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Key Issues

Inadequate Wages and Benefits - Many direct caregivers either live below the poverty line or must work multiple jobs to support their families. Average wages for nursing assistants in nursing homes yield full-time incomes less than $14,000 per year. In home care, the wages are even lower and the work is often part time. Although some agencies offer health insurance to full-time employees, many paraprofessionals cannot afford the premiums required to use the coverage. These conditions lead to higher turnover, labor shortages, and an over-reliance on inexperienced caregivers or temporary workers.

Unreasonable Workloads - Fiscal cutbacks and the rapid discharge of older and sicker patients from hospitals means that home care and nursing home workers have to meet more intense client needs with fewer resources. In the nursing home, the same number of workers are caring for residents with far more complex needs than previously. Shorter home care visits have decreased the time home health aides are able to spend with patients while increasing their (often unpaid) travel time between more clients each day. Home care aides are working harder and longer for fewer dollars.

A Poorly Trained Paraprofessional Workforce - Although federal legislation in the past decade enhanced the training required of CNAs and home health aides, a higher set of training standards is now needed to better prepare paid caregivers for all the services they must deliver to clients - many of whom are now older and sicker and suffering from dementia. The training must move beyond skill development to include competencies in communications, problem solving, and decision making. In addition, providers need to offer experienced caregivers career ladders for advancement that encourage paraprofessional workers to upgrade their skills to keep pace with the increasingly complex demands of their clients. Improving the supervisory skills of managers would also contribute to establishing higher-quality training programs.

Poor Supervision and Job Quality- Although adequate compensation is essential for direct-care workers, many paraprofessionals report that working conditions are of equal importance to wages and benefits when deciding whether to remain employed within healthcare. When asked to identify factors that contribute to "good working conditions," paraprofessionals most often cite: supervision that is consistent, fair and knowledgeable; opportunities to receive the education they need to do their job well; supervisors who respect their observations of client status and listen to what they have to say; inclusion as equal members of care teams and in care planning; and access to the equipment and supplies they need. Not surprisingly, direct-care workers say that their relationship with their immediate supervisor is a key factor in their decision to remain with or leave an employer. Unfortunately, these relationships are often difficult. Most supervisors of frontline workers have not been trained in supervisory skills or cultural competency. They do not have the skills to mentor and develop the large number of employees who report to them, and they are overwhelmed with managing the wide range of issues that direct-care workers bring to their attention every day. 

Absence of Accurate Data to Document Quality Care- The government, through the federal Health Care Financing Administration and state Medicaid departments, pays for 70 % of long-term care services. These public administrative departments, however, do not track what percentage of their reimbursement goes directly to salaries and benefits for direct-care workers. Having access to accurate data on direct-care workers' pay and benefits, along with other workforce indicators such as turnover rates, ratios of workers to residents and workers to supervisors, and number of training hours per year, would assist the government in assessing provider quality. Consumers could also use this information - if available publicly in report-card format - to select high quality long-term care providers. 

No Presence in Policy Discussions - Although paraprofessional workers are critical to our long-term care service delivery system, they have been neglected in policy discussions. Dramatic changes within the healthcare sector - including government cost-containment policies, privatization, and the expansion of managed care - are siphoning resources away from patient care and exacerbating the decline in working conditions for frontline workers. As a result, home care agencies and nursing homes are seeing even higher turnover rates that create a level of instability that compromises client care and endangers the safety of other aides.

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