OLR Research Report

November 13, 2013




By: Kevin E. McCarthy, Principal Analyst

You asked for a discussion of whether there is a shortage, at the national level, in the long-term care workforce. Your question was prompted by a 2001 study prepared by the Urban Institute for the U.S. Department of Health and Human Services that asserted that there were shortages of paraprofessional workers in this industry and that these shortages were likely to increase over time.


Much of the workforce providing long-term care consists of nursing aides, orderlies, and attendants who help provide basic care for residents of facilities such as nursing homes and in other settings. In addition, “personal care aides” (also called personal care assistants) provide non-medical services, typically in people's homes.

The Urban Institute study noted that, at the time of its publication, long-term care providers were reporting unprecedented vacancies and turnover rates for these paraprofessional workers. The study also projected that this shortage would likely increase over time as the population aged. When it published the study, the national unemployment rate was 4.1%. Now, with the rate currently at 7.3%, it is unclear whether a shortage of paraprofessionals in the long-term care industry exists or could be predicted. We have found no data on indicators that might show a current shortage for such workers, e.g., high vacancy rates in long-term care paraprofessional positions and recent salary trends suggest that there is not a shortage of such workers.

The Bureau of Labor Statistics (BLS) has more recently projected that demand for the paraprofessional health care workers will increase faster than overall demand for workers, but slower than demand for healthcare workers in general. In contrast, it projects that demand for home health aides and personal care aides will increase substantially more than overall labor demand. But we have found no projections by BLS or others on the supply of these workers. As a result, we cannot say whether it is likely that there will be these labor shortages in this industry.


Long-Term Care Workforce

According to the BLS, much of the workforce providing long-term care consists of nursing aides, orderlies, and attendants who help provide basic care for residents of long-term care facilities such as nursing homes, as well as patients in hospitals and those receiving care at home. For example, 40% of workers in nursing homes were employed in these occupations as of 2012; in contrast, only 8.3% of these workers were registered nurses.

Nursing aides, such as certified nursing assistants, typically:

1. clean and bathe residents or patients;

2. help them use the toilet and dress;

3. turn, reposition, and transfer patients between beds and wheelchairs;

4. listen to and record health concerns and report that information to nurses;

5. measure vital signs, such as blood pressure and temperature; and

6. serve meals and help patients eat.

Some nursing aides and attendants also dispense medication, depending on their training level and the state where they work. In Connecticut, a number of community colleges have established certified nurse aide (CNA) training programs. The programs are 120 hours and range from 12 weeks to a semester in length.

Orderlies may do some of the same tasks as nursing aides and attendants, although they do not usually provide healthcare services. They typically transport patients and clean equipment and facilities.

In addition to these health care paraprofessionals, personal care aides help the elderly, convalescents, or people with disabilities with daily living activities at the person's home or in a care facility. In the home, their duties may include keeping house and preparing meals. They also may provide assistance at non-residential care facilities.

Urban Institute Study

The Urban Institute study noted that in 2001 long-term care providers were reporting unprecedented vacancies and turnover rates for their workers. However, national data on turnover rates at that time showed wide variation, depending on the source of the data. One source suggested that turnover rates averaged about 45% for nursing homes, while other data placed the rate at over 100% a year. The report also cited a 1999 national survey on long-term care workforce issues conducted by the state of North Carolina that found that recruitment and retention of paraprofessional workers was a major priority in the 42 responding states.

The report also noted that:

difficulty in recruiting nursing and home health aides is likely to become worse as the number of people needing long-term care increases relative to the number of people between ages 20 and 64, who make up most of the workforce. Between 1998 and 2008, BLS estimates there will be 325,000 more nursing assistant and 433,000 more personal care and home health aide jobs, but there is little evidence that there will be enough people to fill them.

Shortages in the Long-term Care Workforce

Current. According to BLS, there were approximately 2.4 million nursing, psychiatric, and home health aides as of 2012. Of these, 1.4 million were “nursing assistants,” of whom more than half (620,000) worked in skilled nursing facilities (nursing homes) and 166,000 in continuing care retirement communities and assisted living facilities. In addition, BLS estimates that there were approximately 985,000 personal care aides working in 2012.

There do not appear to be data to determine whether there is currently a shortage of long-term care workers. Possible indicators of a shortage could include:

1. high numbers of vacancies in the relevant positions,

2. lengthy delays in filling openings,

3. increasing workweeks, or

4. increasing turnover rates.

However, it appears that neither BLS nor any other source collects national data on these variables specifically for the long-term care industry or the paraprofessional occupations that account for much of its workers. For example, the BLS Job Openings and Labor Turnover Survey reports data for the health care and social assistance industry cluster, which includes many industries in addition to long-term care.

Another potential indicator of a workforce shortage is salary trends. If there was a shortage of workers in the long-term care industry, economic theory would argue that salaries would increase. But recent salary trends suggest that this has not been the case in long-term care paraprofessional occupations. According to BLS, the average (mean) annual salary for all full-time workers increased 3.1% between 2010 and 2012; for nursing assistants and personal care aides the increase was 1.7% and 2.0%, respectively (BLS changed its occupational categories between 2009 and 2010).

Future. BLS suggests that as a result of the growing elderly population, many health care paraprofessionals will be needed in long-term care facilities. In 2010, BLS projected that total demand for these workers would grow by 20% from 2010 to 2020, faster than the 14% average for all occupations. However, BLS also noted that demand for these workers may be constrained by the fact that many nursing homes rely on government funding, which tends to increase slower than the cost of patient care. BLS projected that the growth in healthcare related occupations taken as a whole would be 34% during this period. It also projected that demand for personal care aides and home health aides would rise 70% and 69%, respectively, during this period. In addition, as the population ages, there will be an increasing number of people with disabilities.

Neither BLS nor other sources project future supply of workers in these occupations. As a result, we cannot say how likely shortages in this industry will be in the future, although the long-term care industry believes this is likely.

Sources used:

Urban Institute study (2001) “Who Will Care for Us? Addressing the Long-Term Care Workforce Crisis” http://aspe.hhs.gov/daltcp/reports/ltcwf.pdf.

Current paraprofessional employment data


BLS workforce demand projections http://www.bls.gov/ooh/healthcare/nursing-assistants.htm