Upload
others
View
0
Download
0
Embed Size (px)
Citation preview
PHI bull 400 East Fordham Road 11th Floor bull Bronx NY 10458 bull 7184027766 bull wwwPHInationalorg
Known as ldquoAmerica in Miniaturerdquo for its diverse natural terrain Maryland is also a microcosm of the United States when it comes to population change and the growing crisis in care for older adults and individuals with disabilities Within the next decade the number of adults aged 65 and older in Maryland and its urban neighbor the District of Columbia (DC) is expected to increase by more than 330000 (a 36 percent increase from 2015 to 2025) while the population of working-age adults will increase by less than 80000 (just 2 percent)1 Mirroring national realities these trends contribute to a growing mismatch between the population demand for long-term services and supports (LTSS) and the supply of direct services workers who provide them The poor quality of direct services jobs exacerbates this workforce
shortage as workers move to other sectors that offer better wages and benefits more stable hours opportunities for advancement and other advantages2
Providers payers policymakers and other stakeholders in Maryland and DC agree that improving direct services jobs and the stability of the workforce is a pressing priority To help inform efforts to improve recruitment retention and career development this research brief provides a detailed snapshot of LTSS needs and the direct services workforce across this diverse region By taking a collaborative data-driven approach Maryland and DC can lead the nation in addressing these challenges and ensuring that older adults and people with disabilities access the care and support they need in the years ahead
THE DIRECT SERVICES WORKFORCE IN LONG-TERM SERVICES AND SUPPORTS IN MARYLAND AND THE DISTRICT OF COLUMBIA
RESEARCH BRIEF
METHODOLOGYThe analyses in this report include personal care aides home health aides and nursing assistants which are the three primary occupational categories for direct services workers according to the Standard Occupational Classification (SOC) system developed by the Bureau of Labor Statistics (BLS) The North American Industry Classification System (NAICS) was used to define long-term care industries including home care (Home Health Care Services and Services for the Elderly and People with Disabilities) nursing homes (Skilled Nursing Facilities only) and residential care (Residential Intellectual and Developmental Disability Facilities Continuing Care Retirement Communities and Assisted Living Facilities for the Elderly and Other Residential Care Facilities)3
Wages employment trends and employment projections were sourced from the BLS Occupational Employment Statistics (OES) program the BLS Employment Projections program and the Maryland Department of Labor Licensing and Regulationrsquos Office of Workforce Information and Performance (OWIP) Wages were calculated as a weighted average of median hourly wages by occupation in each region (Small survey samples at the local level impede cross-tabulations of wage and employment data by industry and occupation) Median wages are preferable to mean wages which are skewed by a small proportion of atypically highly paid home care workers The Consumer Price Index (CPI) for All Urban Consumers (Current Series) was used to adjust wages for inflation
Direct services worker demographics employment status annual earnings poverty status reliance on public assistance and health insurance status were analyzed from the US Census Bureaursquos American Community Survey (ACS) Given the imprecise coding system used by the ACS two parent industriesmdashIndividual and Family Services and Residential Care Facilities (Except Skilled Nursing Facilities)mdashwere used to examine home care workers and residential care workers
To achieve as much specificity as possible about workforce supply and demand in Maryland while accounting for smaller sample sizes in some areas of the state this report developed regional definitions using elements of metropolitan and non-metropolitan statistical areas (as defined by the US Census Bureau) combined with Workforce Investment Areas (as defined by the Maryland Department of Labor Licensing and Regulation) Because county-specific data are not available through the American Community Survey Public Use Microdata Areas (PUMAs) were converted to counties and then classified into regions to align with the other analyses in this report
2 The Direct Services Workforce in LTSS in MD and DC
GarrettAllegany Washington
Frederick
Montgomery
Howard
AnneArundel
PrinceGeorgersquos
Charles
Dorchester
Wicomico
Talbot
Kent
HarfordCecil
QueenAnnersquos
Caroline
WorcesterSomerset
Calvert
St Maryrsquos
DC
Carroll
Baltimore
BaltimoreCity
METHODOLOGY
The Direct Services Workforce in LTSS in MD and DC 3
The population in the Maryland and DC region is rapidly growing older which is driving up demand for long-term services and supports (LTSS)
From 2014 to 2024 Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers to meet growing LTSS needs
The majority of direct services workers in the region are women (88 percent) and people of color (88 percent) and 32 percent were born outside the US The demographic profile of the workforce varies significantly across the region particularly between rural and urban areas
Direct services workers in Maryland earn a median hourly wage of $1303 and median annual income of $22700 while those in DC earn $1419 per hour and $23700 per year Earnings vary from $14600 for some workers on the Eastern Shore to nearly $28000 in DC
Nearly 1 in 5 direct services workers in DC and more than 1 in 10 in Maryland live in poverty Sixty-three percent of workers in DC and 43 percent in Maryland rely on some form of public assistance
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school though educational attainment rates range from about 40 percent to nearly 60 percent across the region At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance In some parts of the region more than a third of the workforce with health insurance relies on Medicaid Medicare or another form of public coverage
Transportation needs vary across the region most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation
KEY FINDINGS
GarrettAllegany Washington
Frederick
Montgomery
Howard
AnneArundel
PrinceGeorgersquos
Charles
Dorchester
Wicomico
Talbot
Kent
HarfordCecil
QueenAnnersquos
Caroline
WorcesterSomerset
Calvert
St Maryrsquos
DC
Carroll
Baltimore
BaltimoreCity
MARYLAND amp DC REGIONAL DEFINITIONS
Baltimore City County Workforce Regions Baltimore City and Baltimore County
Baltimore Suburbs Workforce Regions Anne Arundel County Mid-Maryland and Susquehanna
District of Columbia DC Suburbs Southern Maryland
Workforce Regions Frederick County Montgomery County Prince Georges County and Southern Maryland
Eastern Shore Workforce Regions Lower Shore and Upper Shore
Western Maryland Workforce Region Western Maryland
KEY FINDINGS
1 5
6
7
8
2
3
4
The Direct Services Workforce in LTSS in MD and DC4
WHAT IS THE DIRECT SERVICES WORKFORCE
The direct services workforce includes personal care aides (PCAs) home health aides (HHAs) and certified nursing assistants (CNAs) who provide essential day-to-day support for individuals with long-term conditions or disabilities in a range of settings including private homes assisted living and other residential facilities and skilled nursing homes As well as providing assistance with personal care (such as bathing dressing mobility toilet care and eating) PCAs may also help consumers with housekeeping transportation and social or employment activities outside the home In comparison HHAs and CNAs perform clinical tasks under the supervision of a licensed professional such as wound care medication administration andor range
of motion exercises (See Figure 1 for more details about each role)
It is important to note that there are a range of direct services roles that fall within these three main categories and merit specific attention even though they are not differentiated within the SOC system Direct support professionals (DSPs) are a key example although classified as PCAs they play a distinct role in providing tailored support for individuals with intellectual and developmental disabilities Advocates stress that tailored strategies to address supply and demand training and job quality issues among DSPs should be identified and implemented
Job Title Training Requirements Responsibilities Care Setting(s)
Certified Nursing Assistant (CNA)
Federal requirements 75 hours
MD 100 hours including 40 hours of practical experience CNA certification is the basis of further credentials including Home Health Aide (below) Geriatric Nursing Assistant or Certified Medication Aide
DC 120 hours including 75 hours of practical experience
bull Assist with activities of daily living (ADLs) bull Perform certain clinical tasks under supervision of a licensed professional (depending on state laws)
Work primarily in skilled nursing facilities (SNFs) but may also work in continuing care retirement communities (CCRCs) assisted living facilities (ALFs) hospitals or in private homes
WHAT IS THE DIRECT SERVICES WORKFORCE
Figure 1 Direct Services Workers by Training Requirements Responsibilities and Care Setting
The Direct Services Workforce in LTSS in MD and DC 5
WHAT IS THE DIRECT SERVICES WORKFORCE
Job Title Training Requirements Responsibilities Care Setting(s)
Home Health Aide (HHA)
Federal requirements 75 hours
MD Individuals must complete the CNA training and certification requirements then pass a competency evaluation HHA training is typically provided by the licensed home health agency employer
DC 125 hours including 40 hours of practical experience
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull Perform certain
clinical tasks under supervision of a licensed professional (depending on
state laws)
Work primarily in private homes but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Personal Care Aide (PCA)
No federal requirements
MD Agency-employed aides are trained by a registered nurse according to the needs of their clients Training for individual providers in participant-directed programs is at the discretion of the participant
DC PCAs providing services under the Medicaid State Plan and both HCBS waiver programs must be certified as HHAs Participant-directed services are not offered under Medicaid
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull May assist with
transportation employment and other
aspects of social engagement outside the
home
Work primarily in private homes (through agencies or direct hire by individuals) but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Source Adapted from Cook Allison 2017 Improving Job Quality for the Direct Care Workforce A Review of State Policy Strategies Working Poor Families Project httpwwwworkingpoorfamiliesorgwp-contentuploads201712Winter-2017-WPFP-Policy-Briefpdf and Bureau of Labor Statistics (BLS) 2018 Occupational Outlook Handbook Washington DC BLS Office of Occupational Statistics and Employment Projections httpswwwblsgovoohhomehtm
The Direct Services Workforce in LTSS in MD and DC6
WHAT IS THE POPULATION DEMAND FOR LTSS
Currently nearly 270000 Maryland and DC residents report difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)10 This figure represents four percent of the total population across the region A much larger proportion of adults aged 65 and above require this assistance 15 percent in Maryland and 18 percent in DC Although many of these individuals will receive unpaid support from family members and friends a significant proportion will require paid LTSS at some point There are also more than 26000 individuals living in nursing homes across Maryland and DC region11
The number of individuals with long-term support needs in the region will increase dramatically as the population grows older12 In Maryland the number of older adults is predicted to grow by 75 percent within the next 30 years from 837500 in 2015 to nearly 15 million in 2045 During the same period the number of adults aged 85 and over will increase by nearly 200 percent With only 5 percent expected growth among working-age adults the ratio of working-age adults to those aged 85 and above in the state will shrink from 321 in 2015 to just 121 by 2045
bull Total spending on LTSS was $78 billion in Maryland and $14 billion in DC in 20144
bull Spending by Medicaid ndash the primary payer of LTSS ndash was $31 billion on LTSS in Maryland ($516 per resident) and $816 million in DC ($1193 per resident) in 20165
bull The total number of Medicaid LTSS recipients was approximately 56000 in Maryland and 22500 in DC in 20136
bull Thanks to rebalancing efforts 56 percent of Medicaid LTSS dollars in both Maryland and DC were spent on home and community-based services (HCBS) in 2016 the national average was 57 percent (ranging from 27 to 81 percent)7 (See Appendix 1 for spending details by setting)
bull Although Maryland has made progress in improving access to HCBS there were still 23000 older adults on waiting lists for sect1915(c) and sect1115 waiver programs as of 20168 There are no waiting lists for DCrsquos waiver programs
bull DC and Maryland share 12th place on the 2017 LTSS Scorecard which evaluates states from the perspective of consumers and their families9 The region is particularly strong on ldquoLTSS affordability and accessrdquo ranking first and sixth in the nation respectively
Note Reference years vary according to source for each of these ldquoQuick Factsrdquo
QUICK FACTS LTSS IN MARYLAND AND DC
WHAT IS THE POPULATION DEMAND FOR LTSS
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
METHODOLOGYThe analyses in this report include personal care aides home health aides and nursing assistants which are the three primary occupational categories for direct services workers according to the Standard Occupational Classification (SOC) system developed by the Bureau of Labor Statistics (BLS) The North American Industry Classification System (NAICS) was used to define long-term care industries including home care (Home Health Care Services and Services for the Elderly and People with Disabilities) nursing homes (Skilled Nursing Facilities only) and residential care (Residential Intellectual and Developmental Disability Facilities Continuing Care Retirement Communities and Assisted Living Facilities for the Elderly and Other Residential Care Facilities)3
Wages employment trends and employment projections were sourced from the BLS Occupational Employment Statistics (OES) program the BLS Employment Projections program and the Maryland Department of Labor Licensing and Regulationrsquos Office of Workforce Information and Performance (OWIP) Wages were calculated as a weighted average of median hourly wages by occupation in each region (Small survey samples at the local level impede cross-tabulations of wage and employment data by industry and occupation) Median wages are preferable to mean wages which are skewed by a small proportion of atypically highly paid home care workers The Consumer Price Index (CPI) for All Urban Consumers (Current Series) was used to adjust wages for inflation
Direct services worker demographics employment status annual earnings poverty status reliance on public assistance and health insurance status were analyzed from the US Census Bureaursquos American Community Survey (ACS) Given the imprecise coding system used by the ACS two parent industriesmdashIndividual and Family Services and Residential Care Facilities (Except Skilled Nursing Facilities)mdashwere used to examine home care workers and residential care workers
To achieve as much specificity as possible about workforce supply and demand in Maryland while accounting for smaller sample sizes in some areas of the state this report developed regional definitions using elements of metropolitan and non-metropolitan statistical areas (as defined by the US Census Bureau) combined with Workforce Investment Areas (as defined by the Maryland Department of Labor Licensing and Regulation) Because county-specific data are not available through the American Community Survey Public Use Microdata Areas (PUMAs) were converted to counties and then classified into regions to align with the other analyses in this report
2 The Direct Services Workforce in LTSS in MD and DC
GarrettAllegany Washington
Frederick
Montgomery
Howard
AnneArundel
PrinceGeorgersquos
Charles
Dorchester
Wicomico
Talbot
Kent
HarfordCecil
QueenAnnersquos
Caroline
WorcesterSomerset
Calvert
St Maryrsquos
DC
Carroll
Baltimore
BaltimoreCity
METHODOLOGY
The Direct Services Workforce in LTSS in MD and DC 3
The population in the Maryland and DC region is rapidly growing older which is driving up demand for long-term services and supports (LTSS)
From 2014 to 2024 Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers to meet growing LTSS needs
The majority of direct services workers in the region are women (88 percent) and people of color (88 percent) and 32 percent were born outside the US The demographic profile of the workforce varies significantly across the region particularly between rural and urban areas
Direct services workers in Maryland earn a median hourly wage of $1303 and median annual income of $22700 while those in DC earn $1419 per hour and $23700 per year Earnings vary from $14600 for some workers on the Eastern Shore to nearly $28000 in DC
Nearly 1 in 5 direct services workers in DC and more than 1 in 10 in Maryland live in poverty Sixty-three percent of workers in DC and 43 percent in Maryland rely on some form of public assistance
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school though educational attainment rates range from about 40 percent to nearly 60 percent across the region At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance In some parts of the region more than a third of the workforce with health insurance relies on Medicaid Medicare or another form of public coverage
Transportation needs vary across the region most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation
KEY FINDINGS
GarrettAllegany Washington
Frederick
Montgomery
Howard
AnneArundel
PrinceGeorgersquos
Charles
Dorchester
Wicomico
Talbot
Kent
HarfordCecil
QueenAnnersquos
Caroline
WorcesterSomerset
Calvert
St Maryrsquos
DC
Carroll
Baltimore
BaltimoreCity
MARYLAND amp DC REGIONAL DEFINITIONS
Baltimore City County Workforce Regions Baltimore City and Baltimore County
Baltimore Suburbs Workforce Regions Anne Arundel County Mid-Maryland and Susquehanna
District of Columbia DC Suburbs Southern Maryland
Workforce Regions Frederick County Montgomery County Prince Georges County and Southern Maryland
Eastern Shore Workforce Regions Lower Shore and Upper Shore
Western Maryland Workforce Region Western Maryland
KEY FINDINGS
1 5
6
7
8
2
3
4
The Direct Services Workforce in LTSS in MD and DC4
WHAT IS THE DIRECT SERVICES WORKFORCE
The direct services workforce includes personal care aides (PCAs) home health aides (HHAs) and certified nursing assistants (CNAs) who provide essential day-to-day support for individuals with long-term conditions or disabilities in a range of settings including private homes assisted living and other residential facilities and skilled nursing homes As well as providing assistance with personal care (such as bathing dressing mobility toilet care and eating) PCAs may also help consumers with housekeeping transportation and social or employment activities outside the home In comparison HHAs and CNAs perform clinical tasks under the supervision of a licensed professional such as wound care medication administration andor range
of motion exercises (See Figure 1 for more details about each role)
It is important to note that there are a range of direct services roles that fall within these three main categories and merit specific attention even though they are not differentiated within the SOC system Direct support professionals (DSPs) are a key example although classified as PCAs they play a distinct role in providing tailored support for individuals with intellectual and developmental disabilities Advocates stress that tailored strategies to address supply and demand training and job quality issues among DSPs should be identified and implemented
Job Title Training Requirements Responsibilities Care Setting(s)
Certified Nursing Assistant (CNA)
Federal requirements 75 hours
MD 100 hours including 40 hours of practical experience CNA certification is the basis of further credentials including Home Health Aide (below) Geriatric Nursing Assistant or Certified Medication Aide
DC 120 hours including 75 hours of practical experience
bull Assist with activities of daily living (ADLs) bull Perform certain clinical tasks under supervision of a licensed professional (depending on state laws)
Work primarily in skilled nursing facilities (SNFs) but may also work in continuing care retirement communities (CCRCs) assisted living facilities (ALFs) hospitals or in private homes
WHAT IS THE DIRECT SERVICES WORKFORCE
Figure 1 Direct Services Workers by Training Requirements Responsibilities and Care Setting
The Direct Services Workforce in LTSS in MD and DC 5
WHAT IS THE DIRECT SERVICES WORKFORCE
Job Title Training Requirements Responsibilities Care Setting(s)
Home Health Aide (HHA)
Federal requirements 75 hours
MD Individuals must complete the CNA training and certification requirements then pass a competency evaluation HHA training is typically provided by the licensed home health agency employer
DC 125 hours including 40 hours of practical experience
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull Perform certain
clinical tasks under supervision of a licensed professional (depending on
state laws)
Work primarily in private homes but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Personal Care Aide (PCA)
No federal requirements
MD Agency-employed aides are trained by a registered nurse according to the needs of their clients Training for individual providers in participant-directed programs is at the discretion of the participant
DC PCAs providing services under the Medicaid State Plan and both HCBS waiver programs must be certified as HHAs Participant-directed services are not offered under Medicaid
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull May assist with
transportation employment and other
aspects of social engagement outside the
home
Work primarily in private homes (through agencies or direct hire by individuals) but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Source Adapted from Cook Allison 2017 Improving Job Quality for the Direct Care Workforce A Review of State Policy Strategies Working Poor Families Project httpwwwworkingpoorfamiliesorgwp-contentuploads201712Winter-2017-WPFP-Policy-Briefpdf and Bureau of Labor Statistics (BLS) 2018 Occupational Outlook Handbook Washington DC BLS Office of Occupational Statistics and Employment Projections httpswwwblsgovoohhomehtm
The Direct Services Workforce in LTSS in MD and DC6
WHAT IS THE POPULATION DEMAND FOR LTSS
Currently nearly 270000 Maryland and DC residents report difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)10 This figure represents four percent of the total population across the region A much larger proportion of adults aged 65 and above require this assistance 15 percent in Maryland and 18 percent in DC Although many of these individuals will receive unpaid support from family members and friends a significant proportion will require paid LTSS at some point There are also more than 26000 individuals living in nursing homes across Maryland and DC region11
The number of individuals with long-term support needs in the region will increase dramatically as the population grows older12 In Maryland the number of older adults is predicted to grow by 75 percent within the next 30 years from 837500 in 2015 to nearly 15 million in 2045 During the same period the number of adults aged 85 and over will increase by nearly 200 percent With only 5 percent expected growth among working-age adults the ratio of working-age adults to those aged 85 and above in the state will shrink from 321 in 2015 to just 121 by 2045
bull Total spending on LTSS was $78 billion in Maryland and $14 billion in DC in 20144
bull Spending by Medicaid ndash the primary payer of LTSS ndash was $31 billion on LTSS in Maryland ($516 per resident) and $816 million in DC ($1193 per resident) in 20165
bull The total number of Medicaid LTSS recipients was approximately 56000 in Maryland and 22500 in DC in 20136
bull Thanks to rebalancing efforts 56 percent of Medicaid LTSS dollars in both Maryland and DC were spent on home and community-based services (HCBS) in 2016 the national average was 57 percent (ranging from 27 to 81 percent)7 (See Appendix 1 for spending details by setting)
bull Although Maryland has made progress in improving access to HCBS there were still 23000 older adults on waiting lists for sect1915(c) and sect1115 waiver programs as of 20168 There are no waiting lists for DCrsquos waiver programs
bull DC and Maryland share 12th place on the 2017 LTSS Scorecard which evaluates states from the perspective of consumers and their families9 The region is particularly strong on ldquoLTSS affordability and accessrdquo ranking first and sixth in the nation respectively
Note Reference years vary according to source for each of these ldquoQuick Factsrdquo
QUICK FACTS LTSS IN MARYLAND AND DC
WHAT IS THE POPULATION DEMAND FOR LTSS
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 3
The population in the Maryland and DC region is rapidly growing older which is driving up demand for long-term services and supports (LTSS)
From 2014 to 2024 Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers to meet growing LTSS needs
The majority of direct services workers in the region are women (88 percent) and people of color (88 percent) and 32 percent were born outside the US The demographic profile of the workforce varies significantly across the region particularly between rural and urban areas
Direct services workers in Maryland earn a median hourly wage of $1303 and median annual income of $22700 while those in DC earn $1419 per hour and $23700 per year Earnings vary from $14600 for some workers on the Eastern Shore to nearly $28000 in DC
Nearly 1 in 5 direct services workers in DC and more than 1 in 10 in Maryland live in poverty Sixty-three percent of workers in DC and 43 percent in Maryland rely on some form of public assistance
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school though educational attainment rates range from about 40 percent to nearly 60 percent across the region At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance In some parts of the region more than a third of the workforce with health insurance relies on Medicaid Medicare or another form of public coverage
Transportation needs vary across the region most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation
KEY FINDINGS
GarrettAllegany Washington
Frederick
Montgomery
Howard
AnneArundel
PrinceGeorgersquos
Charles
Dorchester
Wicomico
Talbot
Kent
HarfordCecil
QueenAnnersquos
Caroline
WorcesterSomerset
Calvert
St Maryrsquos
DC
Carroll
Baltimore
BaltimoreCity
MARYLAND amp DC REGIONAL DEFINITIONS
Baltimore City County Workforce Regions Baltimore City and Baltimore County
Baltimore Suburbs Workforce Regions Anne Arundel County Mid-Maryland and Susquehanna
District of Columbia DC Suburbs Southern Maryland
Workforce Regions Frederick County Montgomery County Prince Georges County and Southern Maryland
Eastern Shore Workforce Regions Lower Shore and Upper Shore
Western Maryland Workforce Region Western Maryland
KEY FINDINGS
1 5
6
7
8
2
3
4
The Direct Services Workforce in LTSS in MD and DC4
WHAT IS THE DIRECT SERVICES WORKFORCE
The direct services workforce includes personal care aides (PCAs) home health aides (HHAs) and certified nursing assistants (CNAs) who provide essential day-to-day support for individuals with long-term conditions or disabilities in a range of settings including private homes assisted living and other residential facilities and skilled nursing homes As well as providing assistance with personal care (such as bathing dressing mobility toilet care and eating) PCAs may also help consumers with housekeeping transportation and social or employment activities outside the home In comparison HHAs and CNAs perform clinical tasks under the supervision of a licensed professional such as wound care medication administration andor range
of motion exercises (See Figure 1 for more details about each role)
It is important to note that there are a range of direct services roles that fall within these three main categories and merit specific attention even though they are not differentiated within the SOC system Direct support professionals (DSPs) are a key example although classified as PCAs they play a distinct role in providing tailored support for individuals with intellectual and developmental disabilities Advocates stress that tailored strategies to address supply and demand training and job quality issues among DSPs should be identified and implemented
Job Title Training Requirements Responsibilities Care Setting(s)
Certified Nursing Assistant (CNA)
Federal requirements 75 hours
MD 100 hours including 40 hours of practical experience CNA certification is the basis of further credentials including Home Health Aide (below) Geriatric Nursing Assistant or Certified Medication Aide
DC 120 hours including 75 hours of practical experience
bull Assist with activities of daily living (ADLs) bull Perform certain clinical tasks under supervision of a licensed professional (depending on state laws)
Work primarily in skilled nursing facilities (SNFs) but may also work in continuing care retirement communities (CCRCs) assisted living facilities (ALFs) hospitals or in private homes
WHAT IS THE DIRECT SERVICES WORKFORCE
Figure 1 Direct Services Workers by Training Requirements Responsibilities and Care Setting
The Direct Services Workforce in LTSS in MD and DC 5
WHAT IS THE DIRECT SERVICES WORKFORCE
Job Title Training Requirements Responsibilities Care Setting(s)
Home Health Aide (HHA)
Federal requirements 75 hours
MD Individuals must complete the CNA training and certification requirements then pass a competency evaluation HHA training is typically provided by the licensed home health agency employer
DC 125 hours including 40 hours of practical experience
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull Perform certain
clinical tasks under supervision of a licensed professional (depending on
state laws)
Work primarily in private homes but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Personal Care Aide (PCA)
No federal requirements
MD Agency-employed aides are trained by a registered nurse according to the needs of their clients Training for individual providers in participant-directed programs is at the discretion of the participant
DC PCAs providing services under the Medicaid State Plan and both HCBS waiver programs must be certified as HHAs Participant-directed services are not offered under Medicaid
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull May assist with
transportation employment and other
aspects of social engagement outside the
home
Work primarily in private homes (through agencies or direct hire by individuals) but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Source Adapted from Cook Allison 2017 Improving Job Quality for the Direct Care Workforce A Review of State Policy Strategies Working Poor Families Project httpwwwworkingpoorfamiliesorgwp-contentuploads201712Winter-2017-WPFP-Policy-Briefpdf and Bureau of Labor Statistics (BLS) 2018 Occupational Outlook Handbook Washington DC BLS Office of Occupational Statistics and Employment Projections httpswwwblsgovoohhomehtm
The Direct Services Workforce in LTSS in MD and DC6
WHAT IS THE POPULATION DEMAND FOR LTSS
Currently nearly 270000 Maryland and DC residents report difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)10 This figure represents four percent of the total population across the region A much larger proportion of adults aged 65 and above require this assistance 15 percent in Maryland and 18 percent in DC Although many of these individuals will receive unpaid support from family members and friends a significant proportion will require paid LTSS at some point There are also more than 26000 individuals living in nursing homes across Maryland and DC region11
The number of individuals with long-term support needs in the region will increase dramatically as the population grows older12 In Maryland the number of older adults is predicted to grow by 75 percent within the next 30 years from 837500 in 2015 to nearly 15 million in 2045 During the same period the number of adults aged 85 and over will increase by nearly 200 percent With only 5 percent expected growth among working-age adults the ratio of working-age adults to those aged 85 and above in the state will shrink from 321 in 2015 to just 121 by 2045
bull Total spending on LTSS was $78 billion in Maryland and $14 billion in DC in 20144
bull Spending by Medicaid ndash the primary payer of LTSS ndash was $31 billion on LTSS in Maryland ($516 per resident) and $816 million in DC ($1193 per resident) in 20165
bull The total number of Medicaid LTSS recipients was approximately 56000 in Maryland and 22500 in DC in 20136
bull Thanks to rebalancing efforts 56 percent of Medicaid LTSS dollars in both Maryland and DC were spent on home and community-based services (HCBS) in 2016 the national average was 57 percent (ranging from 27 to 81 percent)7 (See Appendix 1 for spending details by setting)
bull Although Maryland has made progress in improving access to HCBS there were still 23000 older adults on waiting lists for sect1915(c) and sect1115 waiver programs as of 20168 There are no waiting lists for DCrsquos waiver programs
bull DC and Maryland share 12th place on the 2017 LTSS Scorecard which evaluates states from the perspective of consumers and their families9 The region is particularly strong on ldquoLTSS affordability and accessrdquo ranking first and sixth in the nation respectively
Note Reference years vary according to source for each of these ldquoQuick Factsrdquo
QUICK FACTS LTSS IN MARYLAND AND DC
WHAT IS THE POPULATION DEMAND FOR LTSS
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC4
WHAT IS THE DIRECT SERVICES WORKFORCE
The direct services workforce includes personal care aides (PCAs) home health aides (HHAs) and certified nursing assistants (CNAs) who provide essential day-to-day support for individuals with long-term conditions or disabilities in a range of settings including private homes assisted living and other residential facilities and skilled nursing homes As well as providing assistance with personal care (such as bathing dressing mobility toilet care and eating) PCAs may also help consumers with housekeeping transportation and social or employment activities outside the home In comparison HHAs and CNAs perform clinical tasks under the supervision of a licensed professional such as wound care medication administration andor range
of motion exercises (See Figure 1 for more details about each role)
It is important to note that there are a range of direct services roles that fall within these three main categories and merit specific attention even though they are not differentiated within the SOC system Direct support professionals (DSPs) are a key example although classified as PCAs they play a distinct role in providing tailored support for individuals with intellectual and developmental disabilities Advocates stress that tailored strategies to address supply and demand training and job quality issues among DSPs should be identified and implemented
Job Title Training Requirements Responsibilities Care Setting(s)
Certified Nursing Assistant (CNA)
Federal requirements 75 hours
MD 100 hours including 40 hours of practical experience CNA certification is the basis of further credentials including Home Health Aide (below) Geriatric Nursing Assistant or Certified Medication Aide
DC 120 hours including 75 hours of practical experience
bull Assist with activities of daily living (ADLs) bull Perform certain clinical tasks under supervision of a licensed professional (depending on state laws)
Work primarily in skilled nursing facilities (SNFs) but may also work in continuing care retirement communities (CCRCs) assisted living facilities (ALFs) hospitals or in private homes
WHAT IS THE DIRECT SERVICES WORKFORCE
Figure 1 Direct Services Workers by Training Requirements Responsibilities and Care Setting
The Direct Services Workforce in LTSS in MD and DC 5
WHAT IS THE DIRECT SERVICES WORKFORCE
Job Title Training Requirements Responsibilities Care Setting(s)
Home Health Aide (HHA)
Federal requirements 75 hours
MD Individuals must complete the CNA training and certification requirements then pass a competency evaluation HHA training is typically provided by the licensed home health agency employer
DC 125 hours including 40 hours of practical experience
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull Perform certain
clinical tasks under supervision of a licensed professional (depending on
state laws)
Work primarily in private homes but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Personal Care Aide (PCA)
No federal requirements
MD Agency-employed aides are trained by a registered nurse according to the needs of their clients Training for individual providers in participant-directed programs is at the discretion of the participant
DC PCAs providing services under the Medicaid State Plan and both HCBS waiver programs must be certified as HHAs Participant-directed services are not offered under Medicaid
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull May assist with
transportation employment and other
aspects of social engagement outside the
home
Work primarily in private homes (through agencies or direct hire by individuals) but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Source Adapted from Cook Allison 2017 Improving Job Quality for the Direct Care Workforce A Review of State Policy Strategies Working Poor Families Project httpwwwworkingpoorfamiliesorgwp-contentuploads201712Winter-2017-WPFP-Policy-Briefpdf and Bureau of Labor Statistics (BLS) 2018 Occupational Outlook Handbook Washington DC BLS Office of Occupational Statistics and Employment Projections httpswwwblsgovoohhomehtm
The Direct Services Workforce in LTSS in MD and DC6
WHAT IS THE POPULATION DEMAND FOR LTSS
Currently nearly 270000 Maryland and DC residents report difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)10 This figure represents four percent of the total population across the region A much larger proportion of adults aged 65 and above require this assistance 15 percent in Maryland and 18 percent in DC Although many of these individuals will receive unpaid support from family members and friends a significant proportion will require paid LTSS at some point There are also more than 26000 individuals living in nursing homes across Maryland and DC region11
The number of individuals with long-term support needs in the region will increase dramatically as the population grows older12 In Maryland the number of older adults is predicted to grow by 75 percent within the next 30 years from 837500 in 2015 to nearly 15 million in 2045 During the same period the number of adults aged 85 and over will increase by nearly 200 percent With only 5 percent expected growth among working-age adults the ratio of working-age adults to those aged 85 and above in the state will shrink from 321 in 2015 to just 121 by 2045
bull Total spending on LTSS was $78 billion in Maryland and $14 billion in DC in 20144
bull Spending by Medicaid ndash the primary payer of LTSS ndash was $31 billion on LTSS in Maryland ($516 per resident) and $816 million in DC ($1193 per resident) in 20165
bull The total number of Medicaid LTSS recipients was approximately 56000 in Maryland and 22500 in DC in 20136
bull Thanks to rebalancing efforts 56 percent of Medicaid LTSS dollars in both Maryland and DC were spent on home and community-based services (HCBS) in 2016 the national average was 57 percent (ranging from 27 to 81 percent)7 (See Appendix 1 for spending details by setting)
bull Although Maryland has made progress in improving access to HCBS there were still 23000 older adults on waiting lists for sect1915(c) and sect1115 waiver programs as of 20168 There are no waiting lists for DCrsquos waiver programs
bull DC and Maryland share 12th place on the 2017 LTSS Scorecard which evaluates states from the perspective of consumers and their families9 The region is particularly strong on ldquoLTSS affordability and accessrdquo ranking first and sixth in the nation respectively
Note Reference years vary according to source for each of these ldquoQuick Factsrdquo
QUICK FACTS LTSS IN MARYLAND AND DC
WHAT IS THE POPULATION DEMAND FOR LTSS
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 5
WHAT IS THE DIRECT SERVICES WORKFORCE
Job Title Training Requirements Responsibilities Care Setting(s)
Home Health Aide (HHA)
Federal requirements 75 hours
MD Individuals must complete the CNA training and certification requirements then pass a competency evaluation HHA training is typically provided by the licensed home health agency employer
DC 125 hours including 40 hours of practical experience
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull Perform certain
clinical tasks under supervision of a licensed professional (depending on
state laws)
Work primarily in private homes but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Personal Care Aide (PCA)
No federal requirements
MD Agency-employed aides are trained by a registered nurse according to the needs of their clients Training for individual providers in participant-directed programs is at the discretion of the participant
DC PCAs providing services under the Medicaid State Plan and both HCBS waiver programs must be certified as HHAs Participant-directed services are not offered under Medicaid
bull Assist with ADLs bull Help with household tasks (also known as instrumental activities of daily living [IADLs]) bull May assist with
transportation employment and other
aspects of social engagement outside the
home
Work primarily in private homes (through agencies or direct hire by individuals) but may also work in small group homes or larger care communities including CCRCs ALFs or residential intellectual and developmental disabilities facilities
Source Adapted from Cook Allison 2017 Improving Job Quality for the Direct Care Workforce A Review of State Policy Strategies Working Poor Families Project httpwwwworkingpoorfamiliesorgwp-contentuploads201712Winter-2017-WPFP-Policy-Briefpdf and Bureau of Labor Statistics (BLS) 2018 Occupational Outlook Handbook Washington DC BLS Office of Occupational Statistics and Employment Projections httpswwwblsgovoohhomehtm
The Direct Services Workforce in LTSS in MD and DC6
WHAT IS THE POPULATION DEMAND FOR LTSS
Currently nearly 270000 Maryland and DC residents report difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)10 This figure represents four percent of the total population across the region A much larger proportion of adults aged 65 and above require this assistance 15 percent in Maryland and 18 percent in DC Although many of these individuals will receive unpaid support from family members and friends a significant proportion will require paid LTSS at some point There are also more than 26000 individuals living in nursing homes across Maryland and DC region11
The number of individuals with long-term support needs in the region will increase dramatically as the population grows older12 In Maryland the number of older adults is predicted to grow by 75 percent within the next 30 years from 837500 in 2015 to nearly 15 million in 2045 During the same period the number of adults aged 85 and over will increase by nearly 200 percent With only 5 percent expected growth among working-age adults the ratio of working-age adults to those aged 85 and above in the state will shrink from 321 in 2015 to just 121 by 2045
bull Total spending on LTSS was $78 billion in Maryland and $14 billion in DC in 20144
bull Spending by Medicaid ndash the primary payer of LTSS ndash was $31 billion on LTSS in Maryland ($516 per resident) and $816 million in DC ($1193 per resident) in 20165
bull The total number of Medicaid LTSS recipients was approximately 56000 in Maryland and 22500 in DC in 20136
bull Thanks to rebalancing efforts 56 percent of Medicaid LTSS dollars in both Maryland and DC were spent on home and community-based services (HCBS) in 2016 the national average was 57 percent (ranging from 27 to 81 percent)7 (See Appendix 1 for spending details by setting)
bull Although Maryland has made progress in improving access to HCBS there were still 23000 older adults on waiting lists for sect1915(c) and sect1115 waiver programs as of 20168 There are no waiting lists for DCrsquos waiver programs
bull DC and Maryland share 12th place on the 2017 LTSS Scorecard which evaluates states from the perspective of consumers and their families9 The region is particularly strong on ldquoLTSS affordability and accessrdquo ranking first and sixth in the nation respectively
Note Reference years vary according to source for each of these ldquoQuick Factsrdquo
QUICK FACTS LTSS IN MARYLAND AND DC
WHAT IS THE POPULATION DEMAND FOR LTSS
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC6
WHAT IS THE POPULATION DEMAND FOR LTSS
Currently nearly 270000 Maryland and DC residents report difficulties with activities of daily living (ADLs) or instrumental activities of daily living (IADLs)10 This figure represents four percent of the total population across the region A much larger proportion of adults aged 65 and above require this assistance 15 percent in Maryland and 18 percent in DC Although many of these individuals will receive unpaid support from family members and friends a significant proportion will require paid LTSS at some point There are also more than 26000 individuals living in nursing homes across Maryland and DC region11
The number of individuals with long-term support needs in the region will increase dramatically as the population grows older12 In Maryland the number of older adults is predicted to grow by 75 percent within the next 30 years from 837500 in 2015 to nearly 15 million in 2045 During the same period the number of adults aged 85 and over will increase by nearly 200 percent With only 5 percent expected growth among working-age adults the ratio of working-age adults to those aged 85 and above in the state will shrink from 321 in 2015 to just 121 by 2045
bull Total spending on LTSS was $78 billion in Maryland and $14 billion in DC in 20144
bull Spending by Medicaid ndash the primary payer of LTSS ndash was $31 billion on LTSS in Maryland ($516 per resident) and $816 million in DC ($1193 per resident) in 20165
bull The total number of Medicaid LTSS recipients was approximately 56000 in Maryland and 22500 in DC in 20136
bull Thanks to rebalancing efforts 56 percent of Medicaid LTSS dollars in both Maryland and DC were spent on home and community-based services (HCBS) in 2016 the national average was 57 percent (ranging from 27 to 81 percent)7 (See Appendix 1 for spending details by setting)
bull Although Maryland has made progress in improving access to HCBS there were still 23000 older adults on waiting lists for sect1915(c) and sect1115 waiver programs as of 20168 There are no waiting lists for DCrsquos waiver programs
bull DC and Maryland share 12th place on the 2017 LTSS Scorecard which evaluates states from the perspective of consumers and their families9 The region is particularly strong on ldquoLTSS affordability and accessrdquo ranking first and sixth in the nation respectively
Note Reference years vary according to source for each of these ldquoQuick Factsrdquo
QUICK FACTS LTSS IN MARYLAND AND DC
WHAT IS THE POPULATION DEMAND FOR LTSS
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 7
THE DIRECT SERVICES WORKFORCE SUPPLY
There are nearly 71000 direct services workers in Maryland and DC including 21030 PCAs 18200 HHAs and 31410 CNAs Over the past decade the workforce has grown by 43 percent up from 49300 workers in 2007 The number of CNAs has remained relatively constant however while the HHA workforce has nearly doubled and the number of PCAs has grown by a staggering 280 percent (See Appendix 2 for detailed employment trends by region and occupation)
Although 2045 population estimates are not available for DC projections through 2025 indicate the early stages of a similar trend as the number of adults aged 65 and above will increase by nearly 25 percent within this decade By contrast however DC will also see a 15 percent increase in the number of working-age adults from 2015 to 2025
Within Maryland the Baltimore Suburbs and the DC SuburbsSouthern Maryland will experience the fastest growth in the older population between 2015 and 2045 in both areas the number of adults aged 65 and over will nearly double and those over 85 will increase by more than 200 percent The smallestmdashbut still substantivemdashincreases in the older population will be seen in Baltimore CityCounty and in Western Maryland (See Appendix 3 for detailed population projections)
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx analysis by PHI (July 14 2018)
200
150
100
50
0
20 to 64 years old 65 years and older
85 years and older
2015 lsquo20 rsquo25 lsquo30 rsquo35 lsquo40 rsquo45
5
75
179
PCAs HHAs CNAs
80
70
60
50
40
30
20
10
0
2007 rsquo08 rsquo09 rsquo10 rsquo11 rsquo12 rsquo13 rsquo14 lsquo15 lsquo16 rsquo17
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 2 Projected Population Growth by Age in MD 2015-2045
Figure 3 Direct Services Workforce Employment Trends by Occupation in MD and DC 2007-2017(in Thousands)
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC8
12
10
8
6
4
2
0
PCAs HHAs CNAs
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Direct Service Occupations All Occupations
BaltimoreSuburbs
Baltimore Cityand County
Washington Suburbs and Southern
Maryland
Eastern Shore Western Maryland Washington DC
35
30
25
20
15
10
5
0
Sources Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational Wage Estimates Workforce Investment Areas httpswwwdllrstatemduslmiwages Analysis by PHI (July 17 2018) Current employment data were missing for home health aides in Baltimore City Somerset County Wicomico County and Worcester County and employment data for personal care aides were missing for Harford and Cecil counties Projections Central 2017 Long Term Occupational Projections State Occupational Projections httpwwwprojectionscentralcomProjectionsLongTerm Maryland Department of Labor Licensing and Regulation 2018 Maryland Occupational amp Industry Projections Workforce Region 2014-2024 httpswwwblsgovoescurrentoessrcsthtm Analysis by PHI (July 14 2018) Employment projections for HHAs and CNAs were not available for Caroline Cecil Dorchester Harford Kent Queen Annersquos Somerset Talbot Wicomico or Worcester counties Instead an aggregate occupational group (Standard Occupational Code 31-1000) was used which includes CNAs HHAs orderlies and psychiatric aides (with the latter two occupations constituting a very small portion of the total)
Due to the increasing population demand Maryland will need nearly 40 percent more direct services workers and DC will need 35 percent more workers between 2014 and 2024 By comparison the number of jobs across all sectors is expected to grow by just 6 percent in DC and 18 percent in Maryland during the same period Within Maryland the largest expected growth in the direct services workforce is on the Eastern Shore (27 percent) and in the Baltimore Suburbs (22 percent) while the smallest growth is expected in Western Maryland (2 percent)
THE DIRECT SERVICES WORKFORCE SUPPLY
Figure 5 Employment Projections by Region 2014-2024 (in Percents)
Figure 4 Direct Services Workforce by Region and Occupation 2017 (in Thousands)
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 9
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
Female Male
Home Care Nursing HomesResidential Care
100
80
60
40
20
0
At the national level labor force participation among women ages 20 to 64 who currently comprise the majority of the direct services workforce is declining with fewer women now entering the workforce than in previous generations13 This workforce will increase by 35 million in the next decade compared to 77 million in 1996
to 2006 However the labor force will add another 22 million men aged 20 to 64 in the next decade and notably 53 million more older adults
These trends suggest opportunities to recruit new ldquonon-traditionalrdquo workers to the direct services workforce
WHO ARE DIRECT SERVICES WORKERS
Although broadly reflecting the demographic profile of the direct services workforce across the US14 the direct services workforce in Maryland and DC varies considerably between urban and rural areas Nearly 9 in 10 direct services workers in the region are female (88 percent) and their median age is 38 years old although median age ranges from 29 years in residential care
in DC to 46 years in home care in Maryland Within Maryland the Eastern Shore has the highest proportion of female workers (92 percent) while the DC SuburbsSouthern Maryland have the highest proportion of male workers (16 percent) (See Appendix 4 through 8 for a full picture of the direct services workforce in each region within Maryland)
WHO ARE DIRECT SERVICES WORKERS
Figure 6 Demographic Profile of the Direct Services Workforce in Washington DC (in Percents)
Figure 7 Demographic Profile of the Direct Services Workforce in Maryland (in Percents)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC10
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
More than 87 percent of direct services workers are people of color in Maryland and DC compared to half of all workers in the region15 Black or African-American workers constitute the majority of workers across all care settings Comparing within Maryland however the proportion of people of color in the direct services workforce ranges from 8 percent in Western Maryland to 80 percent in Baltimore CityCounty
Nearly one-third of direct services workers across Maryland and DC were born outside the US while 85 percent of the workforce are US citizens by birth or naturalization
The percentage of direct services workers who were born outside the US ranges from 3 percent in Western Maryland and the Eastern Shore to 63 percent in the DC SuburbsSouthern Maryland
Nearly 50 percent of the direct services workforce have not completed formal education beyond high school although levels of educational attainment vary considerably between care settings Within Maryland the percentage of workers with a high school diploma or less varies from just over 40 percent in the Baltimore Suburbs to nearly 60 percent on the Eastern Shore
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
White Black or African American Hispanic or Latino (Any Race) Asian or Pacific Islander Other
0 2000 4000 6000 8000 10000
Home Care
Residential Care
Nursing Homes
Figure 8 Demographic Profile of the Direct Services Workforce in Washington DC
Figure 9 Demographic Profile of the Direct Services Workforce in Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 11
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Gender
Female 918 973 805 884 828 883
Male 82 27 195 116 172 117
Age
16-24 51 49 82 94 129 112
25-34 332 542 211 203 337 266
35-44 25 251 246 187 211 236
45-54 208 38 221 247 163 199
55-64 135 0 188 187 124 142
65+ 25 121 53 81 36 45
Median 38 29 40 46 36 40
Race and Ethnicity
White 0 0 71 281 22 187
Black or African American 982 100 812 612 715 764
Hispanic or Latino (Any Race) 0 0 71 34 44 21
Asian or Pacific Islander 0 0 46 43 2 19
Other 18 0 0 29 01 09
Citizenship Status
US Citizen by Birth 826 752 599 604 625 679
US Citizen by Naturalization 82 191 202 176 175 172
Not a US Citizen 92 57 199 22 201 149
Educational Attainment
Less than High School 43 94 64 102 126 77
High School Graduate 518 243 495 354 333 442
Some College No Degree 295 561 263 302 323 37
Associates Degree or Higher 144 102 177 242 218 111
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Table 1 Demographic Profile of the Direct Services Workforce in DC and Maryland
WHO ARE DIRECT SERVICES WORKERS
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC12
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm analysis by PHI (July 17 2018)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The critical role that direct services workers play in the provision of LTSS is poorly matched by the quality of their jobs nationally and regionally In Maryland the median hourly wage for all direct services workers in 2017 was $1303 with a range from $1165 for PCAs to $1425 for CNAs By comparison the 2017 living wage for Maryland was estimated at $1462 for a single adult and $3327 for an adult with two children16 Notably adjusting for inflation direct services wages actually decreased by 7 percent from 2007 to 2017
Median wages in 2017 for direct services workers in DC were slightly higher at $1419 with a range from $1382 for PCAs to $1601 for CNAs On the other hand the living wage in DC was $1711 for a single adult and $3282 for an adult with two children17 Unlike in Maryland hourly wages did increase from 2007 through 2017 for direct services workers in DC especially for PCAs (20 percent) and HHAs (12 percent) nonetheless these workers still earn substantively less than CNAs
2007 2017
PCAs-MD HHAs-MD HHAs-DCPCAs-DC CNAs-MD CNAs-DC
$16
$14
$12
$10
$8
$6
$4
$2
$0
Figure 10 Direct Services Workers Median Hourly Wages in MD and DC Adjusted for Inflation 2007-2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 13
Median annual earnings are $22700 for direct services workers in Maryland and $23700 for workers in DC Within the region however annual earnings vary considerably from just $14600 in home care on Marylandrsquos Eastern Shore to nearly $28000 in nursing homes in DC
Low annual earnings are a function of employment status as well as low wages Although approximately 83 percent of all direct services workers in Maryland and DC work full time which is higher than the national average for these workers (69 percent) patterns of work vary substantively within the region and across care settings for example less than 60 percent of home care workers are full time in Baltimore CityCounty the Baltimore Suburbs and the Eastern Shore
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
$30
$25
$20
$15
$10
$5
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Full time Part time
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
588 Full time
727 Full time
663 Full time
711 Full time
862 Full time
68 Full time
Figure 11 Median Annual Income by Region and Care Setting 2017 (in Thousands)
Figure 12 Employment Status by Region 2017
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC14
Due to low wages and annual earnings poverty rates and the use of public assistance are high among direct services workers nationwide including in Maryland and DC More than 1 in 10 direct services workers in Maryland and nearly 1 in 5 in DC live in poverty18 When nearly 40 percent of all direct services workers across the region live below 200 percent of the federal poverty line Within Maryland poverty rates range from 6 percent of nursing assistants in nursing homes in the Baltimore Suburbs to nearly 30 percent of home care workers on the Eastern Shore
In addition to experiencing high rates of poverty 43 percent of direct services workers in Maryland and 63 percent in DC rely on public assistance primarily food and nutrition assistance and Medicaid Within the region public assistance use is particularly high on the Eastern Shore among nursing assistants in nursing homes and in DC among home care workers (76 percent) and residential care workers (74 percent)
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
40
30
20
10
0
Home Care Residential Care Nursing Homes
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
100
80
60
40
20
0
Any Public Assistance Food and Nutrition Assistance Medicaid Cash Assistance
BaltimoreSuburbs
Baltimore Cityand County
DC Suburbs andSouthern Maryland
Eastern Shore Western Maryland Washington DC
Figure 13 Poverty Rates by Care Setting and Region 2017 (in Percents)
Figure 14 Use of Public Assistance by Region 2017 (in Percents)
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 15
At least 1 in 10 direct services workers in Maryland (16 percent) and DC (10 percent) lacks health insurance while 15 percent of direct services workers nationwide are uninsured19 In some parts of the region more than a third of the workforce relies on public health insurance (Medicaid Medicare or other public insurance) including on the Eastern Shore (61 percent) and in DC (57 percent) Western Maryland (37 percent) and the Baltimore Suburbs (35 percent) (See Table 2 for more details on health insurance coverage for direct services workers in the region)
Finally for a low-income workforce transportation time and cost are important elements of job quality and determinants of access to care Most workers in Maryland rely on private cars to get to work (72 percent) while nearly half of workers in DC (46 percent) use public transportation The longest commutes take place among those relying on public transportation across all settings ranging from 45 minutes to one hour
Walked to Work Other Carpooled Public Transportation Drove Alone
0 2000 4000 6000 8000 10000
Washington DC
Western MD
Eastern Shore
DC Suburbs Southern MD
Baltimore Suburbs
Baltimore City County
Figure 15 Mode of Transportation to Work by Region 2017
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) ldquoOtherrdquo includes the response ldquoworked at homerdquo
THE CHALLENGES FOR DIRECT SERVICES JOBS
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
16 The Direct Services Workforce in LTSS in MD and DC
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml January 2012 to December 2016 Basic Monthly CPS httpsthedatawebrmcensusgovftpcps_ftphtml analysis by PHI (July 18 2018)
Workers may work part time for ldquoeconomicrdquo or ldquonon-economicrdquo reasons Economic reasons include not being able to obtain full-time hours due to business conditions within a company or the broader market while non-economic reasons include family caregiving responsibilities educational enrollment health concerns and other personal reasons Across Maryland and DC more workers report non-economic reasons (including 14 percent of home care workers in DC and more than 20 percent in Maryland) than economic reasons for working part time
Washington DC Maryland
Home Care
Residential Care
Nursing Homes
Home Care
Residential Care
Nursing Homes
Employment Status
Full Time 791 81 857 661 877 807
Part Time Non-Economic Reasons 139 124 69 21 95 17
Part Time Economic Reasons 7 66 74 128 28 23
Annual Earnings
Median Personal Earnings $25047 $18402 $27719 $20152 $22177 $25763
Median Family Earnings $49105 $23878 $55206 $57099 $58138 $62290
Poverty Status
Less than 100 155 245 179 134 103 9
Less than 138 181 488 179 244 196 146
Less than 200 367 612 344 452 354 339
Public Assistance
Any Public Assistance 618 763 59 46 366 433
Food and Nutrition Assistance 452 42 362 249 256 327
Medicaid 544 666 427 278 243 216
Cash Assistance 74 137 0 19 19 25
Health Insurance Status
Any Health Insurance 905 96 846 804 842 893
Health Insurance through EmployerUnion 316 321 445 387 539 626
Medicaid Medicare Other Public Coverage 563 763 495 364 274 256
Health Insurance Purchased Directly 47 259 36 151 74 74
Table 2 Direct Services Job Quality in DC and Maryland
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 17
To a large extent the challenges facing the direct services workforce in LTSS in Maryland and DC reflect nationwide realities The workforce is comprised almost entirely of historically marginalized workersmdashincluding women people of color andor immigrantsmdashwho face significant obstacles in education and employment Despite the demands of the job and the unequivocal importance of their contributions these workers still struggle to make a livable wage and achieve economic stability
But underneath these universal realities are significant local variations that require targeted strategies and solutions
Employment supports for immigrant workers may be critical for the workforce in DC and its environs for example but less relevant in the western reaches of Maryland Improving hours for workers in the Baltimore area may be a more pressing concern than in DC where most workers are already full time All workers may face transportation barriers but the solutions will vary for those in urban versus rural areas Combined with broad-based reforms such tailored interventions and employment supports will be essential for building and supporting a direct services workforce that is prepared to meet the needs of older adults and individuals with disabilities now and in the future
THE CHALLENGES FOR DIRECT SERVICES JOBS
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC18
APPENDIX 2Employment Trends in the Direct Services Workforce by Region and Occupation 2007 to 2017
Source US Bureau of Labor Statistics 2018 Occupational Employment Statistics May 2007 to May 2017 State Occupational Employment and Wage Estimates httpswwwblsgovoescurrentoessrcsthtm PCA=Personal care assistant HHA=Home health aide CNA=Certified nursing assistant
Nursing Facilities
Other Institutional Settings
Home and Community-Based Settings
Total
National Rank
Amount
of LTSS Spending
Amount
of LTSS Spending
Amount
of LTSS Spending
MD $1195942 38 $165858 5 $1748754 56 $3110554 23rd
DC $252675 31 $105590 13 $457793 56 $816058 2nd
US $56729271 34 $15543412 9 $94407727 57 $166680410 --
APPENDIX 1Medicaid Expenditures for Long-Term Services and Supports by Setting 2016 (in Thousands)
Source Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015-92016) ldquoOther institutional settingsrdquo include intermediate care facilities for individuals with intellectual disabilities and mental health facilities Percentages may not add to 100 percent due to rounding
APPENDIX 1
Area Occupation 2007 2017 Change Change
District of Columbia PCAs 970 4440 3470 358
HHAs 1210 6910 5700 471
CNAs 3090 3160 70 2
Total 5270 14510 9240 175
Maryland PCAs 4570 16590 12020 263
HHAs 11280 11290 10 0
CNAs 28180 28250 70 0
Total 44030 56130 12100 27
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 19
APPENDIX 3Population Projections by Age Group and Region 2015 to 2045
Source Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) NA = Population projections not available beyond 2025 for Washington DC
APPENDIX 3
Region Age Group 2015 2025 2035 2045 Change Change
Baltimore City 20-64 889115 863666 859433 884861 -4254 0
and County 65+ 207368 259968 288584 291389 84021 41
85+ 33676 33296 42829 57583 23907 71
Baltimore Suburbs 20-64 842631 847392 836563 875350 32719 4
65+ 196412 283273 352786 363107 166695 85
85+ 23199 31966 54430 82042 58843 254
Eastern Shore 20-64 200871 207439 214507 229517 28646 14
65+ 66649 88678 104945 103761 37112 56
85+ 8417 10522 15683 21077 12660 150
DC Suburbs and 20-64 1561159 1580869 1603112 1663239 102080 7
Southern Maryland 65+ 323515 464190 597010 643895 320380 99
85+ 42081 56423 95800 143735 101654 242
Western Maryland 20-64 149654 154287 156465 166433 16779 11
65+ 43552 55357 64521 63624 20072 46
85+ 6171 7067 9411 12215 6044 98
State of Maryland 20-64 3643430 3653653 3667247 3819400 175970 5
65+ 837496 1151466 1404517 1465776 628280 75
85+ 113544 139274 217422 316652 203108 179
Washington DC 20-64 455463 524098 NA NA NA 15
65+ 77004 95292 NA NA NA 24
85+ 11447 12079 NA NA NA 6
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC20
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 113 126 6 95
Female 887 874 94 905
Age
16-24 93 46 141 10
25-34 232 371 275 287
35-44 192 279 159 202
45-54 154 14 202 169
55-64 204 138 20 185
65+ 125 26 23 58
Median 44 36 40 40
Race and Ethnicity
White 284 82 74 146
Black or African American 659 869 868 799
Hispanic or Latino (Any Race) 0 49 05 15
Asian or Pacific Islander 14 0 37 19
Other 44 0 16 21
Citizenship Status
US Citizen by Birth 69 748 871 778
US Citizen by Naturalization 154 75 66 98
Not a US Citizen 156 178 63 124
Educational Attainment
Less than High School 122 247 96 145
High School Graduate 339 26 369 33
Some College No Degree 314 271 404 338
Associates Degree or Higher 226 223 131 187
Class of Worker
For-Profit 674 742 803 743
Non-Profit 122 208 157 159
Independent Providers 204 5 4 97
APPENDIX 4Profile of Direct Services Workforce by Care Setting in Baltimore City and County 2017
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 21
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 596 658 765 68
Part Time 404 342 235 32
Annual Earnings
Median Personal Earnings $20447 $20763 $26401 $22840
Median Family Earnings $56779 $55002 $57558 $55206
Federal Poverty Level
Less than 100 145 143 107 129
Less than 138 217 194 167 191
Less than 200 479 334 388 404
Public Assistance
Any Public Assistance 483 434 425 447
Food and Nutrition Assistance 21 334 334 293
Medicaid 29 269 273 278
Cash Assistance 22 16 35 26
Health Insurance Status
Any Health Insurance 842 856 855 851
Health Insurance through EmployerUnion 379 558 553 497
Medicaid Medicare or Other Public Coverage 412 278 289 327
Health Insurance Purchased Directly 136 56 72 89
Means of Transportation
Drove Alone 632 521 634 603
Carpool 74 78 106 88
Public Transportation 192 344 183 229
Walked to Work 44 37 64 5
Other 19 1 11 14
Worked at Home 39 1 02 17
Median Travel Time (in Minutes)
Drove Alone 20 20 20 20
Public Transportation 30 50 40 40
Walked to Work 15 30 10 15
Carpool 30 25 20 25
Other 15 45 30 45
Total 20 30 25 25
APPENDIX 4
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC22
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 144 127 108 129
Female 856 873 892 871
Age
16-24 201 195 151 185
25-34 146 376 288 253
35-44 168 199 287 211
45-54 263 153 11 187
55-64 156 77 127 125
65+ 66 0 38 39
Median 44 31 39 37
Race and Ethnicity
White 505 394 416 448
Black or African American 407 536 535 481
Hispanic or Latino (Any Race) 29 42 39 36
Asian or Pacific Islander 34 28 11 26
Other 25 0 0 1
Citizenship Status
US Citizen by Birth 844 73 841 811
US Citizen by Naturalization 53 23 77 11
Not a US Citizen 103 4 82 79
Educational Attainment
Less than High School 24 109 43 54
High School Graduate 319 30 471 358
Some College No Degree 401 437 394 409
Associates Degree or Higher 256 154 91 179
Class of Worker
For-Profit 533 733 821 673
Non-Profit 164 20 165 175
Independent Providers 303 66 13 152
APPENDIX 5Profile of Direct Services Workforce by Care Setting in the Baltimore Suburbs 2017
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 23
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 507 63 666 588
Part Time 493 37 334 412
Annual Earnings
Median Personal Earnings $16357 $22492 $25855 $20763
Median Family Earnings $69656 $84854 $71634 $71634
Federal Poverty Level
Less than 100 128 75 63 94
Less than 138 206 297 63 191
Less than 200 377 358 229 329
Public Assistance
Any Public Assistance 504 348 471 45
Food and Nutrition Assistance 261 206 413 289
Medicaid 419 324 144 313
Cash Assistance 04 18 43 19
Health Insurance Status
Any Health Insurance 919 95 954 938
Health Insurance through EmployerUnion 471 566 742 576
Medicaid Medicare or Other Public Coverage 468 348 176 35
Health Insurance Purchased Directly 162 47 76 104
Means of Transportation
Drove Alone 701 846 869 793
Carpool 37 69 29 44
Public Transportation 0 0 0 0
Walked to Work 06 0 2 08
Other 14 45 45 32
Worked at Home 242 4 37 123
Median Travel Time (in Minutes)
Drove Alone 25 20 20 20
Public Transportation 0 0 0 0
Walked to Work 4 0 15 4
Carpool 20 20 30 20
Other 1 15 45 15
Total 25 20 20 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 5
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC24
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 112 263 185 163
Female 888 737 815 837
Age
16-24 65 137 62 78
25-34 193 311 223 225
35-44 21 159 304 228
45-54 294 216 231 26
55-64 179 136 124 154
65+ 58 41 56 54
Median 47 38 41 43
Race and Ethnicity
White 121 127 79 11
Black or African American 721 786 869 777
Hispanic or Latino (Any Race) 59 5 34 5
Asian or Pacific Islander 71 37 13 47
Other 28 0 06 16
Citizenship Status
US Citizen by Birth 385 356 361 372
US Citizen by Naturalization 271 277 344 294
Not a US Citizen 344 368 295 334
Educational Attainment
Less than High School 103 65 6 83
High School Graduate 34 40 52 404
Some College No Degree 265 313 288 281
Associates Degree or Higher 292 221 131 231
Class of Worker
For-Profit 726 752 778 747
Non-Profit 78 211 186 136
Independent Providers 196 37 36 118
APPENDIX 6Profile of Direct Services Workforce by Care Setting in the DC Suburbs and Southern Maryland 2017
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 25
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 647 718 873 727
Part Time 353 282 127 273
Annual Earnings
Median Personal Earnings $22492 $23878 $26401 $24334
Median Family Earnings $59448 $60216 $69020 $62095
Federal Poverty Level
Less than 100 101 84 71 89
Less than 138 221 145 101 171
Less than 200 425 347 28 367
Public Assistance
Any Public Assistance 366 256 341 337
Food and Nutrition Assistance 195 169 212 195
Medicaid 192 139 151 169
Cash Assistance 24 27 1 21
Health Insurance Status
Any Health Insurance 731 751 891 782
Health Insurance through EmployerUnion 39 55 667 503
Medicaid Medicare or Other Public Coverage 263 165 20 225
Health Insurance Purchased Directly 157 87 9 124
Means of Transportation
Drove Alone 699 72 765 722
Carpool 89 134 76 94
Public Transportation 157 116 93 131
Walked to Work 08 16 1 1
Other 17 14 5 26
Worked at Home 31 0 05 18
Median Travel Time (in Minutes)
Drove Alone 30 30 20 30
Public Transportation 60 45 60 60
Walked to Work 10 10 175 10
Carpool 30 30 25 30
Other 45 45 30 30
Total 30 30 25 30
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 6
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC26
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 103 26 63 77
Female 898 974 937 923
Age
16-24 0 123 108 54
25-34 228 306 378 288
35-44 139 283 168 172
45-54 21 98 145 171
55-64 266 167 73 189
65+ 157 23 129 125
Median 50 43 35 43
Race and Ethnicity
White 319 172 302 289
Black or African American 669 81 695 701
Hispanic or Latino (Any Race) 0 18 0 03
Asian or Pacific Islander 0 0 0 0
Other 12 0 03 07
Citizenship Status
US Citizen by Birth 951 100 997 974
US Citizen by Naturalization 34 0 03 19
Not a US Citizen 15 0 0 08
Educational Attainment
Less than High School 152 36 197 146
High School Graduate 498 334 389 437
Some College No Degree 275 239 385 303
Associates Degree or Higher 75 391 29 114
Class of Worker
For-Profit 655 589 705 659
Non-Profit 94 357 232 181
Independent Providers 251 54 63 159
APPENDIX 7Profile of Direct Services Workforce by Care Setting on the Eastern Shore 2017
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 27
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 487 974 789 663
Part Time 513 26 211 337
Annual Earnings
Median Personal Earnings $14638 $26362 $21596 $20447
Median Family Earnings $40962 $48868 $26992 $38338
Federal Poverty Level
Less than 100 291 10 183 225
Less than 138 408 152 449 377
Less than 200 537 391 613 536
Public Assistance
Any Public Assistance 763 668 863 778
Food and Nutrition Assistance 526 591 656 577
Medicaid 394 599 547 476
Cash Assistance 15 0 03 09
Health Insurance Status
Any Health Insurance 856 992 100 924
Health Insurance through EmployerUnion 228 298 429 302
Medicaid Medicare or Other Public Coverage 558 622 687 609
Health Insurance Purchased Directly 188 129 43 133
Means of Transportation
Drove Alone 841 943 873 868
Carpool 19 57 47 34
Public Transportation 0 0 15 04
Walked to Work 24 0 0 13
Other 23 0 0 12
Worked at Home 93 0 66 69
Median Travel Time (in Minutes)
Drove Alone 25 25 20 20
Public Transportation 0 0 60 60
Walked to Work 1 0 0 1
Carpool 15 90 15 15
Other 15 0 0 15
Total 20 25 15 20
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 7
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC28
Home Care
Residential
Care
Nursing Homes
Total
Gender
Male 98 128 7 96
Female 902 872 93 904
Age
16-24 171 28 192 202
25-34 305 192 317 283
35-44 97 172 153 131
45-54 178 43 267 175
55-64 182 114 52 127
65+ 68 199 2 82
Median 36 35 34 35
Race and Ethnicity
White 911 964 842 902
Black or African American 61 18 141 76
Hispanic or Latino (Any Race) 0 0 0 0
Asian or Pacific Islander 0 0 0 0
Other 28 18 16 22
Citizenship Status
US Citizen by Birth 987 982 943 972
US Citizen by Naturalization 0 0 57 18
Not a US Citizen 13 18 0 1
Educational Attainment
Less than High School 182 0 41 97
High School Graduate 422 427 302 386
Some College No Degree 322 315 657 424
Associates Degree or Higher 74 257 0 92
Class of Worker
For-Profit 487 385 75 545
Non-Profit 305 414 109 269
Independent Providers 209 201 141 186
APPENDIX 8Profile of Direct Services Workforce by Care Setting in Western Maryland 2017
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 29
Home Care
Residential
Care
Nursing Homes
Total
Employment Status
Full Time 626 694 852 711
Part Time 374 306 148 289
Annual Earnings
Median Personal Earnings $17230 $20763 $22217 $20763
Median Family Earnings $32948 $41527 $41185 $41185
Federal Poverty Level
Less than 100 186 112 94 141
Less than 138 399 199 213 297
Less than 200 666 465 455 556
Public Assistance
Any Public Assistance 64 515 519 575
Food and Nutrition Assistance 414 298 467 404
Medicaid 403 166 151 272
Cash Assistance 05 0 44 16
Health Insurance Status
Any Health Insurance 879 812 834 85
Health Insurance through EmployerUnion 36 472 667 48
Medicaid Medicare or Other Public Coverage 487 383 182 369
Health Insurance Purchased Directly 69 145 05 66
Means of Transportation
Drove Alone 812 838 885 841
Carpool 39 162 83 81
Public Transportation 0 0 0 0
Walked to Work 06 0 0 03
Other 5 0 33 33
Worked at Home 94 0 0 43
Median Travel Time (in Minutes)
Drove Alone 15 20 15 15
Public Transportation 0 0 0 0
Walked to Work 15 0 0 15
Carpool 75 20 20 20
Other 15 0 1 15
Total 15 20 15 15
Source US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018)
APPENDIX 8
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC30
NOTES
1 Maryland Department of Planning State Data Center 2017 Household Population Projections by Age Sex and Race httpplanningmarylandgovMSDCPagess3_projectionaspx DC District of Columbia Office of Planning 2016 DC Forecasts Population Forecast by Single Age Citywide httpsplanningdcgovnode1212966 analysis by PHI (July 14 2018) ldquoWorking agerdquo includes those aged 20 to 64 years old
2 Espinoza Robert 2017 8 Signs the Shortage in Paid Caregivers is Getting Worse Bronx NY PHI httpsphinationalorgwp-contentuploads201711workforce-shortages-phi60issues01pdf
3 PCAs and HHAs in the nursing home industry were included in the residential care industry These workers are likely supporting residents of Assisted Living Facilities and Continuing Care Retirement Communities that offer nursing services
4 Kaiser Family Foundation (KFF) 2014 Health Care Expenditures by Service by State of Provider httpswwwkfforgotherstate-indicatorhealth-spending-by-servicedataView=0ampcurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D This is a broad estimate including expenditure on three categories home health nursing homes and ldquoother health residential and personal care expendituresrdquo (given that one of the largest sources of spending in the last category is by Medicaid on HCBS) The estimate does not include expenditure through Older Americans Act Title XX of the Social Security Act or the Social Services Block Grant Program or account for the uncompensated assistance that is provided by family members and friends
5 Eiken Steve Kate Sredl Brian Burwel and Angie Amos 2018 Medicaid Expenditures for Long-Term Services and Supports in FY 2016 Baltimore MD Centers for Medicare amp Medicaid Services (CMS) httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltssexpenditures2016pdf Data are for the federal fiscal year (102015 to 92016)
6 Eiken Steve 2017 Medicaid Long-Term Services and Supports Beneficiaries in 2013 Baltimore MD CMS httpswwwmedicaidgovmedicaidltssdownloadsreports-and-evaluationsltss-beneficiaries-2013pdf
7 Eiken et al 2018 The national average does not include California for which detailed information on the delivery of LTSS through managed care was not available
8 KFF 2016 ldquoWaiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waiversrdquo httpswwwkfforghealth-reformstate-indicatorwaiting-lists-for-hcbs-waiverscurrentTimeframe=0ampsortModel=7B22colId2222Location2222sort2222asc227D
9 Reinhard Susan C Jean Accius Ari Houser Kathleen Ujvari Julia Alexis and Wendy Fox-Grage 2017 ldquoPicking Up the Pace of Change 2017 A State Scorecard on Long-Term Services and Supports for Older Adults People with Physical Disabilities and Family Caregiversrdquo httpwwwlongtermscorecardorg2017-scorecard
10 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 5-year Public Use Microdata Sample (PUMS) httpswwwcensusgovprograms-surveysacsdatapumshtml analysis by PHI (July 25 2018) The number of individuals with ADL or IADL support needs ranges from 15000 in Western Maryland to more than 83000 in the DC suburbs Difficulty with ADLs or ldquoself carerdquo is measured in the ACS by asking if respondents have ldquodifficulty dressing or bathingrdquo Difficulty with IADLs or ldquoindependent livingrdquo is measured by asking if respondents have difficulty ldquodoing errands alone such as visiting a doctorrsquos office or shoppingrdquo
11 US Centers for Medicare and Medicaid Services (CMS) 2018 ldquoNursing Home Compare Datasets Provider Informationrdquo httpsdatamedicaregovdatanursing-home-compare analysis by PHI (August 3 2018)
NOTES
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
The Direct Services Workforce in LTSS in MD and DC 31
12 See eg Favreault Melissa and Judith Dey 2016 Long-Term Services and Supports for Older Americans Risks and Financing Research Brief Washington DC Assistant Secretary for Planning and Evaluation US Department of Health and Human Services httpsaspehhsgovbasic-reportlong-term-services-and-supports-older-americans-risks-and-financing-research-brief
13 US Bureau of Labor Statistics (BLS) Employment Projections Program 2017 Civilian Labor Force by Age Sex Race and Ethnicity 1996 2006 2016 and Projected 2026 httpswwwblsgovemp analysis by PHI (August 8 2018) Comparable data for Maryland and DC are not available for the purposes of this analysis
14 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
15 US Census Bureau 2017 American Community Survey (ACS) 2012-2016 American Community Survey 5-Year Estimates Employment Status httpsfactfindercensusgovbkmktable10enACS16_5YRS23010400000US11|0400000US24
16 Massachusetts Institute of Technology (MIT) 2017 ldquoLiving Wage Calculation for Marylandrdquo httplivingwagemitedustates24
17 MIT 2017 ldquoLiving Wage Calculation for District of Columbiardquo httplivingwagemitedustates11
18 For 2016 federal poverty levels see US Department of Health and Human Services 2016 Annual Update of the HHS Poverty Guidelines 81 FR 4036 httpswwwfederalregistergovdocuments201601252016-01450annual-update-of-the-hhs-poverty-guidelines
19 PHI 2018 ldquoWorkforce Data Centerrdquo httpsphinationalorgpolicy-researchworkforce-data-center
NOTES
Author Kezia Scales PhD
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i
copy 2018 PHI
400 East Fordham Road 11th Floor Bronx NY 10458 Phone 7184027766 Fax 7185856852 Email infoPHInationalorg
PHI works to transform eldercare and disability services We foster dignity respect and independence for all who receive care and all who provide it As the nationrsquos leading authority on the direct care workforce PHI promotes quality direct care jobs as the foundation for quality care
Drawing on 25 years of experience working side-by-side with direct care workers and their clients in cities suburbs and small towns across America PHI offers all the tools necessary to create quality jobs and provide quality care PHIrsquos trainers researchers and policy experts work together to
bull Learn what works and what doesnrsquot in meeting the needs of direct care workers and their clients in a variety of long-term care settings
bull Implement best practices through hands-on coaching training and consulting to help long-term care providers deliver high-quality care
bull Support policymakers and advocates in crafting evidence-based policies to advance quality care
For more information visit PHI at PHInationalorg and 60CaregiverIssuesorg
ft i