An international review of the long-term care workforce: policies and shortages

The developed world's population is aging, due to trends of increased life expectancies and decreased fertility rates. These trends are predicted to increase demand on long-term care services. At the same time, the long-term care workforce is in shortage in most of the developed world. Moreover, such shortages are expected to increase due to parallel socio-demographic factors. The increase in demand for longterm care, coupled with shortage in supply of care workers, has promoted some attention from policymakers. The current paper provides an international review of institutional arrangements for long-term care in different developed countries and in particular explores different strategies used or proposed to resolve the shortage in the long-term care workforce.     

Integrated care workforce development: university-community collaboration

ABSTRACT

Behavioral health workforce shortages to provide quality care services for children, adolescents, and transitional age youth are well established. This paper highlights the workforce shortage and the need to infuse interprofessional education to engage in integrated care for children, adolescents and transitional age youth with behavioral health needs. A specialized training curriculum to build behavioral health workforce in Nevada was conceptualized and delivered through 10 workshops under the auspices of the Health Resources & Services Administration (HRSA) funded Behavioral Health Workforce Education and Training (BHWET) grant funded in 2014. To train existing workforce and in alignment with the spirit of the grant to build behavioral health workforce and existing workforce, workshops were extended to social service providers in the community. In an effort to enhance university-community collaboration, workshop presenters were invited from various units in the University and from social service agencies in the community. Implications of such training are addressed from a policy, practice, research, and university-community collaboration perspective.     

Impact of the Health Resources and Services Administration’s state oral health workforce grant program on dental workforce density and access to oral health care

BackgroundThe Health Resources and Services Administration’s Grants to States to Support Oral Health Workforce Activities, otherwise known as the State Oral Health Workforce Program (SOHWP), help states develop and implement innovations that address the workforce needs of dental Health Professional Shortage Areas in a manner appropriate to the states’ individual needs.AimThis cross-sectional study explores the broad impact of the SOHWP by comparing measures of dental workforce density and access to oral health care in states with multiple years of funding versus states with few or no years of funding.MethodsWe used data for 2006–2016 SOHWP awardees together with data from the 2016–2017 Area Health Resources Files and the 2016 Behavioral Risk Factor Surveillance System to compare numbers of dentists per 100,000 population and age-adjusted prevalence of annual dental visits among adults for long-term SOHWP-funded states versus states with few or no years of funding.ResultsMulti-year SOHWP funding is associated with higher workforce density and greater access to oral health care, especially in the Midwest and West.ConclusionAllowing states funding utilization flexibility may result in improved outcomes. This finding can help inform planning and policy about whether and how to scale future training and workforce programs to achieve greater impact.     

Emerging Services for Community-Based Long-Term Care in Urban China

Abstract

China's rapid economic reforms, coupled with the changes in age composition of the demographic structure, have greatly affected the traditional family support system. In response to these changes, efforts to develop new models of community-based long-term care (CBLTC) for elders in China have received growing attention. This paper provides a systematic analysis of the current status of emerging CBLTC systems in Shanghai, China. It covers several domains of the system: service delivery, workforce, financing, and quality of care management. Several main issues involved in the development of the emerging system are addressed, and relevant policy implications are presented in the paper.     

Changing Needs and Changing Service Delivery for Long-Term Care in Hong Kong

Summary

Both the need for and delivery of long-term care in Hong Kong are shaped by the interaction of the traditional and modern. Rapid social change is affecting traditional family structures and roles in care of the elderly, resulting in increased demand for formal care, which to date has been provided mainly by way of residential care. This growth of demand will escalate with rapid population aging in coming decades. In response to this burgeoning demand, current planning is seeking to reshape the established service system and tackle problems in service delivery in ways that will address the bias towards residential care and improve quality of care.     

From pipeline to practice: Utilizing tracking mechanisms for longitudinal evaluation of physician recruitment across the health workforce continuum

PurposeArea Health Education Centers work with community partners to prepare a diverse, primary care workforce particularly among rural and underserved communities. We set out to assess our impact on the physician workforce across a multitude of short-term, intermediate, and long-term benchmarksMethodWe used a comprehensive evaluation scaffolding to assess benchmarks of success across the workforce pipeline including short-term (i.e. pre-medical intent to pursue a health career or medical students’ intent to practice in primary care), intermediate (college matriculation and primary care residency match rates) and longterm measures (licensure and medical practice location of program participants).ResultsWe identified significant findings in each part of the AHEC program continuum. Among our alumni, we found a significant increase in the pre-medical learner’s intent to pursue a health care career. Among medical students, we found a significant increase in intent to practice in primary care, rural areas, and medically underserved communities and a high rate of primary care residency match (compared to peers). Approximately one-third of licensed physicians are now practicing medicine serve in an underserved communityConclusionsOur findings confirm the value of longitudinal evaluation on confirming that participation in an AHEC supported program strengthen the physician workforce development.     

Workforce Issues in Residential Care Facilities in Rural China

This study examined contemporary frontline workforce issues related to residential care for elders in rural China. Residential facilities in rural China are in transition from exclusively providing shelter to childless elders to providing long-term care for frail elders. These facilities are also under pressure to improve the quality of services that they provide. The study is based on in-depth interviews with administrators and field observations of facilities. The study focused on the following issues related to the workforce: recruitment and retention, training, work environment, workforce organization, regulations, compensation, and career ladders. The implications of resident characteristics for demands on the work force were examined. The study found that lack of skilled personnel is one of the major reasons that the overwhelming majority of facilities deny admission to frail and demented elders. Improving workers’ skill is critical if these facilities are to meet the increasing demand for institutional long-term care needs.     

Future of Long-Term Care Financing for the Elderly in Korea

ABSTRACT

With rapid aging, change in family structure, and the increase in the labor participation of women, the demand for long-term care has been increasing in Korea. Inappropriate utilization of medical care by the elderly in health care institutions, such as social admissions, also puts a financial burden on the health insurance system. The widening gap between the need for long-term care and the capacity of welfare programs to fulfill that need, along with a rather new national pension scheme and the limited economic capacity of the elderly, calls for a new public financing mechanism to provide protection for a broader range of old people from the costs of long-term care. Many important decisions are yet to be made, although Korea is likely to introduce social insurance for long-term care rather than tax-based financing, following the tradition of social health insurance. Whether it should cover only the elderly long-term care or all types of long-term care including disability of all age groups will have a critical impact on social solidarity and the financial sustainability of the new long-term care insurance. Generosity of benefits or the level of out-of-pocket payment, the role of cash benefits, and the relation with health insurance scheme all should be taken into account in the design of a new financing scheme. Lack of care personnel and facilities is also a barrier to the implementation of public long-term care financing in Korea, and the implementation strategy needs to be carved out carefully.     

Exploring Policy and Financing Options for Long-Term Care in Taiwan

Summary

Policy and financing arrangements for long-term care are important themes in each country and/or region, and Taiwan, with its unique historic and politico-economic background, can be regarded as a bridge between well-developed and under-developed countries. Policy formulation about long-term care in Taiwan involves several agencies in the government, including Ministry of Health, Interior Affairs, Education, Insurance Bureau, and Economic Council, and formulation of policy objectives has progressed considerably in the last five years. Financing arrangements are less well-developed because the National Health Insurance Program began only in 1995, and most long-term care is not yet covered. As demand for long-term care exceeds supply, and this gap will grow in future, current resource allocation measures are concerned to facilitate the expansion of community care rather than allowing institutional care to absorb more resources. Developing future financing options is now a central task for policymaking, and government must continue to take a leading role in consolidating financing and integrating the service systems.     

Long-Term Care Funding in Canada

Summary

When Canada was founded, health care was delegated as a provincial responsibility. Although the federal government shares a portion of health care costs, it is not directly responsible for the planning, delivery, and governance of health services. The 1984 Canada Health Act set national standards for the provision of physician and hospital services, but it does not apply to home care and long-term care facilities. Consequently, each province has established a unique approach to long-term care, resulting in a health policy mosaic. This paper examines different approaches to funding long-term care with a particular emphasis on the impacts of regionalization and of the implementation of case-mix-based funding systems.     

Older lesbians' experiences with home care: Varying levels of disclosure and discrimination

ABSTRACT

There is considerable evidence that lesbian, gay, bisexual and transgender (LGBT) older adults have experienced barriers to health care access and have profound fears about how they will be treated in the long-term care system, but the specific experiences of older lesbians have received less attention. Most older adults needing long-term services and supports (LTSS) prefer to remain at home, and this is true for lesbians as well. This article reports on a national, qualitative study of the experiences of 20 older lesbians (age 65 and older) with home care workers. The experiences of six informal partner caregivers with home care services are also included. Emergent themes regarding level of disclosure, experiences with homophobia, evaluation of care received, and thoughts about ideal LTSS are described. Most study participants did not disclose their sexual orientation to their home care workers. A significant minority experienced homophobia, but nearly all ultimately found workers who provided good care with which they were comfortable. Their visions of ideal LTSS included greater affordability and particular qualities that were important for home care workers to possess, such as competence, caring and acceptance. Practice and policy implications are outlined including careful recruitment, training and supervision of home care workers to foster lesbian-sensitive care, but also improved wages and work conditions in order to maintain a quality home care workforce.     

Families,Work, and an Aging Population

Abstract

This article examines the intersection of family caregiving, work, and long-term care. Supporting families who provide care in order to minimize negative work effects while enhancing the acceptability of care options is of common concern to employers, state and federal policymakers, and the homecare professionals in the community-based care system. The contribution of families to the long-term care system, how employer policies have developed, how the public policy agenda has addressed family caregiving, and the importance of a more effective partnership on the state level are discussed.     

Migrant Care Workers or Migrants Working in Long-Term Care? A Review of Australian Experience

Discussion of the role of migrant care workers in long-term care (LTC) that has gained increasing attention in the United States and other developed countries in recent years is of particular relevance to Australia, where 24% of the total population is overseas-born, two-thirds of them coming from countries where English is not the primary language. Issues of interest arise regarding meeting LTC workforce demands in general and responding to the particular cultural and linguistic needs of postwar immigrants who are now reaching old age in increasing numbers. This review begins with an account of the overseas-born components of the aged care workforce and then examines this representation with reference to the four factors identified as shaping international flows of care workers in the comparative study carried out for the AARP Public Policy Institute in 2005: migration policies, LTC financing arrangements, worker recruitment and training, and credentialing. The ways in which these factors play out in Australia mean that while overseas-born workers are overrepresented in the LTC workforce, migrant care workers are not identifiable as a marginalized group experiencing disadvantage in employment conditions, nor do they offer a solution to workforce shortages. The Australian experience is different from those of other countries in many respects, but it does show that the experience of migrant care workers is not unique to LTC and points to the need to extend the search for solutions to workforce shortages and improving conditions of all care workers well beyond LTC systems to wider policy settings.     

Organization and Delivery of Long-Term Care in Taiwan

Summary

Taiwan reached the World Health Organization (WHO) benchmark of7%aged 65and over for defining an aging population only as recently as 1993. With this proportion projected to double to 14% by 2020, Taiwan faces a rapid increase in need for long-term care. This article presents an account of the current service delivery system, which is divided between health and social affairs administrations, with a substantial role also taken by the Veteran Administration, and growing provision of facilities that operate outside the government-registered system. While a basic level of both institutional and community care services has developed, they are not organized into an integrated service system. Problems arising from the divisions and overlaps in responsibility are identified in relation to competition for resources, differences in regulation and eligibility, funding arrangements and misallocation of resources, and divergent views about the philosophical basis of long-term care. Other aspects of services fall under each jurisdiction, but there is also some overlap. A case study of Taiwan's second largest city, Kaohsiung City, reports the outcomes of these divisions as a thin spread of a range of services rather than a coordinated service network. Several planning exercises have been undertaken in recent years to address these problems, and although at an early stage of implementation, the outcomes of these plans are seen as shaping the future directions of long-term care in Taiwan.     

The Program of All-Inclusive Care for the Elderly (PACE)

Summary

This article examines the long-term care service system in the United States, its problems, and an improved long-term care model. Problematic quality of care in institutional settings and fragmentation of service coordination in community-based settings are two major issues in the traditional long-term care system. The Program of All-Inclusive Care for the Elderly (PACE) has been emerging since the 1970s to address these issues, particularly because most frail elders prefer community-based to institutional care. The Balanced Budget Act of 1997 made PACE a permanent provider type under Medicare and granted states the option of paying a capitation rate for PACE services under Medicaid. The PACE model is a managed long-term care system that provides frail elders alternatives to nursing home life. The PACE program's primary goals are to maximize each frail elderly participant's autonomy and continued community residence, and to provide quality care at a lower cost than Medicare, Medicaid, and private-pay participants, who pay in the traditional fee-for-service system. In exchange for Medicare and Medicaid fixed monthly payments for each participating frail elder, PACE service systems provide a continuum of long-term care services, including hospital and nursing home care, and bear full financial risk. Integration of acute and long-term care services in the PACE model allows care of frail elders with multiple problems by a single service organization that can provide a full range of services. PACE's range of services and organizational features are discussed.     

The International Migration of Nurses in Long-Term Care

This article describes five major factors that are affecting patterns of international migration among nurses who work in long-term care settings:

• Demographic drivers–The aging of the populations in developed countries and the low to negative growth in the working-age population will increase the demand for international workers to provide long-term care services.

• Gender and race–A dual labor market of long-term care workers, increasingly made up of women of color, is becoming internationalized by the employment of migrating nurses from developing countries.

• Credentialing–The process of credentialing skilled workers creates barriers to entry for migrating nurses and leads to “decredentialing” where registered nurses work as licensed practical nurses or aides.

• Colonial history and geography–The colonial histories of many European countries and the United States have increased migration from former colonies in developing countries to former colonial powers.

• Worker recruitment–Efforts to limit the recruitment of health care workers from some developing countries have had little effect on migration, in part because much of the recruitment comes through informal channels of family and friends.

     

An ICT-Driven Hybrid Automation System for Elderly Care Support: A Rehabilitation Facility Study Case

Abstract

The demographic statistics in developed countries suggest growth in the elderly segment of the population. At the same time, other studies forecast a shortage of nurses, increasing the pressure on hospitals to provide treatment for longer periods of time. These trends suggest a need for new ways of taking care of the elderly population that support safe, comfortable, and independent living. Meanwhile, prominent advances in information and communications technology (ICT) have enabled new systems that address various needs of the elderly. This article presents a case study of a rehabilitation facility located in Tampere, Finland, that uses an automation system in which ambient assisted living (AAL) and building automation (BA) system functionalities are combined. It details a field study summarizing the needs of the users, describes functional scenarios supported by the system, and reports the results of the first usability tests suggesting acceptance of a new technology by residents and caregivers. The unique combination of ambient assisted living and building automation offers a safer and more comfortable environment for the elderly as well as helps caregivers on-site in managing their workloads.     

Safe Motherhood in the Context of Nepal

ABSTRACT

Nepal ranks low on the Human Development Index and has a high maternal mortality rate. Various factors contribute to the high rate of maternal mortality and include a shortage of health care professionals, limited access to basic maternal health care, poverty, illiteracy, women's low social status, a poorly developed transportation system, a limited communication system, political conflict, and a diverse population. Interviews with pregnant women, observational data, and national statistics provide the basis for suggestions provided by the author. These include upgrading and opening new maternal care facilities, integrating midwives into local health services, providing education on women's health needs during pregnancy, and improving public awareness of the availability of maternal care services.     

Vertical Axes on the Long-Term Care Continuum

Abstract

As the continuum of long-term care has expanded, public funding has not accompanied new care options. I detail access, provider profits and resources, and care quality in two types of residential care that fall in the center of the continuum, assisted living and board and care. These two options provide examples of how limited public funding leads to vertical axes, which represent access to services, the resources providers draw on to give care, and the quality of long-term care services, at each service point on the long-term care continuum.     

Long-Term Care Policy and Financing as a Public or Private Matter in the United States

Summary

Effective approaches to assure adequate resources, infrastructure, and broad societal support to address chronic care needs are volatile and potentially unpopular issues that can result in many losers (those getting far less than they want) and few winners (those who gain access to scarce societal resources for care). In the United States, debates on long-term care involve a complex set of issues and services that link health, social services (welfare), and economic policies that often pit public and private sector interests and values against one another. Yet long-term care policies fill a necessary function in society to clarify roles, expectations, and functions of public, non-profit, for profit, individual, and family sectors of a society. By assessing and developing policy proposals that include all long-term care system dimensions, a society can arrive at systematic, fair, and rational decisions. Limiting decisions to system financing aspects alone is likely to result in unforeseen or unintended effects in a long-term care system that stopgap “fixes” cannot resolve. Three underlying policy challenges are presented: the need for policymakers to consider whether the public sector is the first or last source of payment for long-term care; whether government is seen primarily as a risk or cost manager; and the extent to which choice is afforded to elders and family caregivers with regard to the types, settings, and amount of long-term care desired to complement family care.