activities of daily living (IADLs), such as meal preparation and transportation. Personal-care services have been growing and all states now have waiver programs through Medicaid that provide these services to seniors and people with disabilities (Kitchener et al., 2007; Seavey and Salter, 2006).

Whereas home health aides who provide Medicare-certified home care perform their jobs under the supervision of a registered nurse (RN), personal- and home-care workers frequently have no supervision, even though they may perform many of the same services. Furthermore, many personal- and home-care workers may be hired privately by patients, without the involvement of an agency. Because of these hiring practices, little can be done to track the workers in this “grey market,” which makes it difficult to create a demographic profile of the workers or to regulate their work practices (Seavey, 2007b).

As patients move rapidly away from institutional long-term care and toward home- and community-based settings, they are increasingly relying on direct-care workers to provide needed care, including more complex services than previously provided in these settings. Assisted-living facilities, which are community-based facilities that provide more services than a typical home setting but less than a nursing home, are a rapidly growing option for the residential care of older adults (Lyketsos et al., 2007), and the workers serving patients in these settings (including the patients with more complex needs) are typically personal- and home-care aides rather than home health or nurse aides. There is little to no federal regulation regarding the training or staffing requirements for assisted-living facilities; instead, each state regulates workers in these settings.


Direct-care workers are overwhelmingly female (89 percent) and are typically between the ages of 25 and 55, unmarried (including those who are widowed, divorced, or separated), without college degrees, and citizens of the United States (Montgomery et al., 2005; Smith and Baughman, 2007; Yamada, 2002). Approximately 30 percent of direct-care workers are African American and 15 percent are of Hispanic or Latino origin (BLS, 2008a), although this can vary by setting and job title.

In 2005 Montgomery and colleagues examined data from the 2000 Census to create a profile of home-care aides who provide direct long-term care services, including those who are hired privately (Montgomery et al., 2005). The study revealed that as compared to hospital aides and nursing home aides, home-care aides are on average older, more likely to be of Hispanic or Latino origin, more likely to be self-employed, and less likely to have steady year-round employment (Table 5-2).

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