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New Report: ‘We Can Do Better’ to Support Direct Care Workers

April 21, 2020

NEW YORK — A report released today by PHI portrays a fractured and scattered long-term care system failing to improve direct care jobs—a reality that has become even more pronounced during the COVID-19 pandemic as long-term care employers struggle to keep both workers and their clients safe.

We Can Do Better: How Our Broken Long-Term Care System Undermines Care describes both the shortfalls in long-term care financing and the seismic shifts in the long-term care landscape. The report makes it clear that fragmentation and inconsistent oversight of the home care industry in particular, where demand surges by the day, leave many workers without quality jobs—and many consumers without quality care.

We Can Do Better also delineates the many, dispersed stakeholders that comprise the long-term care industry, including employers, federal and state governments, managed care plans, and various “new” players such as franchises, private equity firms, and venture capital firms—among others.

As the country grapples with the worsening COVID-19 crisis, understanding the complexity of the long-term care system will help U.S. leaders strengthen the direct care workforce and the sector’s response.

“The COVID-19 crisis has exposed and heightened the many flaws in our health and long-term care systems, including the barriers facing direct care workers and long-term care providers,” said Jodi M. Sturgeon, president of PHI, a national research and consulting organization widely considered the leading expert on the direct care workforce. “We hope that this report inspires dialogue and solutions for overcoming these barriers, so that we’re never caught unprepared again.”


Though We Can Do Better does not specifically address COVID-19, it directly informs the immediate discussion on the long-term care system’s challenges in responding to COVID-19.

For example, rapidly creating and disseminating standardized COVID-19 training across nursing homes, home care agencies, and residential care settings seems impossible, given the different guiding frameworks, regulatory requirements, and conflicting interests characterizing our long-term care system.

Additionally, our current financing system leaves many long-term care providers and direct care workers without enough financial resources, which means that when a crisis hits, they cannot respond at the necessary scale—immediately or over time.

In this regard, long-term care providers across the board are reporting shortages in personal protective equipment and concerns about staffing levels. Without enough government support, some providers are launching their own fundraisers to pay for these essential supplies—and in some cases, cutting back services or facing closure due to inadequate staffing.


We Can Do Better concludes with two strategies for transforming long-term care and direct care jobs. The first strategy is to reform the long-term care financing system so that the direct care workforce is strengthened and sustained, and consumers do not become impoverished when accessing care.

The second strategy is to rethink how the long-term care sector is organized and regulated—in order to align workforce-related policies and create better workforce standards.

“If we learn from this crisis and focus on transforming long-term care, we’ll be better able to move a quick response in the future that protects both workers and consumers,” said Stephen Campbell, data and policy analyst at PHI and author of We Can Do Better. “We can create an equitable, efficient long-term care system with more consistent oversight over all its players.”

We Can Do Better is the second installment in a year-long series of reports that will examine the importance and impact of the direct care workforce. The final, comprehensive report—Caring for the Future—will be released in January 2021. Each report in the series provides original data, in-depth analyses, and immediate opportunities for action, as well as features the stories of individual direct care workers from around the country.

To complement the series of reports, PHI has launched a year-long, online dialogue about the state of direct care workers, which audiences can follow on Twitter at #CaringForTheFuture.


In conjunction with We Can Do Better, PHI released new data showing the growth and fragmentation in long-term care. Key findings include:

  • Rapid growth in the industry reflects the increased demand for long-term care. From 2007 to 2017, the long-term care industry added 34,700 new establishments in the home care, residential care, and nursing home sectors.
  • Home care is growing the fastest among all long-term care sectors. From 2007 to 2017, home care added 22,200 new establishments (64 percent of all establishments added), versus 12,000 in residential care and only 500 in the nursing home sector.
  • Home care and residential care establishments are largely small businesses. Eighty-seven percent of residential care establishments and 78 percent of home care establishments employ fewer than 50 workers. By comparison, only one-quarter of nursing homes employ fewer than 50 employees.
  • Chains are dominating the residential care and nursing home sectors. Three in five residential care and nursing home establishments are owned by larger firms that have multiple locations. In contrast, just one in three home care establishments are owned by chains.

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


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