As shown in Chapter 2, in 1998, nursing homes, personal care facilities, residential care, and home health and home care agencies accounted for nearly 3.2 million jobs. Of these jobs, 1.18 million, or 37 percent, were paraprofessionals (including nursing assistants, personal care aides, and home health care aides), 9 percent were RNs and 8 percent were LPNs (BLS, 2000). Approximately 57 percent of the paraprofessional workers were employed by nursing facilities, 28 percent by home care agencies, and 15 percent by residential care facilities or programs in 1998 (BLS, 2000).

Long-term care services are labor intensive so the quality of care depends largely on the performance of the caregiving personnel. Personnel standards vary considerably across long-term care settings. For purposes of this report, “staffing levels” include numbers of staff, ratios of staff to residents, and the mix of different types of staff in nursing homes and residential care facilties. In home care, staffing levels cannot be discussed in these terms since each client is served individually and agencies are staffed to meet client needs. Rather, the committee considered the amounts and types of services provided to clients with various needs. In a labor-intensive field such as long-term care, the numbers, training, and competence of staff are widely viewed as critical to the quality of services.

Most of the research on the relationship between quality of long-term care and the number and type of staff and their expertise and skills relates to nursing homes. Some studies have examined home health care workers, but few of these studies have examined the relationship between work force characteristics and quality of care. Little is known about the relationship of staff to quality of care in other long-term care settings.

In addition to staffing levels, a key issue is whether the work force in long-term care has adequate education and training to provide high quality of care to individuals. Federal standards have been set for some personnel in nursing homes and home health agencies, but not for personnel providing care in other types of long-term care settings. Some states also have their own requirements for personnel, particularly for the regulation of health professionals and long-term care administrators. These requirements vary across states.

This chapter discusses the caregiving work force separately for each setting. The committee examined existing standards and reviewed the available empirical evidence and research literature on the relationship of staffing patterns and quality. The committee deliberated on the need for changes in standards, education and training issues, and the work environment.

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