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Direct Care Workers Need Stronger Training Standards and Systems

February 22, 2021

The Biden-Harris administration is exciting news for direct care workers and the long-term care field.

As the COVID-19 pandemic has reinforced, direct care workers are essential to the health and survival of millions of older adults and people with disabilities. Yet the poor quality of direct care jobs—as evidenced by low compensation, inadequate training, limited career paths, and much more—harms workers’ financial security, hinders quality care, and drives many workers out of this sector, a costly and unsustainable trend.

How should President Biden transform the direct care workforce?

Our new report—Caring for the Future: The Power and Potential of America’s Direct Care Workforce—provides a blueprint for this transformation. This report offers a comprehensive, current-day analysis of the direct care workforce and its critical role in the long-term care system. It also provides an extensive list of recommendations across eight key areas, all of which present federal policy opportunities, as well as options for state and local officials. This article, the third in an eight-part series, describes a few critical ideas for strengthening training standards and delivery systems for direct care workers.

Now is the time for federal leaders to strengthen direct care jobs—and here’s one place to start.


To prepare workers with the depth of knowledge and skills required to meet the needs of today’s long-term care consumers

  • Establish a national standard for direct care competencies. Training standards for direct care workers, where they exist, vary widely across geographic locations, care settings, and job titles. Most training standards are not competency-based and many are inadequate for delivering quality care. There should be a national standard for the core competencies required to deliver LTSS that are relevant to all direct care workers, regardless of payment source or setting—recognizing the physical demands, social and emotional complexity, and health-related support activities involved in direct care—and that are transferrable across state lines. To be effective, states should then mandate the implementation, enforcement, and evaluation of this minimum standard. States and employers could build from the national standard to provide training programs that are setting- or population-specific, that are tailored to independent providers in consumer-directed programs, and/or that lead to higher-level or advanced direct care roles.
  • Overhaul direct care worker training curricula to reflect the full set of skills needed for this work. Most training standards and curricula for direct care workers focus on basic tasks and many have not been meaningfully updated in decades, despite considerable changes in LTSS consumers’ needs and the long-term care system. Long-term care leaders and direct care workforce development experts should draw directly on workers’ experiences to understand the range of challenges they face on the job, as well as incorporating consumers’ perspectives where appropriate and other evidence and expertise. Training curricula should address these challenges and upskill the direct care workforce by covering areas like communication, condition-specific care, and reporting, among others.
  • Strengthen training infrastructure to support adult learner-centered training and the attainment of meaningful direct care credentials. To improve direct care training quality, states should incentivize training providers to offer in-person and blended training programs that incorporate best practices for adult learners. Given the growing interest in e-learning and online training for this workforce, training programs using these modalities should be properly evaluated for accessibility and effectiveness before being brought to scale. States should also track and report direct care training and certification data, to improve efficiency and accountability within the sector. If their training information is recorded and made available to training providers and employers, for example, trainees can easily evidence and build on existing competencies to earn higher-level or more specialized direct care titles.
  • Increase funding for direct care training delivery and training standard enforcement. The costs associated with training entry-level direct care workers are not generally reimbursable through Medicaid or Medicare, which places the funding burden on individual workers, employers, or third-party training entities. This funding barrier can undermine access to training programs and/or compromise their quality. Public funding sources should account for training-related costs in reimbursement rates for LTSS, with specific funding marked for training delivery, enforcement, and evaluation. States can also create innovation funds to support employers and other training providers in creating quality training programs, among other innovations.

 * The recommendations above are taken from Caring for the Future: The Power and Potential of America’s Direct Care Workforce.

Read the executive summary of Caring for the Future >>

Download The 5 Pillars of Direct Care Job Quality >>

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.