Nursing Home Workforce Falls as Home Care Labor Pool is on the Rise

The direct care worker occupation has seen substantial growth in recent years, rising from three million workers in 2009 to 4.6 million workers in 2019, but new analysis shows that most of that growth can be attributed to home care.

Nationally, the home care workforce has had a more than twofold increase since 2009, while the number of nursing assistants in nursing homes has decreased slightly.

That’s according to a recent study from policy journal Health Affairs which focused on the shift in the number of caregivers working across different long-term care settings.

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From 2009 to 2020, the overall home care workforce size increased by about 60 workers per 1,000 people with disabilities, from 100.7 workers to 160.8, while nursing homes lost about 10 direct care workers per 1,000 people with disabilities during that time.

As nursing home operators continue to explore how the rise of home health might impact their business, Esther Friedman, research associate professor at the University of Michigan Institute for Social Research, said the data shows that nursing homes’ competition for workers extends beyond home health.

“We did find some substitution but it wasn’t one-to-one,” she explained. “The home care workforce has been increasing at a substantially faster pace than the nursing home workforce has been declining. What we’re really seeing is growth in the direct care workers overall but most of it is happening in home care.”’

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Friedman was one of five researchers to conduct the study.

Still as the home care workforce size increased, the size of the nursing home workforce declined.

The decline in residential care facility jobs has been seen across the industry since the pandemic begun, though nursing homes seemed to have fared worse than other areas of health care.

Employment in the leisure and hospitality industry increased by 164,000 in October and has risen by 2.54 million workers thus far in 2021, but is still down by 1.3 million or 7.9% from February 2020, an analysis by NIC MAP Vision shows.

Health care added 2,000 jobs in November, however, nursing and residential care facilities lost 11,000 jobs. The overall health care sector is down by 450,000 since February 2020.

Friedman said that sometimes the limits of the job can make it difficult for nursing homes to recruit and retain direct care workers.

“There are few opportunities for advancement and promotion and salaries are low. Some states have been working to strengthen the direct care workforce by making these types of jobs more appealing through wage and benefit enhancement,” she observed. “Career ladder initiatives, things like training, mentoring and credentialing. This seems like a good strategy to employ across different settings to help grow the direct care workforce.”

One concern she had moving forward is the variation in how fast states were adopting the shift to home care, with some showing substantial increases in their home care workforce while others actually showed decreases.

“This could be concerning if it means people with disabling conditions in some states have fewer or different options than those in other states,” she said. “This suggests that we also need to be thinking about what’s happening among states and statewide differences to make sure we can give people the care they need and the options for the best setting to meet their particular needs.”

Some states also have more stringent requirements for training and certification that could keep people out of the home care workforce.

North Carolina and Rhode Island, for instance, might show a reduction in home care workers because many direct care workers providing home care services must be certified as nursing assistants in those states.

This indicates that nursing homes, especially those in states that have been slower to grow their home care workforce, should look to diversify and may want to look to add SNF-at-home options in order to attract new workers.

New York, Massachusetts and Washington D.C. showed the most growth with increases of 207, 201 and 175 home care workers per 1,000 people with disabilities respectively between 2009 and 2020.

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