Cover

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Title Page, Copyright, Dedication

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pp. i-vi

Contents

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pp. vii-viii

List of Illustrations

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pp. ix-x

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About the Author

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pp. xi-xii

Paul Osterman is NTU Professor at the Massachusetts Institute of Technology Sloan School of Management.

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Acknowledgments

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pp. xiii-xiv

A great many people helped me with this book, and without their assistance there is no possibility that I could have succeeded. My greatest debts are to Steve Dawson and Carol Rodat, both of PHI, who talked with me numerous times and also provided me with important contacts. Pam Doty of the U.S...

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Preface

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pp. xv-xviii

This is a book about long-term care and the challenges we will face as the need for it grows dramatically with the aging of the baby boom generation. Of the many facets to this issue, I focus here on the direct care workers who deliver long-term care and do so by placing their circumstances in the context of the...

Part I. The State of Play

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1. Introduction

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pp. 2-14

Many of us will need help when we get old—help with shopping, with getting dressed, with using the bathroom. Who will help us? Some people are born with developmental or physical disabilities, and others have accidents that render them unable to live a full life without assistance. Who will help...

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2. The Landscape of Long-Term Care in the United States

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pp. 15-24

The American system of long-term care is enormously complicated. People receive care under diverse arrangements, caregivers work under varied circumstances, financing is a patchwork of different systems, and the industry is highly decentralized and varied. Adding to the complexity is that, for services...

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3. The Direct Care Workforce

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pp. 25-40

It is important not to be naive. Certainly there are home care aides who only go through the motions, or even worse, who abuse or take advantage of clients. Well-designed systems can prevent this to some degree, but nothing can protect against someone who may meet minimal competency expectations...

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4. The Job Market

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pp. 41-51

Someone who wants to take care of people by being a direct care worker can choose from among a variety of arrangements. The first choice is between working in a nursing home as a certified nursing assistant or working in clients’ homes as a home care aide. If the choice is to be a home care aide, then...

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5. Family Caregivers and Consumer-Directed Programs

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pp. 52-67

As we have seen, family caregivers provide a great deal of help and are, in fact, the dominant source of support for both younger and older disabled people. These caregivers are often unpaid and, unfortunately, often unsupported. Family caregivers are also deeply involved in an important variant...

Part II. Moving the Needle

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6. Introduction to Part II

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pp. 70-73

In the first chapter, I laid out a vision for long-term care. At the core was the creation of health teams that include home care aides. These teams would work to help people stay in their homes and communities and be as self-sufficient and independent as possible. Medical care would certainly be a part...

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7. Direct Care Workers: Opportunities and Evidence

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pp. 74-99

Mount Sinai Hospital, a large teaching hospital in the Mount Sinai Health System in New York, is located at the south edge of East Harlem. The hospital’s Visiting Doctors Program sends physicians into the homes of elderly patients, who typically are chronically ill and most of whom also have home...

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8. Obstacles to Change

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pp. 100-117

The first comment is from an interview I conducted with a senior manager at one of the largest home health agencies on the East Coast. She had innovated by initiating several small demonstrations within her agency to expand the role of home care aides, but while the results were promising, the ideas never...

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9. Forces for Change

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pp. 118-137

Human nature is such that we often find ourselves doing what we have always done simply because it is the easiest thing to do. This is doubly true when it comes to public policy. It takes energy and political capital to change established practices, and often the only reward is making new enemies of those...

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10. Moving Forward

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pp. 138-153

The logic laid out in this book is straightforward. Today America’s elderly and disabled citizens are cared for by a low-wage and poorly trained workforce. Continuing in this way is in no one’s interest, and the case is compelling to transform the jobs of direct care workers.
My case rests on multiple legs...

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Appendix A. Defining the Extent of Disabilities

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pp. 154-156

Estimating the extent of a person’s disability can be complicated in several ways. One fundamental question is whether to utilize the tight definition based on criteria laid out in the Health Insurance Portability and Accountability Act (HIPPA) of 1996 or whether to use a more expansive definition...

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Appendix B. Counting Home Care Aides and Certified Nursing Assistants

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pp. 157-161

Counting CNAs is straightforward: virtually all of them work in nursing homes and there are clear definitions of their jobs in the census data. Counting home care aides is considerably more complicated.
Home care aides can be grouped into four categories: unpaid family caretakers, agency home...

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Appendix C. Turnover and Commitment

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pp. 162-164

The challenge in calculating the turnover of home care aides and CNAs moving in and out of the occupation (as opposed to moving to and from specific employers) is that no longitudinal surveys capture a large enough number of aides to produce reliable estimates. Adding to the problem is that the only...

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Appendix D. Future Supply and Demand

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pp. 165-170

Will the future supply of direct care workers match the need? To answer this question we must break it down into three specific questions: How many people will need help? Given this figure, how many direct care workers will be required? And what will be the supply of direct care workers...

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Appendix E. Methods

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pp. 171-173

Federal agencies collect administrative data on financial and utilization topics relevant to long-term care. These data have been collected, organized, and published by several organizations, most notably Truven Health Analytics, the Kaiser Family Foundation, the Pew Charitable Trusts, and AARP. I have...

Notes

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pp. 174-187

References

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pp. 188-201

Index

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pp. 202-212