Who enters and who exits direct care jobs in long-term care settings?

Health & Aging Health Access & Equity Health Care Industry Health Care Policy

健康与老龄化 健康获取与公平 医疗保健行业 医疗保健政策

Millions of older adults and people with disabilities require long-term services and supports (LTSS) to assist with activities of daily living (such as eating, bathing, dressing, and mobility) and instrumental activities of daily living (such as meals and managing medication).

数以百万计的老年人和残疾人需要长期服务和支持 (LTSS) 来协助日常生活活动（例如吃饭、洗澡、穿衣和行动）以及日常生活的工具性活动（例如膳食和管理药物）。

Nearly 1.2 million individuals receive such care in nursing homes and other residential facilities, and nearly 7.3 million receive this care in home and the community.

近 120 万人在疗养院和其他住宿设施中接受此类护理，近 730 万人在家庭和社区中接受此类护理。

Direct care workers (DCWs), i.e., nursing assistants, home health aides, and personal care aides, represent the majority of the LTSS workforce, numbering 4.9 million workers.

直接护理人员 (DCW)，即护理助理、家庭保健助理和个人护理助理，占 LTSS 劳动力的大多数，人数为 490 万人。

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In both residential settings and the community, the quality of care that individuals receive is related to staffing patterns.

在住宅环境和社区中，个人接受的护理质量与人员配置模式有关。

The Centers for Medicare & Medicaid Services (CMS) has noted that nurse staffing has “the greatest impact on the quality of care nursing homes deliver,” and academic research has found that low nurse staffing levels leads to lower quality of care and higher mortality .

医疗保险和医疗补助服务中心 (CMS) 指出，护士人员配置“对疗养院提供的护理质量影响最大”，学术研究发现，护士人员配置水平较低会导致护理质量较低和死亡率较高。

Likewise, higher turnover among home care workers is associated with more falls, worse functional improvement, and more depressive symptoms .

同样，家庭护理人员的流动率越高，跌倒次数越多、功能改善越差以及抑郁症状越严重。

Despite the importance of staffing for LTSS sectors, the labor market for these workers faces several challenges.

尽管人员配置对于 LTSS 行业很重要，但这些工人的劳动力市场面临着一些挑战。

Direct care work is challenging: Long shifts and overtime are common , injury rates are high , and pay is low , averaging $17.73 in 2025, compared to a non-farm sector average of $33.54.

直接护理工作具有挑战性：长时间轮班和加班很常见，受伤率很高，而且工资很低，2025 年平均工资为 17.73 美元，而非农业部门的平均工资为 33.54 美元。

In many nursing homes, staffing levels are below clinical standards, and turnover is high , nearly 46 percent among nursing staff for the average facility, and with only 12 percent of facilities having turnover rates less than 30 percent.

在许多疗养院，人员配置水平低于临床标准，而且流动率很高，一般设施中护理人员的流动率接近 46%，只有 12% 的设施流动率低于 30%。

Turnover in home care agencies is similarly high.

家庭护理机构的人员流动率同样很高。

With an aging population, demand for long-term care is expected to increase, exacerbating these challenges.

随着人口老龄化，对长期护理的需求预计将增加，从而加剧这些挑战。

Recognizing the relationship between quality of care and staffing challenges, CMS is launching efforts to train and recruit nursing staff.

认识到护理质量和人员配置挑战之间的关系，CMS 正在努力培训和招聘护理人员。

It is essential to understand which industries and occupations these direct care workers come from and which jobs they leave these roles for in order to design effective policies to attract and retain workers in these roles.

必须了解这些直接护理人员来自哪些行业和职业以及他们离开这些职位从事哪些工作，以便设计有效的政策来吸引和留住这些职位的工人。

Past work has documented that women and workers of color were less likely to leave direct care work during the COVID-19 pandemic.

过去的研究表明，在 COVID-19 大流行期间，有色人种女性和有色人种工人不太可能放弃直接护理工作。

In this blog, we build upon earlier analyses by focusing on worker flows into and out of the direct care workforce over a longer time period.

在本博客中，我们在早期分析的基础上，重点关注较长时间内进出直接护理劳动力的工人流动情况。

Many of the patterns observed during the pandemic are also present throughout our analysis period, pointing to longer-term trends.

大流行期间观察到的许多模式也存在于我们的整个分析期间，表明了长期趋势。

We leverage nationally representative longitudinal data to describe characteristics of workers who leave and those who stay in these roles, and characterize earnings trajectories for those who stay and those who move to different jobs.

我们利用具有全国代表性的纵向数据来描述离职员工和留在这些职位的员工的特征，并描述留下来的员工和跳槽到不同工作岗位的员工的收入轨迹。

We report these patterns for all LTSS direct care workers, and then separately for residential care (nursing homes and residential care facilities) and home care (including home health care) workers.

我们报告所有 LTSS 直接护理人员的这些模式，然后分别报告住宿护理（疗养院和住宿护理设施）和家庭护理（包括家庭医疗保健）工作人员的这些模式。

We confirm high rates of turnover among LTSS direct care workers, with less than half of workers remaining as a DCW in an LTSS setting the following year.

我们确认 LTSS 直接护理人员的流动率很高，不到一半的工人在次年仍担任 LTSS 环境中的 DCW。

Many of those who leave LTSS DCW roles transition to non-employment, and many of those who leave the paid labor force are providing care for others while not employed.

许多离开 LTSS DCW 角色的人过渡到非就业状态，许多离开有偿劳动力的人在没有工作的情况下为他人提供护理。

Of those who change occupations, most continue to work in health care fields.

在那些改变职业的人中，大多数人继续在医疗保健领域工作。

Finally, we find that older workers, those with no college education, and foreign-born workers are more likely to remain direct care workers than younger workers, those with at least some college education, and workers born in the U.S. In addition, workers who leave DCW roles to other employment receive higher wages and greater access to pensions and health insurance.

最后，我们发现，年龄较大的工人、没有接受过大学教育的工人和外国出生的工人比年轻工人、至少受过大学教育的工人和在美国出生的工人更有可能继续担任直接护理人员。此外，离开 DCW 职位从事其他工作的工人可以获得更高的工资，并有更多的机会获得养老金和健康保险。

Overall, these patterns suggest that most DCW turnover reflects churn within health care rather than to non-health care fields, and churn may be particularly frequent due to the low wages and benefits that DCWs generally earn.

总体而言，这些模式表明，大多数 DCW 流动率反映的是医疗保健领域而非非医疗保健领域的流失，而且由于 DCW 通常赚取的工资和福利较低，流失可能特别频繁。

Thus, efforts to improve working conditions in LTSS settings to match those offered by other health care settings and to create universal competencies for care workers across settings are likely to see significant returns.

因此，改善 LTSS 环境中的工作条件以匹配其他医疗保健环境所提供的工作条件以及为跨环境的护理人员创造通用能力的努力可能会获得显着回报。

Our analysis draws on demographic and employment data from the monthly Current Population Survey (CPS) and wage information from the CPS’s Outgoing Rotation Group supplement from January 2010 through December 2025.

我们的分析借鉴了每月当前人口调查 (CPS) 中的人口和就业数据以及 2010 年 1 月至 2025 年 12 月 CPS 离职轮换组补充资料中的工资信息。

We define LTSS direct care workers as personal care, nursing, psychiatric, and home health aides who work in either nursing care facilities or residential care facilities without nursing (“residential care DCWs”), home health care services, individual and family services, or private households (“home care DCWs”).

我们将 LTSS 直接护理人员定义为个人护理、护理、精神科和家庭健康助理，他们在护理机构或没有护理的住宅护理机构（“住宅护理 DCW”）、家庭医疗保健服务、个人和家庭服务或私人家庭（“家庭护理 DCW”）工作。

We separate these settings to show the extent to which the DCW is similar and how it differs across settings.

我们将这些设置分开，以显示 DCW 的相似程度以及不同设置之间的差异。

CPS respondents are interviewed for four consecutive months, not interviewed for eight months, then interviewed for a final four months.

CPS 受访者接受连续四个月的访谈，八个月不接受访谈，然后最后四个月接受访谈。

Accordingly, each individual provides responses in up to eight months, four of which are in year t and the other four in the same months the following year ( t+1 ).

因此，每个人在最多八个月内提供答复，其中四个是在 t 年，另外四个是在下一年 (t+1) 的同一个月内。

We use this information to create a year-over-year panel to look at workers who stay and leave LTSS direct care roles between years t and t+1 .

我们利用这些信息创建一个逐年调查小组，以查看 t 年和 t+1 年间留在和离开 LTSS 直接护理职位的工人。

We find similar patterns using a monthly panel that looks at changes from the previous month.

我们使用每月面板查看上个月的变化，发现了类似的模式。

The monthly CPS includes detailed information on worker characteristics, occupation, and industry.

每月的 CPS 包括有关工人特征、职业和行业的详细信息。

Survey months four and eight also collect information on wages.

调查第四个月和第八个月还收集工资信息。

We supplement this with information on access to non-wage benefits (health insurance and pensions) from the CPS ASEC supplement, which we calculate at the industry-by-occupation level as a measure of job quality.

我们补充了 CPS ASEC 补充中有关获得非工资福利（健康保险和养老金）的信息，我们按行业按职业水平计算这些福利，作为工作质量的衡量标准。

The full unweighted sample includes 8,815,652 person-year observations and 6,465,378 worker-years, of which 1,454,940 (22.5 percent) have wage information.

完整的未加权样本包括 8,815,652 人年观察值和 6,465,378 工人年观察值，其中 1,454,940 人年（22.5%）有工资信息。

The technical appendix provides more information on sample size, data construction, and job definitions.

技术附录提供了有关样本大小、数据构建和工作定义的更多信息。

We first compare worker characteristics, wages, and benefits of LTSS direct care workers to other groups of health care workers and to non-health care workers using the full CPS cross-section.

我们首先使用完整的 CPS 横截面将 LTSS 直接护理人员的工人特征、工资和福利与其他医疗保健人员群体和非医疗保健人员进行比较。

Comparison groups represent the full spectrum of occupations in the workforce, including competing low-wage sectors and adjacent care-economy occupations both in and out of health care.

比较组代表了劳动力中的所有职业，包括竞争性低工资部门和医疗保健内外的邻近护理经济职业。

Figures 1 and 2 show characteristics of LTSS DCWs compared with other workers, including other nursing staff (LPNs and RNs) and workers in other health care fields, other care fields (education/child care), services (retail and food services), and other industry/occupation combinations.

图 1 和图 2 显示了 LTSS DCW 与其他工人相比的特征，包括其他护理人员（LPN 和 RN）以及其他医疗保健领域、其他护理领域（教育/儿童保育）、服务（零售和食品服务）以及其他行业/职业组合的工人。

Direct care workers, including both those in residential and home care receive lower average pay than other positions (figure 1).

直接护理人员（包括住宅护理人员和家庭护理人员）的平均工资低于其他职位（图 1）。

In the CPS data, wages for these workers average $16–17 an hour, less than half what credentialed nurses (LPNs and RNs) earn, and lower than DCWs in other industries ($19.27), child care ($20.36), and retail positions ($27.37), as well as the average among all workers ($31.47).

在 CPS 数据中，这些工人的平均工资为每小时 16-17 美元，不到有资格的护士（LPN 和 RN）收入的一半，也低于其他行业的 DCW（19.27 美元）、儿童保育（20.36 美元）和零售职位（27.37 美元），以及所有工人的平均工资（31.47 美元）。

LTSS DCWs earn slightly less than cleaning and domestic workers ($18.94), and somewhat more than food service workers ($17.30).

LTSS DCW 的收入略低于清洁工和家政工人（18.94 美元），但略高于食品服务工人（17.30 美元）。

Direct care workers are also less likely to have access to and receive non-wage benefits like pensions and health insurance than are workers in other caregiving and health care roles.

与其他护理和医疗保健角色的工人相比，直接护理人员也不太可能获得和接受养老金和健康保险等非工资福利。

In general, DCW wages and benefits are lower for workers in home care than in residential care (for instance, average wages are $16.63 among home care workers vs. $17.46 for those in residential care).

一般来说，家庭护理人员的 DCW 工资和福利低于寄宿护理人员（例如，家庭护理人员的平均工资为 16.63 美元，而寄宿护理人员的平均工资为 17.46 美元）。

Demographic characteristics also differ between LTSS DCWs and the broader workforce (figure 2).

LTSS DCW 和更广泛的劳动力之间的人口特征也有所不同（图 2）。

Compared to other workers other than child care employees and LPNs/RNs, LTSS DCWs are more likely to be female.

与儿童保育员工和 LPN/RN 以外的其他工人相比，LTSS DCW 更有可能是女性。

They are also more likely to be a race/ethnicity other than non-Hispanic white and to have no education past high school than most other groups of workers we examine, except cleaning and domestic workers.

他们也更有可能是非西班牙裔白人以外的种族/族裔，并且与我们调查的大多数其他工人群体（清洁工和家政工人除外）相比，他们没有高中毕业。

Finally, 25 percent of residential care DCWs and 33 percent of home care DCWs are foreign-born, compared to 19 percent of the broader workforce.

最后，25% 的寄宿护理 DCW 和 33% 的家庭护理 DCW 出生在国外，而更广泛的劳动力中这一比例为 19%。

We disaggregate the industries and occupations that LTSS DCWs go to and come from in figure 3.

我们在图 3 中对 LTSS DCW 进入和来自的行业和职业进行了分类。

About half of LTSS DCWs newly enter or leave this work each year.

每年约有一半的 LTSS DCW 新进入或离开这项工作。

First examining those who leave these roles, we find that of people who were initially working as a LTSS DCW, about 8 percent are working in direct care fields in other health care industries (such as hospitals and physician offices) in the following year.

首先检查那些离开这些职位的人，我们发现在最初担任 LTSS DCW 的人中，大约 8% 的人在接下来的一年里在其他医疗保健行业（例如医院和医生办公室）的直接护理领域工作。

Only about 3 to 4 percent of home care and 6 percent of residential direct care workers go on to work as LPNs and RNs in any industry.

只有大约 3% 到 4% 的家庭护理人员和 6% 的住宅直接护理人员继续在任何行业担任 LPN 和 RN 工作。

This low share of direct care workers transitioning to LPN or RN roles is perhaps unsurprising as RNs and LPNs typically require post-secondary training of at least one year.

直接护理人员过渡到 LPN 或 RN 角色的比例如此之低也许并不令人意外，因为 RN 和 LPN 通常需要至少一年的高等教育培训。

In addition, 4 to 7 percent are working in other, non-nursing health care support jobs in industries such as physician offices and hospitals (see technical appendix for a detailed list of occupations and industries in each category).

此外，还有 4% 到 7% 的人在医生办公室和医院等行业从事其他非护理医疗保健支持工作（有关每个类别的职业和行业的详细列表，请参阅技术附录）。

In total, 75 percent of residential care DCWs who leave for other employment go to work in other health care and LTSS jobs (including as a home care DCW); for home care DCWs, the corresponding share is 60 percent.

总共，75% 的寄宿护理 DCW 转而从事其他医疗保健和 LTSS 工作（包括家庭护理 DCW）；对于家庭护理 DCW，相应份额为 60%。

No field outside health care and LTSS stood out as particularly connected to the LTSS DCW workforce, suggesting that the labor market for LTSS DCWs is primarily defined by health care workers, rather than other common low-wage work.

除了医疗保健和 LTSS 之外，没有任何领域与​​ LTSS DCW 劳动力特别相关，这表明 LTSS DCW 的劳动力市场主要由医疗保健工作者定义，而不是其他常见的低工资工作。

Somewhat surprisingly given pay differentials across occupations, the flows in and out of LTSS DCW work are roughly symmetric—that is, the distribution of LTSS DCWs who come from different roles closely resembles the distribution of jobs they leave LTSS DCW work for.

令人惊讶的是，考虑到不同职业之间的薪酬差异，LTSS DCW 工作的流入和流出大致是对称的，也就是说，来自不同角色的 LTSS DCW 的分布与他们离开 LTSS DCW 工作的工作分布非常相似。

Similar patterns across industries and occupations persist when we examine monthly, rather than annual, flows.

当我们检查每月而不是每年的流量时，不同行业和职业的类似模式仍然存在。

Besides those who change jobs, a relatively large share—11 to 12 percent of residential care and 16 to 17 percent of home care DCWs—enter from non-employment or leave to non-employment.

除了那些换工作的人之外，还有相当大的比例——11%至12%的住院护理人员和16%至17%的家庭护理DCW——是从非就业或休假转为非就业。

The most common activity while being in the labor force before entering and after leaving direct care work is caregiving (“Not employed detail”).

在进入直接护理工作之前和离开直接护理工作之后，在劳动力中最常见的活动是护理（“非就业细节”）。

This pattern highlights the close connection between paid and unpaid work for this workforce.

这种模式凸显了该劳动力的有偿工作和无偿工作之间的密切联系。

Again, patterns are largely similar when looking at monthly flows.

同样，从月度流量来看，模式基本相似。

Figure 3 shows substantial worker flows in and out of LTSS DCW roles.

图 3 显示了进出 LTSS DCW 角色的大量工作人员流量。

We then ask: How do earnings and access to benefits in workers’ new and old jobs compare with LTSS DCW roles?

然后我们会问：与 LTSS DCW 角色相比，工人新旧工作的收入和福利获取情况如何？

Figures 4, 5, and 6 compare demographic characteristics, wage trajectories, and measures of job quality among “stayers” (those who continued to work as residential or home care DCWs 12 months later) and “leavers” (those who leave their residential or home care DCW role 12 months later).

图 4、5 和 6 比较了“留任者”（12 个月后继续担任寄宿或家庭护理 DCW 的人）和“离职者”（12 个月后离开寄宿或家庭护理 DCW 角色的人）的人口特征、工资轨迹和工作质量指标。

For those who leave, wage and benefit changes are only reported for those who leave for other employment.

对于那些离开的人，仅报告那些因其他工作而离开的人的工资和福利变化。

Workers who stay in LTSS DCW roles are more likely to be female, have no more than a high school education, and be foreign born than those who leave (figure 4, see also technical appendix).

与离开的工人相比，留在 LTSS DCW 岗位的工人更有可能是女性、高中以上学历且在国外出生（图 4，另见技术附录）。

In addition, those who stay tend to be older.

此外，留下来的人往往年龄较大。

These patterns indicate that the workers who continue in these roles likely have the fewest outside options in the labor market.

这些模式表明，继续担任这些角色的工人在劳动力市场上的外部选择可能最少。