Halfpoint Images/Getty Images

The home care workforce has grown significantly in most states over the last 12 years, but not necessarily at the expense of nursing homes, a new study finds.

Researchers looking to document state-by-state trends in the direct care workforce found that not all states are performing equally when looking to expand their home- and community-based labor pools. That’s creating a widening gulf between those prepared to shift to more home care options and those less ready, lead author Esther M. Friedman told McKnight’s Friday.

“It’s important to think about whether we’re able to meet the demand for direct care as the population ages at the national level, which is where there’s been a lot of focus,” said Friedman, research associate professor at the Institute for Social Research at the University of Michigan and former social scientist with the RAND Corporation. “But our work suggests we also need to pay attention to state differences in whether the direct care workforce is large enough across states both to meet this demand, but also to provide options so people with disabling conditions and their caregiver can truly select from among the best settings to find the setting that is best suited to their particular needs.”

The home care workforce has been increasing at a substantially faster pace than the nursing home workforce has been decreasing. On average nationally, the U.S. gained about 53 home care workers (represented by those holding personal care aide and home health aide job titles) per 1,000 people with disabilities. In the same 12-year period, the U.S. lost about nine nursing home workers (identified as nursing assistants) per 1,000 people with disabilities, Friedman and colleagues from RAND reported in the December issue of Health Affairs.

But the gains and losses were not consistent across states, which Friedman said should be a key takeaway for policymakers and providers. The gap between states with the largest home care workforce relative to those with the smallest existed at the start of the study period in 2009, but it continued to grow through 2020.

Esther M. Friedman

“States kind of leading in the size of their home care workforce have continued to propel forward, while states that were lagging in the size of this workforce haven’t quite caught up,” Friedman said. “This is only concerning because it means people with disabling conditions in some states might be left with fewer options.”

Policies may jumpstart growth

While the study did not examine causes for job gains and losses, the researchers reported some states have been “working more than others to expand the direct care workforce by providing wage and benefit enhancements and career ladder initiatives such as training, mentoring and credentialing.” They also reported that states in which home care workers do not have union bargaining rights “have been less successful.”

Recent Medicaid policies that have specifically targeted states that have traditionally spent less on HCBS relative to institutional spending have also likely provided a boost in those states. Friedman cited CMS programs intended to rebalance long-term care options, specifically including the Balancing Incentive Programs, or BIP, open only to states that had lower community-based spending.

While Friedman and her team said efforts to bolster home care staffing should include more support policies and worker pay enhancements, she said similar measures also could likely attract more workers to nursing homes. Institutional long-term care will remain an area of focus, too, given demographics and the need to support people whose needs become so great that they can no longer be cared for at home.

In fact, 10 states saw their nursing home workforce grow during the study period, according to the analysis. They were: Alabama, Arkansas, Hawaii, Kansas, Nevada, North Carolina, North Dakota, South Dakota,  Utah and Virginia.

It’s uncertain yet what impact COVID-19 related job departures and the current labor crisis in the U.S. have had on these findings. Researchers did not account for that volatility in the current study.