Sign Up to Receive PHI Alerts

New Report on Direct Care Workers Asks: ‘Would You Stay?’

October 13, 2020

NEW YORK — A new report from PHI released today takes an in-depth look at job quality in the direct care workforce, examining the long-standing barriers and the impact of COVID-19 on this sector, while proposing a new framework to improve direct care jobs in the years ahead.

Would You Stay? Rethinking Direct Care Job Quality examines how poor job quality has defined the direct care job for decades, negatively impacting workers, long-term care employers, consumers, and the economy. The report also reviews how the COVID-19 pandemic has endangered the lives of these essential workers and left them unprepared to manage the crisis.

To correct these problems and dramatically improve direct care jobs, Would You Stay delineates PHI’s new framework for quality jobs in direct care, which spans five pillars: quality training, fair compensation, quality supervision and support, respect and recognition, and real opportunity.

“For too long, direct care jobs have suffered from underinvestment and profound challenges that make it nearly impossible for workers to stay in these roles, much less thrive,” 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.

“At a devastating cost, COVID-19 has made painfully clear that we must transform job quality in this sector once and for all,” added Sturgeon.


Would You Stay describes how direct care workers have been hindered by poor job quality for decades, as evidenced by low compensation, inadequate training, limited career advancement, and a range of gender and racial inequalities that harm a mostly female, people of color workforce.

Poor job quality also drives many workers out of this sector and into other industries where pay, schedules, and workloads are only modestly better.

When direct care wages cannot compete with other occupations, employers struggle to recruit and retain enough workers—a challenge that’s largely contributing to the 8.2 million job openings in direct care that are estimated to occur between 2018 and 2028.

New data from PHI reveals that in all 50 states and the District of Columbia, the direct care worker median wage is lower than the median wage for other occupations with similar entry-level requirements, such as janitors, retail salespersons, and customer service representatives.

In 46 states and the District of Columbia, the direct care worker median wage is less than a dollar higher than the median wage for occupations with lower entry-level requirements (like housekeepers, groundskeepers, and food preparation workers). This figure includes 23 states and the District of Columbia where direct care worker wages are lower than wages for occupations with the most minimal entry-level requirements.

“Even though direct care workers have been deemed essential during this health crisis, their jobs have never been compensated or supported in a manner commensurate with this designation,” said Robert Espinoza, vice president of policy at PHI and author of Would You Stay.

This report also examines the impact of the COVID-19 crisis on this workforce, which amplified both the visibility of this sector and its many deep-seated challenges.

For example, many direct care workers have been forced to make the impossible choice between going to work and risking infecting themselves and their families (without paid sick days, if they become sick) or staying home and descending deeper into poverty.

COVID-19 has also affected the lives and availability of direct care workers; the available data shows that hundreds of nursing assistants have died since the pandemic began, and a recent study estimated that 280,000 direct care workers left this sector from March to May 2020. (Data on home care worker and residential care aide deaths are not available.)


To guide policymakers and industry leaders, Would You Stay delineates PHI’s new framework for job quality in direct care, which includes five pillars and 28 elements:

  1. Quality Training, which ensures that all workers acquire the skills, knowledge, and confidence to succeed in their complex roles. One key element of this pillar is designing competency-based, adult learner-centered instruction with hands-on learning.
  2. Fair Compensation, which enables workers to achieve economic stability, safeguard their health, and plan for the future. Among other elements, this pillar argues for providing a living wage as a base wage and access to full-time hours.
  3. Quality Supervision and Support, which offers workers the support and supervision they need to work safely and effectively. A central element of this pillar is delivering a clear presentation of job requirements, responsibilities, workflows, and reporting structures.
  4. Respect and Recognition, which honors the expertise, contributions, and diverse life experience of workers. One key element of this pillar is positioning direct care workers in an organization’s mission, values, and business plans.
  5. Real Opportunity, which invests in workers’ learning, development, and career advancement. One key element in this pillar is creating opportunities for promotion into advanced direct care roles with wage and title increases.

“It’s time to ensure that direct care workers obtain good jobs that accurately reflect their enormous value and the growing demand for their services,” said Espinoza.


To begin improving jobs for direct care workers, the report proposes two immediate actions.

The first action relates to building the data and evidence base on direct care workers by creating more infrastructure at the state level that can systematically collect, analyze, and report data on these workers. The second action is to strengthen the safety net for low-wage workers by enacting policies that provide paid sick days, comprehensive paid family and medical leave, and affordable childcare and long-term care support.

Both actions would bolster this workforce through this health crisis and beyond. For example, during COVID-19, state leaders have struggled to identify where workforce shortages exist geographically, and many workers have been unable to perform their roles without adequate support such paid sick days, affordable childcare, and more.

Would You Stay is the fourth 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.


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.