An aging population is expected to generate increased demand for home and community services. While the vast majority of assistance continues to be provided by unpaid family members, paid workers now provide 16% of total personal support hours in the United States. This US study uses national data to examine trends in the supply of and demand for paid personal assistance labour force between 1989 and 2004. Findings indicate that the supply of personal assistance workers increased dramatically over this period. Increased Medicaid spending for personal support work was the primary driver behind this growth, rather than increases in demand due to either increasing care recipient needs or shifts out of long-term care and hospital settings. Low wages, short job tenure and lack of benefits for this category of workers create substantial challenges in recruiting and retaining skilled caregivers in the future.

Background: An aging population is expected to generate increased demand for home care and personal assistance services (help with such activities as bathing, eating, dressing, shopping, housework and meal preparation). While only 16% of total personal support hours are provided by paid personal assistance workers (versus unpaid caregivers) in the US, studies have found extensive unmet need for such services. Because most of the literature focuses on the institutional labour force, this study provides added insight by examining trends in the supply of, and demand for, paid personal assistance workers in non-institutional settings in the US.

Methods: Two US national surveys were used to examine the supply of personal assistance workers, Medicaid (i.e., public insurance for low-income individuals) spending and demand for services, and job characteristics such as wages, tenure and benefits. The monthly Current Population Survey (n=60,000), which focuses on labour force issues, provided national data on the supply of workers. The National Health Interview Survey (n=45,000), which provides estimates of the population needing assistance with both activities of daily living (ADLs) and instrumental activities of daily living (IADLs), provided national data on those individuals who had a need for paid personal support services. Individuals were defined as personal assistance workers if they met both occupational and non-institutional setting criteria.

Findings: The supply of personal assistance workers increased steadily over the study period, more than tripling between 1989 and 2004. Similar trends were found in Medicaid spending, suggesting that expanded funding for personal support work was the primary driver for growth in this labour force. In addition, labour force growth was most pronounced in states with the largest Medicaid increases for these services. While increasing demand for services (53% increase in individuals with ADL needs) is also a driver, evidence does not support the suggestion that growth in this labour force can be attributed to shifting patients out of institutions.

Personal assistance worker wages remain among the lowest of all occupations. Wages increased by 55% over this 15 year period (from $5.41/hr to $8.40/hr), barely keeping pace with inflation (52%). In contrast, nursing home aides experienced a 79% wage increase over the same period, while individuals working in entry-level positions in the fast-food industry received an 85% increase. Eighty percent of personal assistance workers had been in their job for less than 2.5 years, compared to 57% of workers in the general labour force. Finally, only 30% of caregivers receive health benefits from employment-based coverage, which can be largely attributed to their part-time/casual/contract status.

Conclusions: Trends in the rising demand for paid personal support services are expected to persist, but attracting and retaining skilled workers will become increasingly challenging if employment conditions remain poor. While this study examines the US labour force, many of the trends and issues are of relevance to Canada, where Personal Support Workers in home settings continue to receive lower wages than institutionbased workers. One notable difference between the two markets is that many home-based Personal Support Workers are certified in Canada, a move the authors of this article recommend for the US. Decision-makers charged with the task of planning for an aging population may wish to consider strategies to improve job tenure, wages and other job characteristics that may aid in the recruitment and retention of paid caregivers.

Reference: Kaye HS. Chapman S, Newcomer RJ, Harrington C. The Personal Assistance Workforce: Trends in Supply and Demand. Health Affairs. 2006; 25: 1113-20.

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