The direct care workforce—including personal care aides, home health aides, long-term care aides and nursing assistants—generally refers to the workforce providing hands-on care and support for older adults and people with disabilities. Direct care professions may vary slightly depending on their scope of practice, required training or the setting in which they deliver care, such as homes and community-based settings or institutions like a skilled nursing facility. However, all direct care workers (DCWs) assist with similar tasks ranging from eating, bathing, errands or appointments to performing minor clinical tasks such as blood pressure readings.
In the United States, there are an estimated 4.6 million DCWs with approximately 2.3 million home care workers, 900,000 workers employed in hospitals and other settings, 700,000 residential care home workers, and 580,000 nursing assistants in nursing homes. The average direct care worker is a 41-year-old woman of color who makes a median wage of $12.27 per hour. Across all DCWs, 59% are people of color and 26% are immigrants.
Studies suggest that between 2018 and 2028, the direct care workforce will need to fill nearly 8.2 million job openings. The increasing demand for long-term care is driven by shifting demographics led by the aging population, increased life expectancies and a higher prevalence of certain chronic health conditions. This field also faces recruitment and retention challenges as it is often characterized as having low pay, poor benefits, minimal training and few advancement opportunities. Such factors can be associated with high turnover rates, which some estimate to range between 45% and 60%. The pandemic’s strain on health care delivery, which is particularly prevalent among these frontline workers, has only compounded these challenges.
State legislatures and other key stakeholders can play an important role in bolstering recruitment and retention efforts in the states. Strategies include supporting training and apprenticeship programs, increasing wages and benefits, and considering multi-tiered approaches to support the direct care workforce.
Training and Apprenticeship Programs
Training and apprenticeship programs can help recruit and retain DCWs to further strengthen the workforce. Research indicates DCWs feel better equipped and motivated to work when they can access high-quality entry-level training, ongoing education opportunities and defined career ladders. States are also instrumental in crafting training and certification programs for DCWs to help improve skills and job and consumer satisfaction.
Washington SB 5092 (2021) appropriated $450,000 from the general fund to support an apprenticeship pathway for DCWs, from home care aide to nursing assistant to licensed practical nurse (HCA-NA-LPN). The legislation also requires the apprenticeship program have a presence in at least three geographic areas that face long-term care workforce shortages.
Tennessee formed a public-private partnership through the Direct Support Professionals Apprenticeship Program to address workforce shortages. The program compensates individuals for on-the-job training, increases wages by $3.50 per hour upon completion of the program and partners with community colleges and universities to train students in direct care work.
Training DCWs to meet the needs of specific populations is another promising retention strategy. Georgia HB 987 (2020) established memory care licensure and dementia training for all DCWs and other long-term care staff in memory care centers. Illinois SB 2301 (2016) established minimum training requirements for employees of home health agencies providing services for people with Alzheimer’s and related dementias.
Wages and Benefits
Research shows higher wages and benefits can similarly lead to better recruitment outcomes and retention rates. As the primary payer of long-term care for older adults and people with disabilities, state Medicaid programs play a significant role in providing wages and benefits for the direct care workforce.
Minnesota statute requires personal care assistance provider agencies to spend at least 72.5% of their Medicaid reimbursement on aides’ wages and benefits. Wisconsin’s Biennial Health Services Budget for 2019-2021 increased the hourly rate for personal care services by 1.5% annually from $16.73 to $17.24 over two years. Indiana HB 1001 (2021) implemented a 14% rate increase for direct support professional wages, aiming to increase the statewide average wage to $15 an hour.
Some states have created task forces or other committees to examine the direct care workforce and recommend strategies that address various challenges. These approaches provide multifaceted solutions.
Wisconsin Executive Order #11 (2019) established the Governor’s Task Force on Care Giving to explore strategies to support caregivers, including the direct care workforce. The Task Force’s report contains 16 policy proposals. These proposals include creating a tiered career ladder leading to potential certified nursing assistant certification, designing a statewide marketing strategy to recognize and recruit DCWs, and developing a one-year pilot program to establish a home care provider registry to help match DCWs with job openings.
The American Rescue Plan Act included a provision to allow states to apply for an increase in the federal medical assistance percentage for spending on Medicaid home and community-based services by 10%. All states and D.C. have submitted spending plans to the Centers for Medicare and Medicaid Services for this opportunity, many of which prioritize supports for direct care workers. State plans identify various initiatives, including DCW wage increases, sign-on or retention bonuses, new training opportunities or even funding to provider agencies to provide transportation assistance for DCWs.