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Long-Term Care Workforce: Better Information Needed on Nursing Assistants, Home Health Aides, and Other Direct Care Workers

GAO-16-718 Published: Aug 16, 2016. Publicly Released: Sep 15, 2016.
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What GAO Found

Federal data sources provide a broad picture of direct care workers—nursing assistants and home health, psychiatric, and personal care aides—who provide long-term services and supports (LTSS), but limitations and gaps affect the data's usefulness for workforce planning. Some states have collected data in areas where federal data are limited, but these have been one-time studies. Federal data show that direct care workers who provide LTSS numbered an estimated 3.27 million in 2014, or 20.8 percent of the nation's health workforce. Federal data show that wages for direct care workers, while differing by occupation, are generally low, averaging between approximately $10 and $13 per hour in 2015. However it is unclear to what extent these wage data include direct care workers employed directly by the individuals for whom they care. The number of these workers, often referred to as independent providers, is believed to be significant and growing. Some states, in coordination with the federal government or on their own, have conducted studies about direct care workers and collected detailed information. These studies showed that a majority of independent providers worked for a family member or someone else they knew.

Direct Care Workers as a Percentage of the Total Health Workforce, 2014

Direct Care Workers as a Percentage of the Total Health Workforce, 2014

The Department of Health and Human Services' (HHS) Health Resources and Services Administration (HRSA), which is responsible for monitoring the supply of and demand for health professionals, has developed some information on direct care workers. However, HRSA has not produced projections of this workforce or developed methods to address data limitations, which is in line with one of the goals in its strategic plan. HRSA's actions include sponsoring research and issuing a 2013 report that summarized federal data on different occupations, including direct care workers. While HRSA has recognized the limitations of existing data and cites these as reasons it has not developed projections for this workforce, the agency has not developed methods to address data challenges. Unless HRSA takes steps to overcome data limitations in order to make projections of supply and demand for direct care workers, policymakers will continue to be hampered in their ability to identify workforce trends and develop appropriate strategies to help ensure a sufficient number of qualified direct care workers.

Why GAO Did This Study

Millions of elderly individuals and persons with disabling conditions rely on LTSS to help them perform routine daily activities, such as eating and bathing. Direct care workers are among the primary providers of LTSS. Reported difficulties recruiting and retaining direct care workers and the anticipated growth in the elderly population have fueled concerns about the capacity of the paid direct care workforce to meet the demand for LTSS. Despite these concerns, policymakers lack data to help assess the size of the problem.

GAO was asked to provide information on direct care workers who deliver LTSS. This report examines (1) federal and state data available on the paid direct care workforce and (2) actions HRSA has taken to develop information and projections on this workforce. GAO analyzed the most recent data available from the Census Bureau and Bureau of Labor Statistics on paid direct care workers' demographics, compensation, and benefits and reviewed efforts to collect data on direct care workers in four states, selected in part for geographic variation. GAO also reviewed HRSA documents and interviewed agency officials about HRSA's previous, ongoing, and planned efforts to improve data.


GAO recommends that HRSA take steps to produce projections of direct care workforce supply and demand and develop methods to address data limitations in order to do so. HHS concurred with GAO's recommendation, stating that developing projections for the direct care workforce is timely and important.

Recommendations for Executive Action

Agency Affected Recommendation Status
Health Resources and Services Administration To improve available data about the direct care workforce, the Acting Administrator of the Health Resources and Services Administration should take steps to produce projections of direct care workforce supply and demand and develop methods to address data limitations in order to do so.
Closed – Implemented
HHS concurred with this recommendation, and in September 2016, HHS's Health Resources and Services Administration (HRSA) awarded a contract to develop a model for the supply, demand, and distribution of long-term services and supports (LTSS) providers. HRSA published the results of this study in March 2018, which projected that demand for direct care workers would grow substantially through 2030. The study did not include projections of the future supply of direct care workers but did discuss the currently supply of these workers. The study stated that the future supply of direct care workers will likely be dependent on factors, including the future competitiveness of wages, employment benefits, and workplace characteristics, that are not able to be estimated in HRSA's current workforce model. In light of an aging U.S. population, HRSA's study provides important information on the projected demand for direct care workers.

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