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Urgent Investment Needed in Direct Care Workforce, Reveals PHI’s New Annual Research Report

September 12, 2023

The direct care workforce is projected to have more new jobs added over the decade than any other single occupation yet continues to struggle with low wages and other barriers that exacerbate recruitment and retention challenges, according to a new report from PHI, the nation’s leading expert on the direct care workforce.

Direct Care Workers in the United States: Key Facts provides an updated annual snapshot of the direct care workforce, including its demographics, roles and responsibilities, job quality challenges, and projected job openings.

“Each year, our research consistently highlights the expanding size of the direct care workforce, the escalating demand for their invaluable services, and the significant economic challenges they encounter,” stated Jodi M. Sturgeon, president and CEO of PHI, a New York-based national organization specializing in research, advocacy, and workforce innovations.

“The need to transform the direct care workforce is both long-standing and pressing,” added Sturgeon.


The direct care workforce is expected to add 1 million new jobs from 2021 to 2031—more new jobs than any other single occupation in the country. When also accounting for jobs that must be filled when existing workers transfer to other occupations or exit the labor force, there will be an estimated 9.3 million total job openings in direct care from 2021 to 2031. This job growth will occur primarily in the home and community-based services sector, with the home care and residential care workforces.

“An increased and strategic investment in direct care workers and the long-term care sector by both government and industry leaders is crucial for meeting the demands of the coming decade,” stated Kezia Scales, vice president of research & evaluation at PHI.


Over the past 10 years, the direct care workforce has seen incremental wage growth. This growth is due primarily to state and federal investments in Medicaid funding for long-term care and the workforce, much of which occurred in response to the pandemic.

Recently though, wage growth has slowed dramatically with the reduction of these supports. After increasing by $0.68 per hour in 2020, the median hourly wage for direct care workers increased by just $0.07 per hour in 2021 and by $0.02 per hour in 2022.

Median annual income for direct care workers is just $23,688. Thirty-nine percent of direct care workers live in low-income households (defined as subsisting at less than 200 percent of the federal poverty level), and 46 percent rely on public assistance, such as Medicaid and food or cash assistance.

As a result, long-term care employers continue to experience acute recruitment and retention challenges in a persistently competitive labor market.


The report underscores the injury and illness rates in the nursing home industry, which are only exceeded by those in veterinary services, spectator sports, bottled water manufacturing, ambulance services, and skiing facilities.

Nursing assistants in nursing homes were nearly eight times more likely to experience workplace injuries than the typical U.S. worker. Injury rates increased by more than 300 percent from 2019 (299 injuries per 10,000 workers) to 2020 (1,014 injuries per 10,000 workers).

The pandemic continues to disproportionately affect direct care workers and those they care for. From January 2020 to July 2023, 164,165 nursing home residents and 3,061 staff died from COVID-19. In the past year alone—from July 2022 through July 2023—over 11,000 resident deaths and nearly 700 staff deaths were attributed to COVID-19.


The direct care workforce continues to be primarily comprised of women, people of color, and immigrants, all of whom face heightened risks of discrimination throughout their lives in housing, education, employment, health care, and more.

  • Women make up 86 percent of the workforce.
  • The median age of direct care workers is 43, and 28 percent of the workforce is aged 55 and over. This is higher than the overall U.S. labor force, where only 23 percent are aged 55 and over.
  • People of color constitute a significant portion of the direct care workforce, making up 62 percent of all direct care workers. This includes 29 percent who are Black or African American, 20 percent who are Hispanic or Latino, and 8 percent who are Asian or Pacific Islander.
  • Immigrants make up a substantial portion of the direct care workforce, constituting 28 percent of the workforce. This is higher than the overall U.S. labor force, where immigrants make up 17 percent.
  • A significant portion of direct care workers also provide unpaid family caregiving, with 25 percent providing such care for one or more older adults. This is higher than the overall U.S. labor force, where the average is 19 percent.

“The challenges detailed in this report underscore the imperative to enhance job quality, ensuring that direct care workers are appropriately compensated and supported, both in recognition of their invaluable role and as a critical step to bolster recruitment and retention in an essential and expanding sector of our nation’s workforce,” added Scales.

Read the full report at:

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