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New Report: ‘Direct Care Work Is Real Work’

July 14, 2020

NEW YORK — PHI released a report today that describes why direct care work should be understood as real work and argues for the need to elevate a rapidly growing, essential workforce whose prospects are severely limited by insufficient training, underappreciation, and few career advancement opportunities, among other factors.

Direct Care Work Is Real Work: Elevating the Role of the Direct Care Worker examines the current training landscape for direct care workers (broadly, home care workers and nursing assistants). This irregular and under-resourced system fails to prepare workers to succeed and threatens quality of care for older adults and people with disabilities. The report also takes a closer look at the aspects of direct care work that are often unseen or underestimated, including its physical demands, social and emotional complexity, and growing contributions to consumers’ health management.

The new report also proposes ways to maximize the role of the direct care worker in care delivery through upskilling, integration into care teams, and advanced roles, reviewing the evidence on such interventions to date.

The challenges facing direct care workers have become heightened during the COVID-19 pandemic, which has revealed this workforce to be both essential and persistently lacking protection and support on the job.

“COVID-19 has emphasized how essential yet undervalued direct care workers remain in our society, the skills their work requires, and how improving training and creating advanced roles are necessary measures for elevating these workers in the long-term care system,” said Jodi M. Sturgeon, president of PHI, a national research, advocacy, and workforce innovations organization widely considered the leading expert on the direct care workforce.

“Direct care workers deserve high-quality jobs that appropriately train and support them for the valuable services they deliver,” added Sturgeon.


Direct Care Work Is Real Work demonstrates that training requirements for direct care workers are uneven and insufficient, with federal mandates applicable only to some workers and state training regulations varying widely across long-term care settings and job titles.

For example, home health aides and nursing assistants are required by federal law to undergo at least 75 hours of training, while personal care aides have no federal requirements and are governed by a thin patchwork of state laws and regulations.

The considerable differences in direct care training standards and quality across states, programs, and job titles mean that many workers lack the proper preparation to do their jobs and are left to fill these gaps on their own.

Moreover, as the report emphasizes, disjointed training regulations make it difficult for workers to translate their experiences across settings (from home care to residential care, for example), limiting their career mobility and the versatility of the workforce overall.


Direct Care Work Is Real Work also describes how training policies and public discourse about direct care do not adequately capture the complexity and scope of this work.

Training requirements for direct care workers tend to focus on the tasks associated with assisting consumers with activities of daily living (ADLs) and instrumental activities of daily living (IADLs). The report points out that less attention has been given to the physical, social, and emotional demands of direct care or the extent to which direct care workers are increasingly supporting people with complex health conditions.

“Direct care workers are constantly overlooked. The value they provide to our communities and health systems is poorly understood, rarely measured, and often exploited. Whether direct care workers are helping people move safely throughout their day, offering emotional support, or managing complex conditions such as Alzheimer’s disease, there is considerable skill involved in what they do,” said Angelina Drake, chief operating officer at PHI and author of Direct Care Work Is Real Work. “We must improve training to better match the demands placed on these workers in the field, incorporate them as valued members of interdisciplinary care teams, and create opportunities for career advancement in direct care.”


Direct Care Work Is Real Work examines how direct care workers are underutilized in the delivery of long-term services and supports (LTSS). The report describes the need for creating more opportunities for “upskilling” (i.e., bolstering training for direct care workers to meet the evolving demands of their roles) and for formally integrating home care workers into care teams.

The report speaks to the importance of building career ladders for workers through advanced roles related to peer mentoring, care coordination, and condition-specific care—matched with elevated titles and enhanced compensation.

Direct Care Work Is Real Work offers two immediate opportunities for strengthening training in long-term care. The first is to develop a national standard for direct care training competencies with requirements for states to adopt these core competencies across direct care roles.

Additionally, the report recommends strengthening the evidence base on the impact of direct care work and leveraging it to increase funding for direct care training and compensation. Upskilling, advanced role, and care team integration demonstrations can measure the impact of better prepared and support direct care workers on outcomes of interest to LTSS payers, including positive health outcomes for consumers and reduced health care spending.

Direct Care Work Is Real Work is the third installment in a year-long series of reports—culminating in a comprehensive final report in January 2021—examining the importance and impact of the direct care workforce. The comprehensive final report will be titled: Caring for the Future: The Power and Potential of America’s Direct Care Workforce.

Read the full report here.

This report was made possible through generous support from the W. K. Kellogg Foundation and the Woodcock Foundation.


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