“The Workforce is the Quality Care” – PHI Experts Talk Job Quality on CAHSAH’s At the Table Podcast

PHI’s Jake McDonald, Senior Policy Advocacy Specialist, and Jenna Kellerman, Senior Director of Workforce Development, recently joined Mark Wilson on At the Table with CAHSAH, the podcast of the California Association for Health Services at Home, to discuss the workforce challenges facing home-based care—and the solutions already within reach.

Below is an excerpt of their conversation, edited for length and clarity.

What are policymakers still not getting about the home care workforce?

Jake: “The best policymaker champions of home care are people whose mom needs a caregiver, and they suddenly realize it’s really, really difficult to find a home care worker. That visceral understanding of how important it is to have a robust home care workforce really opens their eyes. As an organization, we try to use data and research and stories to open people’s eyes without them having to have that kind of immediate experience. We at PHI try to get policymakers to understand that the home care crisis is a job quality problem.”

Jenna: “In 2020, PHI came up with the Five Pillars of Direct Care Job Quality, which build on PHI’s longstanding work defining what makes a quality job. We focus on quality training—recognizing that staff oftentimes are not prepared after they’ve finished their initial training. Many training resources for direct care workers were developed 40 years ago, and there really haven’t been new frameworks for any of those credentials since. We also look at fair compensation. Living wage needs to be the base wage. There is absolutely no way to have a stable, quality workforce if workers don’t make a stable living. Another pillar is quality supervision and support. The fourth is respect and recognition, and that’s an organizational issue, but it’s also a societal issue. And fifth is real opportunity, which is the need to ensure that home care workers can build their skills, have opportunity for promotions to advanced roles, and can move forward in their careers.”

Why is home-based` care so often overlooked in policy discussions?

Jake: “At its core, a lot of people just expect care to be provided for free by family members, especially by women. Women, and especially women of color, have served as the glue that allows our society to function—providing care not just to people who are older and people with disabilities, but also kids. People wrongly assume this isn’t a profession, that this isn’t skilled work.”

Jenna: “There’s also a misunderstanding of how this whole sector works. When I directed an assisted living community, people would come in assuming Medicaid would simply cover their rent and services, that an apartment would be waiting for them. But it’s genuinely hard to get an assisted living apartment, and hard to find a home care worker. People believe there’s an entitlement system there, and there really isn’t.”

Jake: “If I could let every person in the country know that Medicare doesn’t really cover long-term care… that’d be a big part of our job done right there.”

What’s missing when it comes to recruitment and retention?

Jenna: “One of PHI’s Five Pillars of Direct Care Job Quality is real opportunity, and that’s something the field is really lacking—the ability to grow in your career. When your credential only allows you to work in your state, and only within one service line, you get handcuffed to that employer and that sector. In other sectors, you get more education and it’s tied to a wage increase, tied to a job advancement that you can carry with you. That’s not the case in this field. It’s not seen as a real professional job with real professional growth opportunities, because our system is so tangled across the country.”

Are we heading toward a breaking point?

Jake: “It’s bad now, and boy are there challenges coming down the road. California is not unique in facing these issues—this is a national problem. And the federal government is not doing us any favors. We have nearly a trillion dollars in Medicaid cuts that are going to affect reimbursement. We have immigration restrictions and deportations affecting a workforce where more than one in four workers nationwide are immigrants—and nearly half of direct care workers in California are immigrants. All these pieces add up to an incredible set of challenges that are forcing us to a point where something’s got to give.”

What gives you hope?

Jake: “The thing is, we know the solutions. It’s not a mystery. We know these workers are underpaid, and if we pay them more, that’s going to be a really big deal. We know how to improve training—we’ve learned a lot in 35 years about how to teach adults. It’s about getting policymakers and the public to understand how important this is, and that we need to invest in home care to support not just people’s quality of life, but our entire economy, which is really resting on the shoulders of long-term care workers.”

Jenna: “We don’t have to start from scratch. What we’re really trying to do is connect the dots and build upon systems that already exist. That’s part of our big flagship work at PHI right now—our Universal Direct Care Workforce Initiative™. We’re looking at training requirements, inconsistent credentialing, advancement pathways, and tying wages to those credentials. And I have to say, the population that works in this sector is so incredibly amazing. They’re innovative, they’re scrappy, they’re hardworking, their hearts are in the right place. It’s hard to think this whole thing could collapse with these folks as leaders.”

What would you say to providers who are feeling overwhelmed?

Jake: “We see you. We see the margins you’re operating under, how important the work is that you’re doing, and how little support you get. There are best practices out there you can implement—our Five Pillars of Direct Care Job Quality represent a simple way to think about interventions you can make at the provider level to make your workers’ jobs better.”

Jenna: “I’d also advocate for looking at how you’re supporting your staff, when almost 60 percent of direct care workers in California rely on public assistance programs and 36 percent are in poverty. If you can’t provide higher wages, are there other things you can do? Rideshare programs, childcare solutions, better health care options, mental health support—those non-wage benefits can really support people.”

Listen to the full episode of At the Table with CAHSAH on Apple Podcasts, Spotify, or YouTube.