QUALITY JOBS ARE ESSENTIAL - CALIFORNIA'S DIRECT CARE WORKFORCE AND THE MASTER PLAN FOR AGING - PHI
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QUALITY JOBS ARE ESSENTIAL CALIFORNIA’S DIRECT CARE WORKFORCE AND THE MASTER PLAN FOR AGING
PHI works to transform eldercare and disability services. We foster dignity, respect, and independence for all who receive care, and all who provide it. As the nation’s leading authority on the direct care workforce, PHI promotes quality direct care jobs as the foundation for quality care. Author: Robert Espinoza • Contributors: Arielle Altman, Stephen Campbell, Kezia Scales, Jodi M. Sturgeon • Design: RD Design • Photography: Kristen Blush @kristenblush (p.8, p.20, p.21, p.25, and p.26); Constanza Hevia H. @constanzaheviah (inside front cover, p.1, p.3, p.11, p.13, p.17, p.19, p.22, and p.23-upper right; Rachael Porter @porterfiles (cover, p.5, p.23-bottom left, p.24, p.27, and p.29); and Dave Sanders @dave_sanders (p.14 and p.15)
TABLE OF CONTENTS
2 Introduction
4 In Their Own Words: Marichu Buenaventura
6 A
Detailed Snapshot of California’s
Direct Care Workforce
10 In Their Own Words: Kao Saephan
12 C
alifornia’s Master Plan for Aging and
the LTSS Subcommittee Report
13 Primary Goal: Caregiving That Works
17 Additional Goals, Strategies, and Initiatives
28 In Their Own Words: Teresita Sattar
30 Summary: Creating 1 Million High-Quality
Direct Care Jobs in California
31 Appendix 1: Comparison of Key
Direct Care Workforce Recommendations
in LTSS Subcommittee Report to California’s
Master Plan for Aging
37 Appendix 2: Profile of Direct Care
Workforce in California
39 Appendix 3: PHI Framework: The 5 Pillars
of Direct Care Job Quality
Quality Jobs Are Essential: California’s Direct Care Workforce and the Master Plan for Aging 1
Introduction
INTRODUCTION
At the beginning of 2021, California released sector increase consumer spending, decrease
its Master Plan for Aging, a comprehensive public assistance expenditures, and help
10-year blueprint designed “to ensure all prevent unnecessary emergency department
people in California are engaged, valued, visits, hospital admissions, and other costly
and afforded equitable opportunities to health outcomes.
thrive as we go through different ages and
stages of life.”1 The Master Plan speaks to a This report, Quality Jobs Are Essential:
profound concern: as California’s population California’s Direct Care Workforce and
continues to age rapidly and becomes even the Master Plan for Aging, provides an
more diverse, will the state’s aging and long- in-depth analysis of the Master Plan’s
term care systems be adequately prepared? approach to direct care workforce needs.
Moreover, how precisely should California The report opens with a detailed snapshot
strengthen its response to the state’s aging of the direct care workforce in California
and equity realities, and where should it that looks closely at key demographics, job
invest its resources? characteristics, and future job projections.
We then examine each of the goals,
Critical to these questions and the Master strategies, and initiatives in the Master
Plan for Aging is California’s direct care Plan for Aging that pertain to the direct
workforce—nearly 696,000 workers who care workforce, comparing these ideas
serve as the paid frontline of support for against the recommendations offered in a
older adults and people with disabilities separate and earlier Long-Term Services
in various settings throughout the state. and Subcommittee (LTSS) Stakeholder
These workers are central to the health Report (described hereafter as the “LTSS
and overall wellbeing of California’s aging Subcommittee Report”).3 The purpose
population, as well as to the state’s economy, of Quality Jobs Are Essential is to describe
as this job sector is projected to add nearly how the Master Plan supports this
200,000 new jobs between 2018 and 2028.2 workforce, highlight where it incorporated
Unfortunately, despite their profound value, the LTSS subcommittee’s ideas, and
direct care jobs in the state are often poor propose where and how the Master Plan
in quality, as reflected by low compensation, can be strengthened. Because direct care
insufficient training, limited career paths, workers offer important and unique insights
and other dimensions. Undervalued and on this sector, this report also includes
impoverished, these workers often leave the several worker stories told in their own
field for other roles, threatening services and words. We end our report by summarizing
supports for older adults and people with how direct care workers should be
disabilities. The Master Plan for Aging can incorporated into California’s Master Plan
play a meaningful role in correcting these to transform aging throughout the state
inequities—improving economic security for over the next 10 years.
workers and care for consumers, while also
boosting the economy. Good jobs in this
2 Quality Jobs Are Essential
“[The] pay for these jobs
isn’t a living wage here
in the Bay Area.”
RIKA HONAN, Care Supervisor,
E
Caregiver Emergency Response Team
(CERT) Provider at Homebridge
in San Francisco, CA
California’s Direct Care Workforce and the Master Plan for Aging 3
In Their Own Words
CAREGIVER AT COURAGE LLC AND
MEMBER OF PILIPINO WORKERS CENTER
LOS ANGELES, CA
9 YEARS AS A DIRECT CARE WORKER
MARICHU
BUENAVENTURA
ON WHY SHE DECIDED TO BECOME ON SUPPORTING DIRECT CARE
A DIRECT CARE WORKER: WORKERS DURING THE PANDEMIC:
“I’ve been working as a caregiver since I came “I am currently employed with the [homecare
here from the Philippines in 2012. When I cooperative] Courage LLC. There are a lot
first got here, I had no job, and I needed to of benefits working at the cooperative, and I
make ends meet. Back home, I took care of receive better compensation with them than
my grandmother until she died at 101-years- I did with other clients before. I know they
old. Someone from my church talked to care for us workers, especially during the
me about how I could use this caregiving pandemic. I’ve been fortunate to get support
experience to get job security. My first job from both Courage LLC and the Pilipino
I had here was taking care of a patient with Workers Center (PWC) during this time.
progressive supranuclear palsy—so I started They notify me of how to apply to programs
from there. It takes courage and patience to that can help, like cash assistance, delivery of
take good care of others. It can be so hard care boxes with food, and other emergency
dealing with sick people, but I have empathy funds and subsidies. And then I also have
for others and really enjoy this work.” support from other co-caregivers and friends
at PWC who I can confide in.
ON THE IMPACT OF COVID-19:
I used to take the bus to work, Monday
“When we got the stay-at-home order last through Saturday, up to an hour each way,
March, I stopped working because I’m just but now I take a carpool because I am too
so scared of the virus. I experience panic scared to ride the bus. Otherwise, I might
attacks because I’m all alone in the house, have to stop working again. Fortunately, I
and paranoia that I’m going to get sick. was able to get the first dose of the vaccine
I feel emotionally and mentally drained. at the facility where my client lives and will
Sometimes I get mental blocks, and I can’t get my next dose soon. I was happy to be
think straight because I’m too worried about able to get the vaccine because I know many
my present situation. I started working other caregivers haven’t gotten it yet. So
again in August because I was a few months many people are infected with COVID-19
behind in paying my rent and was so worried at the facility, so we are all truly at risk.
about getting evicted. Right now, I’m just Luckily, we have N-95 masks and not just
working once a week. I would like to work surgical masks for protection. But even with
more, but it feels too risky. I pray a lot so I’m the vaccine and PPE, I still have paranoia,
still strong for my children. They are in the especially with the new variant of the virus.”
Philippines, and I haven’t seen them since
I spent New Year’s with them before the
pandemic. I always miss them and cry for
them. That’s the saddest part.”
4 Quality Jobs Are Essential
In Their Own Words As a direct care worker for nine years, Marichu has struggled financially during this pandemic and has not been able to work remotely. California’s Direct Care Workforce and the Master Plan for Aging 5
A Detailed Snapshot of California’s Direct Care Workforce
A DETAILED SNAPSHOT
OF CALIFORNIA’S DIRECT CARE
WORKFORCE4
Direct care workers support older adults and of job titles in the field. Direct care workers
people with disabilities with daily tasks and who are employed directly by consumers, either
activities in a range of settings, from private through Medicaid programs or private-pay
homes to residential settings (such as assisted arrangements, are often called “independent
living) to skilled nursing homes. This workforce providers.” Workers who support individuals
comprises three main occupational groups— with intellectual and developmental disabilities
personal care aides, home health aides, and are known as “direct support professionals.”
nursing assistants—but are known by a variety
DIRECT CARE WORKER EMPLOYMENT
BY OCCUPATION IN CALIFORNIA, 2009 TO 2019
▪ Home Health Aides and Personal Care Aides 595,760 (519% GROWTH)
▪ Nursing Assistants
▪ All Direct Care Workers 100,190 (-7% DECLINE)
695,950 (242% GROWTH)
96,320
107,310
203,630
2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
6 Quality Jobs Are Essential
AA
Detailed
Detailed
Snapshot
Snapshot
ofof
NewCalifornia’s
Jersey’s Direct Care Workforce
Despite their enormous value to Californians, LARGEST OCCUPATIONS IN CALIFORNIA, 2019
direct care workers struggle to work and
survive financially in jobs characterized Direct Care Workers
by poor job quality, growing demand, and 695,950
significant pressures, including most recently Fast Food Workers
the COVID-19 crisis—all detailed in the 436,540
figures to the right. Throughout this section, Cashiers
we also include national figures to compare 431,140
California’s direct care workers with their Retail Salespersons
counterparts nationwide. 418,900
Laborers and Movers
393,460
A Large and Expanding Workforce
California is home to nearly 696,000 direct
care workers—a rapidly growing workforce that
currently outnumbers every single occupation
OCCUPATIONS IN CALIFORNIA
in the state. This workforce has grown
WITH MOST JOB GROWTH, 2018 TO 2028
dramatically over the past decade, as demand
for LTSS has increased—between 2009 and Direct Care Workers
2019, California’s direct care workforce surged 199,700
nearly 250 percent from 203,630 to 695,950 Laborers and Movers
workers. Nationwide, the direct care workforce 66,300
includes 4.6 million workers. Fast Food Workers
65,400
Workforce Diversity Registered Nurses
53,400
The demographic composition of California’s Cooks
direct care workforce is predominantly 53,000
female (81 percent) and very diverse: 77
percent are people of color and 48 percent
are immigrants. The median age for direct
care workers in the state is 47, and 31 percent
OCCUPATIONS IN CALIFORNIA
of direct care workers are aged 55 and older.
WITH MOST JOB OPENINGS, 2018 TO 2028
Nationally, 87 percent of direct care workers
are women, 59 percent are people of color, Direct Care Workers
27 percent are immigrants, and 27 percent 1,247,900
are aged 55 and older. The national median Cashiers
age for direct care workers is 43. 846,000
Laborers and Movers
690,000
Waiters and Waitresses
Charts Sources: U.S. Bureau of Labor Statistics (BLS), Division
of Occupational Employment Statistics. 2020. May 2009 to
656,700
2019 State Occupational Employment and Wage Estimates Fast Food Workers
California. https://www.bls.gov/oes/current/oes_ca.htm; 643,900
Projections Central. 2020. Long Term Occupational Projections
(2018-2028). https://www.projectionscentral.com/Projections/
LongTerm; analysis by PHI (September 2020).
California’s Direct Care Workforce and the Master Plan for Aging 7
A Detailed Snapshot of California’s Direct Care Workforce
A NOTE ON RACIAL AND GENDER
EQUITY FOR DIRECT CARE WORKERS
Systemic racism has long among others. Additionally,
harmed the lives and jobs caregiving has historically
of people of color in direct been defined as “women’s
care—from the creation work” and is still often
of these poor-quality jobs, dismissed as a labor of love
through the decades-long that requires only minimal
exclusion of home care compensation and support,
workers (and other domestic perpetuating poor job
workers) from federal wage quality in this sector. When
and overtime protections, focusing on direct care
to the widespread racial workforce development,
discrimination that people we must center and uplift
of color and immigrants women, people of color, and
continue to face regarding immigrants—these workers
employment, housing, deserve good jobs rooted
education, and health care, in equity and justice.
8 Quality Jobs Are EssentialA Detailed Snapshot of California’s Direct Care Workforce
Low Wages, High Poverty Poor Job Quality Drives a Crisis
In California (and across the country), low A variety of factors—increased longevity,
wages in direct care force many workers high turnover driven by poor job quality,
into poverty. The median hourly wage for direct care worker retirement trends, and
direct care workers in California is $13.18— more—are significantly increasing the
a wage that, adjusted for inflation, actually need to fill job openings in direct care.
decreased by $.86 between 2009 and 2019. California’s long-term care sector will
The annual median income for California’s need to fill 1,247,900 job openings in direct
direct care workers is $17,200. In turn, 44 care between 2018 and 2028, including
percent of the state’s direct care workforce 199,700 new jobs and just over one million
lives in or near poverty, nearly half (49 separations caused by workers who
percent) access some form of public leave this occupation or the labor force.
assistance, and 19 percent do not have Nationally, long-term care providers will
health coverage. How do these figures need to fill 8.2 million job openings in direct
compare to the national profile of these care between 2018 and 2028, including 1.3
workers? For direct care workers in the U.S., million new job openings and 6.9 million job
the median wage is $12.80, median annual openings as existing workers leave the field
earnings are $20,300, 45 percent live in or or exit the labor force altogether.5
near poverty, 47 percent access some form
of public assistance, and 15 percent do not COVID-19’s Repercussions
have health coverage.
The COVID-19 pandemic has further
strained this job sector in California and
throughout the country, though the precise
DIRECT CARE WORKER WAGES BY
effects are still being measured.6 Ongoing
OCCUPATION IN CALIFORNIA, 2009 TO 2019
coronavirus-related impacts on the state’s
direct care workforce and long-term care
$16.78 system include: the disproportionately
$15.34 high number of COVID-19 cases and deaths
$14.04 among direct care workers and their clients
$13.18
$12.59 $12.58 and residents; the exacerbated impacts
on workforce supply and long-standing
job quality challenges in direct care; the
economic fallout on workers, consumers,
and state resources; and the necessary
shift by the state to focus on navigating this
emergency, which could affect how
the state attends to long-term, systemic
needs in the long-term services and
supports system.
2009 2019 2009 2019 2009 2019
Chart Source: U.S. Bureau of Labor Statistics (BLS), Division
▪ Home Health Aides and Personal Care Aides of Occupational Employment Statistics. 2020. May 2009 to
2019 State Occupational Employment and Wage Estimates
▪ Nursing Assistants California. https://www.bls.gov/oes/current/oes_ca.htm;
▪ All Direct Care Workers analysis by PHI (September 2020).
California’s Direct Care Workforce and the Master Plan for Aging 9In Their Own Words
HOME CARE PROVIDER, CAREGIVER
EMERGENCY RESPONSE TEAM (CERT)
PROVIDER AT HOMEBRIDGE
SAN FRANCISCO, CA
1 YEAR AS A DIRECT CARE WORKER
KAO
SAEPHAN
ON WHY HE DECIDED TO BECOME reduce the spread of the virus. I get to hear
A DIRECT CARE WORKER: their stories and learn how they became
homeless and bridge that gap between us.
“I was incarcerated for 16 years, starting at It’s humbling that I can put so much energy
age 19. Towards the end of my incarceration, and strength and motivation into my job
I had the honor of working with a hospice and make a difference in their lives.”
program at a medical facility in a role that
was similar to home care. During that time,
ON THE IMPACT OF COVID-19:
I got to evaluate myself, and I became
the loving and caring person who I now “When the CERT team came about, I saw it
know I was brought into this world to be. as an opportunity to do even more good and
I knew when I got out that I wanted to serve people with the most need. Homebridge
help people in my community and care for prepared me in more ways than I can wrap my
the vulnerable. Fortunately, Homebridge head around, and I follow their instructions
gave me that chance.” and CDC guidelines on how to keep myself
safe. Even so, there are always still potential
ON HIS RELATIONSHIP WITH risks of contracting the virus and getting sick.
HIS CLIENTS: But that is out of my control.
“Each client has their own unique personality It can all be very emotionally draining, and
and characteristics that make them so the stress takes a big toll on me some days.
special. Before the pandemic, I worked with I go to work and help people, come home, go
people who were in housing programs, and to sleep, and then do the same thing all over
I was assigned to clients who I saw regularly again the next day. I’m not able to see my
and built relationships with. I provide parents, friends, or other family. In a sense,
personal care, emotional support, domestic it can feel like I am in prison all over again.
work, and even run errands. I’m there for
My parents are refugees from Laos, and
my clients if they need or want anything,
in the Mien culture, I should be the one
offer an extra hand to help or an extra ear
giving them the care they need. I am an only
to listen, and let them know they are not
child, and they are getting older. But they
alone and that there is somebody out there
are hundreds of miles away, and now I can’t
who cares about them.
even see them. They are worried about me,
When the pandemic started, I volunteered and I’m worried about them. Sometimes
to join Homebridge’s Caregiver Emergency I feel like I am neglecting them, but they
Response Team (CERT) to care for the assure me I’m doing a good job.”
homeless population in San Francisco that
is currently sheltering in hotel units to
10 Quality Jobs Are EssentialIn Their Own Words
As a home care worker
whose work has intensified
during the pandemic,
Kao recognizes both
the value and strain in
delivering quality care.
California’s Direct Care Workforce and the Master Plan for Aging 11California’s Master Plan for Aging and the LTSS Subcommittee Report
CALIFORNIA’S MASTER PLAN
FOR AGING AND THE LTSS
SUBCOMMITTEE REPORT
California released its Master Plan for the plan’s current goals, strategies, and
Aging in January 2021—the culmination of initiatives against the LTSS Subcommittee’s
a process that began in June 2019 when recommendations. We begin with the
California Governor Gavin Newsom issued Master Plan’s fourth goal—”Caregiving
an executive order to create a blueprint That Works”—which speaks most directly to
for how the state supports both a rapidly the policy issues facing California’s direct
growing and diverse demographic of care workers. This goal sets an ambitious
older adults and all Californians as they target of creating one million high-quality
age across the lifespan.7 The Master Plan caregiving jobs within the next 10 years,
recognizes the opportunities that this mainly through three core initiatives under
sizable aging demographic shift poses for the banner of “Good Caregiving Jobs
the state, as older adults contribute “in
Creation”: supporting family caregivers,
untold ways to make the state more vibrant,”
strengthening the direct care workforce
and the profound challenges facing older
(described in the plan as the “caregiving
people across five areas outlined in the
workforce”), and expanding virtual care to
Master Plan: housing; health; inclusion,
meet the needs of caregivers of all types.
equity, and isolation; caregiving; and
Later in Quality Jobs Are Essential, we
economic security.
highlight additional objectives from the
To inform the development of the plan, Master Plan that could also help transform
California sought extensive public input California’s direct care jobs by 2031.
and formed four subcommittees comprised
of diverse stakeholders and key experts The Master Plan is described as a “living
to deepen key dimensions of the Master document for years to come,” which
Plan. One of those subcommittees—the opens the door to new initiatives as the
Long-Term Services and Supports (LTSS) state implements this plan and as other
Subcommittee—issued its final report in concerns emerge. In this spirit, Quality
May 2020.8 This report identifies five broad Jobs Are Essential discusses how each
objectives for the Master Plan to strengthen aspect of the Master Plan that relates to
LTSS in the state, including one objective direct care workers could be strengthened
focused on creating a “highly-valued, and extended, drawing from the guidance
high-quality” direct care workforce. offered in the LTSS Subcommittee Report
and from the California-based experts
This report, Quality Jobs Are Essential, who helped inform our thinking (see
examines how the Master Plan supports Acknowledgements on page 41.)
the direct care workforce, comparing
12 Quality Jobs Are EssentialA Detailed Snapshot of New Jersey’s Direct Care Workforce Pandemic Puts Spotlight on New Jersey’s Direct Care Workforce Shortage
PRIMARY GOAL:
CAREGIVING THAT
WORKS
In this section, we walk through the three main
initiatives outlined under the fourth goal of
the Master Plan for Aging that are aimed at
improving direct care jobs and bolstering this
workforce. For each initiative, we describe why
it matters and how it could be strengthened.
California’s Direct Care Workforce and the Master Plan for Aging 13California’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 4 / CAREGIVING THAT WORKS
STRATEGY B / DIRECT CARE JOB CREATION / INITIATIVE 111
“Convene a Direct Care Workforce Solutions
Table to address workforce supply challenges
and opportunities in skilled nursing facilities.”
How This Could Be Strengthened
The LTSS Subcommittee Report
recommends creating a Direct Caregiver
Workforce Development Task Force to
study the entire workforce, examine
training and workforce development
programs, explore public-private
partnerships, and much more. Accordingly,
this initiative in the Master Plan should be
broadened to include home care workers
and residential care aides, two other
segments of the workforce who would also
benefit from a multi-stakeholder approach
to identifying problems and generating
solutions. Low compensation—a primary
challenge facing these workers, and one
Why This Matters which is inextricably linked to inadequate
reimbursement rates under Medicaid—
Bringing together stakeholders with
should also be addressed as part of this
different perspectives to strengthen the
solutions table.10
direct care workforce has been a successful
approach in many states throughout
the country.9 A well-funded, properly
coordinated “workforce solutions” table
would help ensure that the many distinct DID YOU KNOW?
challenges facing California’s nursing
assistants in nursing homes are explored
In California, the direct care worker
median wage—currently at $13.18—
and solved.
is $3.86 less than the median wage
for all other occupations with similar
entry-level requirements (such as
janitors, retail salespersons, and
customer service representatives) and
$1.11 less than occupations with
▸ Source: PHI. Competitive Disadvantage: Direct Care
lower entry-level requirements (e.g.,
Wages Are Lagging Behind. PHI: Bronx, NY. https://
phinational.org/resource/competitive-disadvantage-direct- housekeepers, groundskeepers, and
care-wages-are-lagging-behind/. food preparation workers).
14California’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 4 / CAREGIVING THAT WORKS
STRATEGY B / DIRECT CARE JOB CREATION / INITIATIVE 112
“Consider expanding online training platforms
for direct care workers—including opportunities
for dementia training for IHSS family caregivers
seeking a career ladder and more—to meet
need as funding available.”
Why This Matters
Direct care workers deserve effective,
competency-based, and adult learner-
centered training that equips them with
the skills, knowledge, and confidence to
succeed in their roles and deliver quality
care.10 When properly designed and
evaluated for effectiveness, online training
and e-learning approaches can help meet
this goal, efficiently reaching vast numbers
of workers in different locations as the
need arises.12 Online training has also been
a beneficial approach during COVID-19,
allowing training programs to be delivered
without safety risks for trainers or
trainees. Overall, this initiative highlights
the importance of expanding training
opportunities for direct care workers development and career ladder training.”
to ensure they are prepared to provide While online training should be an integral
high-quality, condition-specific care (such part of California’s statewide training
as dementia care) and to strengthen career strategy for direct care workers (as
ladders within the workforce.13 described in Initiative 112), in-person and
blended training programs rooted in adult
How This Could Be Strengthened learner-centered principles remain the
gold standard for training in this sector.14
The LTSS Subcommittee Report offers In line with the LTSS Subcommittee Report,
various recommendations related entry-level and ongoing training programs
to strengthening training for direct for direct care workers deserve adequate
care workers; the report’s strongest funding, testing, and expansion.
recommendation is to “invest in local,
regional, and statewide workforce
California’s Direct Care Workforce and the Master Plan for Aging 15California’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 4 / CAREGIVING THAT WORKS
STRATEGY B / DIRECT CARE JOB CREATION / INITIATIVE 113
“Diversify pipeline for direct care workers in
home and community settings by testing and
scaling emerging models (e.g., Healthcare
Career Pathways; High-Road Direct Care;
Universal Home Care Workers; more), to meet
need as funding allows.”
Why This Matters How This Could Be Strengthened
As detailed earlier in Quality Jobs Are The LTSS Subcommittee Report provides
Essential, the number of job openings a range of strategies that could help build
in direct care is expected to increase the pipeline into direct care, beyond
significantly in the next 10 years—a trend those named in the Master Plan. These
driven mostly by workers leaving this additional strategies include: streamlining
sector for other fields (primarily because and coordinating training requirements,
of poor job quality), growing demand, worker licensure, certification, and registry
and retirement trends. Strengthening across state agencies; launching public
and diversifying the pipeline of workers education efforts; and offering employment
entering this field through robust models supports such as providing stipends and
related to recruitment, training, care loan forgiveness for students entering
integration, and advanced roles—as well the field and compensating caregivers for
as new models for this occupation, such training time and mileage. Paired with
as the universal home care approach— adequate compensation for workers, all
merits this level of attention in the Master these approaches and more should be
Plan.15 These models have been shown to explored as part of an initiative to diversify
improve job satisfaction and retention the pipeline for direct care workers across
for workers, care for consumers, and cost the entire LTSS system. The home care
savings for employers and the full system.16 cooperative model, which has historically
To be successful, these models need created high quality jobs with low turnover,
substantial funding and further testing should also be explored in this initiative.17
and implementation.
16 Quality Jobs Are EssentialA Detailed Snapshot of New Jersey’s Direct Care Workforce California’s Master Plan for Aging and the LTSS Subcommittee Report
ADDITIONAL
GOALS, STRATEGIES,
AND INITIATIVES
In this section, we examine how other goals,
strategies, and initiatives in the Master Plan
for Aging can be leveraged to improve jobs
for direct care workers. For each initiative,
we describe why it matters and how it could be
strengthened to support direct care workers.
California’s Direct Care Workforce and the Master Plan for Aging 17California’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 2 / HOUSING FOR ALL STAGES & AGES
STRATEGY D / EMERGENCY PREPAREDNESS / INITIATIVE 27
“Conduct after-action analyses of COVID-19,
including the impact on older, disabled, and
at-risk adults, as one way to identify strategies
to prevent future pandemic, emergency, and
disaster-related deaths and disparities in deaths
by age, ability, income, race, language, and
other equity measures.”
Why This Matters
The COVID-19 pandemic has devastated
The LTSS Subcommittee Report and COVID-19
California, with more than 3.3 million
cases and over 41,000 deaths since its In its preface dated cuts to critical LTSS
onset (as of February 3, 2021, according to May 26, 2020, the LTSS programs, acknowledges
The New York Times). The pandemic has Subcommittee Report widespread inequities
acknowledges that facing older adults and
had a disproportionate impact on older
the subcommittee had people with disabilities,
adults, people with disabilities, and people unanimously approved and signals the importance
of color, among other at-risk populations.18 the recommendations for of “creative problem
It has also had a profound effect on the its report in March 2020, solving and a willingness
state’s direct care workforce and long-term before the COVID-19 to act expeditiously.” Thus,
care sector. An in-depth, “after-action” pandemic. Nevertheless, the LTSS Subcommittee
the report affirms the Reports’ recommendations
analysis of this pandemic would educate value of their original on this topic are relevant
the state and long-term care field on how recommendations, both during the crisis and
to navigate this crisis and protect against expresses concerns about far beyond it.
future health crises. possible state budget
How This Could Be Strengthened
Direct care workers must be an explicit
a problem that has worsened as employers
focus of these analyses. As essential
have needed these supplies to administer
workers on the frontline of this crisis,
vaccines.19 The direct care workforce
direct care workers have been uniquely and
also shrunk during the pandemic’s initial
disproportionately affected by COVID-19.
stage; national research shows that about
PHI’s experience in the field shows that
280,000 direct care workers exited the
many workers contracted—and a notable
LTSS field between March and May 2020.20
portion of them died from—the coronavirus
Additionally, new issues have surfaced
(though the data on this topic is limited).
related to vaccine hesitancy and rollout
Unfortunately, direct care workers and
that would impact this workforce and the
their employers continue to lack adequate
individuals they support.
supplies and support to manage this crisis,
18 Quality Jobs Are EssentialCalifornia’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 2 / HEALTH REIMAGINED
STRATEGY A / BRIDGING HEALTH CARE WITH HOME / INITIATIVE 33
“Advocate with the new federal Administration
to create a universal Long-Term Services and
Supports benefit and assess opportunities for
federal/state partnership (e.g., Milliman study,
Washington State model).”
Why This Matters
A universal LTSS benefit would help Since direct care workers are the paid
California consumers cover the high and frontline of support for LTSS consumers,
unpredictable costs of long-term care a universal LTSS benefit should explore
without impoverishing themselves to how to include and fund a range of policy
qualify for Medicaid.21 This benefit would improvements for direct care jobs so that a
also ease the pressure on strained state robust direct care workforce can effectively
Medicaid programs, allowing for other deliver those services. These improvements
improvements in the system, including could include increased compensation,
efforts to strengthen the direct care enhanced training requirements and
workforce. a stronger training infrastructure, the
creation of advanced roles in this sector,
How This Could Be Strengthened improved training and robust requirements
for supervisors in direct care, an innovation
The LTSS Subcommittee Report
fund and state-level advocate to improve
recommends creating a statewide
recruitment and retention, a robust data
universal LTSS benefit program, relying
collection system, and more.22
on stakeholder partnerships, an actuarial
study, and focus groups, among other
strategies, to craft this program.
“I’m there for my clients if they need or
want anything, offer an extra hand to help
or an extra ear to listen, and let them
know they are not alone and that there is
somebody out there who cares about them.”
KAO SAEPHAN, Home Care Provider, Caregiver
Emergency Response Team (CERT) Provider at
Homebridge in San Francisco, CA
California’s Direct Care Workforce and the Master Plan for Aging 19California’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 2 / HEALTH REIMAGINED
STRATEGY A / BRIDGING HEALTH CARE WITH HOME / INITIATIVE 43
“Reformulate an LTSS aging and disability stake-
holder group to advise on long-term services
and supports for all older adults and people with
disabilities, drawing on stakeholders with
experience on MPA LTSS Subcommittee and
Olmstead Advisory, as well as new members,
with increased diversity and continued
participation by older adults, people with
disabilities, and care providers.”
Why This Matters
An LTSS aging and disability stakeholder
group builds upon the work and
relationships created through the LTSS
Subcommittee Report and establishes a
platform for a broad range of stakeholders
in LTSS to advise how this system address
the lives and experiences of older adults
and people with disabilities. Such a
platform ensures that stakeholders
with different and, at times, competing
ideas—on long-standing challenges and
new ones—can convene to resolve those
differences under the shared goal of
improving LTSS.
How This Could Be Strengthened
force to focus exclusively on direct care
The LTSS Subcommittee Report
workforce challenges, the stakeholder
recommends creating a Direct Caregiver
group described in Initiative 43 of the
Workforce Development Task Force (noted
Master Plan could also include direct care
earlier in this report) and a time-limited
workforce advocates to ensure that their
workgroup to address staffing issues. While
concerns are integrated into broader LTSS
it remains important to convene a task
improvement efforts.
20 Quality Jobs Are EssentialCalifornia’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 2 / HEALTH REIMAGINED
STRATEGY E / DEMENTIA IN FOCUS / INITIATIVE 64
“Promote screening, diagnosis, and care planning
by health care providers for patients and families
with Alzheimer’s and related dementias, through
hub and spoke training model of health care
providers; direct caregiver training opportunities;
and consideration of how dementia standards of
care could be further incorporated in Medi-Cal
and Medicare managed care.”
Why This Matters
The growing rates of Alzheimer’s disease all licensed settings.24 The Dementia
and other forms of dementia require Care Specialist role that has already
building dementia care competency within been pilot-tested in California provides a
the health and long-term care workforce in robust model that could be adapted to the
California.23 As Initiative 64 acknowledges, direct care workforce, boosting dementia
training for direct care workers should be care competency in this workforce while
a key priority in building this competence. providing a much-needed career pathway
Additionally, dementia-specific training in direct care.25
for direct care workers has been shown to
improve job satisfaction and reduce stress,
which can spur a range of positive care-
and cost-related outcomes.
How This Could Be Strengthened
The LTSS Subcommittee Report
recommends various approaches to
promote dementia care competency among
direct care workers that support this
initiative, including building certification
and career ladder programs related to
dementia specialization, and adopting
the Alzheimer’s Association Dementia
Care Practice Recommendations across
California’s Direct Care Workforce and the Master Plan for Aging 21MASTER PLAN GOAL 2 / HEALTH REIMAGINED
STRATEGY F / NURSING HOME INNOVATION / INITIATIVE 68
“Produce ‘COVID 2020’ report on skilled nursing
facilities and COVID-19, with California lessons
learned and recommendations for national
(CMS) policy reform.”
Why This Matters How This Could Be Strengthened
The COVID-19 crisis has had a profound While nursing homes have borne the
and disproportionate impact on nursing brunt of COVID-19, this health crisis has
home residents and workers in California indubitably strained the state’s entire long-
(as in every state across the country), term care system—even if the data are not
raising pressing questions about the need as available for home and community-based
for reform in this sector at the state and services as for nursing homes. The report
federal level. By examining and learning proposed by Initiative 68 should examine
from nursing homes’ experiences, the state the effects of COVID-19 on all long-term
will be better prepared to weather this and care settings in California with a clear focus
future crises, strengthening the delivery of on workers as well as consumers.
care in nursing homes and the quality of
nursing assistant jobs.
22 Quality Jobs Are EssentialCalifornia’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 2 / HEALTH REIMAGINED
STRATEGY F / NURSING HOME INNOVATION / INITIATIVE 69
“Continue to expand transparency on state data
on nursing homes, including quality, staffing,
financing, both in COVID-19 and ongoing.”
Why This Matters
One of the greatest barriers to improving
quality in nursing homes and other long-
term care settings is the lack of consistent
information and accountability.26 COVID-19
has underscored the long-standing need
for greater transparency about long-term
care ownership, management, experiences,
and outcomes—not least with regards to
staffing. With greater transparency across
the field, stakeholders will be able to better
identify the most pressing challenges and
effective solutions.
How This Could Be Strengthened
The LTSS Subcommittee Report In this spirit, the state should strengthen
recommends that the state institute its commitment to data collection and
comprehensive workforce quality and transparency across the board, not just in
safety standards for all LTSS businesses nursing homes. To better track job quality
in California. in direct care across long-term care
settings, as one key priority, the state
should include measures related to
workforce volume, stability, compensation,
and training/credentials (among other
variables), accounting for workers
employed through both agencies and
in consumer-directed programs.
“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.”
ARICHU BUENAVENTURA, Caregiver at
M
Courage LLC and Member of Pilipino Workers Center
in Los Angeles, CA
23California’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 2 / HEALTH REIMAGINED
STRATEGY F / NURSING HOME INNOVATION / INITIATIVE 71
“Explore additional value-based payment
methodology changes in skilled nursing,
focused on care quality, job quality, equity, and
health outcomes.”
Why This Matters How This Could Be Strengthened
Because they provide the majority of While the LTSS Subcommittee Report
paid care to nursing home residents, does not specifically address California’s
significantly influencing residents’ health value-based payment program, this
outcomes, nursing assistants are central initiative holds promise for leveraging and
to achieving value in skilled nursing—for strengthening the direct care workforce.
example, by helping to reduce potentially This initiative should be broadened
avoidable hospitalizations, among other to include home and community-based
costly outcomes.27 Including the workforce services, where home care workers
in value-based payment approaches continually shape care and cost outcomes.28
could be an avenue for incentivizing Further, as the Master Plan is adapted
improvements in direct care jobs and over time, this initiative should consider
amplifying the positive contribution of the range of job quality indicators relevant
these workers. to value-based arrangements, including
compensation, training, turnover, retention,
and more. (See Appendix 3 for PHI’s
framework on direct care job quality.)
“It’s so unfortunate that in the world
we live in, the caregiving profession
receives the lowest category of pay.
Yet it requires a lot of intelligence.”
ALLEN GALEON, Caregiver and Worker Leader,
Pilipino Workers Center in Los Angeles, CA
24 Quality Jobs Are EssentialCalifornia’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 3 / INCLUSION & EQUITY, NOT ISOLATION
STRATEGY A / INCLUSION & EQUITY IN AGING / INITIATIVE 75
“Continue to expand culturally and linguistically
competent communications to older adults,
people with disabilities, and families.”
Why This Matters
Culturally and linguistically competent
communication ensures that all older
adults, people with disabilities, and families
in California—especially people of color
and immigrants with limited English-
proficiency—can genuinely access the
resources they need to age successfully and
in good health.29 Without equitable access
to aging- and health-related resources,
these populations will continue to struggle
with long-standing barriers and disparities
related to health, aging, financial security,
and more.30
How This Could Be Strengthened
The LTSS Subcommittee Report
recommends that the state identify best
practices in cultural responsiveness within Additionally, effectively reaching direct
LTSS, as well as design culturally and care workers—who themselves need
linguistically responsive LTSS workforce culturally and linguistically competent
training across a range of topics. In line health and aging-related resources—
with these recommendations, Initiative might require developing a targeted
75 in the Master Plan should include the outreach approach rooted in worker-
creation of training modules for direct specific frames, messages, and
care workers that build their cultural and communications platforms.31
linguistic competence and help them better
support their diverse clients and residents.
California’s Direct Care Workforce and the Master Plan for Aging 25MASTER PLAN GOAL 3 / INCLUSION & EQUITY, NOT ISOLATION
STRATEGY A / INCLUSION & EQUITY IN AGING / INITIATIVE 107
“Promote current state paid family leave
benefits to older Californians, people with
disabilities, and family caregivers.”
Why This Matters How This Could Be Strengthened
California’s Paid Family Leave program The LTSS Subcommittee Report calls
allows individuals to take paid time off for more funding to support paid family
from work to care for a loved one who is leave outreach, focusing on underserved
sick, bond with a new child, or participate communities and the need for community-
in certain events when a relative in the based partnerships and culturally and
military has been deployed to another linguistically competent information.
country.32 As low-wage workers who cannot Efforts to implement Initiative 107 should
typically afford to take unpaid time off for draw on these recommendations to
these purposes, direct care workers stand effectively reach diverse and underserved
to benefit significantly from this program— older adults, people with disabilities,
but they must be made aware of the family caregivers, and the direct care
program to reap the benefits.33 workers who support them.
26 Quality Jobs Are EssentialCalifornia’s Master Plan for Aging and the LTSS Subcommittee Report
MASTER PLAN GOAL 3 / INCLUSION & EQUITY, NOT ISOLATION
STRATEGY A / INCLUSION & EQUITY IN AGING / INITIATIVE 108
“Assess participation in state paid family leave,
including recent legislation to expand equity, for
equity, including LGBTQ, race, income, gender.”
Why This Matters How This Could Be Strengthened
As described above, the success of In the same spirit, the LTSS Subcommittee
California’s Paid Family Leave program Report recommends an investment
depends on broad participation from in paid family leave outreach that
eligible individuals across the state, acknowledges the unique barriers facing
including older adults, people with LGBTQ people, people of color, poor and
disabilities, family caregivers, and direct low-income people, and women, as noted
care workers. Yet too often, systemic above. Given the high percentages of
inequities and a lack of culturally and immigrants in the state and the direct care
linguistically competent information workforce, this assessment should include
prevent people of color, immigrants, immigration status as well. The LTSS
women, LGBTQ people, and low-income Subcommittee Report also recommends
people from accessing programs like this, that the state allow a caregiver to designate
even though their needs are significant.34 a “family of choice” within the paid family
Assessing participation in paid family leave leave program, which would help prevent
across race, immigration status, gender the exclusion of people without biological
and gender identity, sexual orientation, family or spouses.35
income, and occupation would help the
state understand which populations could
benefit from targeted outreach.
“We work so hard and sincerely from the
heart. But we are being discriminated
against, isolated, underpaid, and abused.”
TERESITA SATTAR, Caregiver at Courage LLC
and Worker Leader at Pilipino Workers Center
in Los Angeles, CA
California’s Direct Care Workforce and the Master Plan for Aging 27In Their Own Words
CAREGIVER AT COURAGE LLC AND
WORKER LEADER AT PILIPINO WORKERS
CENTER, LOS ANGELES, CA
10 YEAR AS A DIRECT CARE WORKER
TERESITA
SATTAR
ON WHY SHE DECIDED TO BECOME Courage gave me a good job that allows
A DIRECT CARE WORKER: me to support myself and my family, and
I benefit from paid sick leave and approval
“Ten years ago, I came to America with the for overtime pay. They have also sent me
hope of pursuing a good life and happiness to a national conference for cooperative
as I believe this is the land of opportunity home care workers, and this training
as long as you work hard for it, using the has helped me work with clients more
knowledge and skills that we have achieved effectively. I feel grateful to them for giving
through our education and experiences. me these opportunities and the chance to
I was an RN in the Philippines for 27 years become one of the co-owner members of
before coming to America, but I did not the cooperative.”
have a nursing license to practice here. By
becoming a caregiver, I have been able to
ON THE IMPACT OF COVID-19:
continue my service to help others. I feel a
sense of fulfillment when I know that I am “When the pandemic started, I decided to
able to give clients quality care.” pause working because I am over 60 years
of age, and I know that I am very vulnerable
ON WHAT SHE FINDS MOST to this virus. I am staying home with my
CHALLENGING IN HER ROLE: 10-year-old grandson right now while his
school is closed and am waiting for the
“When I became a caregiver, I learned that pandemic to go away. It’s a big challenge
this job is often looked down on as the because I have no income to support my
lowest class of workers. This job can be very family, but for now I have a little savings.
much exploited, especially with regards to But I am afraid that soon my savings will be
immigrants of color, particularly women. gone, and I will have to find some other way
As a caregiver, we are in very close contact to earn a living.
with our clients, and I develop much closer
one-on-one relationships than when I was a When people think of frontline workers,
nurse. We work so hard and sincerely from they often think of doctors, nurses, or
the heart. But we are being discriminated police. But COVID-19 affects caregivers,
against, isolated, underpaid, and abused. too, and many of us are not being given the
safety and protection that other workers are
I experienced this myself with my first getting during this pandemic. Caregivers
company, but I stayed for years because I are suffering. We work with our hearts and
felt that my client really needed my help, our minds to give care to others, but I hope
and I also needed to earn a living to survive. our elected leaders realize we also need
Then I left that company to work with care and protection.”
the [homecare cooperative] Courage LLC.
28 Quality Jobs Are EssentialIn Their Own Words
As a caregiver and worker
leader, Teresita knows
that direct care workers
are essential yet worries
how they are mistreated in
these roles.
California’s Direct Care Workforce and the Master Plan for Aging 29Summary: Creating 1 Million High-Quality Direct Care Jobs in California
SUMMARY: CREATING
1 MILLION HIGH-QUALITY DIRECT
CARE JOBS IN CALIFORNIA
By dedicating one of its five core goals to several of the initiatives focus too narrowly
strengthening the direct care workforce and on nursing homes (and in turn, nursing
creating one million high-quality direct care assistants) despite the clear need to also
jobs by 2031, California’s Master Plan for address the state’s home and community-
Aging has rightfully elevated and centered based services system and the home care
these workers in its comprehensive strategy workers who sustain it. Additionally,
to improve aging supports and LTSS across compensation-related initiatives—that
the state. As detailed in this report, the plan would increase wages and benefits, matched
also includes several other goals, strategies, by increased reimbursement rates under
and initiatives that could—with the right Medicaid—are scant in the Master Plan,
detail and funding—strengthen the direct despite the demonstrated effect that poverty-
care workforce over the next 10 years level wages have on direct care workers’
through pipeline development, improved financial security, their retention in this sector,
training and career pathways, better data and the quality and continuity of care they
collection, increased paid family leave deliver. Finally, the Master Plan has a number
uptake, and a heightened focus on equity of ancillary initiatives that were not included
and cultural and linguistic competence in this report’s analysis but rely on a strong
throughout LTSS, among other strategies. and stable direct care workforce, including:
assessing “options to increase Adult Day
The Master Plan also recommends the Services, especially for people with dementia”
formation of key advisory bodies to focus (Initiative 66), creating “opportunities to
on strengthening workforce development, increase stability for IHSS beneficiaries
improving LTSS, and learning from COVID-19 through back-up provider systems and
to better prepare for future crises—all relevant registries” (Initiative 38), and revisiting
to the direct care workforce. Finally, the a “pilot for ‘small house’ nursing homes”
Master Plan proposes creating a universal (Initiative 77). A direct care worker lens on
LTSS benefit that would enhance affordability these initiatives would bolster their efficacy.
and accessibility for consumers—which, this
report argues, must also strengthen jobs for The Master Plan must tackle the concerns
the direct care workers who are the backbone it outlines with authority, clear actions, and
of the LTSS system. adequate funding. Older adults, people
with disabilities, and direct care workers
As a living document, the Master Plan for deserve nothing less.
Aging has plenty of room for improvement
over the next 10 years. As noted in this report,
30 Quality Jobs Are EssentialAppendix 1
COMPARISON OF KEY DIRECT CARE WORKFORCE
RECOMMENDATIONS IN LTSS SUBCOMMITTEE REPORT
TO CALIFORNIA’S MASTER PLAN FOR AGING
LTSS Subcommittee LTSS Subcommittee Report
Report Area Key Recommendation California Master Plan For Aging
Expand Workforce “Establish a Direct Caregiver Explicitly Addressed in Master Plan, Needs
Supply and Improve Workforce Development Task Strengthening: Goal 4 (Caregiving That
Working Conditions Force, to be convened by the Works), Strategy B (Direct Care Job Creation),
Labor & Workforce Development Initiative 111: Convene a Direct Care
Agency.” Workforce Solutions Table
Expand Workforce “Create and enforce comprehensive Implicitly Addressed in Master Plan,
Supply and Improve statewide workforce quality and Needs Strengthening: Goal 2 (Health
Working Conditions safety standards for all businesses Reimagined), Strategy F (Nursing Home
providing LTSS services in Innovation), Initiative 69: “Continue to expand
California, to be administered by transparency on state data on nursing homes,
the state.” including quality, staffing, financing, both in
COVID-19 and ongoing.”
Expand Workforce “Coordinate across state agencies Implicitly Addressed in Master Plan, Needs
Supply and Improve and identify ways to streamline Strengthening: Goal 4 (Caregiving That
Working Conditions employee licensure, certification Works), Strategy B (Direct Care Job Creation),
and registry.” Initiative 113: “Diversify pipeline for direct
care workers in home and community settings
by testing and scaling emerging models (e.g.,
Healthcare Career Pathways; High-Road Direct
Care; Universal Home Care Workers; more), to
meet need as funding allows.”
Expand Workforce “Invest in local, regional and Explicitly Addressed in Master Plan,
Supply and Improve statewide workforce development Needs Strengthening: Goal 4 (Caregiving
Working Conditions and career ladder training. This That Works), Strategy A (Family & Friends
could include public education Caregiving Support), Initiative 112: “Consider
campaigns to attract employees to expanding online training platforms for direct
the field.” care workers – including opportunities for
dementia training for IHSS family caregivers
seeking a career ladder and more - to meet
need as funding available”; and Goal 4
(Caregiving That Works), Strategy B (Direct
Care Job Creation), Initiative 113: “Diversify
pipeline for direct care workers in home and
community settings by testing and scaling
emerging models (e.g., Healthcare Career
Pathways; High-Road Direct Care; Universal
Home Care Workers; more), to meet need
as funding allows.”
California’s Direct Care Workforce and the Master Plan for Aging 31You can also read
