Sign Up to Receive PHI Alerts

Now is the Time to Lift Up North Carolina’s Direct Care Workers

By Kezia Scales, PhD (she/her) | July 6, 2021

North Carolina’s direct care workforce is critical to the state’s long-term services and supports sector, ensuring that older adults and people with disabilities can live and thrive in their homes and communities and across congregate settings.

Yet as the COVID-19 crisis has reinforced, these workers remain undervalued and inadequately supported. For example, direct care workers in North Carolina earn a median wage of just $11.44 an hour and more than half (53 percent) live in or near poverty. Because of poor job quality, direct care workers are increasingly leaving this sector for other fields (such as fast food and retail), which profoundly affects the individuals who rely on their support.

Did you know? PHI’s research shows that from 2018 to 2028, North Carolina’s long-term care sector will need to fill more than 186,000 openings in direct care, including nearly 21,000 new jobs to meet rising demand and 165,500 jobs that become vacant as existing workers transfer to other occupations or exit the labor force.

Yet, a sense of promise is in the air. A wave of new federal announcements—the American Rescue Plan and the American Jobs Plan, as two notable examples—signal a shift in how the federal government is supporting states to strengthen this workforce. At the same time, stakeholders in North Carolina are coming together like never before to champion the needs of the state’s 119,000 home care workers, residential care aides, and nursing assistants.


In this climate, as part of our Essential Jobs, Essential Care initiative, PHI has been working with the North Carolina Coalition on Aging and other leaders to identify the primary policy barriers facing direct care workers and to co-create an advocacy roadmap in response.

In February of this year, we co-hosted a statewide virtual gathering where more than 100 attendees reviewed the latest data on this workforce, heard from direct care workers and other experts in the state about the policy landscape for this workforce, and identified the priority issues to tackle together in the years ahead. Here are three of the most pressing challenges that this initiative will address.


Despite their essential role, direct care workers’ wages have actually decreased over the past decade in North Carolina (adjusting for inflation). Median wages for home health aides and personal care aides, in particular, dropped by seven percent—77 cents—from 2009 to 2019. Considering how low wages impact job quality, workforce stability, and access to services, an unprecedented cross-section of stakeholders has joined together to advocate for change. One specific proposal is the Support Our Direct Care Workforce bill (HB 914), which calls for a Medicaid rate increase tied to a wage pass-through for direct care workers. (The wage pass-through requirement would ensure that a proportion of the rate increase is passed along to direct care workers through increased wages and benefits.) If passed, this legislation would provide a groundbreaking example of how to overcome siloes and enact meaningful reforms that benefit the entire direct care workforce.

North Carolina has experienced decades of direct care workforce innovation—but it’s now time to develop a blueprint for action. Experts and advocates across North Carolina have already identified and taken steps to address many of the challenges facing the state’s direct care workforce; the PHCAST project, for example, developed a comprehensive, competency-based training program to overcome inadequacies in the existing training landscape. As the next step, the state should establish and fund a task force—following the example set by other states and in North Carolina (through a task force focused on nurses)—to specify current workforce concerns, summarize the evidence from previous interventions, and propose recommendations for action. The task force—which could be immediately supported by funds from the American Rescue Plan Act of 2021—should bring together a diverse array of stakeholders and build accountability mechanisms into its recommendations.

Better data on the direct care workforce is needed to inform workforce planning and policy reform. Efforts to improve direct care job quality, grow the workforce, and increase access to care would be strengthened by better data on the size, stability, credentials, and compensation of this workforce. These data are critical for helping track workforce trends, identify needs and solutions, and evaluate outcomes. North Carolina should start by cataloging sources of direct care workforce data across all state agencies—including labor, health, and education, among others—and identifying opportunities to bridge data gaps. Drawing on available federal funds, the state could also commission a statewide survey of direct care workers to better understand their job experiences and challenges, including with regards to COVID-19, and to develop more targeted and evidence-based workforce interventions.


For years, the North Carolina Coalition on Aging and other experts and advocates in North Carolina have led critical advocacy on the direct care workforce. Yet we have never witnessed the type of widespread policy interest at the state and federal levels that marks this moment. Together, we must capitalize on this moment, transforming jobs for direct care workers and care for older adults and people with disabilities.

Learn more about Essential Jobs, Essential Care in North Carolina >>

This initiative is made possible through generous support from the W. K. Kellogg Foundation.

Kezia Scales, PhD (she/her)
About The Author

Kezia Scales, PhD (she/her)

Vice President of Research & Evaluation
Kezia Scales leads PHI’s strategy for building the evidence base on state and national policies and workforce interventions that improve direct care jobs, elevate this essential workforce, and strengthen care processes and outcomes.

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.