New Evaluation Shows How Matching Service Registries Support Quality Jobs and Quality Care

Nationwide, more than 1.5 million individuals and families choose to manage their own home care through publicly funded programs such as Medicaid waivers, state plans, and the Veterans Health Administration. This approach—known as self-direction or consumer-direction—emphasizes choice, control, and flexibility. It empowers people to remain in their homes and communities, reflecting their strong preference to age in place and receive care where they feel most comfortable.

However, one significant challenge remains: connecting self-directing consumers with qualified individual providers (non-family caregivers who work directly for consumers). Finding a good match can be daunting for both parties, with significant implications for consumers’ health and well-being, as well as individual providers’ economic stability and job quality. Matching service registries offer a promising solution to this challenge.

The Center for Medicare & Medicaid Services (CMS) recognized this potential in a 2023 bulletin that promoted matching services as a promising practice and encouraged states to leverage enhanced federal funding for their development. Yet only a handful of states currently operate matching service registries, and little information exists about their uptake and effectiveness. More evidence is needed to make the case for and guide the development of these valuable resources in other states.

To bridge this knowledge gap, PHI conducted an independent evaluation of Carina, a non-profit, web-based platform that aims to enable home care workers to find good jobs providing the best possible care. PHI used a comprehensive mixed-methods approach to evaluate Carina’s impact — including administrative and platform data from 2018 to 2024 with more than 25,000 in-app survey responses along with first-hand perspectives from nearly 600 caregivers and consumers through in-depth surveys and interviews. The study documents both the successes of technology-based solutions in addressing challenges to the direct care workforce, and the need for additional systemic investments to strengthen our nation’s care and support infrastructure.

The Challenge: Self-Direction Without Support

Washington State is a national leader in self-directed care, with nearly 61,000 individuals managing their own services through Medicaid. While 72 percent of these consumers hire family members as their paid caregivers, the remaining 28 percent—more than 17,000 people—must recruit workers from their own communities.

Before Carina, this recruitment fell entirely on individual consumers and workers. Consumers posted flyers, asked friends for referrals, or cold-called workers from state registries. Workers sifted through classified ads and community forums or relied on informal networks that were often hard to access, especially for newcomers to the field. This made it difficult for workers to build stable schedules or reach the 80-hour per month threshold needed for health insurance eligibility, leading to cycles of overwork and underemployment. Carina provides a more structured and accessible platform for workers and consumers to connect, fostering stronger matches and more consistent employment opportunities.

“Without Carina, I honestly don’t know how anyone could find potential new clients within the area we live,” one worker told PHI, capturing the isolation many experienced.

Platform Development: Relationships Over Transactions

Carina emerged through an uncommon process: a collective bargaining agreement between SEIU 775 and the State of Washington in 2015. Rather than developing as a private venture or state initiative, the platform was negotiated as a worker benefit, shaping its design and priorities from the outset.

This collaborative structure ensured that worker protections remained central as the platform evolved. Today, Washington State utilizes an agency-with-choice (co-employment) model of self-directed services, where Consumer Direct Care Network Washington serves as the employer of record, handling legal employment-related activities, and the consumer acts as the day-to-day manager. This means that the workers are employees of both CDWA and the consumer. Carina’s principles and practices work to ensure that the technology is equally effective  for both the consumer and the care provider.

Beyond quick and convenient connections, the Carina platform is designed to facilitate matches between workers and consumers based on compatibility factors including trust and mutual preferences. The platform operates on a bilateral selection process where workers can apply to positions of their choosing, consumers can select candidates for interviews, and both parties have visibility into available opportunities and requirements.

“On Carina I put the hours and days I am available so they know ahead of time,” explained one worker. “I get to meet them in person. We both interview each other to see if we are a good match.”

The Results: Quality Over Quantity

PHI’s evaluation, based on surveys of 393 workers and 188 consumers plus analysis of platform data, documents notable outcomes:

1. Worker Satisfaction and Retention

• 98% of workers would recommend Carina to others
• 91% say the platform has helped them stay in the direct care workforce
• 91% report improved job satisfaction since using Carina
• The median caregiving relationship length was 12 months, with 24% lasting two years or more

2. Job Quality Improvements

• 90% say Carina helped them achieve their ideal schedule
• 84% report reduced travel time between consumers
• 82% say it helped fill gaps in their hours
• 28% use the platform specifically to maintain health insurance eligibility

3. Care Access and Quality

• 91% of consumers would recommend Carina
• 92% say it has helped them remain living at home
• 87% report finding good matches through the platform
• 40% match rate (meaning both parties agree to work together after screening)

Systemic Challenges

Despite Carina’s success in facilitating matches, systemic challenges remain. Demand for workers still outpaces supply in many areas. Consumers in rural areas struggle to find workers, while consumers in urban areas face heavy competition for quality caregivers.

“There needs to be more caretakers and the ability to find diverse caretakers with a wider variety of hours available,” wrote one family member, echoing a common refrain.

Additionally, workers still face the fundamental instability of direct care work. Consumers’ needs change unpredictably, relationships end suddenly, and workers can lose significant income with little notice.

“My client could back away tomorrow, and then I’m out of a paycheck for two weeks, if not longer,” one worker explained during an interview.

Some workers shared that the self-directed model can feel isolating at times without the support structures of traditional agencies, noting both opportunities to strengthen platform safeguards and the unique challenges of working independently.

Lessons for Other States

Carina’s sustainability model offers lessons for other states seeking to strengthen their care and support systems, in an evolving policy landscape. The platform operates through the collective bargaining agreement with stable funding that flows through the benefits system. The economic benefits extend beyond the platform itself. PHI’s analysis suggests that Carina’s success in facilitating long-term relationships reduces turnover costs, while enabling consumers to remain at home generates savings compared to institutional care.

Workers report that the platform’s scheduling flexibility enables them to maximize their earnings within available hours, thereby reducing their reliance on public assistance programs.

Scaling Success

Because only one in five U.S. states has implemented matching service registries, learning from Washington’s experience can be a powerful example to inform state-level innovation going forward. PHI’s evaluation provides evidence that thoughtfully designed platforms can address workforce challenges while improving job quality—but only when embedded in broader efforts to strengthen direct care work.

For states considering this approach, Carina offers a proven model. But replication requires more than building an application—it demands the same commitment to partnership, worker voice, and quality jobs that made the platform possible in Washington.

As one individual provider summarized: “Carina has helped me find a client who is absolutely amazing and has helped me to know I can always find a job.”

PHI’s evaluation included surveys of 393 individual providers and 188 consumers, analysis of six years of platform data, and in-depth interviews with workers across Washington State. The report was commissioned by Carina and conducted independently by PHI from February through August 2024.

Read the full evaluation: More Than Just a Match: Evaluating the Carina Matching Service Registry in Washington State’s Self-Directed Home Care Program