Abstract
The direct care workforce is the backbone of America’s long-term care system—yet the infrastructure supporting these workers remains fragmented and inadequate. Training varies widely, credentials rarely transfer, career advancement is scarce, and wages hover at the poverty level. PHI’s Universal Direct Care Workforce Initiative offers an alternative model: a coherent system of standardized competencies, accessible training, portable credentials, and career pathways. This article presents the model with illustrative state examples and field-leading demonstration projects. It calls for coordinated and transformative action to benefit workers, older adults and individuals with disabilities, families, and the system overall.
Key Words
Medicaid, long-term services and supports, direct care workforce, training, career pathways
Every day, direct care workers provide vital support to millions of older adults and people with disabilities across the United States. They help individuals maintain optimal health, well-being, and quality of life, while also supporting family caregivers and collaborating with other care professionals. Their work is skilled, demanding, and deeply relational—and in ever-greater demand as our population grows older.
Yet their essential contributions are persistently overlooked and undervalued. Training for direct care workers varies widely by state, setting, and employer, but is largely insufficient; career mobility is limited and advancement opportunities are vanishingly rare; and wages hover near the poverty level for many workers, regardless of their skills and experience (PHI, 2025a). These systemic challenges harm workers and their families, drive turnover and shortages, and disrupt access to much-needed care.
Current federal policy actions are further threatening these workers and the services they provide. The Department of Labor aims to strip back minimum wage and overtime protections for home care workers, our country’s largest workforce. Catastrophic Medicaid cuts impact direct care workers as providers and beneficiaries of the program, and punitive immigration policies also disproportionately target this workforce. Hard-won minimum staffing standards for nursing homes, intended to safeguard workers and residents, have been repealed.
This moment calls for decisive—and transformative—action. We must build a better future by aligning and strengthening the fragmented components of our existing long-term services and supports (LTSS) landscape into a coordinated, coherent system. That is the transformation that PHI’s Universal Direct Care Initiative Workforce™ aims to catalyze and sustain.
Putting the Pieces Together
Although exacerbated by recent federal policymaking, direct care workforce challenges are not new—nor are attempts to fix them. To name just two historic efforts: In the early 2000s, the Better Jobs Better Care demonstration project successfully tested a range of recruitment and retention strategies across LTSS settings and states. The last decade’s Personal and Home Care Aide State Training (PHCAST) demonstration developed competency-based training for personal care aides in six states. Our organization, PHI, played a prominent role in those demonstration projects, as part of our 35-year history of designing, testing, and promoting job quality programs and policy interventions.
More recently, the American Rescue Plan Act of 2021 provided states with enhanced federal funds to “supplement, expand, and strengthen” home- and community-based services (HCBS)—with states opting to invest the majority of these funds in workforce recruitment, retention, and training (Centers for Medicare and Medicaid Services [CMS], 2024).
Workforce innovation abounds at the employer level as well, with employers across the LTSS landscape developing new training programs, advancement pathways, peer mentorship programs, and more—often on thin margins, especially for nonprofit and mission-driven providers (or those accountable to targets set by distant owners and investors).
Workforce innovation efforts have been necessarily implemented within a fragmented, incoherent landscape.
But the scalability and sustainability of many efforts have been confounded by two key issues. First, most have focused on one part of an inherently multifaceted issue—e.g., implementing a training program without a portable credential, increasing training requirements without addressing wages, or creating a new career pathway without sufficient funding to incentivize participation.
Second, these efforts have been necessarily implemented within a fragmented, incoherent landscape. The direct care workforce is defined, prepared, and deployed differently across state lines, payment and regulatory structures, service delivery models, and employers (Campbell et al., 2021). Even the most robust and successful intervention for one segment of this workforce in one state or setting can rarely be replicated elsewhere without extensive adaptation.
We need to put the pieces together into one coherent vision.
PHI’s Universal Direct Care Workforce Initiative
At ASA’s On Aging conference in April 2026, PHI introduced our Universal Direct Care Workforce Initiative, which brings decades of workforce efforts and experience together to improve direct care jobs and strengthen our LTSS system.
Central to the initiative is the PHI Universal Direct Care Workforce Model comprising four interrelated elements: universal entry-level competencies, stackable and portable credentials, integrated career pathways, and accessible training infrastructure. This model reflects and amplifies progress that is already underway, as illustrated by the selected state examples below.
Universal Entry-Level Competencies
The model recognizes that every direct care worker should be effectively prepared to provide high-quality, person-centered care—meaning that every worker should receive foundational training on core technical and interpersonal competencies, plus additional training contextualized to specific settings and populations.
Numerous states and organizations are already paving the way toward universal, competency-based training for direct care workers. Washington State is a leading example: In 2012, its Department of Social and Health Services created a new training program for all home care workers, including agency-employed workers and independent providers, with an abbreviated training standard for paid family caregivers and respite providers. The training is linked to a portable credential and bridges to certified nursing assistant (CNA) training for those who seek to expand their employment options.
Maine’s Department of Health and Human Services is developing a universal direct care approach through its Office of Aging and Disability Services (Maine Department of Health and Human Services, n.d.). The state has created a 40-hour, competency-based online training program that meets requirements for personal support specialists (in home and residential care) and direct support professionals (who support individuals with intellectual and developmental disabilities), with the potential to extend to behavioral health and rehabilitation roles. The training may be integrated into a credit-bearing pathway for those who seek further education.
Stackable and Portable Credentials
Career mobility, workforce flexibility, and professional recognition are all stymied by a lack of portable direct care credentials. Many direct care workers must repeat similar training every time they change employers, while others receive a credential that is only recognized within one payment program or state (e.g., tied to a single Medicaid waiver program or one state’s CNA program).
By contrast, the PHI Universal Direct Care Workforce Model emphasizes the critical need for credentials that are portable across employers, programs, and state lines—and stackable, meaning that additional training is documented through micro-credentials, badges, or certificates. These credentials should be tied to payment/reimbursement rates and wage levels, such that direct care workers receive a competitive, livable wage at entry level and then accrue incremental increases with each stackable credential—as they support a wider range of long-term-care consumers.
Michigan offers a promising example of a portable, stackable training and credentialing model comprising three levels: Direct Care Associate, Home and Direct Care Specialist, and Certified Direct Care Worker. The training for each level is anchored in a core competency set endorsed by the Michigan Department of Health & Human Services. The model is intended for statewide implementation, ensuring consistent care across settings with well-defined career pathways that attract and retain a strong workforce.
The Oregon Home Care Commission, a semi-independent state agency based in the Department of Human Services, has developed an exemplary set of stackable home care certifications. These include two certifications leading to overall wage increases, specialized certifications linked to a higher wage when caring for eligible consumers (e.g., those with behavioral health challenges), and certifications for complementary roles, including job coach. These certifications build on minimum statewide training standards for all home care workers that were implemented in 2021 through legislative mandate.
Integrated Career Pathways
The third element of PHI’s model, integrated career pathways, aims to create meaningful career development opportunities through specialization and advanced roles.
Research supports the value of specialized training for direct care workers on specific health conditions or population needs, although more evidence is needed. For example, a scoping review of dementia-care training interventions found evidence of improved outcomes across numerous workforce indicators, though with variation in the quality and strength of the findings (Pond et al., 2025). A recent study of a training program for home health aides caring for adults with heart failure demonstrated positive results for workers and clients (Sterling et al., 2025).
[MKC1]This should just be a link to the training (if desired) rather than a citation — which suggests we’re citing an article about the implementation of this training, rather than the training itself. I can’t tell whether this is meant to refer to the first DSHS source in the ref list or the second one; it can just be replaced with the correct link.
The Michigan model is intended for statewide implementation, ensuring consistent care across settings with well-defined career pathways that attract and retain a strong workforce.
As well as being tied to recognized credentials and wage differentials, skills-development opportunities should be brought to scale, so that career pathway options are universally available. As a rare example of statewide roll-out, Washington State offers two 70-hour training programs focused, respectively, on behavioral health and holistic health, which each result in an Advanced Home Care Aide Specialist credential and a $0.75 hourly wage increase.
Going further, advanced roles for direct care workers leverage their unique skills and maximize their contributions to care, while also providing an elevated job title and higher wage. For example, PHI has developed the Care Integration Senior Aide (CISA) role, an advanced home care role designed to support more timely, coordinated care delivery. We pilot-tested the model in Wisconsin in 2023–2024, finding that the role was well-accepted by home care workers, clients, and other members of the care team, and positively impacted client care and workforce support and stability (Scales & Dieppa Colo, 2025).
One participant underscored the value of advanced roles in creating meaningful career pathways and thereby reducing turnover: “I didn’t want to leave the company … I just wanted to get higher up in my position.”
Although many LTSS providers have developed internal career ladders, advanced direct care roles have rarely been adopted at the state level. The most common exception is the medication aide, an advanced role for CNAs in nursing homes that most states have adopted through legislation (Henreckson, 2023).
Accessible Training Infrastructure
The preceding elements must be integrated into a training system that is accessible and navigable. The direct care workforce is predominantly women and people of color, more than a quarter are immigrants, and 17% have limited or no English proficiency (PHI, 2025b). The median age ranges from 39 years among CNAs to 48 years among home care workers. About half the workforce has a high school diploma/equivalent or less. Taken together, these characteristics indicate the need for training programs that are adult learner–centered and trauma-informed, culturally and linguistically competent, and offered in multiple modalities that meet workers’ diverse learning needs and leverage their lived experience. Free or low-cost training is imperative, ideally with stipends to cover training time and associated costs.
Several states have taken steps to build accessible training infrastructure. The Oregon and Washington programs mentioned above, among others, are free at the point of access.
Some states have introduced testing for direct care workers languages other than English (McDonald, 2024). The Washington, DC, City Council passed legislation in 2024 that requires the Board of Nursing to establish an integrated, competency-based credential for CNAs and home health aides and allows CNAs from neighboring states to practice in DC (supporting interstate portability; Direct Care Worker Amendment Act of 2023, 2024). To promote training accessibility, the law also requires the Department of Health to convene an advisory committee to make recommendations for eliminating barriers to training and career advancement, among other responsibilities.
In summary: the PHI Universal Direct Care Workforce Model posits that competency-based training leads to recognized credentials, which unlock career development opportunities and wage progression. In turn, workers are more equitably prepared and satisfied with their jobs and career options, which improves overall workforce retention. A more well-prepared, stable workforce strengthens care access and quality for LTSS consumers and families. Public and private payers invest in these elements and are rewarded by reduced costs associated with workforce turnover and adverse consumer outcomes.
Building the Evidence Base
With key partners and funders, PHI is leading two flagship projects that will further demonstrate the feasibility and impact of this model in real-world conditions. These projects are designed to generate evidence across different states and regulatory contexts, in rural versus urban regions, and with different partners—to inform recommendations for state and national adoption.
One project in Wisconsin complements the state’s notable progress in building training and career pathways for direct care workers. In 2023, the Wisconsin Department of Health Services launched the Certified Direct Care Professional (CDCP) program, a competency-based training program that prepares trainees for employment across HCBS settings (with a bridge to CNA training as well). The training is freely available online, yields a portable credential, and offers hiring and retention bonuses. The state also offers an evolving suite of stackable, specialized micro-credentials.
‘PHI’s Universal Direct Care Workforce Initiative is designed to benefit the full caregiving ecosystem.’
PHI informed and supported the development of the CDCP program as part of our decade-long engagement with providers, policymakers, and other partners in Wisconsin. This year, we launched a demonstration project with four home care agencies comprising all elements of the universal workforce model, tailored to the state context.
In parallel, PHI is conducting a demonstration project with four home care agencies in New York City. PHI has been designing and testing direct care workforce interventions in New York for more than three decades in collaboration with Cooperative Home Care Associates and other high-road employers and partners. New York represents a particularly complex LTSS system. The state has made progress in setting entry-level training standards and funding enhanced training through initiatives such as Workforce Investment Organizations. The state has also set minimum wage floors for home care workers (Scales, 2024) and created an Advanced Home Health Aide role—although, illustrating the problem of partial solutions mentioned above, the role was unfunded and therefore never implemented. As in Wisconsin, PHI is adapting and testing all elements of the universal workforce model in this complex context.
Because Wisconsin and New York are both Medicaid managed long-term care states (Medicaid and CHIP Payment and Access Commission [MACPAC], 2022), we are engaging managed care organizations (MCOs) across both projects to strengthen implementation and evaluation, and shape replication, scale, and sustainability.
Now Is the Time for Action
PHI’s Universal Direct Care Workforce Initiative is designed to benefit the full caregiving ecosystem. Direct care workers accrue portable credentials, experience meaningful career pathways, and are compensated according to their skills, expertise, and experience. Older adults, people with disabilities, and family caregivers are better able to access continuous, high-quality services, avoiding care gaps and adverse consequences. Employers see improved recruitment, a more stable, better-trained workforce, and reduced dependence on contract staffing. States and private payers see improved consumer outcomes and lower costs across the system through upstream investment in the workforce. Each of these benefits reinforces the others.
Given the scale of recent assaults on LTSS and the direct care workforce, the status quo cannot hold—the only option is to reimagine and rebuild, connecting what exists into a stronger, more coherent system that works today and can be sustained in the future.
We can build this system together. Researchers can evidence the connections between workforce investments and care outcomes. LTSS providers can help pilot and refine new approaches and demonstrate value. Policymakers and payers can invest in the infrastructure needed to bring effective solutions to scale. Advocates, including workers, consumers, and families, can continue to be champions for the changes that will benefit us all.
Acknowledgements
PHI warmly acknowledges our key funders for the Universal Direct Care Workforce Initiative: Margaret A. Cargill Philanthropies (MACP) in Wisconsin; The Harry and Jeanette Weinberg Foundation, CD&R Foundation, Mother Cabrini Health Foundation, New York Community Trust, NYC Workforce Funders, New York Health Foundation, and The Clark Foundation in New York; and the W.K. Kellogg Foundation for our national work.
Kezia Scales, PhD, is vice president of Policy, Research, & Evaluation at PHI, based in North Carolina. Emily Dieppa Colo, MEd, is vice president of Workforce Innovations & Strategy at PHI, based in Michigan. Jodi M. Sturgeon is president & CEO of PHI, based in New York.
Photo credit: Shutterstock/Pro.Sto
References
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Henreckson, J. (2023, November 15). Use of medication aides expands to 2 more states as providers pursue broader workforce solutions. McKnight’s Long-Term Care News. https://www.mcknights.com/news/use-of-medication-aides-expands-to-2-more-states-as-providers-pursue-broader-workforce-solutions/.
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Scales, K. & Dieppa Colo, E. (2025). Advancing care, advancing careers. PHI. https://www.phinational.org/resource/advancing-care-advancing-careers-implementation-and-evaluation-of-the-care-integration-senior-aide-cisa-home-care-role-in-wisconsin/.
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