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Key Facts & FAQ

Understanding the Direct Care Workforce

The direct care workforce continues to evolve—here are the latest facts, terminology, and descriptions.

Key Facts

Total Size

The direct care workforce comprises about 4.5 million workers, including nearly 2.3 million home care workers; over 700,000 workers in residential care homes; about 580,000 nursing assistants employed in nursing homes; and nearly 900,000 workers employed in other settings, such as hospitals.

Direct Care Boom

Between 2018 and 2028, the direct care workforce is projected to add more than 1.3 million new jobs. Home care will add nearly 1.1 million jobs in that period, which represents the largest growth of any job sector in the country. During the same time period, an additional 6.9 million direct care jobs will need to be filled as existing workers leave the field or exit the labor force.

An Aging America

From 2016 to 2060, the population of adults aged 65 and over will almost double, from 49.2 million to 94.7 million, and the number of adults over 85 will nearly triple over the same time period, from 6.4 million to 19 million. The growing number of older adults and increased longevity are the two primary factors spurring demand for long-term services and supports.

Shrinking Aging Supports

However, the population of adults aged 18 to 64 (defined as “working age”) will remain relatively constant. Currently, there are 31 working-age adults for every adult aged 85 and over. By 2060, that number will plummet to 12.

Need for New Workers

Labor force participation among women aged 20 to 64—who currently make up most of the direct care workforce—will increase by only 2.7 million from 2018 to 2028, much less than in previous generations. During the same time period, 904,000 more men will join the labor force and the number of older adults (aged 65 and over) participating in the labor force will increase by 6.1 million.


Who are ‘direct care’ workers?

Direct care workers assist older adults and people with disabilities with daily tasks, such as dressing, bathing, and eating. Direct care workers include personal care aides, home health aides, and nursing assistants. Personal care aides also help their clients with housekeeping and might assist them with errands, appointments, and social engagements outside of the home. Home health aides and nursing assistants perform some clinical tasks, such as blood pressure readings and assistance with range-of-motion exercises.

In what settings are direct care workers employed?

They are largely employed in private homes, group homes, residential care facilities, assisted living facilities, continuing care retirement communities, nursing homes, and hospitals.

What is an ‘independent provider’?

Independent providers are direct care workers who are employed directly by consumers through publicly-funded consumer-direction programs. Although it is difficult to accurately estimate the number of independent providers (given the wide variation in methods used to quantify this workforce), data on enrollment in consumer-direction programs suggest that there are at least one million independent providers across the United States.

How much training do direct care workers need?

Home health aides and nursing assistants are federally required to complete 75 hours of training; personal care aides have no federal training requirements. Training requirements for each of these workforce segments vary by state, and can be compared on our website (under the “Advocacy” section). PHI works closely with providers across the spectrum to create feasible training approaches that equip workers with the necessary skills and competencies to provide quality care.

What is the turnover rate for direct care workers?

Unfortunately, a large-scale, comprehensive assessment of turnover in this field does not exist. Turnover is difficult to measure without systematized processes to collect workforce data at the provider and state levels, and most studies have measured turnover for only a subset of the home care workforce (by payer, population served, geographic area, etc.). PHI’s literature reviews on this topic show turnover rates between 40 and 60 percent, and Home Care Pulse recently surveyed private-duty home care agencies and found a national turnover rate of 82 percent in this segment of home care.

What’s the size of the workforce shortage in direct care?

Unfortunately, there is no reliable national estimate of the current workforce shortage in direct care, since most states don’t systematically collect the necessary workforce supply data, and measures of care need vary widely. Some researchers have hypothesized about the future workforce shortage, however, by relying on broad assumptions about population growth and care utilization patterns. As one example, in 2017 MIT Professor Paul Osterman estimated that there will be a national shortage of 151,000 direct care workers by 2030 and 355,000 workers by 2040.

What is the ‘gray market’?

Regarding home care, the “gray market” is where consumers hire home care workers directly—outside of a consumer-directed services program. Our workforce data does not capture the gray market, which is very difficult to measure.

What are the sources for PHI’s data on direct care workers?

Our wage and employment trends are sourced from the Bureau of Labor Statistics (BLS) Occupational Employment Statistics (OES) program, and our employment projections are sourced from the BLS Employment Projections program. For other statistical profiles, we have relied on data from the American Community Survey and Current Population Survey conducted by the U.S. Census Bureau.

Why do PHI’s calculations for the number of direct care workers differ from occupation data from the Bureau of Labor Statistics?

The Bureau of Labor Statistics (BLS) provides data by industry, by occupation, and by industry and occupation. Occupations are defined by skills, training, education, and on-the-job responsibilities, while industries are defined by primary business activities. Whenever possible, PHI uses the BLS data that combines these two classifications.

For example, we define “home care workers” as those who fulfill a particular set of on-the-job responsibilities (such as assisting with activities of daily living) in distinct settings (private homes and certain community-based establishments). To analyze this segment of the workforce, we combine data on three occupations (personal care aides, home health aides, and nursing assistants) in two industries (Home Health Care Services and Services for the Elderly and People with Disabilities). Thus, personal care aides, home health aides, and nursing assistants who work in other long-term care industries are excluded from our home care data.

Does PHI’s data on immigrant workers include undocumented workers?

Yes, but not all undocumented workers. Our statistical portrait on immigrant direct care workers analyzes American Community Survey data, which does not specify whether non-citizen immigrants are lawful, temporary lawful, or undocumented–but likely undercounts undocumented immigrants, for various reasons.

Is there a workforce shortage in home care?

Yes. Greater demand for home care services, paired with slow growth in the labor force, has created a significant shortage in home care and the broader direct care sector. Additionally, home care jobs suffer from high turnover, and our experience in the field shows that states are increasingly struggling to find and keep workers. This challenge will magnify in the years ahead, as demand for home care multiplies. Read our brief on the workforce shortage.