million workers were employed in direct-care occupations in 20061 (BLS, 2008c,d). Still, the current number of direct-care workers is insufficient to meet demand (GAO, 2001a,b; Stone, 2004). The need for direct-care workers is expected to increase in the coming decades, mainly because of the aging of the population but also because the number of females aged 25 to 54—the typical direct-care worker demographic—is projected to remain flat (PHI, 2001).
A further trend that may exacerbate this unfulfilled need, especially for personal- and home-care aides, is a shift away from institutional care to home- and community-based care. Policy makers and payers are increasingly implementing home- and community-based care programs in response to consumer preferences and legal mandates and with the hope that costs will be lower for at least some types of services. However, caring for older adults in these settings may require proportionately more direct care-level staff than in institutional facilities (National Center for Health Workforce Analysis, 2004). The workforce providing non-institutional personal assistance and home health services tripled between 1989 and 2004, and Medicaid spending for these services also increased significantly during that time (Kaye et al., 2006). Over that same time period, the workforce providing similar services in institutional settings remained relatively stable. In fact, the BLS predicts that personal- and home-care aides and home health aides will represent the second- and third-fastest growing occupations between 2006 and 2016 (BLS, 2007b). This trend will not only lead to an increase in demand for services in non-institutional settings but will also require home-based workers to deliver more skilled care to patients with more complex needs (Seavey, 2007b). In home- and community-based care settings, carers work more independently and rely on personal skill and judgment; however, many direct-care workers do not receive the education or training they need in order to be prepared for the care of older patients with complex care needs.
A major factor in the deficit of direct-care workers is the poor quality of these types of jobs. Direct-care workers typically receive very low salaries, garner few benefits, and work under high levels of physical and emotional stress. In 2005 the median hourly wage for all direct-care workers was $9.56, about one-third less than the median wage for all U.S. workers (Dawson, 2007). Direct-care workers are more likely to live in poverty, to lack health insurance, and to rely on food stamps than other workers (GAO, 2001b). Additionally, these workers have high rates of job-related injury, most often due to overexertion in the care of a patient (BLS, 2007a). All of these factors contribute to the unacceptably high rates of vacancies