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Fund, Implement, and Evaluate Direct Care Workforce Interventions

From advanced roles to care integration to recruitment and retention, a wide array of workforce interventions will help stabilize the direct care workforce.

The growing population of older adults in this country and the persistence of poor job quality in direct care will continue to generate a workforce recruitment and retention crisis in the foreseeable future. To ensure that the long-term care sector can meet the growing demand for direct care workers —and that workers can thrive professionally and financially in these critical roles—a wide range of direct care workforce interventions are needed, including interventions that strengthen the job pipeline into direct care; approaches that better integrate these workers into the consumer’s interdisciplinary care team; and advanced role opportunities that provide a career ladder with elevated titles, functions, and compensation. These interventions should be properly funded, implemented, and evaluated with an eye to their impact on worker, client, and cost outcomes.


To strengthen and leverage the direct care workforce while building the evidence base for future investments in this workforce, we recommend the following:

Strengthen the workforce pipeline in direct care. Demographic shifts and persistently poor job quality have created significant workforce shortages in long-term care. To ensure there are enough qualified direct care workers to meet consumer demand, targeted efforts are needed to attract more candidates to these jobs. Recruitment strategies and training programs should be designed to meet the unique demographic, cultural, linguistic, learning, transportation, and care needs of a particular region. Programs should also be designed to recruit new populations for direct care jobs, such as men and workers displaced by COVID-19, as two examples. States should support such efforts, including efforts specifically aimed at independent providers in consumer-directed programs, and ensure that publicly funded job placement services are prepared to connect jobseekers with free direct care training and employment programs.

Integrate direct care workers onto the care team. Though direct care workers spend more time with consumers than any other paid provider, they are rarely consulted by—or trained to communicate with—members of the consumer’s interdisciplinary care team. Research shows, however, that bringing direct care workers’ observations about consumers to care teams—either through direct communication pathways between entry-level workers and other care team members, or via advanced direct care workers serving as intermediaries—can maximize the direct care workforce in care coordination and improve consumer outcomes and cost savings. The public and private sectors should invest in implementing, evaluating and scaling-up care team integration initiatives, with attention to the different approaches required for different long-term services and supports (LTSS) service-delivery models and settings.

Develop rungs in the career ladder that are accessible to direct care workers and that build on their experience. Today’s direct care workers have few options for advancement within direct care; for example, pursuing the next formally recognized rung on the career ladder, licensed practical nurse (LPN), requires time, resources, and educational credentials that are often inaccessible to direct care workers. With support, employers can take a leadership role in creating and evaluating advanced roles for direct care workers that represent an elevation in title, function, and compensation. States should also establish and fund advanced direct care roles that meet the needs of employers and consumers, such as those specializing in care coordination, worker retention, condition-specific care, and more.

Key Takeaways

Employers need effective recruitment and retention interventions to ensure they can meet the growing demand for direct care workers.
We must design approaches that maximize the contribution of direct care workers to care coordination, improved consumer outcomes, and cost savings.
Direct care workers deserve career advancement opportunities with elevated titles, functions, and compensation.

By the Numbers: Workforce Interventions


Turnover rate for nursing home staff. Source: "High Nursing Staff Turnover In Nursing Homes Offers Important Quality Information,” ‘Health Affairs,’ 2021


Turnover rate for home care workers. Source: “Caregiver Turnover Rate Falls to 64% as Home Care Agencies ‘Flatten the Curve,” ‘Home Health Care News,’ 2020.


The estimated savings per supervisor (among those reporting time efficiencies due to the training) in a 2006-2010 PHI-led intervention that reached more than 2,000 supervisors and led to enhanced problem solving and efficiency on the job.

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