The Changing Face of Long-Term Care and How a New Immigrant Workforce Will Shape Its Future

Between 2008 and 2050, the population of non-Hispanic whites is projected to decrease dramatically, while the populations of Hispanics, Asians, and blacks will be ever on the rise. These changes will increase the demand for long-term-care workers and supportive community services. Demand for long-term-care and supportive community services (LTC-SCS) is linked to the age structure of the population and related rates of chronic illness, disability, and frailty (Fried et al., 2004). Future demand in America will be affected by the near doubling of the number of people ages 65 and older in the United States in twenty-five years: from 37 million in 2006 (12 percent of the population) to 72 million in 2030 (nearly 20 percent of the population) (AgingStats, 2010). The racial and ethnic composition of older adults is also changing rapidly. Between 2008 and 2050, the population of non-Hispanic whites is projected to fall from 80 percent to 59 percent of older adults (51.7 million), while the proportion of Hispanics will increase from 7 percent to 20 percent (to 17.5 million), Asians from 3 percent to 9 percent (to 7.5 million), and blacks from 9 percent to 12 percent (to 10.5 million). These changes will increase the demand for LTC-SCS workers. The Bureau of Labor Statistics projects that between 2008 and 2018, there will be 837,000 new jobs for aides in LTC-SCS (a 48 percent increase) and 736,000 new nursing jobs (up 22 percent). Most new jobs for registered nurses will be in medical settings, especially hospitals. Most new jobs for licensed practical nurses will be in nursing homes and other residential care settings, including facilities serving older adults, persons with intellectual disabilities, and persons with mental health and substance-abuse disorders. Almost all new health aide jobs will be in nursing homes or residential care, home health, and supportive community services for older adults and persons with disabilities; while almost all new jobs for personal-care aides will be in home- and community-based settings. The various aides who perform hands-on care for persons with disabilities are referred to in this article as direct-care workers (DCW). The recent Institute of Medicine (IOM) report highlights characteristics of these jobs that are relevant (IOM, 2008), as follows: * Home health aide and nurse aide positions in most states have minimal training requirements (e.g., seventy-five to 100 hours classroom time plus practical experience), and there are few, if any requirements for privately hired aides. * Seventeen percent of homecare aides are self-employed, compared to almost no nursing home or hospital aides. * Direct-care jobs have characteristics that are not attractive to many workers, including low wages and benefits, high stress, difficult clients, inadequate staffing, and high injury rates. These lead to high turnover and vacancy rates. * Without the protection of agency employment, new consumer-directed jobs will pose new obstacles, risks, and uncertainties to workers (Dale et al., 2005). The Immigrant Population Of the 307 million United States residents in 2009, 38.5 million (12.5 percent) were foreign born (Gryn and Larsen, 2010). Of the foreign born, about 28 million (72 percent) were legal immigrants, and 11 million (28 percent) were illegal (Passel and Cohn, 2010). The legal immigrants included naturalized citizens (37 percent of the total), legal permanent immigrants (31 percent), and legal temporary migrants (4 percent). Legal permanent immigrants have green cards, which entitle them to live and work indefinitely in the United States, and become naturalized citizens after five years. The most common way to obtain a green card is by reuniting with relatives who are U.S. residents. This method accounted for 65 percent of legal immigrants in 2008 (Martin et al., 2009). Spouses, minor children, and parents of U.S. citizens can qualify under this uncapped category. …