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The aging of the baby boom generation and health care policy changes represented by the Affordable Care act create challenges for the long term care industry in America. In 2011 the first of the baby boomers turned 65 years old. By 2030 a total of 78 million baby boomers, 19% of the population, will be 65 or more years old and eligible for Medicare (U.S. Census Bureau 2010). Discussions of potential health care worker shortages often focus on the need for more physicians and nurses to care for an aging population. These changes are putting pressure on long term care providers to modify and adapt their services and the care provided to patients. Direct service workers (DSWs) play an important role in caring for elderly patients. DSWs are long term care workers who provide direct care to patients and include certified nurse aides, home health aides, personal care attendants and similar titles. DSWs have the most direct contact with those for whom they provide care and are often referred to as the eyes and ears for the health care system (Dawson, 2007). Basic skills and competencies required of DSWs have been identified by the Federal Money Follows the Person grant to Ohio (Austin, Lepicki, & Mullins, 2011). The Institute of Medicine (IOM) Report “Retooling for an Aging America: Building the Health Care Workforce” suggests an efficient use of the workforce requires more delegation of job duties that will allow each worker to be used at his or her highest skill level. This may mean the expansion of the duties and responsibilities of the DSW (IOM, 2008). This would in turn suggest that DSWs who are expected to fulfill expanded roles will need additional training to learn expanded competencies and skills in the near future.

The work of DSWs typically is stressful, poorly compensated, and prone to job-related injuries. These factors make recruitment and retention of workers difficult (Population Reference Bureau, 2010). The IOM report recommends improving benefits and compensation, working conditions, and the quality and quantity of training provided to these workers as ways to enhance recruitment and retention (IOM, 2008). Coogle et al. (2007) report that a training program in geriatric case management using home care personnel showed some support for the impact of training on retention. A follow-up six to 12 months after completion of training showed evidence of improved retention and job satisfaction among DSWs in the study. A study of DSWs’ perceptions of their initial and ongoing training in nursing homes, assisted living facilities, and home health agencies shows that between 40 and 50% of DSWs believed they would benefit from more extensive initial training. The findings suggest that methods of providing continuing education and topics covered need to be improved (Menne et al., 2007).

The Affordable Care Act of 2010 contains a number of initiatives that recognize the importance of the direct service workforce, including grants and incentives to improve recruitment, training, and retention of these workers (Alliance for Health Reform, 2011). With the increase in people needing their services and looming shortages of health care professionals, the importance of DSWs cannot be overstated. With the likelihood of fewer professionals to supervise their work, DSWs are working more independently and being asked to take more responsibility, especially in providing home care (IOM, 2008; Dawson, 2007). There is general agreement that how long-term care will be provided will change in many ways in the coming years. Yet, there is little in the professional literature about the skills and competencies that the workers who have the most direct contact with the elderly will need in the future. Evidence suggests that these underappreciated and underpaid workers have both the interest and capacity to contribute in more meaningful ways to the care of the burgeoning senior population in the United States (Dawson, 2007). The current need is not to understand how DSWs will provide care for seniors in 10 to 15 years; those who provide educational services need up-to-date information about the skills and competencies needed within the next three to five years.

Policies, resources and technology in the long-term care industry are in flux as health care undergoes reform. Administrators for facilities and agencies that provide long term care services regularly deal with the changing demands of providing quality care for the aging population with declining numbers of health care professionals. These administrators must adapt their services to meet the needs of their clients, the families of clients, and a changing industry. To retain a competent work force, they must provide appropriate training and find paths for advancement to retain workers. Key informant interviews revealed that many administrators in Ohio have already begun to modify the skill sets and competencies they require their DSWs to perform. These administrators are a good source of information about the need for the skills and competencies that will be needed by DSWs in the next three to five years.


This work is made possible through a subgrant from the Ohio Office of Medical Assistance (OMA) to the Ohio Colleges of Medicine Government Resource Center (GRC) as part of the Ohio Direct Service Workforce (ODSW) Initiative. Funding to support the ODSW Initiative, including this research project and report, comes from the federal Money Follows the Person (MFP) Demonstration Grant (CFDA 93.791) to OMA from the U.S. Department of Health and Human Services, Centers for Medicare and Medicaid Services (CMS). However, the content of this report does not necessarily represent policy of OMA or the U.S. Department of Health and Human Services, and endorsement by OMA and the Federal Government should not be assumed.