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 The Quality Forum

Can we maintain quality while increasing the LTC workforce by 80 percent?

 

In the June issue of Health Affairs, a paper by Joanne Spetz and colleagues at the University of California San Francisco projected that 2.5 million additional long term care workers would be needed in the next 15 years.

That sounds like a lot of additional long term care staff. And it is when realizing that currently statisticians estimate there are about 3.7 million long term care workers.

When they assumed the current mix of nursing care center and home-based services, the projection was even higher: 2.9 million additional workers, or almost an 80 percent increase.

No wonder this made headlines among industry newsletters. Imagine if any other type of business projected the need for developing 80 percent more workers in the next 15 years.

The Bureau of Labor and Statistics estimates that the workforce as a whole will need to increase by about 10 percent over the next 10 years. While the government projections are less detailed than those in this paper, they did project a need for 50 percent more personal care and home health aides, and 20 percent more registered nurses (RNs) and nurse assistants over the next 10 years.

The sheer magnitude in workforce growth is only part of the story. The other part is trying to understand what the future of long term care services will look like. As typical in these situations of an uncertain future, the baseline projection reflects the current mix of workers in institutional and noninstitutional settings. These projections are then modified based on different scenarios of how much institutional care will shift to home- and community-based services, or some form of residential care.

The 2.5 million additional long term care workers assumed a 20 percent shift from institutional providers that are staffed more heavily with more skilled workers such as RNs and licensed practical nurses (LPNs).

Without this shift, according to these projections, there will be more RNs, LPNs, and nurse assistants required and fewer home health and personal care aides required. And without this shift, about 2.9 million more workers are required.

But is it really that easy to substitute personal care services for nursing services?

The paper highlights the various programs included in the Affordable Care Act to use Medicaid dollars to support noninstitutional alternatives, such as the Balancing Incentive Program and the Community First Choice Option.

Even with optimistic growth projections for these programs, they will have only a modest impact on the need for skilled nursing and institutional long term care options. As we have known for decades, home- and community-based services offer a very desirable alternative, but by no means a panacea.

Despite the lack of clarity about how future frail elders will receive long term care services (or choose not to), these projections demonstrate an extraordinary demand over the next 15 years, one that is not possible to meet with our current alternatives and workforce. The question for all of us is how to evolve to meet this need, but not just in terms of workforce. Upcoming generations of older persons want greater autonomy, purpose, and quality of their lives wherever they reside. 

Andy Kramer, MD, is a long term care researcher and professor of medicine who was instrumental in the design and development of the Quality Indicator Survey.

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