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Direct Care Workers Deserve a Transformation

By Jodi M. Sturgeon (she/her) | January 13, 2021

Every day around the country, direct care workers leave their homes to ensure that older adults and people with disabilities have the care and support they need to be safe and to fully participate in their communities.

These 4.6 million workers are the paid frontline of support for consumers and their families, growing as a workforce annually as people live longer and demand surges. They work in private homes, nursing homes, and residential care settings, such as assisted living. They are unquestionably essential. They are predominantly women, people of color, and immigrants—diverse and consistently marginalized workers. These workers are not valued, compensated, or supported at the level they deserve. Our new report—Caring for the Future: The Power and Potential of America’s Direct Care Workforce—explains why these and other challenges to ensuring a quality direct care job exist and offers a clear and achievable path forward.

Last year brought to the forefront two significant, large-scale challenges for this essential workforce. COVID-19 emerged as an unprecedented crisis, infecting 16.6 million people and claiming 302,314 lives in the U.S. (as of mid-December, according to The New York Times). The pandemic further strained the chronically under-funded, siloed, and otherwise dysfunctional long-term care system. As a result, direct care workers and their employers have lacked sufficient resources to deliver quality care through this crisis, which has disproportionately impacted the populations that make up most of their clients and residents: older adults (specifically those with certain underlying conditions), people with disabilities, and people of color. The impact of COVID-19 and an under-resourced system continues today as providers struggle to not only provide quality care, but to adequately protect and support their workforce.

“The impact of COVID-19 and an under-resourced system continues today as providers struggle to not only provide quality care, but to adequately protect and support their workforce.”

At the same time, George Floyd’s May 2020 murder at the hands of police officers helped spark an uprising and compelled a national reckoning on racial injustice nationwide. As a workforce comprised primarily of women and people of color, direct care workers are disproportionately impacted by race and gender inequalities and the systemic racism deeply embedded in our long-term care system. PHI has pledged an ongoing commitment to gender and racial justice for the direct care workforce. Caring for the Future explicitly speaks to both the importance of effectively navigating COVID-19 and addressing the consequences of gender and racial injustice on direct care workers.

This report also acknowledges the extraordinary policy window that has been opened in this moment. The long-term work and persistence of direct care workforce advocates has generated an ever-growing level of awareness and support for these workers among policymakers, practitioners, and the general public. In the last few years alone, state and federal leaders have moved a range of policy proposals to strengthen this job sector, news outlets have broadened the media coverage on the many challenges facing direct care workers, and workforce development innovators have designed responsive interventions to improve these jobs and deliver quality care to consumers. Moreover, while PHI has worked successfully on bipartisan initiatives for decades, we also recognize that the recent election of President Joe Biden offers a powerful opportunity to shine the national spotlight on these essential workers and the federal policies that are needed to support them. Never has there been such a clear opportunity to transform direct jobs once and for all.

“Never has there been such a clear opportunity to transform direct care jobs once and for all.”

It is remarkable how much has changed in long-term care and the direct care workforce since I joined PHI almost 16 years ago—much of which is detailed in Caring for the Future. We have seen several developments in the system, including: the significant growth of long-term services and supports (LTSS) and the direct care workforce, spurred largely by the increase in older adults; the gradual shift to Medicaid managed care models, which have added new incentives and complexities to LTSS delivery and direct care job quality; the expansion of home and community-based services as states have rebalanced their Medicaid spending on LTSS, which has boosted demand for home care workers; and the sweeping impact of the Affordable Care Act, which decreased the uninsured rate among direct care workers by 26 percent from 2010 to 2014. It is equally remarkable what has not changed in that time: the persistent challenges associated with insufficient reimbursement rates under Medicaid, which make it impossible for employers to invest in the workforce; and the dogged and widespread gender and racial inequalities within and beyond long-term care, which threaten more marginalized workers and consumers.

During this time, I have been proud to work alongside a growing ecosystem of advocates in the workforce, aging, and long-term care sectors to respond to these developments in long-term care and achieve remarkable wins for direct care workers. As one notable example at the national level, in 2015, I celebrated PHI’s years of hard work and collaboration with these leaders when the U.S. Department of Labor’s final home care rule went into effect, extending wage and overtime protections under the Fair Labor Standards Act to more than two million home care workers nationwide. I have also been encouraged to see more leaders enter and expand this field in the last decade, a growing evidence base of workforce interventions and demonstration projects in direct care, deeper news coverage on the multiple challenges facing direct care workers, and a positive shift in public and political support for these workers. All these developments attest to our collective power as a sector and the urgency with which we must continue to strengthen these jobs. And yet, we still have much work ahead of us to create a stable, well-prepared, and economically secure workforce.

New Report: ‘Caring for the Future’

Caring for the Future: The Power and Potential of America’s Direct Care Workforce offers a comprehensive, current-day analysis of the direct care workforce and its critical role in the long-term care system. The first section describes in detail the direct care workforce, including an analysis of how the direct care role has changed over time and a statistical overview of key demographics, socio-economic characteristics, and employment projections. The next section broadens the report’s focus to the long-term care system, including its financing shortfalls, its seismic shifts over the years, its fragmentation and inconsistent oversight, and its many dispersed stakeholders—all of which coalesce to reinforce poor job quality in direct care.

Section three examines the training landscape for direct care workers; the defining aspects of direct care that are often unseen or underestimated (such as its physical demands, social and emotional complexity, and growing contributions to consumers’ health management); and the promise of upskilling, care integration, and advanced roles. Section four takes a closer look at job quality for the direct care workforce, including how poor-quality jobs affect the entire sector and the impact of COVID-19 on workers and employers. This section also delineates PHI’s new and current framework for job quality, which includes 29 elements across five pillars: quality training, fair compensation, quality supervision and support, respect and recognition, and real opportunity. Caring for the Future concludes with a detailed slate of concrete recommendations for policymakers, employers, and other stakeholders to strengthen this workforce across eight core areas. We hope they inspire and guide leaders across the field to design policies and practices that holistically improve direct care jobs nationwide.

In time, 2021 could be remembered as the tipping point for a direct care workforce national movement. But it will take concerted efforts across sectors and a significant public-private investment to achieve the recommendations outlined in Caring for the Future.

Direct care workers deserve this transformation—and without it, we will never achieve the consistent quality of care we all deserve.

**This article appears as the introduction to our new report, Caring for the Future, which can be accessed here.

Caring for the Future

Our new policy report takes an extensive look at today's direct care workforce—in five installments.

Workforce Data Center

From wages to employment statistics, find the latest data on the direct care workforce.