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Direct Care Workers’ Impact on Social Determinants

October 25, 2021

Over the last 18 months, we have been talking about the social determinants of health, even if we haven’t used those words to describe them.

Throughout the pandemic, data have shown that the spread and severity of COVID-19 infections have not been distributed equally across the U.S. Low-income people and people of color, among other groups, continue to be disproportionately impacted. Frontline health care workers — and direct care workers in particular — face increased risks for exposure and infection, as do much of the population they serve. It’s likely many of us have considered how factors like our neighborhood, occupation, cultural identity, education level, social connections, or housing have shaped our quality of life during this time.


The conditions in which we live that influence our health and wellbeing are known as the social determinants of health. While specific components vary per model, the social determinants of health generally include:

  • Economic stability: Reliable access to sufficient money to support the things one needs to stay healthy
  • Education: Access to quality educational opportunities that support literacy, promote career development, and help develop other skills associated with resiliency and positive health outcomes
  • Social and community context: Positive interpersonal and community relationships that nurture one’s social and emotional needs and may expand access to supportive resources
  • Health care: Access to comprehensive, high-quality, and affordable health care services, including preventative care and treatment for illness and injury
  • Neighborhood and built environment: A physical environment that supports the health and safety of its residents and workers, such as one free from violence and pollution

Some models of social determinants also include the broader political and economic systems under which a person lives, the impact of racism and other forms of discrimination, and/or specific categories for behavioral health, including supports for mental illness and substance abuse.

In recent decades, there has been an increased focus on social determinants in public health and biomedical research. Less attention has been given to the role of long-term services and supports. Yet these services — which take place in settings where people carry out their daily lives — are uniquely situated at the intersection of multiple social determinants of health.


Long-term services and supports, also known as long-term care, are the health and social services provided to people who require assistance with activities of daily living, often as a result of functional limitations related to age, illness, and/or disability. The majority of long-term care is delivered by direct care workers, a group of more than 4.6 million home care workers, residential care aides, and nursing assistants in nursing homes, among others. They work in settings where a wide range of environmental, social, economic, and physical factors interact to shape one’s health.

Direct care workers are critically important to the safety, health, and wellbeing of the people they support. However, these occupations have been severely undervalued over time. Direct care workers’ contributions to consumers’ quality of life have been under-recognized and under-researched, particularly compared to other health and social service providers. This is evident in the uneven and outdated training regulations for direct care roles. Where they exist, training standards for these occupations tend to focus on assistance with daily tasks and some support for physical health, but pay less attention to direct care workers’ impact on social determinants.


Researchers and advocates are increasingly calling for direct care workers to be better integrated into interdisciplinary care teams where they can formally contribute to care coordination and help manage or improve consumers’ physical and social determinants of health. For the last two years, PHI has developed an advanced role for home care workers that serves as a full, equal member of the care team — and is focused on maximizing frontline home care workers’ contributions to social determinants.

The Care Integration Senior Aide (CISA) is an advanced position designed by PHI with support from the New York City Workforce Funders, National Fund for Workforce Solutions, and JPMorgan Chase Foundation. With enhanced training, CISAs are prepared to make visits to consumer homes to support care delivery and coordination. There, they can recognize signs of common chronic conditions and/or social determinants of health and coach entry-level home care workers to also recognize and report these factors. CISAs then share observations from their home visits with the rest of the interdisciplinary care team.

PHI’s CISA program prepares trainees to build on their existing direct care experience — and to deepen their understanding of the social determinants of health. CISAs can support other home care workers and family caregivers in identifying social determinants that may be out of a consumer’s control. For example, understanding that a home care recipient does not have access to a safe environment to exercise can help a home care worker view her client’s diabetes symptoms from a more empathetic perspective. Reporting that lack of access to the care team may also help initiate interventions, such as recommendations for free at-home exercise programs or visits from an occupational therapist.


The CISA role has undergone early pilot-testing in New York City, and PHI is preparing to expand its implementation with new home care agencies. This advanced position incorporates learnings from the success of a similar role called the Care Connections Senior Aide. Originally designed to improve care transitions, Care Connections Senior Aides were found to impact a broad range of factors, including social determinants.

One of these Senior Aides, Marisol Rivera of Cooperative Home Care Associates, spoke with PHI about the advantages advanced roles offer when they take social determinants of health into account.

“An aide called concerned that a client, who uses a wheelchair and is unable to leave the home independently in the city, did not have any food at home,” Marisol recounted. “I was able to speak with my supervisor and the client’s benefits coordinator to arrange for her to get groceries delivered using her EBT card.” (EBT stands for Electronic Benefits Transfer, a debit card eligible recipients can use to access public benefits.)


As the COVID-19 pandemic continues, it is more important than ever to consider how social and environmental factors affect our safety and wellbeing. Building from programs like CISA and the Care Connections Project, employers and health systems can do more to support direct care workers’ contributions to the social determinants of health.

“I think every agency should have these roles,” says Rivera. “They will prevent a lot of hospitalizations.”

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