How to Better Support and Build Our Direct Care Workforce

During the pandemic, people began paying attention to the essential workers who can’t work from home. Among them are direct care workers — aides who support older adults and people with chronic health conditions in their homes, personal care attendants who support people with intellectual and developmental disabilities, and certified nursing assistants who work in skilled nursing facilities. We spoke to Kezia Scales, PhD, senior director of policy research at PHI, a research and consulting nonprofit focused on the direct care workforce, about how health and long-term care organizations can make better use of their talents.

Transforming Care is a publication series from the Commonwealth Fund that explores the people and places reinventing healthcare.

Scales: The pandemic has made what were already demanding, difficult jobs even harder and more stressful. In the early stages, direct care workers were often the last to be considered for PPE distribution, information, and training on how best to provide care. As time went on, they continued to risk their health and lives without, in most cases, additional support like hazard pay or even paid sick leave. We are now facing an unprecedented workforce crisis. Providers are struggling to find and retain enough direct care workers to deliver necessary services.

Scales: We’ve seen a noticeable, if modest, increase in the median wage for direct care workers, up to $14.27 per hour in 2021, but that’s still not a competitive and livable wage — and we certainly haven’t seen a migration of workers to the industry. A real challenge in this field is the limited number of career pathways. You go in as a home care worker earning a certain wage, you develop rich experience and skills, but you may find yourself with the same job title and earning pretty much the same wage 20 years later.

Scales: There are several reasons direct care workers are undervalued, including the fact that these jobs are traditionally performed by women, predominantly women of color who because of racism and sexism have not been recognized as providing skilled, valuable labor. Another reason is that Medicaid is the main financer of long-term services and support, and Medicaid funds are always in competition with other state budget items such as education.

Scales: We are seeing exciting investments in job quality and workforce infrastructure across states. Colorado implemented a minimum wage of $15 an hour for home care workers. Several other states, including Wisconsin, are strengthening training programs and creating career ladders for direct care workers. North Carolina is funding research on workers’ experiences to inform policy changes. And the federal government is creating a technical assistance center to promote best practices and support states and providers in recruitment and retention efforts.

Scales: Aside from family members, no one else spends as much time with care recipients as direct care workers. They know their needs and can recognize changes in status. We need to enable them to fulfill their role as observers and reporters as effectively as possible. But it’s just as important to make sure that other members of the care team hear and make use of their input. That may mean training around active listening and cultural competence. It also may mean assessing communication pathways: are direct care workers able to join interdisciplinary team meetings, for example? Are there other ways for them to share their observations? We also need a feedback loop to keep workers updated.

Scales: There’s so much opportunity. Some providers have created advanced roles where experienced direct care workers coach and support other direct care workers. Direct care workers can also improve care for particular conditions, including dementia. Up to 50% of people in nursing homes are living with dementia. Direct care workers know their patients’ preferences and routines, can identify the triggers of distress, and can spot symptoms that may lead to ED visits and hospitalizations. By boosting dementia care skills across this workforce and creating specialist roles, we could improve care quality and outcomes for people living with dementia, strengthen career opportunities for direct care workers, and reduce costs.

Scales: The direct care workforce crisis and the nursing crisis are mutually reinforcing. If there isn't a direct care worker available to fulfill a certain task, it falls to a nurse who’s likely already too busy. Likewise, turnover among nurses can leave direct care workers without adequate supervision and support.

The health and long-term care industry are competing with other industries for entry-level staff. This is a workforce crisis that no single provider can solve. We really have to think about how the industry can come together, with policymakers and others, to improve these jobs and truly value the crucial work that direct care workers do every day.

The Commonwealth Fund is a nonprofit foundation supporting independent research on health care issues and making grants to promote better access, improved quality and greater efficiency in healthcare, particularly for society’s most vulnerable, including people of color, people with low income and those who are uninsured.

Martha Hostetter and Sarah Klein produce the Commonwealth Fund's Transforming Care publication series, which explores the people and places reinventing healthcare.