LTSS Choices

International Review of Experts’ Recommendations for Reforming the Long-Term Services and Supports Workforce

Published December 8, 2021

The COVID-19 pandemic exacerbated an already challenging environment for finding and maintaining a strong workforce of paid staff who deliver long-term services and supports (LTSS). This critical workforce, which includes nurses, personal care aides, home health aides, and nursing assistants, is essential to meeting the daily caregiving needs of those who require LTSS. But LTSS workers face persistent physical and mental health risks, poor wages and benefits, and inadequate training.

This report builds on the previously published “International Review of Innovations to Protect Nursing Home Residents from Infectious Diseases Such as COVID-19.” It describes the LTSS workforce in the Organisation for Economic Cooperation and Development (OECD), of which the United States is a member country. It reviews the challenges LTSS workers face, summarizes experts’ recommendations for reform, and offers examples from some OECD countries that are innovating to improve the situation for their LTSS workforce.

The LTSS Workforce

Across the OECD, 70 percent of LTSS workers are direct care workers with different job titles such as personal care aides, home health aides, and nursing assistants. Pay in the LTSS sector is 35 percent lower than pay in hospitals; 45 percent of workers are part time; 20 percent are temporary; 50 percent perform shift work (which is unpredictable).

LTSS workers in OECD countries perform many health-related tasks for which they often receive little training. The most common gaps in LTSS workers’ skills relate to knowledge of geriatric care, safe management of clients’ or residents’ needs, care following discharge from a hospital, stress and crisis management, methods of coping with bereavement, prevention of disability, and use of new technologies. They also often lack appropriate training in infection control.

Risks to LTSS Workers’ Physical and Mental Health

Not only do LTSS workers typically have poor-quality jobs, they also face substantial physical and mental health risks. Sixty-four percent encounter physical risks such as back problems and work irregular hours or at night which can result in sleep disruptions with a broad range of health effects. Workers report high levels of stress from their care responsibilities, insufficient numbers of staff, and the need to work extra shifts.

Physical injuries to LTSS workers most commonly result from overexertion, from lifting and repositioning their clients, and violence inflicted by other people or animals. They experience exhaustion from severe time constraints and understaffing, and often serve clients and residents who have cognitive impairment or dementia, which can result in harassment of and injuries to workers. They are exposed not only to the same infections that afflict their clients and residents but also to hazardous drugs and chemicals.

Innovations to Address the Challenges LTSS Workers Face

Given poor job quality and high levels of risk, a sufficient supply of trained LTSS workers is difficult to maintain. Across OECD, achieving a sufficient and adequately trained workforce is one of the major challenges for the LTSS infrastructure. Given their aging populations, OECD countries would have to boost the number of LTSS workers by 30 percent by 2040 to maintain the current ratio of LTSS workers to older adults.

Across OECD, innovations to address LTSS workforce issues are focused on:

  • Staffing levels, both setting recommendations for staffing levels and finding creative efforts to recruit workers, often from outside the usual pool of workers.
  • Pay and benefits, with goals such as ensuring parity across the health and LTSS sectors, creating opportunities for full-time jobs, and improving benefits.
  • Training, often with a focus on geriatric care competencies in topics such as dementia, palliative care, infection control, and in the principles of person-directed care.
  • Mental health supports, such as counseling services and support for LTSS workers for anxiety, trauma and bereavement.


A comprehensive approach to bolstering the LTSS workforce during a pandemic involves addressing

staffing, quality of work, fair pay, training, and preventing or treating the mental and physical health risks that LTSS workers face. Australia serves as a good example; its approach (outlined in the report) during the COVID-19 pandemic could be replicated during future outbreaks, and it could provide guidance for tackling the current and ongoing challenges facing the LTSS workforce.


International Review of Experts’ Recommendations for Reforming the Long-Term Services and Supports Workforce

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Suggested Citation

Reinhard, Susan C., and Jane A. Tilly. International Review of Experts’ Recommendations for Reforming the Long-Term Services and Supports Workforce. Washington, DC: AARP Public Policy Institute. December 9, 2021.


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