Personal Care Aides in Adult Day Services Centers and Residential Care Communities: United States, 2022.

Personal care aides (PCAs), along with other direct care workers, provide the hands-on care, including help with activities of daily living for individuals receiving care in residential care communities (RCC) and adult day services centers (ADSC). Recruitment and retention of such workers is a challenge as low pay, inadequate training, unsatisfactory roles and lack of benefits contribute to turnover. Using data from the 2018 National Study of Long-Term Care Providers, the only nationally representative data about PCAs in RCCs and ADSCs, this study will assess differences in training hours, benefits, and work roles among PCAs in these settings. About 76% of RCCs and 66% of ADSCs employed aides. On average, PCAs received 32 hours and 51 hours of initial training in ADSCs and RCCs, respectively. Results from bivariate analyses (accounting for complex survey design), showed that benefits received by PCAs varied by sector. A higher percentage of PCAs in ADSCs than in RCCs received health insurance for employees (60% vs. 46%), and pension (51% vs. 40%). About 51% of ADSCs and 46% of RCCs reported that PCAs rarely or sometimes attended care plan meetings. Further, 11% of RCCs and 15% of ADSCs reported that aides rarely or sometimes worked with the same care recipient. This overview of PCA activities, training and benefits may provide insights into approaches to improve the retention of PCAs and subsequently the quality of care provided across sectors.

This report presents national results from the National Post-acute and Long-term Care Study to describe providers and services users in seven major settings of paid, regulated post-acute and long-term care services in the United States. Data are from the 2020 National Post-acute and Long-term Care Study, which includes surveys of adult day services centers and residential care communities and administrative data from the Centers for Medicare and Medicaid Services on home health agencies, hospices, inpatient rehabilitation facilities, long-term care hospitals, and nursing homes. The findings show variation in characteristics of the seven post-acute and long-term care settings. About 68,150 providers served roughly 7.3 million people in the United States; about one-half of these providers were residential care communities, and about one-quarter were nursing homes. The Northeast had a higher percentage of adult day services centers than other settings, the Midwest had a higher percentage of nursing homes, the South had a higher percentage of long-term care hospitals, and the West had a higher percentage of residential care communities. Among the settings, more registered nurses were employed in inpatient rehabilitation facilities and long-term care hospitals, and more licensed practical nurses in home health agencies and long-term care hospitals. The most common services were skilled nursing and therapeutic services. Adult day services centers had the highest percentage of users younger than age 65, while nearly one-half of hospice and nursing home users were age 85 and older. Adult day services centers had the highest percentage of other non-Hispanic and Hispanic users among the settings. The percentage of users with selected diagnoses and activities of daily living difficulties varied by setting. The providers described in this report comprise a large share of the U.S. post-acute and long-term care industry. This report provides the most recent nationally representative information on these providers and services users and updates findings from previous National Center for Health Statistics reports.

Residential care communities (RCCs) employ approximately 660,000 personal care aides—nearly three-quarters of the direct care workforce in these settings—yet these workers receive minimal training and are not licensed healthcare professionals. Despite their essential role, national patterns of aide staffing and their relationship to RCC characteristics remain unknown. This study examines how training requirements and organizational factors are associated with aide hours per resident day (HPRD) using data from the 2022 National Post-acute and Long-term Care Study. A weighted sample of 518 RCCs was analyzed using regression models. Higher aide staffing levels were significantly associated with RCCs that reimbursed aides for initial training (β = 0.84, SE = 0.36) and with facilities operating at greater than 85% occupancy (β = 0.82, SE = 0.34). In contrast, lower staffing levels were observed in RCCs requiring more than 60 hours of initial training (β=-1.36, SE = 0.58), serving 1–25% (β=-1.19, SE = 0.57) or ≥ 25% (β=-2.01, SE = 0.51) Medicaid-supported residents, and those with more than 50 beds (β=-2.14, SE = 0.30). Neither continuing education requirements nor ownership type were significantly associated with staffing. Findings underscore the importance of supporting aide training reimbursement in association with higher staffing ratios. However, more extensive initial training requirements may reflect an expectation of greater responsibility per aide, potentially reducing staffing needs. Further research is needed to explore the trade-offs between training hours and staffing levels and to better understand the influence of Medicaid participation on workforce capacity in RCCs.

This report examines telemedicine use by office-based physicians and long-term care providers in the United States, stratified by electronic health record use and by provider or practice size. Further, it examines differences in telemedicine use before and after the COVID-19 pandemic onset among office-based physicians and assesses telemedicine use during the first year of the COVID-19 pandemic for long-term care providers. Nationally representative estimates in this report are derived from data collected in the 2019 and 2021 National Electronic Health Records Survey, which assesses characteristics of office-based physicians, and the 2020 National Post-acute and Long-term Care Study, which assesses characteristics of adult day services centers and residential care communities. Measures include telemedicine using audio with video or web videoconference for patient care, electronic health record use for more than accounting or billing purposes, and size of physician practices and long-term care providers. In 2021, 80.5% of physicians in office-based settings used telemedicine for patient care, up from 16.0% in 2019. In 2020, 20.5% of adult day services centers and 44.5% of residential care communities used telemedicine to care for users with COVID-19. Office-based physicians, adult day services centers, and residential care communities that used electronic health record systems were more likely to also use telemedicine compared with those not using electronic health records. Large practices and providers were more likely to use telemedicine compared with small practices and providers. Findings from this report describe telemedicine use among office-based physicians and long-term care providers. Practices and providers that used electronic health records and were larger were more likely to also use telemedicine for patient care during the COVID-19 pandemic.

Residential care communities (RCC) and adult day services centers (ADSC) were greatly impacted by COVID-19. As state-regulated home- and community-based care settings (HCBSs), they experienced changing regulations, outbreaks among care recipients and staff, and new challenges to safely provide services. Using a nationally representative sample of over 11,600 RCCs and census of nearly 5,500 ADSCs from the 2020 National Post-acute and Long-term Care Study, this study examined the prevalence and regional variation (p<.05) of practices to mitigate COVID-19. Preliminary data show that most RCCs (87%) and ADSCs (72%) screened for symptoms. Most RCCs limited communal activities (83%) and ADSCs reduced hours or temporarily closed (73%). More RCCs used video telemedicine than audio-only (40% vs 34%) to assess, diagnose, or treat users. However, more ADSCs used audio-only than video telemedicine (25% vs 17%). Over 80% of all providers always or sometimes imposed in-person restrictions on family, visitors, volunteers, and non-essential services providers. More ADSCs in the Midwest (82%) and South (80%) screened symptoms than Northeast (68%) and more ADSCs in the Midwest (85%) limited hours/temporarily closed than Northeast (72%). More RCCs in the Midwest (43%) and South (41%) used video telemedicine than Northeast (36%); however, a lower percentage of ADSCs in the Midwest (9%) and South (12%) used video telemedicine than Northeast (25%). Results show a variety of experiences in the first year of the COVID-19 pandemic among these two HCBSs. Practices to mitigate COVID-19 while continuing to provide needed services were common, with some differences across settings and US regions.

This study describes the relationships between the number of selected chronic conditions among residents and the number and provision methods of services provided by residential care communities (RCCs). Estimates are from the 2016 wave of the National Study of Long-Term Care Providers conducted by the National Center for Health Statistics. Chronic conditions were measured by whether the RCC reported having at least one resident with any of the most common chronic conditions: dementia, diabetes, depression, or heart disease. Services included were mental health, social work, therapeutic, dietary, and skilled nursing. Each service type was categorized by provision method (provided by employees, arrangement or referral only, or not provided). Among RCCs, 63% had all four conditions among residents, 23% had three, 12% had one to two, and 1% had none. About 66% of RCCs provided all five services, 16% provided four, 15% provided 1-3, and 3% provided none. Of the 63% of RCCs that had all four conditions among residents, 69% provided all five services, 29% provided 1-4, and 2% provided none. In these RCCs, a greater percentage provided dietary (69%) and skilled nursing services (33%) with employees compared to the other methods; a greater percentage provided therapeutic (85%) and mental health services (83%) solely through arrangement or referral compared to the other methods. This study found that, in 2016, RCCs with multiple selected conditions among their residents tended to provide a greater number of services for managing chronic conditions. How these RCCs provide services varied based on service type.

Residential care communities (RCCs) employ nearly 660,000 personal care aides but few studies have examined personal care aide staffing nationwide. This study examines RCC characteristics associated with aide hours per resident day. We used the 2022 National Post-acute and Long-term Care Study to analyze variables of interest without missing data (n = 518) and produced weighted regression model estimates. Variables associated with higher staffing ratios included reimbursement for initial training (b = .84, se = .36) and occupancy greater than 85% (b = .82, se = .34). Factors related to lower staffing included initial training of more than 60 hours (b = -1.36, se = .58), Medicaid support for 1-25% of residents (b = -1.19, se = .57), Medicaid support for 25% or more residents (b = -2.01, se = .51), and having more than 50 beds (b = -2.14, se = .30). This study provides new insights into aide staffing ratios in RCCs that are important for future investigation, policy/advocacy, and workforce practice.

Emergency department (ED) visits are an important part of healthcare utilization. However, ED visits can be costly, lead to hospitalizations, and are sometimes unnecessary. Studies characterizing ED visits among long-term care settings have been largely focused on nursing homes where the unit of analysis is typically the resident. Facility- or community-level analyses describing residential care communities (RCCs) with ED visits are limited. Using RCCs as the unit of analysis, this study examines community-level factors associated with RCCs that have residents with ED visits. Community-level factors include ownership and chain affiliation, Medicaid participation, electronic health records use, service provision, nurse staffing, U.S. census region and metropolitan status. The study uses data from the 2016 National Study of Long-Term Care Providers conducted by the National Center for Health Statistics. In 2016, about 81% of RCCs had at least one resident visiting the ED in the past 90 days and around 19% of RCCs had no residents with ED visits in the past 90 days. Bivariate analyses indicated that ED visits varied by chain affiliation, ownership status, electronic health records use, and Medicaid participation. Logistic regression modeling to examine factors associated with whether or not RCCs had any residents with ED visits in the past 90 days will also be presented. Results may benefit efforts focused on implementing practices to reduce ED visits in RCCs.

Correlates of Administrator Tenure in US Residential Care Communities

In 2014, the total registered nurse, licensed practical or vocational nurse, and aide staffing level among all residential care communities was about 2 hours and 50 minutes. Registered nurse staffing levels differed for two of the three organizational characteristics (size and metropolitan statistical area [MSA]) and for only one of the four resident composition characteristics (primarily serving residents needing any assistance with activities of daily living). Licensed practical or vocational nurse staffing levels differed for all three organizational characteristics (size, MSA, and ownership) and for only one of the four resident composition characteristics (primarily serving residents diagnosed with Alzheimer’s disease or other dementias). In contrast, differences in aide staffing levels were common when examining both community organizational and resident composition characteristics. Registered nursing, licensed practical and vocational nursing, and aide staffing levels varied geographically by state.

The 2017 Environmental Scan

In 2014, aides provided more hours of care in the major sectors of long-term care than the other staffing types shown. Aides accounted for 60% of all staffing hours in nursing homes, compared with licensed practical or vocational nurses (21%), registered nurses (13%), activities staff members (5%), and social workers (2%). Aides accounted for 75% of all staffing hours in residential care communities, in contrast to activities staff members (11%), registered nurses (7%), licensed practical or vocational nurses (6%), and social workers (1%). In adult day services centers, aides provided 41% of all staffing hours, followed by activities staff members (32%), registered nurses (12%), licensed practical or vocational nurses (9%), and social workers (6%).

Fall-related injuries among older adults are common and expensive; can result in hospitalizations, functional decline, and nursing-home placement; and, are more common in institutionalized settings. Even falls not resulting in injury can increase fear of falling, future fall risk, depression, and social isolation. Falls in assisted living and similar residential care communities (RCCs) have been less studied than in nursing home settings. A 2010 Cochrane systematic review found that 20% to 30% of falls in long-term care facilities are preventable. We present results from the National Study of Long-Term Care Providers conducted by the National Center for Health Statistics. In 2016, 22% of current RCC residents had a fall in the prior 90 days, representing 175,000 RCC residents in the United States; in 20% of RCCs, more than one-quarter of residents had a fall. Among residents with a fall, 15% had a fall-related injury; in 7% of RCCs, more than one-quarter of residents sustained a fall-related injury. Among residents with a fall, 19% went to a hospital as a result of the fall; in 11% of RCCs, more than one-quarter of residents went to a hospital as a result of the fall. Four-tenths of RCCs reported using a fall risk assessment tool as standard practice with every resident; almost three-fourths of RCCs report using some type of formal fall reduction intervention. Results will be further examined by selected resident case-mix and other RCC characteristics. Results may inform strategies to target RCCs that might benefit from evidence-based fall reduction interventions.

Every two years since 2012, the National Study of Long-Term Care Providers includes provider surveys with residential care communities (RCCs) and adult day services centers (ADSCs), via a multi-mode approach using Web, hard-copy questionnaires, and computer-assisted telephone interviewing. In each wave, we struggled to achieve target response rates. First, diversity among providers surveyed—e.g. RCC size, type of ADSC—presents unique challenges. For RCCs, small communities have lower response compared to larger ones. For ADSCs, how they define themselves (medically vs socially oriented) influenced their decision to participate. Second, respondents’ perceived burden, particularly the time required to complete the survey, is a recurring concern especially for directors of multiple RCCs and ADSCs. Finally, reaching target respondents—directors, administrators or operators—is problematic. These challenges affect data quality. In this presentation, we share results of our efforts to enhance contacting and interviewing protocols intended to address low participation associated with these challenges.

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