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Fighting the Coronavirus Requires a Strong Direct Care Workforce

March 12, 2020

The news seems to worsen by the day. According to the latest statistics, there were more than 1,200 confirmed cases of coronavirus in the U.S. and nearly 128,000 cases globally—with many more expected as the virus spreads and testing improves.

As the number of COVID-19 cases surges, we must question whether health care workers—direct care workers, in particular—are adequately supported to care for themselves and the people who are most at risk: older people and people with serious medical conditions.

Here are six considerations as we strengthen the national response to coronavirus.


While anyone can contract the coronavirus, health experts note that some people are at much higher risk, including older people and people with chronic illnesses such as cardiovascular diseases, diabetes, hepatitis B, chronic obstructive pulmonary disease, chronic kidney diseases, and cancer. Our collective response should prioritize interventions that reach these groups—and the workforce that largely supports them.

Direct care workers are the paid frontline of support for older people and people with disabilities in a variety of settings, including private homes, nursing homes, and residential care settings. The number of people who rely on their support is sizable: according to the U.S. Department of Health and Human Services, an estimated 8.3 million people require paid long-term care in the U.S. And for socially isolated older individuals—a growing concern, as described in a recent report—a direct care worker might be their only source of support.

Did you know? According to PHI, the direct care workforce comprises about 4.5 million workers, including nearly 2.3 million home care workers; over 700,000 workers in residential care; about 580,000 nursing assistants employed in nursing homes; and nearly 900,000 workers employed in other settings, such as hospitals.


Infection control is a standard training topic for home health aides and nursing assistants, who offer clinical support and are federally required to undergo at least 75 hours of training. However, for personal care aides—who make up the largest segment of the direct care workforce—the training landscape is bleak: training for these workers is not subject to any federal training requirements and instead is governed by  a patchwork of state-level training requirements that are thin, insufficient, and inconsistent across and within states. Moreover, for all direct care workers, the training infrastructure (personnel, training materials, and testing and certification systems) is vastly underfunded, which means that the quality of training programs (in content and methods, for example) varies considerably and that typical training programs are unlikely to provide practical guidance on an outbreak of this scale and complexity.


Our research shows that among direct care workers who took time off for family care or medical reasons between 2012 to 2017, only about one in three (or 35 percent) were able to take paid leave. Without paid leave, direct care workers can’t afford to take time off; direct care workers earn a median hourly wage of $12.27 and 44 percent live in or near poverty. More broadly, the limited safety net for all low-wage workers threatens our health and our economic security.


Government leaders and public health experts are promoting two responses to the coronavirus that don’t work for direct care workers: remote work and “social distancing” (the practice of “remaining out of congregate settings, avoiding mass gatherings, and maintaining distance (approximately 6 feet or 2 meters) from others when possible”). Direct care requires workers to provide support largely in person—in clients’ homes, nursing homes, and across residential care settings—and to care for many clients each day. For example, nursing assistants employed in nursing homes support on average about 12 residents at a time.


When direct care workers become ill and have no other option but to take time off without pay (at the risk of losing their jobs), who will replace them? Across the country, long-term care employers are already struggling to recruit and retain enough direct care workers to meet demand—a challenge that will magnify over time. From 2018 to 2028, the long-term care industry will need to fill 8.2 million job openings in direct care, including 1.3 million new jobs and an additional 6.9 million jobs that will become vacant as existing workers leave the field or exit the labor force.


Moments like this compel introspection and demand action. Direct care workers deserve a large-scale transformation that improves their abilities to respond effectively to an outbreak of this scale. Federal and state policymakers should invest in higher compensation, stronger training standards, and advanced roles for these workers, as well as access to paid leave and health insurance for all low-wage workers. A targeted response to the coronavirus will require relevant protocols, supports, and systems—and a smart, coordinated, and well-funded national response—but this response will fall short if the workforce implementing it is too under-resourced and destabilized to rise to the challenge.

Leadership requires remaining steady yet bold through an uncertain moment. It requires visionary change and new approaches that replace the ones that no longer work. Let’s build the workforce we need to make sure all of us remain safe and healthy for years to come.

Caring for the Future

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

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