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How Pennsylvania Can Transform the Direct Care Workforce

July 1, 2019

In March 2018, I visited Harrisburg, PA to present the latest data on direct care workers, as well as PHI’s field-tested strategies for strengthening the direct care workforce, to the Pennsylvania Long-Term Care Council. The Council, a 35-member group tasked with making recommendations about how to improve the state’s long-term care system, decided nearly two years ago that workforce recruitment and retention should be a top priority.

At that March meeting, the Council heard from direct care workers about what they needed to be successful in the field. Their suggestions were comprehensive and emphatic—higher wages, better benefits, improved training, additional support, and overall, more respect.

These suggestions come through strongly in the Council’s final recommendations, which were recently released in A Blueprint for Strengthening Pennsylvania’s Direct Care Workforce. The seven recommendations in the blueprint are designed to grow the workforce pipeline and improve direct care worker job quality across the long-term care continuum.

To inform next steps on this blueprint, I compiled seven related examples from around the country that demonstrate how these recommendations can be realized.

Awareness and Outreach

The blueprint recommends that Pennsylvania’s governor convene a workgroup to design and implement a public awareness campaign to raise the profile of direct care jobs. The Wisconsin Department of Health Services is pursuing this strategy as part of the WisCaregiver Careers program, an ambitious initiative to recruit and retain 3,000 new nursing assistants in nursing homes across the state. The WisCaregiver Careers website and social media channels feature promotional videos in which nursing assistants compellingly describe the emotional rewards of their work. Nearly 2,000 people have already enrolled in the program since it launched in March 2018.

Standardized Training and Career Pathways

Achieving the blueprint’s goals of high-quality, standardized training and distinct career pathways for direct care workers will be challenging but worth the effort. In 2012, a state-sponsored workgroup in Iowa pilot-tested a new direct care worker training system, which was characterized by modular, stackable credentials that were portable across long-term care settings. This portability was possible because the training curricula were rooted in the competencies needed by all direct care workers, regardless of care setting. The evaluation results showed that the program led to better training outcomes, higher job satisfaction, and lower turnover.

Livable Wages

The blueprint calls for a gradual increase in direct care worker wages to $15 per hour by 2025, in line with Governor Tom Wolf’s call for a raise in the minimum wage for all workers. Setting wage floors can be tricky, however: although increasing wages for direct care workers improves their economic stability, an overall increase in the minimum wage can inadvertently intensify competition for workers across sectors, making it difficult for direct care employers to recruit and retain candidates.

Colorado faced a similar challenge after voters approved a popular initiative to increase the state’s minimum wage to $12 per hour by 2020. In response, the state recently enacted a minimum wage of $12.41 for all Medicaid-reimbursed home care workers, which will help, though not necessarily solve, the challenge of increased competition for workers.

Care Team Integration

The Council recommended that all direct care workers be required to participate in the care-planning process. Already, nursing homes are required by federal policy to include nursing assistants in care planning—and proponents of culture change have developed a range of innovative approaches to empowering nursing assistants as full members of the care team. In Pennsylvania, the state could pilot-test similar approaches in home care and other long-term care settings.


One specific way to capitalize on technology, as the blueprint recommends, is to use digital communication tools to strengthen the connection between direct care workers and other members of the care team. For example, home care workers can use mobile devices to communicate directly and effectively with clinical professionals about their clients’ health, as demonstrated in a recent pilot program in New York City called Care Connections. This program—which also included an advanced role for home care workers—led to an 8 percent decrease in consumers’ emergency room usage, among other positive outcomes for consumers, family members, and workers.

Expand the Labor Pool

To expand the direct care workforce labor pool, the blueprint recommends that Pennsylvania develop incentives for students to work in direct care jobs, such as tuition assistance and loan forgiveness programs. As well as building a pipeline of younger workers into direct care, the state could identify ways to recruit other populations of potential workers, including men and older workers. As one example, three states (Pennsylvania, New Jersey, and New York) leveraged funds through a federal workforce development program to train older workers as nursing assistants and home health aides.

Data Collection

Robust data on direct care workforce volume, stability, and compensation are essential for realizing all of the blueprint’s recommendations. Policymakers in Pennsylvania could follow the example of the Texas Health and Human Services Commission, which recently added questions about workforce recruitment, retention, compensation, and benefits (among other topics) to its Medicaid cost reports.

These examples from across the country demonstrate that all the recommendations in the Pennsylvania Long-Term Care Council’s blueprint for the direct care workforce are attainable. They are worth pursuing—Pennsylvania’s workforce deserves quality jobs, and state residents need quality care. The blueprint is a critical step toward achieving these twin goals.

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