November 2007

Grant Results


Staff from Health Workforce Solutions (HWS) conducted a study to define and characterize the occupations that make up the frontline health and health care workforce to assist staff from the Robert Wood Johnson Foundation (RWJF) in identifying priorities for future investment.

Staff also produced a chartbook containing comprehensive employment data on the frontline health and health care workforce.

Key Results

Key Findings

  • More than 6 million people work in frontline occupations, half of the total health and health care workforce.
  • Females dominate the frontline workforce (79 percent), with one-third of the workers part of a racial minority (18 percent African American, 10 percent Hispanic and 4 percent Asian).
  • This workforce is growing rapidly and its workers are poorly paid.

RWJF provided two grants totaling $509,055 to support this project from November 2004 through December 2006.

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The quality of health and health care services begins with the frontline health care worker-the home health aide, nursing aide, psychiatric technician, social worker or human services assistant. These workers are often the first and most frequent point of contact for patients and clients of both institutional and community health services.

Nonetheless, speakers at a series of workshops on the frontline workforce that RWJF convened in fall 2005 noted that although frontline health care workers deliver vital care and services, many of them are poorly paid, do not receive benefits and have little opportunity for advancement. These conditions may contribute to high turnover rates among frontline workers and to workforce shortages.

The frontline workforce is also often underrepresented in research and outreach initiatives, according to researchers at Health Workforce Solutions of San Francisco, a consulting firm specializing in health care workforce issues.

This occurs in part because the frontline health care workforce encompasses people from many occupations. Therefore, information must be accessed from multiple sources, including federal and state agencies, and in many different formats before arriving in a form that researchers, policy-makers and advocates can use.

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Historically, RWJF's health care workforce initiatives have focused on professional occupations in the health care field, including physicians, registered nurses and health care executives. RWJF has also funded a number of "pipeline" programs to bring disadvantages students into these professions.

Recognizing the importance of the fast-growing, frontline segment of the health care workforce, from December 2004 to April 2006, RWJF provided more than $228,000 to fund five research projects to understand better frontline health care workers and the issues they faced. (See Grant Results on ID# 053326 et al., "Research Projects Identify Issues Facing Frontline Health Care Workers.")

These projects identified a common set of challenges preventing the expansion of existing workforce training programs or the creation of new ones to alleviate worker shortages and lead to the delivery of consistent high-quality care. The challenges fell under three broad categories:

  • Make it Easier. To improve the quality of health care and create advancement opportunities for frontline workers, it must become easier for workers to combine work, family and the continuation of their education.
  • Making it Work. Each of the key stakeholders in training for frontline health care workers has systemic or organizational problems that prevent effective training programs from expanding.
  • Making it Pay. Ultimately, frontline worker training programs have to benefit both employers and workers.

Using the information obtained from these grants, RWJF staff planned to develop a long-term funding strategy to address the needs of these essential workers.

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This project was one of the next steps. The goal was to develop further information to assist RWJF staff in identifying funding priorities for its human capital programming. Health Workforce Solutions, the consulting firm, carried out the project.

Project staff:

  • Gathered and analyzed employment data on the frontline health care workforce.
  • Compiled the data in a chartbook.

Data Gathering and Analysis

Under the first grant (ID# 052218), project staff:

  • Identified 78 occupations that could be considered part of the frontline health care workforce and gathered data for each occupation from federal sources such as the 2000 Standard Occupational Classification from the federal Bureau of Labor Statistics and from state sources such as state labor market information databases on:
    • The estimated number of workers employed in the occupation.
    • Annual median wage.
    • Licensure requirements.
    • Education levels.
    • Job growth outlook.
  • Met with RWJF staff in January 2005 to identify the occupational characteristics of interest to RWJF and to narrow the list of occupations for further study. The group agreed to exclude all occupations except those whose workers had:
    • A high level of direct patient care or delivery of support services.
    • Median annual wages (as of November 2003) of approximately $40,000 or less.
    • Required educational training of a bachelor's degree or less.
    • Employed population (as of November 2003) of more than 30,000.
  • Culled the list to 21 occupations and conducted Web-based research to define further the demographic information for those 21 occupations, adding variables such as:
    • Demographic information including average age and vacancy/turnover rates.
    • Regional variations.
    • Key workforce challenges.

Producing a Chartbook

Given the importance of this emerging group of occupations and the lack of comprehensive, coordinated data for researchers and policy-makers, RWJF provided Health Workforce Solutions with a second grant (ID# 053870) to compile a chartbook of data about the frontline workforce.

The chartbook was to serve as a resource for workforce policy-makers and analysts, occupational associations, employers, foundations and researchers.

Project staff:

  • Expanded the profiled occupations to 32 from 21. The additions included certain allied health professions requiring licenses (such as cardiovascular technologists and technicians, respiratory therapy technicians, dental assistants and pharmacy aides). Allied health professionals support and increase the efficiency of physicians, dentists or primary clinical specialists. See Appendix 1 for a complete list of the 32 occupations.
  • Used both federal and state resources to gather additional occupational data, including:
    • 2002–12 national and state employment projections.
    • 2004 national and state wage outlook and trends.

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  • Project staff produced a 239-page chartbook titled, Workers Who Care: A Graphical Profile of the Frontline Health and Health Care Workforce. Health Workforce Solutions also produced it on CD. This chartbook contains data about the occupations comprising the frontline workforce, including:
    • A view of the frontline workforce as a whole.
    • Occupational variations in areas such as educational levels, wages and projected growth.
    • In-depth occupational profiles that illuminate state variations in key information.
  • The chartbook was downloaded from RWJF's Web site more than 700 times from November 2006 to June 2007.

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Project staff documented the following findings from the first grant (ID# 052218) in a report to RWJF:

  • Frontline health workers in the 21 occupations first examined perform five key roles that share common characteristics. These roles and the frontline workers carrying them out are:
    • Clinical Support: Direct caregivers in clinical settings who typically operate under the direction of a physician or registered nurse. They include:
      • Medical assistant
      • Emergency medical technician and paramedic
      • Pharmacy aide
      • Physical therapist aide
      • Home health aide
      • Personal and home care aide
      • Nursing aide, orderly and attendant
    • Public Health Delivery: Operate heavily within the public health infrastructure, although they can be found in other settings. They include:
      • Health educator
      • Occupational health and safety specialist and technician
      • Social worker-medical and public health
    • Community Health Delivery: Operate across different segments of the community health system. They include:
      • Social and human service assistant
      • Community and social service specialist
      • Social worker-child, family and school
    • Behavioral Health Delivery: Concentrated in the behavioral health sector, which includes mental health, substance abuse and addiction care. They include:
      • Counselor-mental health
      • Counselor-substance abuse and behavioral disorder
      • Social worker-mental health and substance abuse
      • Psychiatric aide
      • Psychiatric technician
    • Health Care System Support: Little to no direct contact with patients or clients. Their functions, although critical to the overall care delivery process, are more system-support oriented. They include:
      • Clinical lab technician
      • Medical records and health information technician
      • Medical transcriptionist
  • These frontline occupations face numerous challenges. These include:
    • Clinical support and community health delivery occupations are fast-growing occupations with high projected need over the next five to seven years. These workers experience:
      • High turnover fueled by low wages
      • Low or no benefits
      • Low recognition
      • Minimal supervision and training support
    • Public health delivery and health care system support occupations have higher educational levels than other groups but face common challenges such as chronic staff shortages and organizational budget pressures.
    • Behavioral health delivery workers face similar challenges to public health delivery and health care system support workers with additional challenges, including:
      • Stigma associated with their patients' suffering from mental health disorders/substance abuse.
      • High burnout.
      • Calls for change in both academic preparation and professional development to keep pace with innovation around treatment of dual diagnosis, evidenced-based practice and cultural competency.

Project staff reported the following findings in Workers Who Care: A Graphical Profile of the Frontline Health and Health Care Workforce:

  • More than 6 million people work in frontline occupations-half of the total health and health care workforce.
  • Females dominate the frontline workforce (79 percent) with one-third of the workers part of a racial minority (18 percent African American, 10 percent Hispanic and 4 percent Asian).
  • This workforce is growing rapidly. The frontline workforce collectively is growing faster (projected 32.6 percent growth from 2002 to 2012) than the growth rate for all health and health care occupations (28.3 percent), and significantly faster than the growth rate for all occupations (14.8 percent) in the United States.
  • This workforce is fairly evenly distributed across the four regions of the United States (Northeast, Midwest, South and West) with the exception of the western region. That is, the West has 26 percent of the total U.S. population but only 17.8 percent of the frontline workforce. In contrast, the Northeast has 18 percent of the U.S. population but 22.4 percent of the frontline workforce.
  • Frontline workers are poorly paid. Workers in the frontline workforce generally earn less than $40,000 per year. The mean annual wage for the total frontline workforce is $32,180.


At the end of the chartbook, project staff provided recommendations about how to improve the training, status and deployment of the frontline workforce for each of the following audiences:

  • Health and health care employers
  • Teaching and learning organizations
  • Professional associations and accrediting organizations
  • Researchers and the institutions that support them
  • Policy-makers and public agencies
  • Foundations

See Appendix 2 for the recommendations.

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In early 2006, RWJF launched a national program, Jobs to Careers: Promoting Work-Based Learning for Quality Care, in partnership with the Hitachi Foundation. Jobs to Careers is a $15.3 million initiative to establish systems that train, develop, reward and advance current frontline health care workers to improve and ensure the quality of care provided to patients and communities.

The program supports partnerships among employers, educational institutions and other organizations to expand and redesign systems to:

  • Create lasting improvements in the way that institutions train and advance their frontline workers.
  • Test new models of education and training that incorporate work-based learning.

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Health Care Workforce Data


Health Workforce Solutions (San Francisco,  CA)

  • Defining RWJF's Scope of Interest in Frontline Health and Health Care Workers
    Amount: $ 193,490
    Dates: November 2004 to May 2005
    ID#:  052218

  • Creating and Disseminating a Frontline Health and Health Care Workforce Data Chartbook
    Amount: $ 315,565
    Dates: September 2005 to December 2006
    ID#:  053870


David Cherner, M.B.A., M.P.H.
(415) 981-4300

Web Site

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Appendix 1

Thirty-Two Occupational Groups Profiled in the Chartbook

Allied Health Roles

  1. Cardiovascular Technologists and Technicians
  2. Emergency Medical Technicians and Paramedics
  3. Medical Assistants
  4. Medical and Clinical Laboratory Technicians
  5. Medical Records and Health Information Technicians
  6. Occupational Health and Safety Specialists
  7. Pharmacy Technicians
  8. Radiologic Technologists and Technicians
  9. Respiratory Therapy Technicians
  10. Surgical Technologists

Community and Public Health Roles

  1. Health Educators
  2. Medical and Public Health Social Workers
  3. Social and Human Services Assistants

Long-Term Care Roles

  1. Home Health Aides
  2. Nursing Aides, Orderlies and Attendants
  3. Personal and Home Care Aides

Mental Health and Substance Abuse Roles

  1. Mental Health Counselors
  2. Mental Health and Substance Abuse Social Workers
  3. Psychiatric Aides
  4. Psychiatric Technicians
  5. Substance Abuse and Behavioral Disorder Counselors

Other Frontline Occupational Roles

  1. Child, Family and School Social Workers
  2. Dental Assistants
  3. Dietetic Technicians
  4. Licensed Practical and Licensed Vocational Nurses
  5. Medical Transcriptionists
  6. Occupational Therapist Assistants
  7. Pharmacy Aides
  8. Physical Therapist Aides
  9. Physical Therapist Assistants
  10. Recreational Therapists
  11. Rehabilitation Counselors

Appendix 2

Recommendations for Stakeholder Groups

  • Health and health care employers
    • Create new practice models and policies to reshape the nature of the work for the frontline workforce.
    • Assist this transition by investing in care and service management technologies to allow fewer workers to do more with less time and to engage patients and their families in more productive ways.
    • Integrate work and education to create laddered opportunities for the existing frontline workforce to take advantage of these new policies and technologies.
    • Create more collaborative, team-oriented work settings.
    • Develop new strategic partnerships with labor and professional organizations.
  • Teaching and learning organizations
    • Assess training programs in the context of emergent employer needs and changing student situations and demands.
    • Create delivery mechanisms to employ new teaching and learning technologies that allow for more distance learning, assessment of competence and work-based learning.
    • Commit to students throughout a lifetime of practice and growth, not just a short-term training or educational program.
  • Professional associations and accrediting organizations
    • Invite other aligned and similar frontline groups into larger affinity combinations to consolidate action.
    • Encourage education programs to respond to the need to create new value by changing the competencies provided to students, broadening the work to educate more generally and making the movement through education efficient and continuous after graduation.
    • Alter the accreditation and licensure processes to focus less on testing for entry and more on continuous improvement of quality and adaptation to changes in the environment.
    • Work to ensure that the system is an agent of change by encouraging innovation, lowering regulations and simplifying processes involved for assuring professional status.
  • Researchers and the institutions that support them
    • Develop a national discussion to focus and refine a shared research agenda related to how frontline health professionals can transition to the new roles described above.
    • Facilitate partnerships between education and delivery groups and organizations (particularly in the private sector) to provide support for research and access to key data for action research projects that meet the business needs of the sponsoring organizations.
  • Policy-makers and public agencies
    • Enhance understanding among employers, labor and policy-makers of the role and experience of regional workforce centers in developing programs to integrate education and work.
    • Target and fund breakthrough innovations that bring rapid cycle improvement to education, transition to work, retraining and assessment of value.
    • Use existing relationships at the community level to build stronger programs among labor, management, practice and education to demonstrate the value of such enlarged and expanded partnerships.
    • Build on the existing leadership of community and local agencies and partnerships to strengthen their ability to negotiate and play a genuine broker role among the various parties, including labor, schools and employers.
  • Foundations
    • Convene key actors at the local, regional or state level to discuss priorities, share resources and determine if a shared vision can emerge.
    • Fund demonstration programs, particularly when they involve more than one key partner or when they involve a truly innovative approach or have a demonstrated way of measuring the value of the experiment.
    • Build the leadership skills and capacities of key actors across the continuum of stakeholders, particularly at the local and regional levels.
    • Recognize achievement that advances the principles of an improved frontline workforce and highlight particular models that are worthy of replication and implementation.

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(Current as of date of this report; as provided by grantee organization; not verified by RWJF; items not available from RWJF.)


Workers Who Care: A Graphical Profile of the Frontline Health and Health Care Workforce. San Francisco: Health Workforce Solutions, 2006. Available on a CD and online.

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Report prepared by: Barbara Matacera Barr
Reviewed by: Janet Heroux
Reviewed by: Molly McKaughan
Program Officer: Victor A. Capoccia

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