The direct care workforce crisis that for decades has stymied long-term services and supports (LTSS), has now become a full-blown emergency. The COVID-19 pandemic has ravaged LTSS settings, driving many direct care workers out of their jobs because of illness, fear, family responsibilities or other reasons. In a labor market rife with job vacancies, long-term care employers are finding it almost impossible to compete for workers. Demand for LTSS continues to rise inexorably as our population grows older and people live longer with complex conditions.
As a result, this workforce—already the country’s largest, at 4.6 million workers—is projected to add nearly 1.3 million new jobs within the decade. Yet direct care workforce shortages already threaten access to essential care for older adults and people with disabilities across the country.
Now Is the Moment for Action
We may have reached the tipping point. Finally, caregiving has hit the national agenda. President Biden’s American Jobs Plan proposed a $400 billion investment in home- and community-based services (HCBS)—the largest and most diffuse segment of our LTSS system—with an explicit emphasis on “well-paying caregiving jobs.”
The Better Care Better Jobs Act fills in the details, requiring states to implement direct care job quality improvements (among other provisions)—and congressional leaders currently are hashing out an infrastructure package that could provide the funding.
Direct care training—standards, curricula and delivery systems—should be better developed, standardized and resourced.
To make the most of this moment, PHI—the nation’s leading authority on the direct care workforce—recently released a federal policy report outlining nearly 50 concrete recommendations for action by the White House, Congress and key federal departments and agencies. This article summarizes a selection of the report’s recommendations, while recognizing that all the measures are critically needed to overcome the deeply entrenched challenges facing direct care workers and the LTSS system overall.
Address Financing and Compensation
This new report begins with two related priorities: reform long-term care financing and increase compensation for direct care workers. To meet the first priority, Congress and the Centers for Medicare & Medicaid Services should support states in ensuring that Medicaid reimbursement rates are sufficient to cover quality services and improve direct care jobs. Given the unsustainable pressure on Medicaid as the default payer of LTSS, however, alternative financing models—such as the social insurance program outlined in the WISH Act—must also be explored.
In parallel, the report recommends a slate of targeted actions to improve wages and benefits for direct care workers, such as creating a national compensation strategy for direct care workers and passing the American Families Plan, which would enhance access to affordable childcare, paid leave and other vital benefits.
Support Workforce Development and Innovation
The report also argues that the direct care training landscape—including training standards, curricula and delivery systems—should be better developed, standardized and resourced. Among other training-related recommendations, the report calls for national competency-based training standards for all direct care workers, including personal care aides; enhanced federal support for states to improve their training infrastructure; and new research on training gaps and best practices.
The report also identifies a range of opportunities for federal leaders to invest in workforce innovations—including pipeline development programs, upskilling and advanced roles and much more. One immediate recommendation is to enact and fully fund the Direct Creation, Advancement, and Retention of Employment (CARE) Opportunity Act, which proposes to invest more than $1 billion over five years in collaboratively designed and robustly evaluated direct care workforce interventions.
Collect, Monitor and Report Workforce Data
The report also makes it clear that national and state-level data on the direct care workforce—e.g., data on workforce size, stability, credentials and compensation across occupations and settings—is woefully inadequate. Policymakers, industry leaders and other stakeholders need this data to specify workforce challenges, design solutions and evaluate their impact.
Direct care workers need to inhabit leadership roles and structural gender and racial inequities in the workforce must be addressed.
Among other recommendations, the report calls for the development of a standard definition of “direct care worker” to improve comparability across data systems; the creation of a Direct Support Professional occupational classification to distinguish direct care workers who support individuals with intellectual and developmental disabilities; federal support to build better data workforce collection systems across states; and original research to fill in significant gaps in knowledge on direct care workers and the individuals they support.
Strengthen Leadership, Equity and the Public Narrative
Finally, PHI’s federal policy report provides recommendations for elevating direct care workers into leadership roles, addressing the structural gender and racial inequities they face and shifting the public narrative on this workforce. A primary recommendation is that the U.S. Department of Health and Human Services should convene a stakeholder advisory council—with direct care workers meaningfully involved—to develop a national direct care workforce strategy. This advisory council could take on a range of the workforce challenges already identified, including compensation, training standards and workforce data.
The report also calls for supportive immigration policies, new research on disparities within the workforce, equity-focused workforce interventions and strategic communications campaigns, among other recommendations for addressing inequities and elevating this workforce.
This report offers a clear vision for transforming direct care jobs in long-term care. We must all now advocate for the bold and coordinated actions needed to make that vision a reality.
Kezia Scales, PhD, is director of Policy Research at PHI. She is based in Durham, NC.