A Profile of the Direct Care Workforce in Home- and Community-Based Services

Abstract

We used data from the 2020 American Community Survey to compare direct care workers (DCWs) in home and community-based services (HCBS) with workers in other long-term supportive services (LTSS), such as skilled nursing facilities (SNFs) and assisted living facilities (ALFs). Compared to DCWs in SNFs and ALFs, a higher proportion of DCWs in HCBS were over age 65, Latino/a, and single. A lower proportion of DCWs in HCBS worked for a for-profit company, worked year-round and full-time, and had employer-based health insurance.

Keywords

home- and community-based care and services home care long-term services and supports employment

What this paper adds

• This paper adds to the existing literature documentation of trends in the direct care workforce within long-term supportive services.

• This paper adds to the existing literature the demographic characteristics of direct care workers in HCBS as compared to direct care workers in other LTSS.

• This paper adds to the existing literature the employment characteristics of direct care workers in HCBS as compared to direct care workers in other LTSS.

Application of study findings

• Applications of study findings include an understanding of the employees in HCBS and other LTSS (i.e., age, race/ethnicity, gender, marital status, education, financial status) for recruitment and retention.

• Applications of study findings include an understanding of the employers in HCBS and other LTSS (i.e., type of employer, full-time vs. part-time, year-round vs. part-year, source of health insurance) for recruitment and retention.

• Applications of study findings include recruitment and retention strategies for future direct care workers in HCBS and other LTSS.

Background and Objectives

The U.S. is experiencing an unprecedented surge in its oldest-old population (those age 85 and older), which is projected to reach 18 million by 2050. The need for long-term supportive services (LTSS) will consequently rise. This means increased demand not only in residential care facilities such as skilled nursing facilities (SNFs) and assisted living facilities (ALFs), but also in home and community-based services (HCBS). HCBS can help delay or prevent unnecessary institutionalization and keep the overall LTSS costs to individuals and families and to Medicaid down (Friedman et al., 2021; Nisbet & Morgan, 2019). With population aging, increased life expectancy, and the desire of older adults to age in place, there is increased demand for workers in the home and HCBS is the fastest-growing job sector in LTSS (Hartmann & Hayes, 2017; Shaw et al., 2021). At the same time, low pay and high turnover make recruitment and retention of workers in HCBS difficult (Nisbet & Morgan, 2019; Yoon & Khan, 2020) and some researchers and policymakers foresee occupational shortages in HCBS (Bandini et al., 2021).

The formal caregivers primarily responsible for delivering LTSS are direct care workers (DCWs). These frontline workers provide patient care under the direction of nursing staff, assistance with activities of daily living (ADLs), such as eating, bathing, dressing, and toileting, and assistance with instrumental activities of daily living (IADLs), such as housekeeping, meal preparation, and transportation (Kelly et al., 2020; Nisbet & Morgan, 2019). Previous studies have described demographic and employment characteristics of DCWs within specific industries such as SNFs (Kennedy et al., 2021); ALFs (Kelly et al., 2020) and those in HCBS (Bandini et al., 2021; Montgomery et al., 2005; Yoon & Khan, 2020). The goals of our study are: 1) to provide an updated profile of DCWs in HCBS and 2) to compare the demographic and employment characteristics of DCWs in HCBS with those of DCWs in other LTSS (i.e., SNFs and ALFs). These comparisons enable us to offer more detailed information to inform the recruitment and retention of DCWs as much of the LTSS workforce continues to shift from residential care facilities to HCBS.

Research Design and Methods

In this study, we used data from the U.S. Census Bureau’s (2022) American Community Survey’s Public Use Microdata Sample (PUMS). The American Community Survey (ACS) is an ongoing survey conducted by the U.S. Census Bureau. It collects detailed demographic, economic, and housing information. It samples approximately 3.5 million housing units and group quarters each year. The PUMS consists of a sample of detailed records from the ACS and represents a 1% sample of the entire U.S. The subsample of DCWs that we used in our study consisted of 20,580 records. When applying weights included in the sample file, the total number of DCWs represents 2,818,759 persons.

Information on LTSS industries (HCBS and other LTSS) in which DCWs are employed came from the North American Industry Classification System (NAICS), which is the standard used by Federal statistical agencies (e.g., the U.S. Census Bureau) in classifying business establishments for the purpose of collecting, analyzing, and publishing statistical data related to the U.S. business economy (U.S. Census Bureau, 2022). For the purposes of our study, HCBS industries in LTSS included: 1) home health care services (817); 2) individual and family services (837); and 3) private households (929). Other industries in LTSS included: 1) skilled nursing facilities (827) and assisted living facilities (829). (U.S. Census Bureau, 2022). These industries are described below.

Information on LTSS occupations came from the Standard Occupational Classification (SOC), which was first developed by the U.S. Census Bureau in 2000. The present study takes advantage of a 2018 change to the occupation codes in the PUMS, in which a single occupational category (nursing, psychiatric, and home health aides) was split into three separate occupations: home health aides; nursing assistants; and orderlies and psychiatric aides. This change enables us, and other researchers and policymakers, to identify with greater precision workers who are in distinctly different roles within the LTSS workforce. For our purposes, the LTSS workforce included 1) personal and home care aides (an occupation category unchanged from previous versions of the SOC); 2) home health aides; and 3) nursing assistants.

Industries in Long-Term Supportive Services

Home and Community-Based Services

The home health care services industry consists of organizations that provide skilled nursing, therapy, social work, and aide services to patients in their own homes (Medicare Payment Advisory Commission (MedPAC), 2022). These services include: personal care services; homemaker and companion services; physical therapy; medical social services; medications; medical equipment and supplies; counseling; 24-hour home care; occupational and vocational therapy; dietary and nutritional services; speech therapy; audiology; and high-tech care, such as intravenous therapy (U.S. Census Bureau, 2022).

The individual and family services industry includes organizations primarily engaged in providing non-residential social assistance services to improve the quality of life for older persons or persons with disabilities in such areas as day care, nonmedical home care or homemaker services, social activities, group support, and companionship (U.S. Census Bureau, 2022).

Finally, private households are engaged in employing workers on or about the premises in activities primarily concerned with the operation of the household. Private households may employ a diverse array of workers such as cooks, maids, nannies, butlers, gardeners, and caretakers (U.S. Census Bureau, 2022). However, we excluded most of these workers from our sample to include only workers who are employed by private households to deliver LTSS.

Other Long-Term Supportive Services

According to the North American Industry Classification System (NAICS), which is used by the U.S. Census Bureau, skilled nursing facilities comprise all establishments primarily engaged in providing inpatient nursing and rehabilitative services. This industry includes all nursing care facilities that provide post-acute care and/or long-term care. In other words, these establishments include all facilities that are also known as nursing homes. These establishments have a permanent core staff of registered or licensed practical nurses who, along with other staff, provide nursing and continuous care services. Individuals requiring nursing care usually require and extended stay in the care facility (U.S. Census Bureau, 2022).

Assisted living facilities belong to an industry separate from skilled nursing facilities in the NAICS. This industry comprises establishments primarily engaged in providing a range of residential and personal care services without on-site nursing care for 1) older adults and other persons who are unable to fully care for themselves and/or 2) older adults and other persons who do not desire to live independently. Individuals live in a variety of residential setting with meals, housekeeping, social, leisure, and other services available to assist residents in daily living (U.S. Census Bureau, 2022).

Occupations in Long-Term Supportive Services

Personal and home care aides are DCWs who assist older or disabled adults with instrumental activities of daily living (IADLs) at the home or in a daytime non-residential facility (e.g., an Alzheimer’s day center). Duties performed at a place of residence typically include IADLs such as keeping house (making beds, doing laundry, washing dishes) and preparing meals. Personal and home care aides also serve meals and supervise activities at non-residential facilities. Finally, personal and home care aides may advise families and older and disabled adults on such issues as nutrition, cleanliness, and household utilities (U.S. Census Bureau, 2022).

Home health aides are DCWs who assist older, convalescent, or disabled adults with IADLs (see above) and with activities of daily living (ADLs), which include routine, personal care, such as bathing, dressing, and grooming. They work mostly in the homes of patients or in other residential settings (such as independent living communities). Home health aides also perform some delegated nursing tasks under the supervision of nurses and receive additional hours of training as required by the Center for Medicare and Medicaid Services (CMS) (Nisbet & Morgan, 2019).

Nursing assistants are DCWs who provide basic patient care, such as medication assistance and taking vital signs, under the direction of nursing staff. They also provide ADL and IADL assistance, including personal care, such as bathing, dressing, and grooming and household tasks, such as serving meals and changing linens (Centers for Medicare and Medicaid Services, 2002; U.S. Census Bureau, 2022). They work in residential settings and in institutional settings (such as hospitals, SNFs, and ALFs). Nursing assistants are required to complete a state-approved education program, and to pass their state’s competency exam, to become licensed or certified (U.S. Bureau of Labor Statistics, 2022).

Results

Distribution of the Direct Care Workforce in Long-Term Supportive Services by Occupation and Industry

As shown in Table 1, DCWs in HCBS comprised nearly two-thirds (64.2%) of the more than 2.8 million DCWs in LTSS in 2020. More than three-fourths (76.8%) of all personal and home care aides in LTSS worked in HCBS; 16.4% worked in ALFs and 6.8% worked in SNFs. Personal and home care aides also represented the largest occupation in the HCBS workforce; personal and home care aides comprised more than half (56.4%) of the more than 1.8 million DCWs in HCBS. The next-largest occupation was home health aides, who comprised 32.3% of DCWs in HCBS. The vast majority of all home health aides in LTSS worked in HCBS (96.8%); the remainder worked in SNFs and ALFs. Nursing assistants made up the remaining 11.3% of DCWs in HCBS. More than one-fifth (22.8%) of all nursing assistants in LTSS worked in HCBS; 60.2% of nursing assistants worked in SNFs and 16.8% worked in ALFs.

Table 1.

Estimates of Direct Care Workers in Long-Term Supportive Services by Occupation and Industry.

	Occupation
Industry	Personal and Home Care Aides	Home Health Aides	Nursing Assistants	Total
HCBS
Home health care services	335,783	510,905	154,767	1,001,455
Individual and family services	519,088	61,580	40,733	621,401
Private households	165,330	11,464	8,625	185,419
Other LTSS
Skilled nursing facilities	89,029	9,556	534,125	632,710
Assisted living facilities	218,769	9,692	149,313	377,774
Total	1,327,999	603,197	887,563	2,818,759

Note: U.S. Census Bureau (2022).

Demographic Characteristics of DCWs in Long-Term Supportive Services Industries (Home and Community-Based Services and Other Long-Term Supportive Services)

As shown in Table 2, DCWs in HCBS industries (i.e., home health care services, individual and family services, and private households) were older than DCWs in other LTSS (i.e., SNFs and ALFs). Less than 10% of DCWs employed by home health care services (9.6%), individual and family services (9.5%) and private households (7.9%) were under age 25. By comparison, 21.6% of DCWs employed by SNFs and 22.7% of DCWs employed by ALFs were under age 25. Conversely, there were higher proportions of older workers in HCBS than in other LTSS. More than one-third of DCWs employed by home health care services (34.1%), individual and family services (37.9%), and private households (41.9%) were age 55 and over. In contrast, 18.8% of DCWs employed by SNFs, and 21.0% of DCWs employed by ALFs were age 55 and over.

Table 2.

Demographic Characteristics of Direct Care Workers by Industry.

	Total	HCBS			Other LTSS
	Total	Home Health Care Services	Individual and Family Services	Private Households	Skilled Nursing Facilities	Assisted Living Facilities
Number of Workers	2,818,759, %	1,001,455, %	621,401, %	185,419, %	632,710, %	377,774, %
AGE
Under 25	13.8	9.2	9.5	7.9	21.6	22.7
25–34	19.1	17.2	17.4	10.3	24.2	22.6
35–44	17.4	18.5	14.4	15.9	18.9	17.4
45–54	19.5	21.1	20.8	24.0	16.5	16.4
55–64	20.8	22.6	25.2	27.0	15.0	15.5
65 or older	9.5	11.5	12.7	14.9	3.8	5.5
GENDER
Male	13.5	11.5	18.0	15.4	10.2	16.1
Female	86.5	88.5	82.0	84.6	89.8	83.9
RACE/ETHNICITY
White, non-Latino/a	38.9	34.3	40.5	43.9	41.5	41.9
African American, Non-Latino/a	29.0	30.2	21.8	19.0	35.4	32.3
Other, non-Latino/a	12.3	11.9	15.5	13.9	10.2	10.8
Latino/a	19.8	23.7	22.2	23.3	12.9	15.1
MARITAL STATUS
Married	37.3	38.4	40.1	38.2	34.7	34.2
Widowed	4.3	5.1	4.9	6.3	2.5	3.1
Divorced/separated	20.8	23.4	21.4	24.7	17.5	16.5
Never married	37.6	33.1	33.7	30.8	45.3	46.2
EDUCATION
Not HS graduate	14.6	17.1	17.4	14.0	10.9	9.8
High school graduate	36.5	35.8	34.2	30.9	40.0	39.0
Some college	28.6	26.2	26.2	28.8	32.2	32.7
Associate’s degree	9.3	9.2	9.4	10.2	9.8	8.0
College graduate	11.0	11.8	12.8	16.0	7.1	10.4
OTHER
With a disability	11.3	12.3	12.8	14.7	8.3	9.9
Moved in past year	13.9	12.0	11.5	12.1	16.4	19.1
Speak language other than English at home	31.1	35.1	36.7	32.7	22.8	24.6
Not a U.S. citizen	11.2	13.2	12.0	12.6	7.6	9.5

Note: U.S. Census Bureau (2022).

DCWs in HCBS industries were predominantly female; in 2020, between 80-90% of DCWs employed by home health care services (88.5%), individual and family services (82.0%), and private households (84.6%) were women. These proportions were similar to the large female majorities among DCWs employed by SNFs (89.8%) and by ALFs (83.9%).

The direct care workforce in HCBS was majority non-white in 2020. Less than half of DCWs employed by home health care services (34.3%), individual and family services (40.5%), and private households (43.9%) were white, which were similar to the proportions among DCWs employed by SNFs (41.5%) and by ALFs (41.9%). However, there were higher proportions of Latino/a DCWs employed in HCBS industries than by other industries in LTSS. Nearly one-quarter of DCWs employed by home health care services (23.7%), individual and family services (22.2%), and private households (23.3%) were Latino/a, which was considerably higher than the proportions of Latino/a DCWs employed by SNFs (12.9%) or by ALFs (15.1%).

The proportion of married DCWs was slightly higher in HCBS industries than in other industries in LTSS. Roughly two-fifths of DCWs employed by home health care services (38.4%), individual and family services (40.1%), and private households (38.2%) were married, as compared to 35.7% of DCWs employed by SNFs and 34.2% of DCWs employed by ALFs. Higher proportions of DCWs in HCBS were also widowed and divorced or separated than were DCWs in SNFs and ALFs. In HCBS industries, 5.1% of DCWs in home health care services, 4.9% in individual and family services, and 6.3% in private households were widowed, as compared to 2.5% in SNFs and 3.1% in ALFs. Nearly one-fourth of DCWs working in HCBS were divorced (23.4% in home health care services, 21.4% in individual and family services, 24.7% in private households), as opposed to 17.5% in SNFs and 16.5% in ALFs. Conversely, a slightly lower proportion of DCWs in HCBS industries were never married. Roughly one-third of DCWs employed by home health care services (33.1%), individual and family services (33.7%), and private households (30.8%) were never married; in contrast, nearly one-half of DCWs employed by SNFs (45.3%) and by ALFs (46.2%) were never married.

A higher proportion of DCWs in HCBS industries had less than a high school education as compared to DCWs in other industries in LTSS. Nearly one-fifth of DCWs employed by home health care services (17.1%), individual and family services (17.4%), and private households (14.0%) were not high school graduates, as compared to 10.9% of DCWs employed by SNFs and 9.8% of DCWs employed by ALFs. At the same time, a higher proportion of DCWs in HCBS were college graduates: 11.8% of DCWs employed by home health care services, 12.8% of those employed by individual and family services, and 16.0% of DCWs employed by private households; this was higher than the 7.1% of DCWs employed by SNFs and the 10.4% employed by ALFs who were college graduates.

Home and Community-Based Services industries had higher proportions of workers with a disability than other industries in LTSS. Between 10-15% of DCWs employed by home health care services (12.3%), individual and family services (12.8%), and private households (14.7%) had a disability as compared to 8.3% of DCWs employed by SNFs and 9.9% of DCWs employed by ALFs. Lower proportions of DCWs in HCBS industries moved in the previous year in comparison to DCWs in other industries in LTSS. Between 10–15% of DCWs employed by home health care services (12.0%). Individual and family services (11.5%), and private households (12.1%) moved in the previous year, as compared to 16.4% of DCWs employed by SNFs and 19.1% of DCWs employed by ALFs.

Finally, HCBS industries employed larger proportions of DCWs who spoke another language at home or were not U.S. citizens than other LTSS. More than one-third of DCWs employed by home health services (35.1%), individual and family services (36.7%), and nearly one-third (32.7%) of DCWs employed by private households spoke English as a second language, as compared to 22.8% of DCWs employed by SNFs and 24.6% of DCWs employed by ALFs. Non-U.S. citizens comprised 13.2% of DCWs in home health care services, 12.0% in individual and family services, and 12.6% in private households, as compared to the 7.6% of DCWs in SNFs and the 9.5% in ALFs who were not U.S. citizens.

Employment Characteristics of DCWs in Long-Term Supportive Services Industries (Home and Community-Based Services and Other Long-Term Supportive Services)

As shown in Table 3, more than three-fourths of DCWs employed by home health services (79.4%) worked for a for-profit company, a slightly higher proportion than DCWs employed by other industries in LTSS, specifically skilled nursing facilities (78.5%) and assisted living facilities (71.8%), respectively. Other DCWs in HCBS industries, including those employed by individual and family services (49.6%) and those employed by private households (62.5%) were less likely to be employed by for-profit companies than DCWs who worked in residential care facilities. Non-profit companies employed one-fifth (20.3%) of DCWs who worked in individual and family services and 20.3% of DCWs who worked in assisted living facilities; these were the highest across LTSS industries (HCBS or other LTSS). Individual and family services also employed the highest proportion of DCWs (21.7%) who worked for the government, among LTSS industries. Finally, private households had the highest proportion of self-employed DCWs (35.0%) across LTSS industries.

Table 3.

Employment Characteristics of Direct Care Workers by Industry.

	Total	HCBS			Other LTSS
	Total	Home Health Care Services	Individual and Family Services	Private Households	Skilled Nursing Facilities	Assisted Living Facilities
Number of Workers	2,818,759, %	1,001,455, %	621,401, %	185,419, %	632,710, %	377,774, %
CLASS OF WORKER
For-profit company	70.5	79.4	49.6	62.5	78.5	71.8
Non-profit company	13.7	9.2	20.3	0.0	14.6	20.3
Government	8.5	4.8	21.7	2.5	5.3	4.8
Self-employed	7.3	6.5	8.5	35.0	1.6	3.1
WORK STATUS
Year-round, full-time	48.0	41.9	43.6	37.0	59.9	56.9
Year-round, part-time	26.1	32.0	30.7	27.6	16.4	16.4
Part-year, full-time	10.5	10.0	8.7	12.3	11.4	11.4
Part-year, part-time	15.3	16.0	17.0	23.1	12.2	12.2
POVERTY RATIO
Less than 0.50	4.9	6.0	5.0	7.3	3.8	2.7
0.50–0.99	10.9	12.3	10.8	12.7	9.3	8.9
1.00–1.49	12.6	14.1	11.5	11.0	11.7	12.7
1.50–1.99	13.7	14.3	12.1	10.9	14.2	15.5
2.00–2.99	22.7	21.4	22.7	18.7	25.8	22.8
3.00 or more	34.4	31.4	37.2	38.9	33.8	36.4
WAGE AND SALARY INCOME
Less than $10,000	27.5	29.9	31.1	53.1	17.6	19.2
$10,000 to $19,999	24.3	27.1	26.0	18.1	20.5	23.7
$20,000 to $29,999	23.5	21.4	19.5	10.4	30.5	30.1
$30,000 to $39,999	13.7	11.5	11.6	7.7	19.6	16.1
$40,000 to $49,999	5.6	4.6	6.0	3.9	7.1	6.0
$50,000 or more	5.4	5.5	5.8	6.7	4.7	5.0
HEALTH INSURANCE
With insurance	84.0	81.6	86.7	80.4	85.6	85.1
From employer	42.3	33.9	39.8	31.1	56.3	51.0
From medicare	10.7	12.9	14.3	15.4	4.4	6.9
Purchased directly	13.3	14.6	13.0	19.0	10.1	12.5
From medicaid	28.7	32.0	32.6	28.9	22.7	23.4

Note: U.S. Census Bureau (2022).

DCWs in HCBS industries were less likely to be year-round and full-time employees than DCWs in other industries in LTSS. Less than half of DCWs employed by home health care services (41.9%), individual and family services (43.6%), and private households (37.0%) worked year-round and full-time, as opposed to more than half who were employed by skilled nursing facilities (59.9%) and assisted living facilities (56.9%). Conversely, DCWs in HCBS were more likely to be year-round and part-time employees than those in residential care facilities. Nearly one-third of DCWs employed by home health care services (32.0%), individual and family services (30.7%), and private households (27.6%) worked year-round and part-time, while less than one-fifth of DCWs employed by skilled nursing facilities (16.4%) and assisted living facilities (18.3%) worked year-round and part-time. Finally, private households employed the highest percentage (23.1%) of DCWs who worked part-year and part-time across all LTSS industries.

A higher proportion of DCWs in HCBS industries lived below the federal poverty level (FPL) that DCWs in other industries in LTSS. Nearly one-fifth of DCWs employed by home health services (18.3%), individual and family services (15.8%), and private households (20.0%) were below the FPL, as compared to 13.1% of DCWs employed by skilled nursing facilities and 11.6% of DCWs employed by assisted living facilities. Similarly, a higher proportion of DCWs in HCBS earned less than $20,000 in annual wage and salary income than in other LTSS. More than half of DCWs employed by home health care services (57.0%), individual and family services (57.1%), and private households (71.2%) earned less than $20,000 a year, as compared to 38.1% of DCWs employed by skilled nursing facilities and 42.9% of DCWs employed by assisted living facilities.

More than four-fifths of DCWs in HCBS industries had health insurance in 2020; this was roughly similar to the proportion of DCWs in other industries in LTSS. However, a lower proportion of DCWs in HCBS received health insurance from their employer than DCWs in residential care facilities. Less than 40% of DCWs employed by home health care services (33.9%), individual and family services (39.1%) and private households (31.1%) were insured through their employer, as compared to 56.3% of DCWs employed by skilled nursing facilities and 51.0% of DCWs employed by assisted living facilities. Conversely, higher proportions of DCWs in HCBS received health care insurance from Medicare or from Medicaid than did DCWs in residential care facilities. Among DCWs employed by home health care services, 12.9% were covered by Medicare and 32.0% by Medicaid. Medicare covered 14.3% of DCWs employed by individual and family services, while Medicaid covered 32.6% of these workers. More than 15% of DCWs employed by private households were covered by Medicare and 28.9% of these workers were covered by Medicaid. In contrast, less than 10% of DCWs in skilled nursing facilities (4.4%) and assisted living facilities (6.9%) were covered by Medicare and less than 25% of DCWs in skilled nursing facilities (22.7%) and assisted living facilities (23.4%) were covered by Medicaid.

Discussion

Home and Community-Based Services have become a vital link in the continuum of LTSS, supporting older adults and persons with disabilities, promoting aging in place, and helping to control the costs of care for individuals, families, and public programs such as Medicaid (Friedman et al., 2021; Nisbet & Morgan, 2019). Today, HCBS providers employ nearly two-thirds of the DCWs in LTSS, a broad category of industries in the U.S. economy that encompasses not only HCBS, but also residential care facilities (i.e., SNFs and ALFs). The growth of the direct care workforce is HCBS reflects the overwhelming preference of older adults and persons with disabilities to age in place. This desire, in combination with population aging and increased life expectancy, means that the demand for DCWs in HCBS will continue to increase in the next two decades. What concerns researchers, policy makers, and especially older adults, persons with disabilities, and their families, is whether the supply of DCWs in HCBS will keep pace with this demand. It is necessary to all these stakeholders that we understand better the individuals who fill DCW jobs in HCBS, and how they are distinct from DCWs in SNFs and ALFs, so that we can recruit, train, and retain a workforce sufficient to meet the needs of older and disabled persons aging in place tomorrow and in the decades ahead.

Our study revealed demographic and employment patterns in the direct care workforce in HCBS industries, some that were similar to those in other industries in LTSS, others that were distinct. Although the number of male DCWs working in HCBS (and in all LTSS) has tripled since 2000 (Kelly et al., 2022), women continued to comprise the vast majority of the DCW workforce in HCBS as they do in residential care facilities. The results of a related study of the male direct care workforce (Kelly et al., 2022), as well as anecdotal evidence, suggest there is a growing demand for male personal and home care aides, particularly among the increasing number older male clients living alone who may prefer a male DCW. However, the continued stigmatization of formal caregiving as “women’s work” contributes to both HCBS and other industries in LTSS remaining highly feminized overall (Smith et al., 2020).

Other characteristics we found among DCWs in HCBS differed, sometimes sharply, from those among DCWs in other LTSS. Compared to SNFs and ALFs, HCBS industries employed higher proportions of workers who were older, Latino/a, not high school graduates, spoke a language other than English at home, and were not U.S. citizens. All of the above factors are disadvantages in the U.S. workforce and, we believe, related to higher proportions of DCWs in HCBS being near or below the FPL, receiving low income in wages and salaries, and obtaining health insurance through government programs (i.e., Medicare and especially Medicaid) than workers in other LTSS. Previous studies described the disadvantages DCWs in SNFs and ALFs relative to the overall labor force (Dill et al., 2013; Kennedy et al., 2021); our findings indicate that these disadvantages are even more pronounced among DCWs in HCBS industries.

Finally, DCWs in HCBS were more likely to be part-time workers than those employed in other LTSS industries. While the part-time nature of HCBS may be perceived as an advantage for some DCWs in terms of flexibility, for others this may be a disadvantage in terms of compensation. DCWs in HCBS may have to care for multiple clients, and to coordinate the schedules of care for these clients, in order to make up full-time work. The structure of work in HCBS is unique and this must be taken into consideration by DCWs when they choose to work in HCBS or in other LTSS industries.

There are numerous interpretations for these findings. For example, these results may indicate that for immigrants to the U.S. (particularly those who are from Latin American countries) and for those who have less formal education, the most readily available jobs in LTSS tend to be in HCBS. Age and language are less likely to be obstacles to employment when the job is to provide care to one client at home (as in HCBS) as opposed to multiple clients in a residential care facility. Also, higher proportions in HCBS of DCWs in the age 55–64 and age 65 and over age groups may suggest that these industries offer not only “entry-level jobs,” but also “exit-level jobs,” attracting older workers, many who may have previous experience in other LTSS industries.

Other employment characteristics of DCWs in HCBS shed further light on which workers may be attracted to these jobs. Compared to DCWs in SNFs and ALFs, higher proportions of HCBS workers worked for non-profit employers, government employers, or were self-employed. Also, higher proportions of DCWs in HCBS worked part-time than did DCWs in SNFs and ALFs. Together, these findings suggest that while HCBS tends to pay DCWs less than SNFs and ALFs, they may offer DCWs other advantages, such as lower barriers to employment, and greater autonomy and flexibility (particularly for those HCBS workers who are self-employed). Further, relative to DCWs in SNFs and ALFs, a lower proportion of DCWs in HCBS moved in the past year. Thus, despite employment characteristics that may make work in HCBS appear more tenuous than work in hospitals and residential care facilities, we found no evidence to suggest that HCBS workers are more likely to move from job to job. This stability may also be seen as a benefit to the clients that HCBS workers serve.

In conclusion, our study indicates that the direct care workforce in HCBS, the fastest-growing segment within LTSS, shares certain characteristics with other LTSS industries such as SNFs and ALFs (e.g., predominantly female) but is distinct in several others (e.g., higher concentrations of older, Latino/a, and part-time workers). Limitations to this study include our use of 1% PUMS data from the ACS. Although this survey is conducted annually, which is an advantage over the decennial U.S. Census, it is a sample of roughly three million U.S. addresses, as opposed to the entire U.S. population, which means that the ACS provides a less exact measure than the U.S. Census of demographic and employment characteristics. A second limitation is that we used data from the 2020 ACS, which means that the full impact of the COVID-19 pandemic, which has brought comprehensive and at times catastrophic changes to HCBS and other LTSS, cannot be assessed from the data available. Future researchers will be in a better position to describe the long-term impact of the pandemic on LTSS, particularly its acceleration of the continued shift of care from SNFs and ALFs to HCBS.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article: This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

ORCID iD

Christopher M. Kelly

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