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State Workgroups Confront the Direct Care Workforce Crisis

October 29, 2019

Nationwide, there will be nearly 7.8 million direct care worker job openings between 2016 and 2026. Unfortunately, the long-term care system will struggle to fill these jobs, a challenge created by major factors such as demographic changes (that are increasing demand) and poor job quality (that is driving many workers away from this field). Without enough direct care workers, many consumers will not have access to the care they need, worsening their health and quality of life. And family caregivers will not be able to access the supports their loved ones require, limiting their ability to remain employed.

A growing number of states are responding to this crisis by developing state-level workgroups that can identify the many challenges facing the direct care workforce—and identify targeted solutions. Workgroups ensure that all parties’ needs are considered by including a variety of stakeholders, such as those that represent consumers, family caregivers, workers, long-term care providers, payers, and others. Together, these stakeholders reach agreement on how best to address the workforce shortage, which increases the likelihood of action once the workgroup issues its recommendations.

To help inform efforts in other states, PHI recently looked at 16 direct care workforce workgroups that have been convened since 2003. We identified these workgroups through original reports they published online. (A list of workgroups and reports can be found at the end of this article.) While these workgroups varied in terms of size, duration, structure, and scope, they all focused on the direct care workforce either as a primary or secondary topic. Additionally, all of the reports included recommendations for strengthening the direct care workforce.

Despite the variation among these workgroups, their reports and recommendations had remarkable synergy. In particular, each of the following five recommendations appeared in five or more reports:

  1. Increase compensation – Ten workgroups indicated that direct care workers are under-compensated and recommended increasing wages and/or benefits. Specific recommendations included enhancing Medicaid reimbursement, funding health insurance for direct care workers, and boosting the minimum wage.
  2. Improve training – Nine workgroups identified entry-level training for direct care workers as an area for improvement. Specific recommendations included establishing core competencies and standardizing training curricula for this workforce.
  3. Boost public awarenessSeven workgroups determined that negative social attitudes are a barrier to attracting and retaining enough direct care workers. Specific recommendations included creating a worker ombudsman to promote education and awareness of labor rules, establishing a high school occupational awareness program, and implementing a public education campaign.
  4. Develop career advancement opportunitiesSix workgroups proposed developing career advancement opportunities for direct care workers. Specific recommendations included providing advanced training, establishing portable credentials, and developing advanced specialty certifications.
  5. Establish workforce data systemsSix workgroups identified stronger data systems as a priority area. Specific recommendations included creating a state workforce data agency and establishing new data collection protocols.

States have an important role to play in strengthening the direct care workforce so that consumers have access to the long-term services and supports they need—and workgroups provide a great path forward. In addition to the five shared recommendations (which can be used as a starting point for discussion and action), states can draw on learnings from the workgroups identified in this article to create an approach that meets their needs and contexts.

For example, a workgroup in Alaska created a core competency assessment tool that can be used in training, continuing education, and performance evaluations. In Minnesota, a workgroup used a survey of workers and consumers to inform its recommendations for addressing the workforce shortage. If successful, states can broaden the scope of these workgroups to help shape statewide strategies that address the many challenges facing both direct care workers and their clients.

Direct Care Workgroups & Reports


Committee on Workforce Competency
Assessment Tools for the Alaska Core Competencies, January 2011

Health Workforce Planning Coalition
Alaska Health Workforce Plan, May 2010


Citizens Workgroup on the Long-Term Care Workforce
Will Anyone Care? Leading the Paradigm Shift in Developing Arizona’s Direct Care Workforce, April 2005


Iowa Direct Care Worker Advisory Council
Iowa Direct Care Worker Advisory Council: Final Report, March 2012


Maine Council on Aging
2018 Wisdom Summit: Maine Blueprint for Action On Healthy Aging, September 2018

Maine’s Work Group for Community-Based Living
Improving Quality and Availability of Direct-Care Workers, October 2003


Cross-Agency Direct Care and Support Workforce Shortage Working Group
Recommendations to Expand, Diversify and Improve Minnesota’s Direct Care and Support Workforce, March 2018

Direct Care/Support Workforce Summit
Direct Care/Support Workforce Summit: Summary Report and Next Steps, November 2016

New Hampshire

Governor’s Commission on Health Care and Community Support Workforce
Recommendations on Health Care and Community Support Workforce, December 2016

New Mexico

New Mexico Direct Caregivers Coalition
Senate Joint Memorial 6 Task Force Phase 2 Report, October 2018
Senate Joint Memorial 6 Task Force Phase 1 Report, October 2017


Pennsylvania’s Long-Term Care Council
A Blueprint for Strengthening Pennsylvania’s Direct Care Workforce, April 2019

Direct Care Workforce Workgroup
Addressing Pennsylvania’s Direct Care Workforce Capacity, December 2007

Rhode Island

Healthcare Workforce Transformation Planning Process
Healthcare Workforce Transformation: Preparing the Workforce for a Healthy Rhode Island, May 2017


Direct Service Workforce Advisory Committee
Stakeholder Recommendations to Improve Recruitment, Retention, and the Perceived Status of Paraprofessional Direct Service Workers in Texas, June 2008


Washington State Long-Term Care Workers Training Workgroup
Final Report: Findings and Recommendations, December 2007

To let us know about other workgroups or reports, please contact Allison Cook at or (718) 928-2067.

PHI would like to thank Eliza Kissam, our policy intern in summer 2019, for her work in identifying and analyzing these state workgroups and reports.

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