning and help-seeking early.

Assessing the Usability and Feasibility of Digital Assistant Tools for Direct Support Professionals: Participatory Design and Pilot-Testing

BACKGROUND

The United States is experiencing a direct support professional (DSP) crisis, with demand far exceeding supply. Although generating documentation is a critical responsibility, it is one of the most wearisome aspects of DSPs' jobs. Technology that enables DSPs to log informal time-stamped notes throughout their shift could help reduce the burden of end-of-shift documentation and increase job satisfaction, which in turn could improve the quality of life of the individuals with intellectual and developmental disabilities (IDDs) whom DSPs support. However, DSPs, with varied ages, levels of education, and comfort using technology, are not likely to adopt tools that detract from caregiving responsibilities or increase workload; therefore, technological tools for them must be relatively simple, extremely intuitive, and provide highly valued capabilities.

OBJECTIVE

This paper describes the development and pilot-testing of a digital assistant tool (DAT) that enables DSPs to create informal notes throughout their shifts and use these notes to facilitate end-of-shift documentation. The purpose of the pilot study was to assess the usability and feasibility of the DAT.

METHODS

The research team applied an established user-centered participatory design process to design, develop, and test the DAT prototypes between May 2020 and April 2023. Pilot-testing entailed having 14 DSPs who support adults with IDDs use the first full implementation of the DAT prototypes during 2 or 3 successive work shifts and fill out demographic and usability questionnaires.

RESULTS

Participants used the DAT prototypes to create notes and help generate end-of-shift reports. The System Usability Scale score of 81.79 indicates that they found the prototypes easy to use. Survey responses imply that using the DAT made it easier for participants to produce required documentation and suggest that they would adopt the DAT if this tool were available for daily use.

CONCLUSIONS

Simple technologies such as the DAT prototypes, which enable DSPs to use mobile devices to log time-stamped notes throughout their shift with minimal effort and use the notes to help write reports, have the potential to both reduce the burden associated with producing documentation and enhance the quality (level of detail and accuracy) of this documentation. This could help to increase job satisfaction and reduce turnover in DSPs, both of which would help improve the quality of life of the individuals with IDDs whom they support. The pilot test results indicate that DSPs found the DAT easy to use. Next steps include (1) producing more robust versions of the DAT with additional capabilities, such as storing data locally on mobile devices when Wi-Fi is not available; and (2) eliciting input from agency directors, families, and others who use data about adults with IDDs to help care for them to ensure that data produced by DSPs are relevant and useful.

Higher levels of state funding for Home- and Community-Based Services linked to better state performances in Long-Term Services and Supports

OBJECTIVE

To examine the relationship between the level of state funding for Home- and Community-Based Services (HCBS) and state overall and dimension-specific performances in Long-Term Services and Supports (LTSS).

DATA SOURCES AND STUDY SETTING

We employed state-level secondary data from the Medicaid LTSS Annual Expenditures Reports, the American Association of Retired Persons (AARP) State Scorecards, the U.S. Census, and Federal Reserve Economic data, spanning the timeframe of 2010-2020.

STUDY DESIGN

Overall state LTSS rankings, along with dimension-specific rankings, were modeled separately against state Medicaid spending on HCBS relative to total Medicaid spending on LTSS. All models were adjusted for state covariates, secular trend, and state fixed effects.

DATA COLLECTION/EXTRACTION METHODS

The study sample included all 50 states and the District of Columbia. However, California, Delaware, Illinois, and Virginia were excluded from FY2019 due to missing data on Medicaid HCBS expenditures.

PRINCIPAL FINDINGS

Every 10 percentage-point increase in the proportion of Medicaid LTSS spending to HCBS demonstrated 2.05 points improvement (95% confidence interval [CI]: -3.88 to 0.22, p = 0.03) in rankings for state overall LTSS system performance, 2.92 points improvement (95% CI: -4.87 to 0.98, p < 0.01) in rankings for the Choice of Setting and Provider dimension, as well as 1.73 points (95% CI: -3.14 to 0.32, p = 0.02) ranking improvement in the dimension of Effective Transitions.

CONCLUSIONS

Our study suggested promising effects of increased state funding for HCBS on LTSS performance.

Changes in Health Care Workers' Economic Outcomes Following Medicaid Expansion

Importance

The extent to which changes in health sector finances impact economic outcomes among health care workers, especially lower-income workers, is not well known.

Objective

To assess the association between state adoption of the Affordable Care Act's Medicaid expansion-which led to substantial improvements in health care organization finances-and health care workers' annual incomes and benefits, and whether these associations varied across low- and high-wage occupations.

Design, Setting, and Participants

Difference-in-differences analysis to assess differential changes in health care workers' economic outcomes before and after Medicaid expansion among workers in 30 states that expanded Medicaid relative to workers in 16 states that did not, by examining US individuals aged 18 through 65 years employed in the health care industry surveyed in the 2010-2019 American Community Surveys.

Exposure

Time-varying state-level adoption of Medicaid expansion.

Main Outcomes and Measures

Primary outcome was annual earned income; secondary outcomes included receipt of employer-sponsored health insurance, Medicaid, and Supplemental Nutrition Assistance Program benefits.

Results

The sample included 1 322 263 health care workers from 2010-2019. Health care workers in expansion states were similar to those in nonexpansion states in age, sex, and educational attainment, but those in expansion states were less likely to identify as non-Hispanic Black. Medicaid expansion was associated with a 2.16% increase in annual incomes (95% CI, 0.66%-3.65%; P = .005). This effect was driven by significant increases in annual incomes among the top 2 highest-earning quintiles (β coefficient, 2.91%-3.72%), which includes registered nurses, physicians, and executives. Health care workers in lower-earning quintiles did not experience any significant changes. Medicaid expansion was associated with a 3.15 percentage point increase in the likelihood that a health care worker received Medicaid benefits (95% CI, 2.46 to 3.84; P < .001), with the largest increases among the 2 lowest-earning quintiles, which includes health aides, orderlies, and sanitation workers. There were significant decreases in employer-sponsored health insurance and increases in SNAP following Medicaid expansion.

Conclusion and Relevance

Medicaid expansion was associated with increases in compensation for health care workers, but only among the highest earners. These findings suggest that improvements in health care sector finances may increase economic inequality among health care workers, with implications for worker health and well-being.

Use of home and community-based services and loneliness in older people with functional limitations: a cross-sectional study

BACKGROUND

Loneliness is one of the major health problems among older adults. Among this population, home and community-based services (HCBS) have become increasingly popular. Despite its health benefits, little is known about the relationship between HCBS use and loneliness in older people with functional limitations. We aim to explore the characteristics of loneliness among older people with functional limitations and examine the association between HCBS use and loneliness in China.

METHODS

We used a cross-sectional data from the 2018 China Health and Retirement Longitudinal Study, which includes a nationally representative sample of Chinese residents aged 65 and older with functional limitations. Logistic regression models were used to examine the associations between HCBS use and loneliness, and we further used propensity score matching to address potential sample selection bias.

RESULT

In China, 46% of older people with functional limitations felt lonely and only 22% of older people with functional limitations reported using HCBS in 2018. Compared with participants who did not receive HCBS, those who received HCBS were less likely to report loneliness (OR = 0.81, 95% CI = 0.63, 0.99, p = 0.048), and the results remained significant after addressing sample selection bias using propensity score matching.

CONCLUSION

Our results showed that loneliness was common among Chinese older people with functional limitations, and the proportion of HCBS use was low. There was robust evidence to support that among older people with functional limitations, HCBS use was associated with decreased loneliness. Further policies should promote the development of broader HCBS use for older people with functional limitations to reduce their loneliness.