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PHI Releases In-Depth Report on the Direct Care Workforce

January 12, 2021

NEW YORK — A new report from PHI provides a comprehensive, current-day analysis of the direct care workforce and offers eight concrete recommendations to improve jobs for this rapidly growing workforce of home care workers, residential care aides, and nursing assistants.

Caring for the Future: The Power and Potential of America’s Direct Care Workforce presents in detail today’s direct care workforce, including an overview and statistical profile of these workers; describes how shortfalls in long-term care financing and the industry’s fractured nature harm direct care jobs; discusses the inadequate training landscape for these workers and the need to maximize their role in care delivery; and promotes the value of improving direct care job quality, which has been troubled for decades.

This report also explores how the COVID-19 crisis—more than any other significant development in history—has reinforced how undervalued direct care workers remain in health care and society at large, which threatens their economic security and the quality of services they deliver. Though direct care workers were deemed essential at the onset of COVID-19, they have struggled with limited compensation, benefits, training, and job supports to navigate this crisis.

“As this pandemic has made devastatingly clear, direct care workers are essential to the health and survival of millions of older adults and people with disabilities, but the quality of their jobs doesn’t reflect this enormous value,” said Jodi M. Sturgeon, president of PHI, a national research, advocacy, and workforce innovations organization widely considered the nation’s leading expert on the direct care workforce.

“It’s time that leaders across the country, from government to the private sector and more, prioritize this workforce and transform these jobs once and for all,” added Sturgeon.


Direct care workers provide daily support to older adults and people with disabilities. Nationwide, this workforce includes 4.6 million workers, including about 2.4 million home care workers, 735,000 residential care aides, 566,000 nursing assistants in nursing homes, and 900,000 direct care workers in other settings such as hospitals, employment and vocational rehabilitation services, and others.

Because of growing demand (spurred largely by a rapidly aging population) and high turnover (rooted largely in poor job quality), demand for these workers continues to grow significantly.

From 2018 to 2028, the long-term care sector will need to fill 8.2 million job openings in direct care, including 1.3 million new jobs to meet rising demand and 6.9 million openings caused by workers who transfer to other occupations or exit the labor force altogether.

Caring for the Future posits that unless public and private sector leaders invest significantly in this workforce—improving jobs across the five pillars of direct care job quality described in a recent publication by PHI and included in this report—long-term care employers will not be able to recruit and retain enough direct care workers to meet growing demand.

“For too long, direct care jobs have remained poor quality, impacting workers, employers, and consumers and their families. A positive transformation of this job sector will make life easier for all of these groups,” said Robert Espinoza, vice president of policy at PHI.


To transform the direct care job in the years ahead, Caring for the Future provides an extensive list of recommendations across eight key areas, including:

  1. Reform long-term care financing to strengthen direct care jobs, which includes strengthening public financing for long-term care (including direct care jobs), increasing reimbursement rates under Medicaid and other public payers, and protecting and strengthening Medicaid to cover more individuals and improve direct care jobs.
  2. Increase compensation for direct care workers, which includes paying direct care workers a living wage, improving access to full-time schedules, strengthening the social safety net and enhancing access to workplace benefits, and evaluating the unintended impact of wage increase measures on workers, employers, and consumers.
  3. Strengthen training standards and delivery systems for direct care workers, which includes establishing a national standard for direct care competencies, overhauling and strengthening direct care training curricula and infrastructure, and increasing funding for delivering direct care training and enforcing training standards.
  4. Fund, implement, and evaluate direct care workforce interventions, which includes strengthening the workforce pipeline in direct care, providing additional skill-building at the entry level, integrating direct care workers into the care team, and developing rungs in the career ladder for direct care workers.
  5. Improve direct care workforce data collection and monitoring, which includes creating robust workforce data collection systems, updating federal industry and occupational classification codes, and strengthening and integrating direct care workforce quality measures into research, policy, and practice.
  6. Center direct care workers in leadership roles and public policy, which includes establishing a statewide workgroup to move policy recommendations related to this workforce, creating a division of paid care, and integrating direct care workers into key advisory roles and leadership positions in the public and private spheres.
  7. Rectify systemic gender and racial inequities for direct care workers, which includes developing strategies to address systemic barriers within this job sector, building the evidence base on equitable direct care workforce interventions, and bolstering supports for immigrant direct care workers.
  8. Shift the public narrative on direct care workers, which includes funding public education campaigns on this workforce, building communications capacity to advocate effectively for direct care policy solutions, and supporting storytelling projects that empower workers to tell their stories in their own words.

A new federal administration headed by President-elect Joe Biden could provide ample opportunities for advancing policies that strengthen the direct care workforce.

“The Biden Plan for Mobilizing American Talent and Heart to Create a 21st Century Caregiving and Education Workforce,” released in July 2020, proposed various measures to improve jobs for direct care workers, including increasing compensation, improving access to affordable health insurance and paid sick leave (among other benefits), establishing an innovation fund in long-term services and supports, and expanding access to home and community-based services.

The more expansive set of recommendations in Caring for the Future builds on this plan.

“This country is at a critical and promising moment in history when we can finally move forward a range of strong policy measures that improve direct care jobs and enhance care for older adults and people with disabilities—we need to act now,” said Kezia Scales, director of policy research at PHI.

Read the full report here.

This report was made possible through generous support from the W. K. Kellogg Foundation, the Woodcock Foundation, and The John A. Hartford 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.