XII. Long-Term Services and Support Model Components

Published 2023

In this module:

Modeling supply
Modeling demand
Exhibit data

This module describes the data, assumptions, and methods used to adapt the Health Workforce Simulation Model (HWSM) to model the sector-specific long-term services and support (LTSS) workforce. LTSS includes nursing homes, residential care facilities, home health, hospice, and adult day services centers. Because of data limitations, home health and home-based hospice visits are combined into home care. The Medical Expenditure Panel Survey (MEPS), which is used for modeling home health visits, does not distinguish between visits associated with chronic care management and visits following hospital discharge for acute conditions. Hence, all home health visits are included under LTSS for modeling purposes.

In this module, we focus on modeling nursing assistants (NAs), home health aides (HHAs), and personal care aides (PCAs).

Modeling of other health care occupations providing LTSS is described in other modules:

The module on the nurse workforce describes modeling of registered nurses (RNs) and licensed practical nurses (LPNs).
The module on physicians, advanced practice nurses (APRNs), and physician assistants (PAs) describe modeling of these respective occupations.
The module on allied health describes various allied health occupations that provide LTSS.

As illustrated in Exhibit XII‑1, approximately 2.8 million health care workers in the 2021 American Community Survey (ACS) are in the three major LTSS settings. These workers account for approximately 16% of the estimated 17.2 million health care workers in the 2021 ACS. Nearly 2.4 million workers, or 86% of the LTSS total, are in the five largest LTSS occupations: NAs, PCAs, RNs, HHAs, and LPNs. Many of these workers work part time.

For most health care occupations, those individuals working in LTSS settings constitute a small proportion of total workers in that occupation. The nearly 402,420 RNs in LTSS constitute only 12% of the RN workforce. The small percentage of the workforce in LTSS for many occupations means that LTSS employers (e.g., nursing homes, residential care facilities, and home health agencies) are competing against other health care setting employers (e.g., hospitals) to recruit and retain workers. Further compounding recruiting and retention issues for the LTSS is the industry’s history of low pay and challenging working conditions, which contributes to high turnover and attrition from the industry.1 2 3

Exhibit XII-1: LTSS Workforce, 2021 American Community Survey

HWSM Occupation	Nursing Facility	Residential	Home Health	Total LTSS	% Occupation Total
Nursing Assistants	423,090	115,050	135,000	673,140	51%
Personal Care Aides	81,440	202,660	349,100	633,200	40%
Home Health Aides	5,250	5,350	465,120	475,720	80%
Registered Nurses	219,920	35,450	147,050	402,420	12%
Licensed Practical and Licensed Vocational Nurses	145,860	33,470	61,460	240,790	39%
Physical Therapists	12,780	8,330	23,340	44,450	15%
Social Workers All Other	19,900	12,210	8,200	40,310	7%
Physical Therapist Assistants and Aides	11,800	7,470	11,390	30,660	26%
Occupational Therapists	11,390	4,910	11,420	27,720	19%
Dietetic Technicians and Ophthalmic Medical Technicians	18,620	3,950	3,180	25,750	55%
Other Health Care Support Workers	3,820	19,050	2,250	25,120	12%
Health care Social Workers	9,090	3,970	8,430	21,490	23%
Occupational Therapy Assistants and Aides	13,310	6,750	-	20,060	37%
Medical Assistants	3,970	10,070	480	14,520	2%
Other Therapists	4,870	4,130	4,860	13,860	6%
Dietitians and Nutritionists	8,780	1,910	2,950	13,640	11%
Medical Records Specialists	4,820	4,170	4,410	13,400	7%
Substance Abuse and Behavioral Disorder Counselors	9,740	2,670	160	12,570	9%
Clinical Laboratory Technologists and Technicians	3,520	5,650	1,980	11,150	3%
Speech Pathologists	3,830	730	4,520	9,080	5%
Miscellaneous Health Technologists and Technicians	690	6,870	800	8,360	5%
Nurse Practitioners	4,170	3,060	160	7,390	3%
Psychiatric Technicians	3,750	2,850	510	7,110	6%
Recreational Therapists	3,250	660	2,970	6,880	34%
Physicians	930	3,920	1,630	6,480	<1%
Respiratory Therapists	3,280	1,010	1,100	5,390	4%
Mental Health Counselors	1,210	3,340	230	4,780	3%
Other Health care Practitioners and Technical Occupations	1,180	2,720	210	4,110	4%
Pharmacy Technicians	1,020	1,090	570	2,680	<1%
Child, Family, and School Social Workers	1,150	650	350	2,150	3%
Orderlies and Psychiatric Aides	80	780	910	1,770	3%
Educational, Guidance, and Career Counselors and Advisors	950	30	790	1,770	<1%
Dental Assistants	280	60	1,040	1,380	<1%
Marriage and Family Therapists	-	940	360	1,300	4%
Phlebotomists	670	50	570	1,290	1%
Other Community and Social Service Specialists	400	700	160	1,260	1%
Pharmacists	150	710	310	1,170	<1%
Radiologic Technologists and Technicians	220	900	-	1,120	<1%
Dental Hygienists	300	550	200	1,050	<1%
Physician Assistants	500	470	-	970	<1%
Clinical and Counseling Psychologists	190	130	580	900	4%
Emergency Medical Technicians	130	170	340	640	<1%
Massage Therapists	110	-	500	610	<1%
Paramedics	120	120	260	500	<1%
Mental Health and Substance Abuse Social Workers	-	490	-	490	1%
Medical Transcriptionists	30	-	300	330	<1%
Diagnostic Medical Sonographers	-	230	-	230	<1%
Pharmacy Aides	170	30	-	200	<1%
Health care Diagnosing or Treating Practitioners, All Other	50	-	150	200	1%
Dentists	140	-	-	140	<1%
Surgical Technologists	130	-	-	130	<1%
Podiatrists	-	120	-	120	<1%
Nuclear Medicine Technologists and Medical Dosimetrists	-	-	100	100	<1%
Opticians, Dispensing	-	90	-	90	<1%
Total	1,041,050	520,690	1,260,400	2,822,140	16%

Source: 2021 American Community Survey. Note: Estimates of full-time equivalents were calculated by dividing each person’s reported weekly hours worked by 40 hours.

Modeling supply

HWSM supply projections focus on occupations with high education requirements. These requirements create time lags to train new workers. Information on future adequacy of supply for these workers can help mitigate supply inadequacies. Such occupations usually require a license. In other modules we describe the data, assumptions, and methods for modeling supply of RNs, LPNs, and various licensed therapist and other health occupations that work in LTSS settings.

Modeling supply of NAs, HHAs, and PCAs (often referred to collectively as direct care workers) poses two major challenges:

There are low barriers to entry into the occupation. States have either no formal training requirements or minimal requirements. Hence, there is little information on the numbers of people entering this occupation each year.
There are a few barriers to leaving the profession. Occupations with low pay and little formal education, such as aides and assistant, are sensitive to earnings. They can move in and out of the direct care workforce based on how earnings as a direct care worker compare to earnings from other occupations. Hence, the direct care workforce experiences high rates of turnover and attrition which presents challenges for modeling who will leave the workforce.4

Because of these challenges, we use a different approach to supply modeling than used for modeling other health occupations in HWSM. Specifically, we look at growth in the population from which the supply of direct services workers comes and model the implications if the LTSS sector can maintain its share of the candidate pool. Using the combined 2017-2021 ACS files, we see that direct care workers are disproportionately younger adults, but all ages are represented (Exhibit XII‑2). Minority populations are highly represented among direct care workers (Exhibit XII‑3). Most direct care workers are female (Exhibit XII‑4).

There are an estimated 2.3 million full time equivalent (FTE) individuals working as a direct care worker in a LTSS role, with FTE defined as 40 hours worked per week. Comparing demographics of these direct care workers in the 2017-2021 ACS with the adult population in from 2017-2021, the LTSS FTE direct care workforce comprised approximately 1.26% of adult females and 0.19% of adult males (Exhibit XII‑5). While FTEs for non-Hispanic Black females were equal to 2.85% of the total adult population for this demographic, FTEs for non-Hispanic White males were equal to only 0.12% of the total adult population for this demographic. We modeled growth in the size of the adult population by age, sex, and race/ethnicity and the ratio of FTE direct care workers for each demographic group. If the LTSS workforce can maintain these ratios, then supply of direct care workers will grow at the rate of this weighted population demographic. Supply will grow faster (or slower) if these ratios increase (or decrease)—e.g., if wages and working conditions in LTSS are more competitive and desirable (or less competitive and less desirable) than in alternative careers that might employ people in this candidate pool.

Exhibit XII-5: FTE LTSS Direct Care Workforce, by Race/Ethnicity and Sex: 2021

Parameter	FTE Direct Care Workers in LTSS	Total Adult Population	FTEs as Percent of Adult Population
Female	1,489,800	118,395,000	1.26%
Female White, non-Hispanic	607,500	71,390,000	0.85%
Female Black, non-Hispanic	443,000	15,549,000	2.85%
Female Other, non-Hispanic	153,000	10,931,000	1.40%
Female Hispanic	286,300	20,525,000	1.39%
Male	219,200	118,019,000	0.19%
Male White, non-Hispanic	88,200	72,059,000	0.12%
Male Black, non-Hispanic	60,900	14,336,000	0.42%
Male Other, non-Hispanic	33,500	10,179,000	0.33%
Male Hispanic	36,600	21,445,000	0.17%
Total	1,709,000	236,414,000	0.72%

Source: Analysis of the 2020 & 2021 Census State Population by Characteristics and 2021 Health Workforce Simulation Model population database.5 Note: The “Other” category combines all remaining racial or ethnic groups which are not modeled separately due to small sample size in many of the databases analyzed (e.g., the Medical Expenditure Panel Survey for analyzing health care use patterns). This category includes Native Americans, Alaska Natives, Native Hawaiians and other Pacific Islanders, Asian Americans, Middle Easterners and North Africans, and others who self-identify as other than White, Black, or Hispanic.

Modeling demand

The projected demand for LTSS and workforce follows the common model estimated on the baseline population and health care usage as outlined in the other modules. This includes projected number of residents in nursing homes, number of residents in residential care facilities, and home health visits. Projections of future residents in nursing homes and residential care facilities are based on growth and aging of the population, with men and women in each age group having different probabilities of moving from community residency to an institutional setting. These probabilities are based on analysis of residency type in the 2021 ACS, and scaled to match published statistics. The total number of people living in nursing homes and residential care in the initial year, by state and age group, is constructed to match published numbers from Centers for Disease Control and Prevention (CDC), showing nearly 1.2 million nursing home residents and 918,700 people living in residential care nationally.6 7

To model demand for adult day service centers, we use probabilities for population cohorts defined by age group estimated from the National Study of Long-Term Care Providers (NSLTCP).8 Multiplying these probabilities by the projected size of each age cohort in the HWSM population database produces projections of demand for adult day care and providers. Approximately 4,200 adult day service centers reported employing around 24,300 FTE nurses and social workers. The workforce modeled for the LTSS projections include an estimated 10,577 nurse aides, 6,464 RNs, 2,090 LPNs, and 2,191 social workers working in adult day service centers.

This section focuses on the occupations working primarily in the long-term care settings: HHAs, NAs, PCAs, and social workers. HWSM uses provider staffing patterns to convert demand for LTSS into demand for the relevant occupations. HWSM multiplies these staffing patterns to the appropriate workload drivers—which include home health visits, residents in nursing homes and residential care facilities, and patient days in adult day service centers. To calculate staffing ratios (Exhibit XII‑6), we divided the workload driver for each employment setting by estimates of FTE providers (plus the estimated shortfalls) from the 2021 ACS.

Exhibit XII-6: Ratio of Annual Care Utilization to Full-Time Equivalents (FTEs), 2021

Occupation	Home Health	Nursing Home	Residential Care	Adult Day Service Centers
Personal Care Aides	314,266	81,502	207,150	-
Nursing Aide	133,701	436,708	113,268	10,577
Home Health Aide	397,527	6,997	7,375	-
Social Workers	2,716	3,063	16,082	2,191
Annual Utilization	50.5 million home health visits	1.2 million residents	914,929 residents	227,679 patient days

Staffing Ratios
Occupation	Home Health	Nursing Home	Residential Care	Adult Day Service Centers
Personal Care Aides	116.81	10.72	3.21	N/A
Nursing Aide	81.25*	2.16	6.32	16.85
Home Health Aide	24.36*	119.98	86.58	N/A
Social Workers	2,668.61	380.62	55.14	100.74

Note: Standardized FTE definition, 1 FTE=40 hours/week; Numbers may not sum to 100% because of rounding. Home Health Aides, Personal Care Aides, Nursing Assistants and Social Worker totals reflect starting year shortages.

Annual home health visits vary by occupation. * indicates staffing ratio is based on home health visits specific to the occupation as calculated using 2015-2019 MEPS; all other occupations use ratios based on total annual home health visits (regardless of type of visit). NA indicates occupation is not applicable to the employment setting.

Staffing Ratios based on FTE supply count for each health occupation. Final demand projections for all occupations scaled to supply FTEs defined as working 40 hours/week plus starting year shortages.

Demand scenarios modeled

As with other health occupations modeled, HWSM models demand for LTSS workers under two scenarios as described in other modules:

The Status Quo scenario models a continuation of recent (2015-2019) national patterns of care use extrapolated to the future population. This scenario captures geographic variation in demographics, health risk factors, disease prevalence, insurance coverage, level of rurality, and household income that can affect demand for physician services. Similarly, the scenario captures population growth and aging—and the associated implications for disease prevalence and other health risk factors—over the projection horizon.
The Reduced Barriers scenario estimates the number of health care workers required if populations that historically faced barriers to accessing health care services demonstrated care use patterns comparable to populations perceived to have fewer barriers to accessing care. The scenario modifies the health care use patterns of nonmetropolitan county residents, racial and ethnic minority populations, and people without health insurance to the health care use patterns of their peers living in metropolitan counties, who are non-Hispanic White, and who have health insurance. This scenario focuses primarily on care delivered in ambulatory and hospital settings, as well as home health care. The number of residents in nursing homes and residential care facilities and the number of people receiving care in adult day services centers under this scenario is identical to the Status Quo scenario projections.

Date Last Reviewed:

December 2023

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