During and beyond the COVID-19 pandemic, direct care workers have served as the paid frontline of support for millions of older adults and people with disabilities. Yet poor-quality jobs continue to threaten their livelihood and this job sector. This article describes the roles, responsibilities, and key characteristics of the direct care workforce, examines COVID-19's impact on these workers, and discusses how government leaders, employers, and others have responded. It concludes with critical themes from this crisis, and policy and practice recommendations to improve these jobs, navigate this crisis, and strengthen this job sector in the long term.
direct care workers, home care workers, home health aides, nursing assistants, personal care aides, job quality, workforce, long-term care, long-term services and supports, COVID-19
The COVID-19 pandemic—an unprecedented crisis that has infected 50.3 million and ended the lives of more than 800,000 people in the United States, as of mid-December 2021—continues to ravage our country and long-term care settings in particular. Direct care workers serve as the paid frontline of support in this system and thus provide ample lessons to inform workforce interventions across the long-term care workforce. By definition, direct care workers help ensure that older adults and many people with underlying conditions, who are at high risk of serious complications of COVID-19, can access critical, daily support no matter where they live. Unfortunately, a range of systemic challenges has made it difficult for workers to deliver this support and to survive financially.
This article examines the direct care workforce, including its roles, responsibilities, and key characteristics. It describes COVID-19's impact on these workers and how providers, government leaders, nonprofit organizations, and others have responded to this pandemic. This article concludes with key themes from this crisis and various policy and practice recommendations to improve these jobs, navigate this moment, and strengthen this essential job sector in the long term.
Understanding the Direct Care Workforce
Direct care workers provide critical daily support to millions of older adults and people with disabilities, assisting them with activities of daily living (such as bathing, dressing, eating, toilet care, and mobility) and instrumental activities of daily living (such as preparing meals, shopping, housekeeping, managing medications, and attending appointments) (Campbell, et al., 2021). While direct care work requires significant skill, it is often unseen or underestimated, including its physical demands, social and emotional complexity, and contributions to consumers’ health management.
The direct care workforce spans three main occupational groups—home health aides, personal care aides, and nursing assistants—and includes independent providers (workers employed directly by consumers) and direct support professionals (workers who support individuals with intellectual and developmental disabilities, known also as DSP). Direct care workers are employed in a variety of settings, including private homes, residential care environments (such as assisted living), and nursing homes. Research shows that these workers often have more than one job, within and outside of long-term care, which has contributed—along with poor job quality and insufficient funding for long-term care employers—to the disproportionate spread of COVID-19 across and within nursing homes and other settings (Chen & Long, 2020).
There are 4.6 million direct care workers in the United States, including 2.4 million home care workers, 675,000 residential care aides, and 527,000 nursing assistants employed in nursing homes (PHI, 2021a). Due to increased demand spurred largely by the growing numbers of older adults, between 2019 and 2029 the long-term care sector will add an estimated 1.3 million new direct care jobs. Already, the direct care workforce is larger than any other single occupation.
In terms of demographics, 87% of direct care workers are women, 61% are people of color, 27% are immigrants, and 27% are ages 55 and older (PHI, 2021b). These figures underscore how marginalized populations form the foundation of this workforce, while these workers in turn support a population of older adults and people with disabilities who are also in many instances dealing with systemic inequities.
Direct care workers face a variety of challenges related to their jobs, including inadequate compensation; limited training and advancement opportunities; a lack of support, respect, and recognition; and widespread gender and racial inequities related to education and employment. The cumulative effects of these problems are evident in their economic profile and long-term care employers’ general inability to compete with other fields for these job candidates.
‘Direct care wages in most of the country are neither livable nor competitive.’
Direct care workers earn a median wage of $13.56 and often work part-time schedules, which result in median annual earnings of $20,200—44 percent of these workers live in low-income households (PHI, 2021b). Direct care wages in most of the country are neither livable nor competitive; recent research reveals that the direct care worker median wage is lower than the median wage for other occupations with similar entry-level requirements in all 50 states and the District of Columbia. And in many states, it remains lower than the median wage for occupations with lower entry-level requirements (Espinoza, 2020a).
Poor job quality also contributes to high turnover among these workers—65 percent for home care workers and 99 percent for nursing assistants, according to two recent studies—which prevents employers from recruiting and retaining enough workers and consumers from receiving quality, continuous care (Gandhi & Grabowski, 2021; Holly, 2021). All these conditions will magnify between 2019 and 2029, as long-term care employers will need to fill 7.4 million job openings in direct care, including 6.1 million job openings as existing workers leave the field or exit the labor force altogether and the million-plus new job openings mentioned earlier in this article (PHI, 2021b).
The Impact of COVID-19
COVID-19 has profoundly impacted direct care workers. Widely deemed "essential" since the onset of this health crisis, these workers have been on the frontline of this dangerous situation, although too often with little protection to stay safe on the job—or the proper compensation and benefits to maintain economic security (Espinoza, 2020b). A qualitative study of home healthcare workers in New York City—an early epicenter of the pandemic—found that these workers felt invisible despite their essential role, received varying levels of information and support from their employers, often had to seek supplies and other resources on their own, and reported a heightened risk of transmission (Sterling, et al., 2020).
These workers were also forced into impossible choices, such as taking care of a client who had become infected with COVID-19, which posed risks to themselves and their families, or staying home and seeing their financial situation worsen. A national survey launched in November 2020 of more than 9,000 direct support professionals substantiated these themes: 47% of these workers said they were exposed to COVID-19 at work and transmission was higher in congregate settings. In addition, while 97% had been designated "essential" and 54% reported that their work lives had worsened, only 30% of survey respondents had received salary increases (Institute on Community Integration, 2021).
In nursing homes, where COVID-19 has had a disproportionate impact, nursing assistants have experienced similar challenges. A study conducted from May to June of 2020 found these workers were often afraid of infecting themselves and their families (White, et al., 2021). They experienced burnout due to the high number of cases, inadequate staffing, the emotional intensity of supporting residents regularly infected with and dying from this virus, and a lack of supportive communications and collaboration at work. They also felt demoralized by the negative media coverage of nursing homes, which stood in stark contrast to the "heroic" attention afforded to hospital staff. Because of these and other conditions across long-term care environments, between March and May of 2020 the direct care workforce contracted by 280,000 workers (Weller, 2020).
As well as affecting their livelihood and well-being in a range of ways, the pandemic has directly impacted the health of direct care workers. As of July 2021, at least 582,000 nursing home staff have contracted COVID-19, and more than 1,700 have died from this virus (Centers for Disease Control and Prevention [CDC], 2021a). Unfortunately, because of inadequate reporting in other long-term care settings, this type of data does not exist for residential care aides or home care workers, though they have also likely experienced high rates of infections and deaths.
Adjustments and Innovations
As with the other healthcare providers, individual long-term care employers have adopted a range of strategies to support their workers and continue delivering care during this pandemic (CDC, 2021b). Primary methods include educating workers about COVID-19 and infection control and prevention, among other topics; providing COVID-19 testing and regular health checks, such as temperature and symptom screenings; educating workers on properly donning and doffing personnel protective equipment (PPE); and increasing vaccination uptake; among other measures. These practices are inconsistent across the long-term care sector, though they have improved significantly since the start of the pandemic, when the scientific understanding of COVID-19 was nascent and when information, PPE, and other resources were in short supply. Federal funding also has been expanded to cover more long-term care employers, though it remains insufficient to manage the ongoing emergency.
On the state policy front, from March 2020 to January 2021, 16 states enacted hazard pay measures that benefited direct care workers; these measures ranged from 1.5 to 17 months in duration and from $250 to $5,000 (K. Scales, personal communication, August 6, 2021). Unfortunately, these policies were short-term, lacked enforcement mechanisms, and had limited availability (i.e., some were offered on a first-come, first-served basis). Additionally, 15 states plus the District of Columbia enacted, introduced, or modified some form of paid leave policy since COVID-19 began until January of this year. But many states did not enact either of these types of policies, which left countless workers without financial support.
Nursing assistants felt demoralized by the negative media coverage of nursing homes.
At the federal level, COVID-19 response strategies have had mixed results. In March 2020, the Centers for Medicare & Medicaid Services waived its training requirements for nursing assistants in nursing homes, creating a large, national cadre of "temporary nurse aides" with very limited training and without any tracking mechanisms to monitor or describe these workers (Centers for Medicare & Medicaid Services, 2020).
Moreover, the federal government has yet to issue guidance on how to transition these workers into permanent roles—through bridge training and competency assessments, for example—so that nursing homes can retain these workers when the public emergency order ends. This short-term measure also has frustrated many workforce advocates who believe that nursing assistants need minimum national training standards that can withstand any health crisis.
Nonprofit organizations also have responded to COVID-19. PHI—a national organization widely regarded as the country's leading expert on the direct care workforce—issued regular, almost weekly articles and analyses on the pandemic in the first three months, focusing on topics such as state and federal policy developments, guidance for employers and workers, and implications for the industry, among other issues (J. Sturgeon, personal communication, August 9, 2020).
It also administered a rapid-response survey of its audiences to raise awareness of their challenges, launched a web portal with related resources, gathered stories of workers impacted by the coronavirus, and participated in various national workgroups led by organizations throughout the aging, disability, and workforce fields. For employers, PHI focused on two strategies in New York City and beyond: creating a suite of instructor-led, online modules on COVID-19 to build the competence and confidence of direct care workers during the pandemic; and strengthening employers’ abilities to deliver virtual training on core, specialty, and COVID-related topics. On the latter, PHI worked with select employers to overcome technology barriers by renting digital tablets that workers could use to access this training.
Many other organizations also have produced resources to support direct care workers through the pandemic. For example, early in the crisis, organizations such as the Gerontological Society of America, the Leadership Council of Aging Organizations, the Eldercare Workforce Alliance, among many others formed task forces and held regular meetings and briefings to quickly respond to emerging concerns. The National Association of Direct Support Professionals (DSP) responded by producing a self-care toolkit for DSP, hosting educational webinars with experts from around the country, and releasing articles on different aspects of COVID-19 as relevant to DSP, among other actions (J. Raffaele, personal communication, August 5, 2021).
As one example of the private sector’s response to the COVID-19 pandemic, CareAcademy, a company specializing in online training for home care workers, created a COVID-19 course in March 2020 that has reached nearly 214,000 viewers and enrollees since its release (E. Sessions, personal communication, August 6, 2021). In August 2020, CareAcademy designed a more robust COVID-19 certification for home care workers with various courses on infection control and prevention, working with PPE, and COVID-19 basics, among other topics. Since the middle of last year, CareAcademy also has used its online platform to educate, recruit, and train home care workers nationwide, helping them enter a sector that desperately needs a stronger pipeline.
The COVID-19 pandemic has reinforced at least three significant themes related to the direct care workforce. First, during this health emergency, direct care workers have been widely deemed “essential” by states, but the quality of their jobs still falls short of their worth. Throughout the pandemic, despite the scattered short-term measures related to hazard pay and paid leave, direct care workers have struggled with low wages, limited benefits, inadequate training, and many other challenges. Without a significant funding investment and public-private leadership to correct these problems, the poor quality of direct care jobs will remain.
Second, COVID-19 has also underscored the reality that direct care workers and long-term care consumers are inextricably entwined. Substandard jobs in this sector harm both workers and the people they support—whereas proper compensation, robust training, and well-designed advancement opportunities, among other measures, can yield positive outcomes for workers, consumers, employers, and the economy. Improving direct care jobs is thus one of the best responses to a healthcare crisis. As described later in this article, public and private sector leaders must adopt a wide range of measures that strengthen these jobs and move our country through this pandemic and beyond.
The third major theme the pandemic has underscored relates to the social inequities that direct care workers have long faced as women, people of color, and immigrants. These inequities are rooted in labor and health policy: for example, during the New Deal in the 1930s, members of Congress employed sexist and racists arguments for decades to exclude a largely female, people of color workforce from critical wage and overtime protections (Nilsen, 2021). Additionally, since its inception, Medicaid has been eroded because of racist decisions and racist, inaccurate ideas that people of color are taking advantage of an overly generous program—one that supports millions of low-income people with health and long-term care coverage (Nolen, Beckman, & Sandoe, 2020). Inadequate Medicaid funding and insufficient reimbursement rates also are the primary (though not exclusive) reasons that long-term care employers are not able to create quality jobs in direct care. A race and gender-explicit lens is needed to fully support the entire direct care workforce through and beyond this critical juncture.
Despite all these challenges, the COVID-19 crisis has increased the visibility of this workforce among policymakers, providers, and the public. As a result, several opportunities exist to begin transforming these essential jobs. The recommendations below are rooted in PHI's three decades of experience working closely with direct care workers, employers, and other stakeholders in long-term care to fully understand how to improve job quality for this workforce.
There are several actions that employers and policymakers can take to support direct care workers through and beyond COVID-19. First, short of government mandates for all long-term care workers (such as a recent federal mandate for federally funded nursing homes), direct care experts are advising that all long-term care employers consider implementing vaccine mandates—though they should first remove access barriers wherever possible, engage workers to inform and communicate this decision, and institute monitoring mechanisms related to recruitment and retention. Employers that do not implement a mandate should design risk-mitigation strategies such as mandatory weekly testing and enhanced PPE requirements for unvaccinated staff. At the policy level, federal and state government leaders should ensure ongoing funding support for staffing and infection control and prevention supplies (at a minimum), strengthen data collection on COVID-19 and these workers, and commission "lessons learned" analyses related to this topic.
Improving direct care jobs is one of the best responses to a healthcare crisis.
A comprehensive approach to transforming the direct care job in policy and practice requires a framework that addresses every element of job quality. Released in October 2020, PHI's current framework on job quality for direct care workers spans five pillars—quality training, fair compensation, quality supervision and support, respect and recognition, and real opportunity—and 29 concrete elements from which employers and government officials can draw to design a multitude of interventions (PHI, 2020). For example, to improve compensation in direct care, the framework proposes eight key strategies: a living wage, full-time hours, consistent scheduling, benefit plans, paid sick days and paid leave, and three additional strategies. Another pillar, real opportunity, delineates four primary strategies, including continuous learning and career advancement opportunities.
Federal leadership for this workforce would help states and employers improve direct care jobs across these five pillars of direct care quality, and recent developments are promising. The Biden-Harris administration has prioritized the “care economy” in its first six months in office, introducing a plan to invest $400 billion in expanding home- and community-based services and improving jobs for direct care workers as part of a broader infrastructure package (The White House, 2021a). Also, funding from the American Rescue Plan Act will support states in strengthening their long-term care services and improving direct care jobs, among other investments (The White House, 2021b). Congressional leaders also have introduced other bills to support this workforce; one critical bill is the Direct CARE Opportunity Act, which would build the evidence base on direct care workforce interventions, another is the U.S. Citizenship Act of 2021, which would provide a pathway to citizenship for millions of undocumented immigrants, including those working in direct care (PHI, 2021c).
A recent report from PHI also delineates several recommendations for key federal departments and agencies (as well as the White House and Congress) (PHI, 2021c). The recommendations span eight issue areas critical to this job sector: financing, compensation, training, workforce interventions, data collection, direct care worker leadership, equity, and the public narrative. Three key recommendations include developing a national compensation strategy that guides states in raising wages for this workforce; establishing a national, competency-based training standard for all direct care workers; and funding states to improve their data collection infrastructure on the direct care workforce.
The COVID-related challenges facing direct care workers and this country persist. New variants and low vaccination rates—spurred by rampant misinformation and ongoing access barriers—have prevented our country from successfully tackling this pandemic. Furthermore, while public funding for this sector increased in early 2021 due largely to the enactment of the American Rescue Plan Act, employers and workers remain concerned about their ability to continue responding in the long term. And everyone worries about the potential emergence of a far more dangerous variant of the coronavirus, which could again turn this sector upside down.
Direct care workers are critical to the COVID-19 response and our collective future. These workers want and deserve quality jobs that allow them to survive financially and deliver high-quality care to millions of older adults and people with disabilities. But it will take concerted action to create this ideal.
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.
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