Since the early stages of the COVID-19 crisis, direct care workers have been deemed “essential” to the response. These 4.6 million home care workers, residential care aides and nursing assistants have provided critical support to older adults and people with disabilities in various settings, yet often without the compensation and support to perform their jobs safely and effectively. This story is not new—and I recently wrote a new report for PHI, “Would You Stay? Rethinking Direct Care Job Quality,” that aims to learn from COVID-19 and compel our sector to adopt a new framework that transforms this job for the benefit of workers, employers, older adults and people with disabilities.
An Unrelenting Pandemic, An Unprotected Workforce
As of October 1, 2020, more than 7.2 million COVID-19 cases had been reported in the United States, and more than 207,000 people had died. Among the most at-risk groups in this virus have been older people (particularly those living in nursing homes and those with multiple chronic conditions) and people of color (who are more likely to be exposed as essential workers and likelier to live with the conditions at risk of COVID-19 complications). Direct care workers—who support and represent these populations—have been one of the most critical segments of the essential workforce during this calamity.
COVID-19 has amplified the many long-standing challenges facing the direct care workforce, including inadequate training, limited career paths and a general lack of respect, recognition and opportunity. Because this workforce consists primarily of women, people of color, and/or immigrants, these workers have dealt with a history of systemic inequalities, from being concentrated as people of color into low-wage jobs with limited protections to dealing with the impact of racist and sexist policy decisions that have devalued this job over the years and weakened Medicaid, which funds this sector and provides these workers health coverage.
Low compensation is another primary barrier for these workers. Direct care workers have struggled with low wages for years; recent research from PHI shows that the median wage (adjusted for inflation) for these workers increased by only 19 cents between 2009 and 2019. Direct care wages are also not competitive in today's job market. PHI produced new research for this report showing that in all 50 states and the District of Columbia, the direct care worker median wage is lower than the median wage for other occupations with similar entry-level requirements, such as janitors, retail salespersons and customer service representatives. (This finding also obscures the reality that the complex nature of direct care work merits stronger training requirements than these occupations—another barrier for this workforce.) Simply put: these essential jobs just don’t pay enough.
As our new report describes, complicating this situation is that most state and federal policy responses to this coronavirus—hazard pay, childcare support for essential workers, temporary nursing assistants and public health emergency leave, among others—have been temporary, which reinforces the need for permanent solutions that transform this workforce once and for all.
The Five Pillars of Direct Care Job Quality
Job quality frameworks have enormous value for employers, workforce development professionals and policymakers, helping them to create jobs across sectors that improve job satisfaction, economic security and career mobility for workers while reducing turnover, increasing productivity and generating cost savings for employers and the economy.
Given the many changes over the years in long-term care, as well as the knowledge gleaned from new research and workforce interventions, a new framework is needed to transform direct care jobs and move our sector forward. Our report introduces PHI's new framework for job quality in direct care, which spans five pillars and 29 concrete strategies or elements.
The five pillars of direct care job quality are quality training (training that covers technical and relational skills, among other elements); fair compensation (a living wage, access to full-time hours and health coverage, and other aspects); quality supervision and support (consistent, accessible and supportive supervision, among other dimensions); respect and recognition (the opportunity for direct care workers to influence organizational decisions, and more); and real opportunity (employer-sponsored continuous learning, advanced roles and other approaches).
Implementing these many job improvements—and transforming this job sector—will require the leadership of policymakers, industry leaders and employers, as well as a significant, front-end investment that will benefit the entire sector in the long term.
It should not have taken a tragic and unprecedented health crisis to shed light on the many barriers facing direct care workers. Yet crises can open policy windows. We must capitalize on this moment to boost this sector and dramatically improve jobs for these critical workers and care for their clients and residents. Our new framework offers a detailed roadmap for this transformation—we must act now or the next pandemic will be as catastrophic.
Robert Espinoza is the vice president of Policy at PHI, where he directs a national policy advocacy and research program focused on the direct care workforce. He also serves as a member of the board of directors for the American Society on Aging and the National Academy of Social Insurance.