Older adults often require a team to keep them healthy and well as they age. As older adults experience an increasing number of chronic conditions, care becomes more complex and the healthcare team expands, with a need to coordinate care across primary care clinicians and specialists. As activities of daily living (ADLs) such as eating, bathing and personal care become more difficult, older adults who are otherwise relatively healthy rely upon some combination of informal and formal caregivers, including family members, friends and home health aides to continue living in their home or in the community. Eventually, older adults may need to move into residential care facilities such as assisted living or skilled nursing for more round-the-clock care.
Declining Workforce Caring for Older Adults
The team caring for older adults is in crisis, with long-running concerns about a shortfall in the number of available workers. There are more than 118,000 family medicine physicians and another 250,000 nurse practitioners (NPs) in family medicine, many of whom care for older adults. More than a third of visits to primary care clinicians, including those who practice family medicine, are by patients ages 65 and older. Yet, as of 2021, only 10,000 primary care clinicians, including physicians and NPs, have specialized training in geriatric medicine.
While from 2016 to 2021 the overall number of active physicians specializing in geriatric medicine increased, keeping pace with the growth in the population ages 65 and older is challenging, and the future is not looking bright as the number of new geriatric medicine residents and fellows has declined over this same period.
‘Between January 2020 and January 2023, the LTSS workforce declined from 4.9 million workers to 4.6 million workers.’
The workforce picture is bleaker for older adults needing long-term care services and supports (LTSS), such as home health care, residential care or skilled nursing care. Between January 2020 and January 2023, the LTSS workforce declined from 4.9 million workers to 4.6 million workers, a trend largely driven by declining employment in skilled nursing facilities (SNFs).
While the pandemic contributed to this decline as families moved their older family members out of SNFs due to high rates of COVID-19 illness and death, the decline started before the pandemic as state Medicaid and Medicare Advantage plans shifted investments to home- and community-based services.
Nearly half of LTSS workers are direct care workers, including nursing assistants, home health aides and personal care aides. But these direct care workers have been experiencing the highest turnover rates among healthcare workers both before and during the pandemic. Contributing to the high turnover are low wages and lack of benefits such as paid sick leave or health insurance, which have left direct care workers—mostly women and people of color—to face difficult decisions between remaining employed and risking their health, versus not working and protecting their families during the pandemic.
Recruiting and Retaining a Workforce to Care for Older Adults
Workers caring for older adults appear to be driven by an intrinsic motivation that goes beyond wages when considering the near poverty level wages of direct care workers and the low salary of geriatricians relative to other specialties. We cannot, however, rely upon this motivation alone to recruit and retain an adequate workforce to care for older adults. A number of programs and initiatives exist that could bolster this workforce, and they all require investment to scale.
One approach is to expand funding for the Geriatrics Workforce Enhancement Program (GWEP) and the Geriatrics Academic Career Awards (GACA) (both administered by the Health Resources and Services Administration under Title VII of the Public Health Services Act), which aim to grow the workforce to care for older adults. GACA targets junior faculty to become academic geriatricians or geriatrician specialists.
GWEP provides funding to health professions schools and programs from a variety of fields to improve the integration of geriatrics and primary care as well as improve engagement of family and community members in the care of older adults. Of note about these programs is that training can be targeted to more than physicians and nurses, engaging health professions from the fields of pharmacy, dentistry, social work and more. Companion efforts to improve compensation by extending loan forgiveness to those who train in geriatrics through extending the National Health Service Corps Loan Repayment Program would be beneficial.
We need to recognize and reward workers’ dedication by investing in their future via increased wages and benefits and new career pathways.
The Senate Budget committee is considering a request to expand the budget of the U.S. Department of Health and Human Services Administration for Community Living (ACL) by $11.5 million in FY2024 to operationalize a resource hub of model policies and best practices to recruit and retain the direct care workforce, as well as develop new programs to support this workforce. Included in this request is the implementation of the National Strategy to Support Family Caregivers, which identified more than 500 actions that federal, state, community and other leaders can take to support family caregivers. Many of these caregivers are women providing unpaid caregiving valued at $600 billion to fill in LTSS workforce gaps.
Sens. Casey (D-PA) and Kaine (D-VA) have introduced the Better Care Better Jobs Act that would increase funding for home- and community-based services under Medicaid through federal matching and increasing payment rates, which in turn would increase wages for the direct care workforce.
Additionally, other state initiatives to support direct care workers to get into higher paid jobs should be evaluated and eventually scaled; for example, the Washington State Workforce Training and Education Coordinating Board in 2023 launched an apprenticeship program for direct care workers to become licensed practical nurses. These efforts are necessary for LTSS to be competitive with other service sectors such as retail and food services, which often advertise better pay and benefits.
Conclusion
Older adults need a high functioning and dedicated team with the appropriate training to provide the best care and social support so they can have the best years to come. While many people enter these professions with a commitment to serve older adults, we need to recognize and reward their dedication by investing in their future via increased wages and benefits and new career pathways. Solutions to the workforce crisis in caring for older adults are many, so now we need the political will to make them a reality.
Bianca Frogner, PhD, is a professor in the Department of Family Medicine in the School of Medicine at the University of Washington in Seattle, and the principal investigator of two Health Resources and Services Administration Health Workforce Research Center grants, one focused on allied health and another on the training and education of health professionals to address health equity.
Photo credit: Shutterstock/Ground Picture
