Direct care workers provide services in both institutional settings (like nursing homes and assisted living facilities) and home- and community-based settings (like patient homes or adult day care programs).
The direct care workforce is diverse across gender, race and ethnicity, immigrant status, parental status, and educational attainment. Direct care workers are predominantly women (87%) and people of color (61%). Women of color grew as a share of the workforce across every long-term care setting between 2009 and 2019.
States have several policy levers to strengthen the direct care workforce amid the rising demand for services, including altering training requirements, expanding scope of practice, establishing career pathways and leveraging federal and state funding to increase wages.
Setting Training Requirements
States are responsible for setting training and practice requirements for direct care workers. Varied training and certification requirements across states make it challenging to transfer across positions and settings, and limit career mobility and versatility within the direct care workforce.
Training requirements for new direct care workers vary depending on the tasks performed and setting. CNAs and home health aides are federally required to complete at least 75 hours of training. In addition to federal requirements, at least 30 states require additional CNA training and 17 states require additional home health aide training. Maine sets the highest requirements for both positions at 180 hours.
Training requirements for personal care aides are set by states, not by the federal government. Fourteen states have consistent requirements for agency-employed personal care assistants across private and Medicaid-funded home care agencies.
Across the direct care workforce, training requirements focus on tasks associated with instrumental and other activities of daily living, such as personal hygiene, getting in and out of a wheelchair and eating. Several states have implemented additional training requirements to address patient safety and prepare workers to handle the challenges associated with direct care work. For example, Kentucky requires at least six hours of dementia-related training within the first 60 days of employment and Colorado requires two hours of continuing education on dementia diseases and related disabilities, person-centered care, care planning, activities of daily living and dementia-related behaviors and communication.
Setting Scope of Practice
States are responsible for setting licensure requirements for health professions, but formal licensure processes vary greatly across direct care workforce positions and settings. The scope of practice for direct care workers varies greatly from state to state—in part due to the diversity of practice settings and various training models required.
CNAs may assist patients with activities of daily living and perform certain clinical tasks as delegated and supervised by another onsite licensed professional. Acceptable tasks may include basic nursing skills, infection control, basic restorative care (such as rehabilitation activities following injury) and addressing a patient’s mental health and social service needs.
Home health aides are generally supervised by a registered nurse but may be supervised by another licensed provider as well. In addition to activities of daily living, home health aides may:
- Perform simple procedures as an extension of therapy or nursing services (such as blood pressure reading, infection prevention and wound care).
- Assist in movement or range-of-motion exercises.
- Assist in administering medications that are ordinarily self-administered (such as reminding a patient to take their medication, bringing them fluid or opening a bottle).
Personal care aides may provide activities of daily living as well as tasks such as household maintenance, chores, meal preparation and medication management. Their scope of practice does not include basic nursing or medical activities, and supervision of these tasks by a nurse or other health care provider is not usually required.
With additional training or certification, CNAs, home health aides and personal care aides may also administer medications in some states. Idaho requires unlicensed assistive professionals who are supervised by licensed nurses to complete a board-approved training program to assist patients who cannot independently administer their medication. Illinois allows nurses to delegate medication administration to unlicensed personnel in community-based or in-home care settings, but not in institutional or long-term care facilities. New York established a new profession, the Advanced Home Health Aide. These are home health aides who are trained to provide advanced tasks under the delegation and supervision of registered nurses, including administering routine medications.
Establishing Career Pathways
Career pathway programs have emerged to improve the recruitment and retention of direct care workers and to better support the populations they serve.
Many states collaborate with local education institutions to establish pathway programs into and throughout the direct care workforce. New Mexico created a Spanish-language 15-week program that trains immigrants as home care workers, providing scholarships to cover the costs of tuition and childcare. Iowa established two pathway programs, one in local high schools to train students to become CNAs prior to graduation, and another with Indian Hills Community College allowing CNAs to progress to licensed practical nurse positions. Missouri and Minnesota both implemented apprenticeship programs that include opportunities for CNAs and other direct care workers to obtain additional training and work experience while continuing to receive compensation for their work.
Leveraging State and Federal Funds to Increase Wages
Despite high demand, direct care jobs typically pay wages that put them below the poverty threshold. The median hourly wage for direct care workers is $13 per hour. Nearly half of women of color in the direct care workforce live in or near poverty and rely on some form of public assistance (such as food and nutrition assistance). As the single largest payer of institutional and HCBS care, Medicaid funding has a significant impact on the direct care workforce and states can leverage Medicaid to support the direct care workforce.
The American Rescue Plan Act of 2021 (ARPA) included a temporary increase in federal matching funds that states can leverage to strengthen HCBS. While the funding increase was temporary, states have used those funds to increase Medicaid reimbursement rates, provide retention payments and one-time bonuses to workers, and offer scholarships and loan forgiveness. Iowa appropriated $14.6 million in ARPA funds to increase reimbursement rates for providers in Intermediate Care Facilities for Intellectual Disabilities through 2024. The entire rate increase must be used for wages and associated costs for direct care workers and frontline management. North Carolina appropriated $210 million in 2021 to increase the hourly wages for HCBS direct care workers from $7.25 per hour to $15 per hour.
While states must spend down ARPA funds by March 2024, states can also use Medicaid funds in more permanent ways to supplement payments and wages for the direct care workforce. At least 19 states are actively addressing direct care workforce wages by leveraging traditional Medicaid program funds to increase provider payment rates and wages in institutional and HCBS settings.
As demand for long term services and supports continues to grow across the country, states are implementing a variety of strategies—including altering training requirements, expanding scope of practice and leveraging state and federal funding to strengthen the direct care workforce.