The Eldercare Workforce Alliance (EWA), a coalition of 28 national organizations united to address the immediate and future workforce crisis in caring for an aging America, strongly supports the mandate of the Commission on Long-Term Care to recommend sensible, sustainable solutions for the financing and delivery of long-term services and supports (LTSS).  Our member organizations represent consumers, family caregivers, and healthcare professionals, including direct-care workers.

The formulation of a national strategy to address long term care challenges is among our nation’s most pressing issues, as 10,000 Americans turn 65 every day. According to the Institute of Medicine (IOM), the number of people with impairments who require assistance is likely to grow substantially in coming years. Focusing on older adults alone, the IOM conservatively estimates that the number of older people with impairments or limitations could increase from approximately 14 million in 2007 to more than 28 million in 2030. [i]

To respond to these needs, the Commission must recommend strategies for building, sustaining, and deploying the workforce needed to meet elders’ growing demand for LTSS.

Long-Term Services and Supports Challenges Demand an Immediate Solution

LTSS Financing to Support Access and Quality

Medicaid is currently the primary source of public financing for LTSS and represents a significant portion of state budgets.[ii]  More and better financing options are needed to enable older people who have, or who may develop, functional impairments to remain independent and to reside in their homes and communities.   Furthermore, financing must be adequate to ensure reimbursements and compensation support quality care and access to home- and community based services.  Unfortunately, the current system is biased toward providing services in institutional settings, which are more costly.  Alternative financing options must respond to the demand for home-based care delivery, which is increasing due to individuals’ preferences for receiving supports and services at home rather than in an institutional setting; legal decisions supporting the right to receive care in the least restrictive settings possible; and resulting state and federal policy initiatives aimed at increasing access to home and community?based services.[iii]

Home-Based Care Delivery Workforce

Currently, home-based long-term services and supports are provided primarily by family members and friends caring for their loved ones, and by over 2.5 million home-based direct-care workers.

AARP Public Policy Institute’s study, “Valuing the Invaluable: The Growing Contributions and Costs of Family Caregiving, 2011 Update,” reports that unpaid care by family and friends, worth approximately $450 billion annually in 2009, represents more than twice the value of formal paid long-term services and supports. In addition, caregivers to persons 50 or older reported spending an average of more than 10 percent of their annual income on out of pocket caregiving expenses, equivalent to an average of $5,531 in 2007, with long-distance caregivers averaging $8,728 annually.  Without the contributions of family caregivers, the economic cost of health care and long?term care services would increase astronomically. Supporting the essential role of family caregivers must be an important part of the Commission’s deliberations.

The efforts of family caregivers are supplemented by care provided by the paid workforce.  Seventy to eighty percent of paid, hands?on long?term care is provided to older adults by direct-care workers[iv] with oversight, in some states, from licensed nurses. These workers provide physically and emotionally demanding and often life?sustaining services. They cook, bathe, feed, and attend to the everyday personal and medical needs of people who receive support in their homes and communities. In doing so, they ensure that individuals can maintain their independence and continue to live in their own homes.

Already the U.S. is dealing with an acute shortage of direct?care workers; a shortage that will only worsen over the next 20 years as millions of Americans will need long term health care.  Home care occupations are projected to be the top two fastest-growing occupations in the nation within the next decade. [v]   To ensure that direct-care workers are able to provide the highest-quality care to all long-term care consumers, these positions should offer comprehensive training, certification, appropriate supervision, and career advancement opportunities; have livable, family-sustaining wages; affordable health insurance and other benefits; as well as balanced workloads and full-time hours if desired.[vi]

The direct care provided by family caregivers and direct-care workers must be supported by a broader eldercare workforce that is trained with the skills and knowledge to meet older adults’ unique needs to prevent unnecessary hospitalization, institutionalization or deterioration. Unfortunately, as detailed in two recent Institute of Medicine reports[vii], interdisciplinary health care teams[viii] with special training in geriatrics and gerontology will likely be in critically short supply to meet the burgeoning demand unless we take sufficient steps to prepare for future workforce needs.


EWA urges the Commission on Long-Term Care to devote essential attention to its prescribed duties related to the long?term care workforce, including the workforce of family caregivers, and examine and provide recommendations pertaining to workforce size, development, and infrastructure. EWA looks forward to working with the Commission, and offering our expertise to help identify the best strategies to address our long term care workforce challenges.

[i] The Future of Disability in America., Institute of Medicine (US) Committee on Disability in America; Field MJ, Jette AM, editors. Washington (DC): National Academies Press (US); 2007

[ii] Kaiser Commission Medicaid and the Uninsured. “Medicaid and Long?Term Care Services and Supports,” June 2012.

[iii] PHI, “Caring in America: A Comprehensive Analysis of the Nation’s Fastest-Growing Jobs: Home Health and Personal Care Aides” by Dorie Seavey, PhD, Director of Policy Research and Abby Marquand, MPH, Policy Research Associate, December 2011.

[iv] Paraprofessional Healthcare Institute, Direct-care Health Workers: The Unnecessary Crisis in Long-Term. The Aspen Institute, January 2001.

[v] PHI, “Facts 1: Occupational Projections for Direct-Care Workers 2010-2020,” February 2013

[vi]  Dawson, Steven L., “Improving Jobs and Care: A National Sector Strategy,” PHI.

[vii] The 2008 Retooling for an Aging America: Building the Health Care Workforce and the 2012 Mental Health and Substance Use Workforce for Older Adults: In Whose Hands?

[vii]i Teams include nurses, physicians, direct?care workers, physical, occupational and speech therapists, pharmacists, social workers, psychiatrists and psychologists, as well as others.

The positions of the Eldercare Workforce Alliance reflect a consensus of 75 percent or more of its members. These endorsements reflect the consensus of the Alliance and do not necessarily represent the position of individual Alliance member organizations.

The Eldercare Workforce Alliance is a project of The Advocacy Fund