examining predictors of turnover in a residential-care setting found that the physical condition of the neighborhood3 in which the facility was located was by far the strongest predictor of turnover, outweighing other factors such as starting wages, availability of health insurance, Medicaid census, and average case mix (Konetzka et al., 2005).

In the following sections, several of these challenges are discussed in more detail, along with the effect that these factors have on patient outcomes. Initiatives to overcome these barriers are also discussed later in this chapter. It is important to note that the chapter provides only a general discussion of challenges to the recruitment and retention of direct-care workers and that, depending on the type of direct-care worker, the setting, and the source of dissatisfaction, these various factors may weigh more or less heavily in a particular situation.

Financial Disincentives

Direct-care workers receive low hourly wages, which contributes to the lower appeal of these jobs. In fact, in 2007 Forbes magazine profiled personal- and home-care aides as one of the top 25 worst-paying jobs in America (Maidment, 2007). Table 5-5 shows the median wages for direct-care occupations in a variety of settings that are important in the care of older adults.

The average annual earnings of female direct-care workers are significantly lower than the average annual earnings of female workers in general ($17,228 versus $30,441), and 19 percent of female direct-care workers have incomes below the poverty level versus 8 percent of female workers in general (Smith and Baughman, 2007). The low incomes of direct-care workers are due in part to the fact that many direct-care workers do not have predictable hours or the opportunity to work more hours if desired (Dawson, 2007).

Direct-care workers have limited access to employee benefits, including health insurance coverage, sick leave, and retirement benefits (Brady et al., 2002; Dawson, 2007; GAO, 2001b; Smith and Baughman, 2007). Approximately one-quarter of direct-care workers lack health insurance coverage (Hams et al., 2002; Lipson and Regan, 2004). Often these workers are unable to afford their share of the health insurance premiums or they are ineligible for coverage because they work part time or they work independently of an agency. As can be seen in Table 5-6, female direct-care workers are considerably less likely to have health insurance coverage than are female workers in general. This situation can vary dramatically by occupation and region, however. A study of home-care workers in Los


The condition of the neighborhood was likely a proxy for many of the resource issues that cannot be measured well and typically cannot be included in these studies.

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