FEDERAL POLICY PRIORITIES FOR THE DIRECT CARE WORKFORCE - PHI National
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FEDERAL POLICY PRIORITIES FOR THE DIRECT CARE WORKFORCE
CONTENTS
5 Introduction
6 About the Direct Care
Workforce
8 Why Federal Leaders Should Strengthen
This Workforce
10 Federal Recommendations
10 Financing
13 Compensation
16 Training
19 Workforce Interventions
22 Data Collection
25 Direct Care Worker Leadership
28 Equity
31 Public Narrative
37 Appendix 1: Profile of the U.S.
Direct Care Workforce
39 Appendix 2: PHI Framework:
The 5 Pillars of Direct Care Job Quality
40 Appendix 3: Highlights of PHI’s Record of
Bipartisan Federal Policy Action
ABBREVIATIONS
ACL Administration for Community Living
CDC Centers for Disease Control and Prevention
CMS Centers for Medicare & Medicaid Services
DOE U.S. Department of Education
DOL U.S. Department of Labor
FLSA Fair Labor Standards Act
GAO U.S. Government Accountability Office
HCBS Home and community-based services
HHS U.S. Department of Health and
Human Services
HRSA U.S. Health Resources and
Services Administration
LTSS Long-term services and supports
NIH National Institutes of Health
OMB Office of Management and Budget
Federal Policy Priorities for the Direct Care Workforce 1
“We aren’t hearing as much
about home health aides in
the news, but we are dealing
with our own crises during
this pandemic. It’s a scary
time right now for us,
as well as for our clients
and their families.”
ZULMA TORRES
ome Health Aide at Cooperative
H
Home Care Associates, Bronx, NY
2 Federal Policy Priorities for the Direct Care Workforce
INTRODUCTION
Throughout the country, millions of economic development, and address long-
direct care workers—home care workers, standing societal inequities. An investment
residential care aides, and nursing in this workforce also helps all U.S.
assistants—ensure that older adults workers. To paraphrase a popular saying in
and people with disabilities have the our field: direct care workers perform the
support they need across care settings. work that makes all other work possible.
The COVID-19 crisis has reinforced the
enormous value of these workers, and This report offers an extensive and detailed
government officials have rightfully deemed set of federal policy recommendations
them “essential” during this period—one of aligned with the recommendation areas
the greatest truisms ever publicly affirmed in our flagship report, Caring for the
about this workforce. Future: The Power and Potential of
America’s Direct Care Workforce: financing,
Unfortunately, the quality of direct care compensation, training, workforce
jobs does not reflect their essential interventions, direct care worker leadership,
contribution. These jobs are often equity, and the public narrative.1 It also
characterized by inadequate compensation, includes recommendations for navigating
limited training and advancement and learning from the COVID-19 crisis.
opportunities, long-standing inequities, and
a general lack of recognition and support. PHI has worked successfully on
As a result, employers struggle to recruit bipartisan policy initiatives for decades
and retain workers during a time when (see Appendix 3). We trust this collaboration
the rapid aging of this country continually will continue and welcome conversations
drives up demand for these workers— on any of these ideas.
with many workers opting for modestly
better jobs in fast food and retail. Without
enough workers willing to take these jobs,
consumers are forced to go without the
services they need, and family caregivers
are left without support and respite.
A new presidential administration provides
hope and possibility. Federal leaders—
the White House, Congress, and key federal
departments and agencies—can institute
a broad range of actions that will
improve economic security for direct
care workers, enhance care for
older adults and people with
disabilities, support long-term
care employers, promote
Federal Policy Priorities for the Direct Care Workforce 3
ABOUT THE DIRECT CARE WORKFORCE
Direct care workers support older adults Unfortunately, despite their enormous
and people with disabilities with daily value—as demonstrated most recently
tasks and activities across settings, from during the COVID-19 crisis—this workforce
private homes to residential care homes has struggled with poor job quality for
(such as assisted living) to skilled nursing decades with regards to compensation,
homes. This workforce comprises three training, career advancement, employment
main occupational groups—personal care supports, and more. Direct care work is
aides, home health aides, and nursing often unseen or underestimated, including
assistants—but are known by a variety of job its physical demands, social and emotional
titles in the field. Direct care workers who complexity, and contributions to consumers’
are employed directly by consumers, either health management. Poor job quality affects
through Medicaid programs or private-pay workers, who cannot sustain and succeed in
arrangements, are often called “independent these roles; consumers, who cannot access
providers.” Workers who support individuals high-quality continuous care; and employers,
with intellectual and developmental who struggle to find and keep the workers
disabilities are known as “direct support they need to meet growing demand.
professionals.”
More than ever, a significant federal
investment in this workforce is
desperately needed.
DIRECT CARE WORKERS
AT A GLANCE
4.6 million | Number of direct care workers
87% | Percentage of direct care workers who are women
59% | Percentage of direct care workers who are people of color
27% | Percentage of direct care workers who are immigrants
$12.80 | Median hourly wage for direct care workers
45% | Percentage of direct care workers living in or near poverty
36% | Percentage of direct care workers who lack affordable housing
47% | Percentage of direct care workers accessing some form of public assistance
(food and nutrition assistance, Medicaid, and/or cash assistance)
7.4 million | Number of job openings in direct care between 2019 and 2029,
including 1.3 million new jobs to meet rising demand and 6.9 million openings caused
by workers who transfer to other occupations or exit the labor force altogether
Source: PHI. “Workforce Data Center.” Accessed 6/8/2021. https://phinational.org/policy-research/workforce-data-center/.
4 Federal Policy Priorities for the Direct Care Workforce
“It takes courage and
patience to take good care
of others. It can be so
hard dealing with sick
people, but I have empathy
for others and really
enjoy this work.”
MARICHU BUENAVENTURA
Caregiver at Courage LLC and Member
of Pilipino Workers Center
Los Angeles, CA
Federal Policy Priorities for the Direct Care Workforce 5
WHY FEDERAL LEADERS
SHOULD STRENGTHEN THIS WORKFORCE
Direct care workers struggle to make Nearly half of direct care workers live in or
ends meet in their jobs, which drives near poverty, a critical reason why so many
them into poverty and out of this workers leave long-term care for other
field. Federal leaders should improve industries, like retail and fast food. Recent
economic security for these workers and research from PHI showed that in all 50
help stabilize this job sector. states and the District of Columbia, the
direct care worker median wage is lower
than the median wage for other occupations
with similar entry-level requirements, such
as janitors, retail salespersons, and customer
service representatives. In many states,
“There’s too much work direct care worker wages cannot even
to get done and not enough compete with occupations with lower entry-
level requirements.
people doing the work.
And I know that a lot of A growing number of older adults and
people with disabilities rely on these
that has to do with pay.” workers to live and thrive, yet poor job
quality makes it difficult to meet this
CAMRAN HAYES
need. Federal leaders should ensure that
H
ome Care Specialist more individuals can access workers in the
and Personal Care Worker
long-term care setting of their choice.
at Community Living
As the number of older adults surges in the
Alliance, Madison, WI
decades ahead, from 56.1 million in 2020
to 94.7 million by 2060, demand for direct
care workers will also increase significantly
(see the figure on page 9).2 However, unless
these jobs are transformed, turnover
will remain high, job openings will be
left vacant, and consumers will suffer the
consequences of this staffing crisis.
6 Federal Policy Priorities for the Direct Care Workforce
Direct Care Worker Projected Job Openings, 2019 to 2029
LABOR FORCE EXITS 3,330,000
OCCUPATIONAL TRANSFERS 2,821,000
NEW JOBS 1,276,400
Source: PHI. “Workforce Data Center.” Accessed 6/8/2021. https://phinational.org/policy-research/workforce-data-center/.”
Job growth and a strong economy should Like in many other sectors where these
go hand in hand, but substandard jobs populations form the majority, these
in sectors like direct care disrupt this workers are forced to struggle financially in
equation. Federal leaders should advance jobs that are not tenable in the long term.
economic development by transforming Promoting equity is one more reason why
these jobs. At 4.6 million workers, the federal leaders should prioritize these jobs.
direct care workforce is now larger than
The COVID-19 pandemic has reinforced
any other occupation in the country. The
and amplified the deep-rooted
quality of direct care jobs should reflect
challenges facing the direct care
the size and value of this workforce—but
workforce. Federal leaders should help
instead, poor job quality leads to high and
us move out of this crisis and remain
costly turnover, increased expenditure on
focused on sustainable workforce
public assistance, and reduced consumer
solutions. Already, the Biden-Harris
spending. The lack of robust training and
administration has acted decisively to help
advancement opportunities for direct
this country emerge from the COVID-19
care workers foregoes other economic
crisis, from a successful (though unfinished)
benefits as well; research has shown that
vaccine roll-out campaign to guiding states
investment in training and advanced roles
and employers with dealing in the long
can reduce emergency department visits,
term with “temporary nurse aides” hired
hospital admissions, and other expensive
during the COVID-19 crisis—and much more.
health outcomes.
While federal measures will still be needed
The individuals who make up this to address the immediate challenges of
essential workforce have long dealt COVID-19 until this health crisis sunsets, the
with the historical inequities created recommendations in this report focus on
by structural racism and gender broader measures to dramatically improve
inequality. Federal leaders should jobs for our country’s direct care workers.
right these wrongs once and for all.
Women, people of color, and immigrants
comprise most of the direct care workforce.
Federal Policy Priorities for the Direct Care Workforce 7
FEDERAL RECOMMENDATIONS
Reform Long-Term
Care Financing
to Strengthen Direct
Care Jobs
A stronger financing approach to long-term care would
improve job quality for direct care workers, as well as better
meeting consumers’ needs.
Poor job quality in direct care has persisted to create good direct care jobs. From
for decades—and it has been primarily strengthening Medicaid (including raising
shaped by inadequate public investment Medicaid funding levels and providing
in long-term care and its primary payer, adequate reimbursement rates to providers)
Medicaid. As this country rapidly ages and to designing new social insurance programs
individuals live longer, demand for direct in long-term care at the state and federal
care workers will surge, further straining level, significant policy action is needed to
Medicaid resources and making it nearly bolster financing in this sector and transform
impossible for policymakers and employers direct care jobs.
KEY FACTS
52% $54,000- 1
Percentage of long-term
services and supports (LTSS)
spending in 2018
$106,000
Yearly estimated median
Number of
state-based social
insurance programs
attributed to Medicaid.3 in long-term care
costs for LTSS.4 (Washington State).5
8 Federal Policy Priorities for the Direct Care WorkforceRecommendations
• Medicaid Reform. Congress and the (that include workers) to create and regularly
Centers for Medicare & Medicaid Services update an “HCBS workforce plan” that
(CMS) should protect and reform Medicaid, details the specific needs and costs of fully
the primary public payer of long-term supporting home care workers. These
care. As a key priority, Congress and CMS workforce plans should include a strategy to
should support states in ensuring that establish a wage floor based on a living wage
long-term care providers receive adequate (with guidance on the formula from federal
reimbursement rates to deliver quality leaders), higher wages tied to advancement,
services and improve direct care jobs.6 and a transparent rate-setting process that
covers all care delivery costs, including a
• Alternative Financing Models. Alternative baseline rate for managed care plans.
financing models are needed to address
the increased and unsustainable pressures
on Medicaid as the primary payer of long-
term care. (Recent research shows that
56 percent of people turning 65 between “You need to work really hard
2020 and 2024 will require some form on this job, to work really hard.
of paid LTSS at some point in their lives.7) You do a lot of things for your client
As one key action, Congress should enact
and fully fund the Well-Being Insurance and at the same time the pay is very,
for Seniors to be at Home (WISH) Act. very low. That is something that
The WISH Act would create a federal I don’t like from it. This is
social insurance program in long-term the only thing that I don’t like.
care through a public-private partnership, The salary is very low.”
assisting individuals with the high costs
of these services. To ensure consumers MARIA MARRERO
can truly benefit from enhanced access to Certified Home Health Aide
long-term care, the Act should also include at HomeCare Options
measures to transform and fully finance Totowa, NJ
direct care jobs.8
• HCBS Access and Workforce Plans.
Congress should introduce, enact, and
fully fund the Home and Community-
Based Services Access Act, which would
fund states to develop and strengthen
their HCBS infrastructure and further
invest in the home care workforce.
The Act would abolish Medicaid’s
historical institutional bias by making
HCBS mandatory. Federal leaders should
also ensure that this Act requires states to
convene multi-stakeholder workgroups
Federal Policy Priorities for the Direct Care Workforce 9PHI’S NATIONAL
ADVOCACY
LEADERSHIP
In response to the growing interest in
state-based social insurance programs in
long-term care, PHI issued a report with
nine concrete strategies for ensuring
that eligible consumers can access the
support they require from a high-quality,
adequately supported workforce.11
In addition, as part of PHI’s multi-state
advocacy initiative in Michigan, New
Jersey, New Mexico, New York, and North
Carolina, advocates across these states
are focusing on improving wages and
reimbursement rates under Medicaid as
one of their top three priorities to pursue
over the next two years.12
s top priorities for the workforce, the
A care plans. CMS should also provide
Act should also address training, career guidance and technical assistance to
advancement, recruitment, retention, states on how to invest in the direct
and innovation. workforce through value-based payment
arrangements. Effectively leveraging
• Public Investment Standards and the role of direct care workers in value-
Value-Based Payment. CMS should bayed payment arrangements helps
incentivize states to build minimum improve health care quality while reducing
standards for direct care jobs into their unnecessary costs.10
contracts with providers and managed
10 Federal Policy Priorities for the Direct Care WorkforceIncrease
Compensation for
Direct Care Workers
irect care workers deserve better wages and benefits
D
to improve their economic security and overall wellbeing.
Wages for direct care workers are untenably Unfortunately, policy proposals that
low and have barely budged over the last aim to increase wages for low-wage
10 years. As a result, direct care workers workers (including direct care workers)
are often forced into poverty, cannot are rarely paired with an increase in
make ends meet or support their families, public funding that would help long-term
and end up leaving this field for other care employers cover these higher wages
industries, such as fast food and retail. without cutting service hours for older
Exacerbating this injustice is the reality adults and people with disabilities.
that many direct care workers lack access The entire long-term care system
to full-time schedules and critical supports needs sufficient funding and reform to
such as health coverage, paid sick days, improve the economic wellbeing of
paid family and medical leave, or affordable these essential workers.
childcare and long-term care support.
KEY FACTS 13
$0.19
Growth in the inflation-
$20,300
Median annual earnings for
15%
Percentage of direct care
adjusted median hourly direct care workers. workers without any health
wage for direct care workers insurance.
between 2009 and 2019,
from $12.61 to $12.80.
Federal Policy Priorities for the Direct Care Workforce 11Recommendations
• American Families Plan. Congress should enacted, federal leaders should provide
enact and fully fund the American Families rules and guidance to states on how to
Plan, which would expand affordable implement these new provisions, taking
childcare, universal preschool, expanded into consideration the needs of payers,
higher education access, individual and providers, workers, and consumers
family tax credits, and comprehensive paid across long-term care settings, and
leave for millions of workers, including key considerations such as Medicaid
direct care workers.14 Once the plan is reimbursement formulae, managed care
contracts, employment practices, and
consumer and worker education, among
other needs.
“It’s so unfortunate that in the • National Compensation Strategy.
CMS, ACL, HRSA, DOL, and other
world we live in, the caregiving stakeholders should work together to
profession receives the lowest develop a national compensation strategy
category of pay. Yet it requires that addresses direct care workforce
a lot of intelligence. It requires concerns. Among its responsibilities,
this inter-agency group should develop
a lot of agility to be able specific recommendations on how
to respond to a need or an states should set their Medicaid rates to
emergency.” ensure competitive wages and benefits
for direct care workers, considering
ALLEN GALEON
both traditional Medicaid and managed
Caregiver and Worker Leader at Pilipino
care contexts. The recommendations
Workers Center, Los Angeles, CA
should take into account full-time
scheduling barriers, “benefit cliffs” and
“benefit plateaus,” and other factors
and possibilities. The recommendations
should then be translated into regulations
for rate-setting and enforcement
processes at the state level.
• Financial Support Programs. DOL should
fund financial literacy and counseling
programs that help direct care workers
(among other low-wage workers)
understand complex job-related benefits
and supports (including health insurance
options), navigate financial challenges,
and plan for their short- and long-term
financial futures.
12 Federal Policy Priorities for the Direct Care WorkforcePHI’S NATIONAL
ADVOCACY
LEADERSHIP
PHI provided in-depth research and
policy analysis on extending wage and
overtime protections to U.S. home care
workers for nearly a decade before the
U.S. Department of Labor announced,
in December 2011, that it would extend
these protections under the Fair Labor
Standards Act.17 We also joined forces with
several national organizations to ensure
implementation of the ruling, launching
a “Campaign for Fair Pay” that helped
solidify this win. At the state level, PHI was
instrumental in designing and helping to
pass New York State’s historic 2011 Wage
Parity Law, which established a consistent
wage floor with benefits for home health
aides and personal care aides.18
• Benefit Cliffs and Plateaus. DOL and
HHS should develop a strategy with
analysis, rules, regulations, and guidance
to help states address benefit cliffs and • State and Regional Public Authorities.
benefit plateaus among low-wage workers, DOL should fund the creation of state or
including direct care workers. (These cliffs regional public authorities that improve
and plateaus occur when, as low-wage job quality (including by setting wage
workers’ wages and hours increase, their floors) for independent providers, while
total compensation drops or remains the promoting the principles of consumer
same due to a corresponding decrease in direction. (Independent providers are
public benefits.) This strategy should build direct care workers employed directly
on existing research and guidance from by consumers through publicly funded
the field and explore approaches such consumer-direction programs.) While this
as adjusting the design of public benefit figure is difficult to calculate, PHI estimates
eligibility limits and requirements and that at least one million independent
working with workers to reduce the impact providers are employed through Medicaid-
of losing benefits, among other strategies.15 funded consumer-directed programs.16
Federal Policy Priorities for the Direct Care Workforce 13Strengthen Training
Standards and
Delivery Systems for
Direct Care Workers
oday’s direct care workers need a training approach that
T
appropriately prepares them for the complex and valuable
services they deliver.
The training landscape for direct care the workforce overall. Additionally, training
workers makes it nearly impossible to requirements for direct care workers tend
ensure that they are adequately skilled and to focus on the tasks associated with
prepared to succeed in their roles. Training assisting consumers with activities of daily
requirements for direct care workers are living and instrumental activities of daily
uneven and insufficient throughout the living, yet less attention has been given to
country, with federal mandates applicable the physical, social, and emotional demands
only to some workers and state-level of direct care or the extent to which direct
training regulations varying widely across care workers are increasingly supporting
states, long-term care settings and job titles. people with complex health conditions.
Moreover, disjointed training regulations The entire training landscape—its standards,
make it difficult for workers to translate their curricula, and general infrastructure—must
experiences across settings (from home care be better developed, standardized, and
to residential care, for example), limiting resourced.
their career mobility and the versatility of
KEY FACTS 19
32 18 7
States (plus DC) that States (plus DC) that States with no training
have expanded training have expanded training requirements for personal
requirements for nursing requirements for home health care aides.
assistants beyond the aides beyond the 75-hour
75-hour federal minimum. federal minimum.
14 Federal Policy Priorities for the Direct Care WorkforceRecommendations
• National Competency-Based Training s part of this effort, CMS should set
A
Standard. CMS, ACL, DOL, DOE, and and fund minimum standards for training
other relevant stakeholders should work quality, for example in regard to instructor
together to establish a national standard qualifications, student-teacher ratios, and
for direct care competencies that draws training space and equipment, among other
on existing core competency sets and factors.
is applicable to all direct care workers
regardless of payment source. CMS should
• New Research. DOL should commission a
study on the national training infrastructure
also require that states adopt these core
for direct care workers to identify gaps
competencies with the ability to tailor
and best practices. As well as summarizing
them to state-specific requirements and
the evidence base on direct care training
regulations. Federal leaders should provide
interventions, this study should examine in
guidance to states on how to integrate
detail the characteristics and geographic
these competencies into their training
standards and credentialing programs,
among other concerns.
• Personal Care Aide Training
Requirements. CMS should create “Working in these advanced roles
minimum federal training standards has given me a lot of confidence in
for personal care aides, ensuring parity
with home health aides and nursing what I do. I feel good about being
assistants. Personal care aides are a able to help more clients, more
rapidly growing yet largely unregulated workers, and more family members
part of the direct care workforce. in this way. I continue to learn,
• Training Infrastructure. Federal leaders which is also good for me.”
should support states in strengthening MARISOL RIVERA
their direct care workforce training Care Coordinator at
infrastructures, including by providing Cooperative Home Care
funding to develop and enforce Associates, Bronx, NY
competency-based training standards
and deliver and evaluate training. As
two avenues, Congress should enact and
fully fund the Direct Support Worker
Training Reimbursement Act, which
would increase federal matching payments
for training programs focused on the direct
care workforce, and the Mollie Baldwin
Upskilling of Personal and Home Care
Aides Act, which would fund competency-
based upskilling training models in direct
care.20 Additionally, CMS should expand
Medicaid to cover entry-level training costs
for all direct care occupations.
Federal Policy Priorities for the Direct Care Workforce 15PHI’S NATIONAL
ADVOCACY LEADERSHIP
For years, PHI has been tracking training
requirements for personal care aides, home
health aides, and nursing assistants across the
50 states and DC, describing the significant
variance across states and occupations and
highlighting the urgent need to strengthen
and standardize these requirements.21 PHI’s
workforce innovations division has also innovated
in this area: as one leading example, our
Homecare Aide Workforce Initiative used a mix of
training, recruitment strategies, peer mentoring,
coaching supervision, supportive services, and
case management to improve job satisfaction
and retention (among other outcomes) among
participating home care workers.22
coverage of existing training programs;
the extent to which these programs
measure workforce, care, and cost • Job Quality Measures. HHS and DOL
outcomes; funding needs and mechanisms should develop and incorporate a core
for training; the use and efficacy of set of direct care workforce quality
e-learning and virtual training; and the measures into federally funded long-term
prevalence of complementary training for services and supports programs and
direct care supervisors, among other areas. demonstrations, informed by the National
This study should also assess how the Quality Forum final report of September
direct care training landscape addresses 2016. Grantees leading projects that
topics such as dementia care; other types of involve direct care workers should be
condition-specific care; social isolation and required to submit progress and final
loneliness; cultural, linguistic, and lesbian, reports on how their projects have met
gay, bisexual, and/or transgender (LGBT) these quality standards.
competence; and much more.
16 Federal Policy Priorities for the Direct Care WorkforceFund, Implement,
and Evaluate
Direct Care Workforce
Interventions
rom advanced roles to care integration to recruitment and
F
retention, a wide array of workforce interventions will help
stabilize the direct care workforce.
The growing population of older adults including interventions that strengthen the
in this country and the persistence of poor job pipeline into direct care; approaches
job quality in direct care will continue that better integrate these workers into the
to generate a workforce recruitment consumer’s interdisciplinary care team; and
and retention crisis in the foreseeable advanced role opportunities that provide a
future. To ensure that the long-term care career ladder with elevated titles, functions,
sector can meet the growing demand for and compensation. These interventions
direct care workers—and that workers should be properly funded, implemented,
can thrive professionally and financially and evaluated with an eye to their impact
in these critical roles—a variety of direct on worker, client, and cost outcomes.
care workforce interventions are needed,
KEY FACTS
99%
Turnover rate for
65%
Turnover rate for
$6,000
The estimated savings per
nursing home staff.23 home care workers.24 supervisor (among those reporting
time efficiencies due to the
training) in a 2006-2010 PHI-led
intervention that reached more
than 2,000 supervisors and led to
enhanced problem solving and
efficiency on the job.25
Federal Policy Priorities for the Direct Care Workforce 17Recommendations
• Workforce Interventions Investment loneliness, mental health, vulnerable
and Inter-Agency Coordination. DOL, in people (such as LGBT individuals), and
coordination with HHS and DOE, should others. These interventions should engage
fund and evaluate a broad range of direct workforce development providers,
care workforce interventions in areas such educational institutions, direct care
as: entry-level and specialized training, employers, labor organizations, and
advanced roles, recruitment and retention, industry associations, among other
stakeholders, and evaluate their impact on
employment, care, and cost outcomes.
• Boosting the Direct Care Field. Congress
should enact and fully fund the Direct
“As a peer mentor, I train Creation, Advancement, and Retention
new home health aides of Employment (CARE) Opportunity Act,
which would invest more than $1 billion
and make myself available over five years in workforce interventions
to support a group of five that improve training, recruitment,
aides. They can come retention, and advancement opportunities
in the direct care workforce.26 This Act is
to me with any questions designed to support interventions in high-
or concerns they have, or to need areas and encourage consultation
simply talk about their day.” with diverse stakeholders, and it requires
that interventions be evaluated for their
JANET FOLSOM impact on workers, consumers, and overall
ome Health Aide, Certified Nursing Assistant,
H care costs.
and Peer Mentor at Knute Nelson
Alexandria, MN • Advanced Role Evidence Base. Congress
should re-introduce, enact, and fully
fund the Improving Care for Vulnerable
Older Citizens and People with Disabilities
through Workforce Advancement Act,
supervision, e-learning, technology, and which would build the evidence base on
more. CMS, ACL, HRSA, and other relevant advanced role models in direct care, with
agencies should also support new models a specific focus on models that better
of service delivery across long-term care integrate workers into the interdisciplinary
settings, including universal worker roles, care team and models where workers
models that connect workers to other can improve support for individuals with
services (such as housing supports), and complex chronic conditions.27 As designed,
models that maximize the direct care role the Act would prioritize advanced
through upskilling, care integration, and role interventions that address vulnerable
meaningful career ladders. Additionally, populations, neglected regions of the
CMS and DOE should support approaches country, and rural and urban needs.
that strengthen workers’ abilities to support
individuals with dementia, people at risk
or dealing with social isolation and
18 Federal Policy Priorities for the Direct Care WorkforcePHI’S NATIONAL
ADVOCACY
LEADERSHIP
For years, PHI’s workforce innovations have
greatly helped direct care workers and their
employers. Our Care Connections Project
created an advanced role for home care
workers—the “Care Connections Senior
Aide”—which has helped improve job
satisfaction, decrease emergency department
visits, and reduce family caregiver strain.31
As another example, in 2014 PHI worked
with local colleges, municipal agencies, and
private employers to better recruit, train,
and retain direct care workers through the
City University of New York (CUNY) system.
This intervention led to high employment
and retention rates: 76 percent of trainees
secured a job and 75 percent of those
workers retained their jobs three months
after completing the training.32
• Recruitment and Retention. ACL should certification records of direct care workers
commission a study on recruitment and (with privacy safeguards in place). PHI
retention challenges in the direct care has identified only 14 matching service
workforce, scan the field for best practices registries in 10 states (as of 2019), and
in program design on these topics, and many of them are under-resourced and not
promote these findings broadly. The agency maximizing their potential.28
should also work with experts in the field to
develop a recruitment and retention guide
• Dementia Care Competence. HHS
should create a strategy to build dementia
for ACL grantees that are leading projects
care competence among direct care
that employ direct care workers.
workers (and other health care workers),
• Matching Service Registries. DOL building on the recommendations from the
should commission a feasibility study to Workforce Development Workgroup that
assess the strengths, risks, logistics, and was formed as part of the 2020 National
total costs of launching and promoting Research Summit on Care, Services and
matching service registries in every state. Supports for Persons with Dementia and
A matching service registry is an online job Their Caregivers.29 More than 6 million
board where consumers and workers find individuals are currently living with
each other based on needs, preferences, Alzheimer’s in the U.S.—by 2050, this
and availability—and can serve as a useful number will grow to 13 million.30
platform for centralizing training and
Federal Policy Priorities for the Direct Care Workforce 19Improve Direct
Care Workforce
Data Collection and
Monitoring
L ong-term care leaders need better data on the size, stability,
credentials, and compensation of the direct care workforce
and on direct care job quality.
When it comes to tracking and measuring need to make sound decisions that would
key workforce dimensions such as size, improve these workers’ jobs. Additionally,
stability, credentials, and compensation federal industry and occupational codes
(among other variables), federal and need updating, which includes developing
state data collection systems remain a new code for direct support professionals
inadequate and under-resourced. As a result, (among other improvements), and job quality
policymakers, industry leaders, and other metrics need widespread adoption across
long-term care stakeholders—at the local, research, policy, and practice.
state, and federal levels—lack the data they
KEY FACTS
1 23% 12
Number of staffing Percentage of nursing Number of years since the
measures included in homes reporting Centers for Medicare &
the national 5-Star staffing shortages during Medicaid Services (CMS)
Quality Rating System the peak of the COVID-19 published a report calling for
for nursing homes.33 pandemic.34 a minimum data set on the
direct care workforce.35
20 Federal Policy Priorities for the Direct Care WorkforceRecommendations
• Workforce Definitions and Eligibility • Job Quality Measures. HHS and DOL
Requirements. DOL, in coordination with should develop and incorporate a
CMS and other relevant agencies, should core set of direct care workforce quality
work with experts in the field to establish measures into federally funded long-
a definition of “direct care worker” that term services and supports programs
captures the core competencies of this role and demonstrations, informed by the
and specifies the additional competencies National Quality Forum’s final report
required for distinct settings (such as HCBS from September 2016.36 Grantees leading
versus nursing home care) and population projects that involve direct care workers
served (such as older adults or individuals should be required to submit progress and
with intellectual and developmental final reports on how their projects have
disabilities). This definition could be used met these quality standards.
to bring greater consistency to the laws
and other public policies that govern
this workforce.
• Data Collection Infrastructure. “You need a whole lot of
DOL should fund states to build
and strengthen their data collection
patience to do this job.
infrastructure on the direct care You don’t know what kind
workforce—toward the goal of of day your clients are
systematically collecting employer-
level data on the direct care workforce
going to have, or what you
statewide and centralizing the training are going to be dealing with.
and certification records of direct care All clients are different.”
workers (with clear privacy safeguards
in place). This investment in state-level RICARDO ARAUJO
data collection infrastructure should Home Health Aide at
be informed by an updated, national Cooperative Home Care
minimum data set on this workforce Associates, Bronx, NY
and paired with guidance and
requirements for reporting and analysis.
• Minimum Data Set on Direct Care
Workers. CMS should update its
minimum data set recommendations on
the direct care workforce, which were
developed in 2009 by the National Direct
Service Workforce Resource Center.
This set should include workforce volume,
stability, compensation, and training/
credentialing rates—and should account for
workers employed across long-term care
settings and by all employer types.
Federal Policy Priorities for the Direct Care Workforce 21PHI’S NATIONAL
ADVOCACY
LEADERSHIP
In 2009, as part of the National Direct
Service Workforce Resource Center
created by CMS, PHI developed a first-
ever, expert-informed minimum data
set on this workforce, which included
specific indicators related to workforce
volume, stability, and compensation and
a list of additional variables for more
detailed analysis.39 Additionally, our
annual research on direct care workers,
typically released the week of Labor
Day, provides a detailed and up-to-date
statistical picture for the field on direct
care demographics, occupational roles,
job quality challenges, and projected
job openings.40
• Direct Support Professionals
Classification. The Office of Management
and Budget (OMB) should work with
long-term care and workforce experts to (conducted in 2007), the first and only
update the existing federal industry and national probability surveys focused on this
occupational classification codes so that workforce.
they characterize the direct care workforce
more accurately. Specifically, OMB should • New Research. HHS and the National
establish a Direct Support Professional Institutes of Health (NIH) should
Standard Occupational Classification code fund original studies on the direct
to distinguish these workers from nursing care workforce, including studies that
assistants, home health aides, and personal measure workforce size and composition;
care aides. Congress could alternatively consumers’ experiences with direct care
enact and fully fund the Recognizing the workers; and a variety of other vital,
Role of Direct Support Professionals Act, understudied topics.
which accomplishes this goal.37 This action • Lessons Learned Report. HHS should
would help researchers and other leaders commission and release a report on
measure and describe the workforce lessons learned from the COVID-19
capacity for supporting individuals with crisis related to direct care workers,
intellectual and developmental disabilities. building on the final report to CMS from
• National Direct Care Surveys. The the Coronavirus Commission for Safety
National Center for Health Statistics at the and Quality in Nursing Homes and the
CDC should re-issue its National Nursing upcoming report from the Committee
Assistant Survey (conducted in 2004) on the Quality of Care in Nursing Homes
and National Home Health Aide Survey at the National Academies of Sciences,
Engineering, and Medicine.38
22 Federal Policy Priorities for the Direct Care WorkforceCenter Direct Care
Workers in Leadership
Roles and Public Policy
irect care workers are experts on their jobs and care delivery,
D
and they should help define the future of this workforce.
As the paid frontline of long-term care for leaders should create workgroups to
older adults and people with disabilities, develop action plans to improve these
direct care workers possess unique insights jobs—and include workers front and
on how to improve the quality of their jobs center in these groups. Divisions of paid
and the delivery of care. Unfortunately, care can be instituted at different levels of
their experiences and wisdom are often government with the remit of supporting
left out of the discussions and initiatives direct care workers, childcare workers, and
shaping policy and practice in this rapidly housekeepers to access their rights and
growing job sector. To address these benefits, among other offerings. Finally,
problems, a variety of mechanisms exist to direct care workers should be tapped for
center direct care workers in leadership key advisory roles and leadership positions
roles and public policy. Federal and state across the public and private sector.
KEY FACTS
16 1 38%
Number of statewide Number of divisions of Turnover rate in worker-owned
direct care workgroups paid care that have been home care cooperatives,
that have been convened created at either the local, compared to the turnover rate
since 2003.41 state, or federal level.42 of 65 percent or higher in the
broader direct care field.43
Federal Policy Priorities for the Direct Care Workforce 23Recommendations
• National Strategy on the Direct his council should include direct care
T
Care Job. HHS should develop a national workers themselves, and its strategy should
direct care workforce strategy, convening include identifying funding for the council’s
a stakeholder advisory council to identify recommendations, producing regular
actions that government, providers, public- progress reports, and developing new
private sector organizations, philanthropy, recommendations as needed. This council
and others can take to completely could take on some of the challenges
transform the direct care job. described above, including the national
compensation strategy, competency-based
training standards, and updated workforce
definitions.
“If I could make a change, it • Paid Care Division. DOL should establish
would be for this field to show a division of paid care to work with
states and localities in assisting direct
more appreciation for what we care workers, childcare workers, and
do, because we are the main housekeepers with legal and employment
backbone of this work. We’re concerns, building on the successful model
the most hands-on with clients in New York City.44 This division would
and spend more time with also educate and support employers in
fulfilling their responsibilities, and monitor
them than anyone else.” trends and new developments across these
MICHELLE GODWIN job sectors. As one example, the division
ertified Nursing Assistant
C could continue monitoring compliance
Killearn Lakes, Tallahassee, FL with the “Home Care Final Rule” that went
into effect in 2015, extending wage and
overtime protections under the Fair Labor
Standards Act (FLSA) to home care workers
nationwide.45
• Domestic Worker Rights. Congress
should enact and fully fund the Domestic
Workers Bill of Rights Act, which would
provide a number of rights and protections
for home care workers, childcare
workers, and housekeepers related to
compensation, worker protections, sick
leave, discrimination, privacy, health and
safety, and more.46
24 Federal Policy Priorities for the Direct Care WorkforcePHI’S NATIONAL
ADVOCACY
LEADERSHIP
In 2020, PHI launched the Direct Care
Worker Story Project, which works with
direct care workers nationwide to document
their stories and share their ideas for
transforming their jobs.48 This project aims
to enhance the visibility of this workforce,
amplify workers’ voices, and draw on
their unique wisdom to inform policy
and practice. Our multi-state advocacy
initiative—Essential Jobs, Essential Care—
has also ensured that workers are centered
as experts and advocates in state-level
advocacy.49 As one example, direct care
workers led panels during the first statewide
gatherings for this initiative in early 2021,
grounding these conversations in their
frontline experiences.
• Statewide Workgroups. DOL should fund
states to establish and maintain statewide
workgroups focused on the direct care • Leadership Development. DOL should
workforce.47 These workgroups should fund leadership development programs for
bring together diverse stakeholders across direct care workers to build their leadership
the state to assess the direct care workforce and advocacy capacities, while connecting
landscape and identify an expansive set of this program to leadership positions in
policy recommendations to improve these government and the community.
jobs. Workgroups could also advocate
• Policy Events. DOL and HHS should
together to advance these ideas and
hold regular convenings, hearings, and
identify new possibilities as they emerge.
briefings on various topics related to the
• Stakeholder Advisory Groups. HHS and direct care workforce, including but not
DOL should require that grantees leading limited to staffing challenges, training and
projects that involve direct care workers advancement, data collection and research,
form stakeholder advisory groups that equity and inclusion, and much more.
include these workers. These events should allow for public input
and engagement.
Federal Policy Priorities for the Direct Care Workforce 25Rectify Structural
Gender and Racial
Inequities for
Direct Care Workers
Women, people of color, and immigrants in the direct care
workforce merit more attention and support.
Systemic racism has long harmed the political climate has become increasingly
lives and jobs of people of color in direct hostile to immigrants in recent years,
care—from the creation of these poor- limiting targeted supports for immigrants
quality jobs, through the decades-long who are a critical part of this workforce.
exclusion of home care workers (and other Despite these numerous challenges, policy
domestic workers) from federal wage and and practice interventions aimed at direct
overtime protections, to the widespread care workers do not often account for the
racial discrimination that people of color unique structural barriers and inequalities
and immigrants continue to face regarding they face on the job and in their daily lives,
employment, housing, education, and limiting the evidence base on race and
health care, among others. Additionally, gender-explicit workforce interventions in
caregiving has historically been defined as this sector. When focusing on direct care
“women’s work” and is still often dismissed workforce development, we must center
as a labor of love that requires only minimal and uplift women, people of color, and
compensation and support, perpetuating immigrants—these workers deserve good
poor job quality in this sector. Finally, the jobs rooted in equity and justice.
KEY FACTS 50
$11.13 53% $37,600
Median hourly wage Percentage of women Median family income
for home care workers who of color home care workers for women of color home
are women of color, versus living in or near poverty, care workers, compared to
$12.38 for white men. compared to 38% $47,100 for white men.
of white men.
26 Federal Policy Priorities for the Direct Care WorkforceRecommendations
• Pathway to Citizenship. Congress should African-American, Asian, American Indian/
enact and fully fund the U.S. Citizenship Act Alaska Native, Middle Eastern/North
of 2021 to provide a pathway to citizenship African, and Native Hawaiian or Other
for approximately 11 million undocumented Pacific Islander), immigrants, and LGBT
immigrants, including direct care workers populations, as key examples.
(classified as “essential workers”).51
• Workplace Violence Prevention.
• Immigrant Supports and Building Congress should enact and fully fund the
the Pipeline. HHS should fund measures Workplace Violence Prevention for
that support immigrant direct care Health Care and Social Service Workers
workers, including immigrant-specific Act, which would require DOL to recognize
workforce programs in direct care. The U.S. and address workplace violence in health
Department of State should create special care, social service, and other sectors.
visas for direct care workers that would
build the pipeline for this workforce;
these visa programs should include
strong worker protections and should not “Ten years ago, I came to America
tie an immigrant worker’s immigration
status to their employer.52
with the hope of pursuing a good
life and happiness, as I believe
• Research on Immigrants and the this is the land of opportunity as
Gray Market. BLS, the U.S. Census long as you work hard for it, using
Bureau, and other agencies should
integrate additional questions related to the knowledge and skills that
immigrants in relevant federal surveys, we have achieved through our
building the knowledge on this critical education and experiences.”
segment of the direct care workforce.
HHS should also fund new studies on TERESITA SATTAR
immigrants working on the “gray market” Caregiver at Courage LLC
and Worker Leader at
(where consumers directly hire home
Pilipino Workers Center,
care workers using private funds), which Los Angeles, CA
would increase understanding on the
unique challenges and characteristics
of this nearly invisible segment of the
direct care workforce. HHS should create
ethical standards for conducting this
research without threatening the safety
and security of respondents.
• Equity-Focused Interventions.
HHS, DOL, and ACL should invest in
workforce interventions with explicit
racial and gender equity lenses, including
interventions that target different
communities of color (Latinx, Black/
Federal Policy Priorities for the Direct Care Workforce 27PHI’S NATIONAL
ADVOCACY LEADERSHIP
In June 2017, PHI released a first-ever research
brief on immigrant direct care workers at a time
when the political rhetoric on immigration had
become increasingly toxic. Our study offered
a new angle on this debate, generating news
coverage in media outlets like The New York
Times, Washington Post, and many others.56
Later that year, PHI launched a four-part research
series examining racial and gender disparities
within the direct care workforce, looking closely
at the distinct realities of Black/African-American,
Hispanic/Latino, and Asian and Pacific Islander
direct care workers and offering ideas for
promoting racial equity for this workforce.57
his Act would be one step toward
T • LGBT Protections. Congress should enact
protecting direct care workers in and fully fund the Equality Act, which
long-term care, who experience would ban discrimination based on sex,
disproportionately high rates of injury sexual orientation, and gender identity
on the job due to a variety of in public accommodations and facilities
workplace risks.53 (among other areas).55 These expanded
non-discrimination protections would
• Underserved Communities. Congress cover long-term care settings, where many
should enact and fully fund the Career
LGBT direct care workers are employed
Advancement for Direct Support Aid
and LGBT individuals reside and receive
Workers Act, which would fund direct
services. Once enacted, the Office for
care workforce interventions focused on
Civil Rights should provide guidance to
education, training, and advancement,
direct care workers and their employers
with an emphasis on communities of color
(among other stakeholders) about these
and workers in rural areas (among other
new rights and protections.
vulnerable populations).54
28 Federal Policy Priorities for the Direct Care WorkforceShift the Public
Narrative on
Direct Care Workers
o challenge unfair representations and change minds
T
about direct care workers, we must invest in public education,
capacity building, and storytelling.
The realities and challenges facing direct stakeholders need sufficient resources
care workers are too often invisible in the to launch impactful public education
public and political discourse. Additionally, campaigns and build their communications
direct care is often wrongly described as capacities to advocate for direct care
low-skilled work, which underplays the workforce reforms. Moreover, storytelling
complex competencies that it requires—and projects are a practical approach that should
does not reflect the training, compensation, be better funded to enhance these workers’
or respect that direct care workers deserve. visibility, amplify their voices, and draw on
To positively shift the public narrative on their wisdom to inform policy and practice
direct care workers, advocates and other in this sector.
KEY FACTS
1.5 M 60 23
Number of timeline Number of ideas Number of in-depth
deliveries on Twitter generated by PHI’s direct care worker stories
generated by PHI’s year-long #60CaregiverIssues published online in the
Caring for the Future campaign to help address first seven months of
report series and public the growing workforce PHI’s Direct Care Worker
education campaign. shortage in home care. Story Project.
Federal Policy Priorities for the Direct Care Workforce 29Recommendations
• Framing Strategy. HHS should fund a • Strategic Communications Capacity.
research-based framing strategy—similar to DOL and HHS should adequately fund
the “Reframing Aging” initiative—to help grantees that are leading interventions
develop effective, strength-based frames related to direct care workers to develop,
and messages on the value and needs of implement, and evaluate strategic
direct care workers.58 communications campaigns that integrate
framing and messaging strategy, branding
and graphic design, earned and digital
media, and more. Evaluating these efforts
would help build the evidence base on
“I do my best to build how to effectively communicate about this
relationships, and I start by workforce to change attitudes and beliefs
and build support. Special attention should
thanking them for allowing me be given to communications campaigns
to come in and help them. that are culturally and linguistically
I understand everybody moves competent and campaigns that focus on
differently and everybody hurts more invisible communities within the
differently, and I try to be very direct care workforce (e.g., immigrants,
LGBT workers, etc.).
compassionate in my care.”
CRYSTAL PROFFITT • The National Direct Care Workforce
Resource Center. HHS should
ertified Nursing Assistant and Certified Hospice
C
Palliative Nursing Assistant at Transitions permanently fund the National Direct Care
LifeCare, Raleigh, North Carolina Workforce Resource Center, the country’s
premier online library of information on
the direct care workforce.59 Updated and
relaunched in 2020 by PHI, the National
Direct Care Workforce Resource Center
• Market Research. HHS should commission supports researchers, policymakers,
and fund a comprehensive, nationally practitioners, advocates, and journalists
representative quantitative market research in better understanding—and building the
study on direct care workers, yielding knowledge base on—this critical workforce.
insights on their values, needs, and wants.
This study would bring visibility to this
growing yet undervalued workforce and
inform policy and practice, including
recruitment and retention strategies in
different parts of the country. Research
on consumers’ and family caregivers
perspectives on the direct care workforce
would also be valuable.
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