✯
✯
2003 National Health Policy ✯Conference
January 22-23, 2003
J.W. Marriott
Washington, D.C.
Critical Workforce Issues in
Long Term Care
Carol Raphael, President & CEO
Visiting Nurse Service of New York
2003 National Health Policy Conference, Washington, D.C.,
January 2003
1
Demand for Long Term Care
Services
2
Demand: Demographic Trends
• “Baby boom” generation to retire in 2010
• There are 32 million people aged 65+
– By 2030:
• 70 million will be over 65, or
• 1 in 5 people
• Number of people aged 85 and over will double to
7 million in 2020:
– This number will double again to 14 million by
2040
3
Demand: Service Trends
• As population ages:
– Greater use of LTC services
– Expansion of home and community-based care
and residential settings
– Need for assistance with A.D.L.s and I.A.D.L.s
• 40% (8.5 million) of those aged over 70 have at
least one A.D.L/ I.A.D.L.
– May increase to 21 million by 2030
• By 2050, over 25 million people will be limited in
activities and need assistance
4
LTC Workforce Compared with Other
Health Care Sectors
• Role of:
– Nurses in home and community-based system
– Paraprofessionals:
• Provide 70-90% of direct care to the elderly
– Informal caregivers:
• Family members comprise 70% of caregivers
– 42% are adult children and 25% are spouses
• May precede, accompany or substitute for formal care
• National economic value:
– $257 billion annually*
– 1 in 4 households
*Source: National Family Caregivers Association per HCFA, Office of the Actuary, Levit K. et al,
Health Affairs 2002;21
5
LTC Workforce Compared with Other
Health Care Sectors, continued
• Role of:
– Patient/customer preferences:
• Control
• Security
• Knowledge
• Length of Relationships
• Cultural Diversity
• Proxy for Quality
6
Supply:
Who Comprises the LTC
Workforce?
7
Profile of the LTC1 Workforce
Nurses
1. Number
512,0003
2. Average Age5
44
3. % racial/ethnic
minority6
10%
4. Earnings7
1Defined
$42,071
Paraprofessionals
Informal Caregivers2
615,000
54 million4
45
47
85% - 90%
49%
< $10,000 - $14,000
$0
as the chronically ill, disabled or elderly population who need some type of social or medical care; 2Caregivers
who provide care to the LTC population as defined in this chart. 3Assumes that 20% of total licensed RNs (or, 2.558M
RNs per MinorityNurse.com) are in LTC; 4Source: National Family Caregiving Association survey, 2000; 5Sources:
Family Caregiving Alliance, Direct Care Alliance; 6Sources: MinorityNurse.com, Direct Care Alliance, Navaie-Waliser,
M., American Journal of Public Health, 2002; 7Source: same as footnote 6.
8
Macro Factors Affecting Supply
Formal
•
•
•
•
Labor Market
Health Care Policy
Immigration
Welfare Policy
Informal
• Women in workforce
• Family size
• Mobility
9
What Affects Both Formal & Informal Caregivers
• Key Point: Widening Gap
Traditional Supply of Paid & Non-Paid Caregivers is
Shrinking
12%
10%
8%
By 2010
11%
6%
4%
2%
0%
-2%
Women Aged 25-44
Women Aged 65+
-4%
-4%
-6%
10
Source: Bureau of Labor, 2000
Main Factors in RN Supply
• Shrinking Pool:
– Less enrollment in nursing schools
– Other career opportunities
– Nursing education focused on acute care
– Under-representation of minorities
– Gender issues
11
Main Factors in RN Supply, continued
The Aging of the RN Workforce
2500
2000
60s
50s
40s
30s
20s
1500
1000
500
0
1980
1990
2000
(proj.)
2010
(proj.)
Source: American Hospital Association: Trend Watch, June 2001, Vol. 3, No. 2
*Number of RNs in thousands
2020
(proj.)
12
Main Factors in RN Supply, continued
• Working Conditions:
– Complex patients with multiple conditions
and comorbidities
– Increased regulatory burden & required
documentation
– Need to keep up with rapid advances in
medicine and technology
– Interaction with family dynamics
– Role as “care manager”
13
Main Factors in RN Supply, continued
• Results:
–High turnover
–High vacancy rates
–Increased retirement rate
14
Paraprofessional Supply Issues
Projected Paraprofessional Shortage by 2010
Demand
907
634
Supply
0
200
400
600
800
1000
In thousands
Source: Bureau of Labor, 2001 and Paraprofessional Healthcare Institute
15
Paraprofessional Supply Issues, continued
2. Working Conditions:
–
–
–
–
–
–
Compensation
Benefits
Difficult to get steady, full-time employment
Lack of career mobility
Little respect and recognition
Demanding job:
• High rate of injuries
• Unpleasant tasks
16
Paraprofessional Supply Issues, continued
• Results:
– High turnover rates:
• 94% - 100% in SNFs
• 32% in home health care
– Unionization efforts
17
Family Caregiver Supply Issues
Family Caregivers per Person Needing Care
12
10
8
11
63% Decrease
in Supply
6
4
4
2
0
1990
Source: Family Caregiving Alliance
2050
18
Family Caregiver Issues
• Other Issues:
– Hard to navigate health system
– High stress levels
– Burdens:
• Financial:
– Change of work status
» Missed work
» Decreased productivity
» Loss of job or career opportunities
• Emotional: 51% suffer from depression
• Physical: 49% have one + chronic conditions
19
Options
A. Provider/Industry Initiatives:
– IOM Study
– Nursing Homes
• Wellspring
– Home & Community-Based Initiatives
• Visiting Nurse Service of New York
– Work:
» Redesigning job
– Recruitment & Retention:
» Strengthening training
» BSN Internship program
» Improving paraprofessional benefits
– Support:
» Mentoring
» Giving employees “voice”
20
Options, continued
B. Policies
1. Formal Caregivers:
• Federal Level:
– Nursing home staffing ratios
– Public disclosure of quality indicators
• State Level:
– Wage and benefit pass through
– Training
– Career advancement
– Transportation reimbursement
21
Options, continued
2. Policy Strategies for Informal Caregivers:
– Financial incentives
• Tax breaks
– Consumer Directed Options
• “Cash and counseling” model
– Supportive Services
• Respite Care
• Information
• Assistance with access
22