Strengthening the Dementia Care Workforce: Analyzing Economic Policies' influence on Workers and their Patients Living with Dementia

The long-term care industry is one of the fastest growing sectors of the economy, while also creating some of the lowest-paid and lowest-quality jobs. These precarious working conditions are costly for workers – who are disproportionately women and women with various racial and ethnic backgrounds – and the patients they care for. On the worker side, the conditions of long-term care jobs keep families in poverty and contribute to sex and racial economic disparities in the workforce. Worker turnover is high, and worker shortages are pervasive. These precarious working conditions may deteriorate the quality of care workers can provide and have a detrimental impact on patient outcomes, potentially contributing to or exacerbating health disparities among patients. This could be particularly an issue for people living with Alzheimer's disease and Alzheimer's disease and related dementias (AD/ADRD), where continuity of care and communication between the care team is paramount. The working conditions of this workforce, both wages and workload, have important implications for turnover and overall well-being. In Aim 1, we will study the impact of wage changes, instrumented through minimum wage laws and pandemic-related wage protections, on home health care worker outcomes, including wages, turnover, and poverty. In Aims 2 and 3, we will study the impact of staffing regulations and unionization, respectively, in nursing home settings, on the welfare of the workers, measured by wages, turnover, and reliance on contract staff. We will look for heterogeneity in the effects of workplace policies on workers, based on geography (urban vs. rural), and agency/facility metrics (star rating, percent Medicaid, percent patients who are of different racial or ethnic group). In each aim, we will take the next important step, which is to estimate how these workforce changes are related to patient outcomes, including functional status, physical and mental health, and health care utilization and mortality. We will focus our analysis on people living with dementia; over one-third of home health care recipients and one-half of residents in nursing homes have AD/ADRD.10 This group is likely the most vulnerable to staffing changes, training, and disruptions. We will look for heterogeneity in the effects of workplace policies on patients by both facility (e.g.,profit status, rurality) and patient-level characteristics (e.g., race, ethnicity, sex). This project will build the evidence base on which we can make informed policy recommendations that could improve the lives of the dementia care workforce and their patients.