Sign Up to Receive PHI Alerts

Expand Navigation
State Index Tool Methodology & FAQ

Methodology & FAQ

Learn more about the Direct Care Workforce State Index.

FAQ

What is the Direct Care Workforce State Index?

Created and led by PHI—the nation’s leading expert on direct care workers—the Direct Care Workforce State Index offers a data-driven picture of how states’ public policies support direct care workers and direct care workers’ economic experiences and outcomes. This online interactive tool enables users to rank and compare states based on two composite measures: the range of policies states have enacted to support these and other low-income workers and the economic status of direct care workers.

What data does this index include?

The data that informs this tool is drawn from PHI’s existing resources, including the Workforce Data Center and other PHI publications, and from external resources, including reports and websites, state administrative and legislative documents, and other sources. Most data were collected, compiled, updated, and/or published in 2022, with some exceptions. Please see the Methodology section for an explanation of each indicator included in the index, along with its source and date.

Why did PHI create this tool?

In response to deep-rooted, large-scale challenges facing direct care workers and the individuals they support, a growing number of states in recent years have prioritized measures to improve these workers’ jobs, strengthen this workforce, and improve recruitment and retention in this sector. However, the workforce shortage in direct care continues to intensify, and states must do much more to address it. This online tool aims to help a range of stakeholders understand how states are supporting their direct care workers, where they can improve, and how they compare to other states.

Who are the primary audiences for the index?

This index is primarily intended for state policymakers and advocates, who can use the information to inspire and inform policies that strengthen this workforce. Other audiences include public and private funders, researchers, industry leaders, long-term care employers, journalists, and more.

What are the highest-ranking states, according to this index?

According to the index, the top 5 states for direct care workers are: Washington State (1), Rhode Island (2), District of Columbia (3), Maine (4), and New Jersey (5). The states with the most opportunity for improvement regarding direct care workers are: Texas (51), Mississippi (50), Louisiana (49), Alabama (48), and North Carolina (47).

Are these rankings definitive?

No. While these scores and rankings provide an important lens on the policy realities shaping direct care jobs across different states, they certainly do not capture the complexity and nuance of each state. Therefore, caution should be used when comparing states on the basis of these overall scores and rankings.

When was this tool launched?

PHI launched the index on January 10, 2023.

Will there be future versions of this tool and other related resources?

PHI will update the state policy index in 2026. In 2023, PHI will release a research report detailing findings from this state index along with a slate of recommendations.

Methodology

The Direct Care Workforce State Index centralizes a range of information and analysis about direct care workforce policies and outcomes across all 50 states and the District of Columbia. The data that informs this tool is drawn from PHI’s existing resources, including the Workforce Data Center and other PHI publications, and from external resources, including reports and websites, state administrative and legislative documents, and other sources.

As well as offering comparable statistics on the size, demographics, and expected growth of the direct care workforce in each state, the Direct Care Workforce State Index provides a composite score for each state based on two sub-indexes: the “Worker Supportive Policy Index” and the “Direct Care Workforce Economic Index.” The indicators that comprise each of these sub-indexes are described below, along with the data source and year (meaning the year the data were collected, compiled, updated, or published, depending on the source).

WORKER SUPPORTIVE POLICY INDEX

For the Worker Supportive Policy Index, states are ranked according to a composite score reflecting both direct care workforce policies and universal labor policies. Each state’s total score is based on an average of two averages, i.e., the average scores for all direct care workforce policies and for all universal labor policies.

Direct Care Workforce Policies

Direct care workforce policies are defined as state policies that improve direct care worker compensation, training, and access to employment. Each of these policy indicators are equally weighted in the sub-index based on standardized scores (as shown in brackets for each indicator below).

Personal Care Aide Training Standards Key Provisions

This indicator comprises the following 10 personal care aide training provisions. For this indicator, states received 10 points for each provision (for a possible total of 100):

  1. Consistent Requirements Across Medicaid
  2. Private-Pay Training Requirements
  3. Requirements in Consumer-Directed Programs
  4. Any Training Hours Specified
  5. Any Competency Assessment Specified
  6. Portable Credentials
  7. Central Training Registry
  8. Requirements for Instructor Qualifications
  9. State-Sponsored Curriculum
  10. Continuing Education Requirements in Place

Source: https://www.phinational.org/advocacy/personal-care-aide-training-requirements/; updated 2019

Home Health Aide Training Standards Exceed Federal Minimum

Federal regulations require that home health aides employed by Medicare- or Medicaid-certified home health agencies complete 75 hours of training and 12 hours of continuing education. For this indicator, states are scored on whether they have set a higher minimum training hours standard for home health aides (100=yes, 0=no).

Source: https://www.phinational.org/advocacy/home-health-aide-training-requirements-state-2016/; updated 2016

Nursing Assistant Training Standards Exceed Federal Minimum

Federal regulations require that nursing assistants employed by Medicare- or Medicaid-certified nursing homes complete 75 hours of training and 12 hours of continuing education. For this indicator, states were scored on whether they have set a higher minimum training hours standard for nursing assistants in nursing homes, based on PHI’s review of state training regulations (100=yes, 0=no).

Source: https://www.phinational.org/advocacy/nurse-aide-training-requirements-state-2016/; updated 2016

Dollar-Amount Wage-Pass Through Policy (Current)

A dollar-amount wage pass-through is a state policy that requires Medicaid-funded employers to pay direct care workers a specified base wage or increase direct care worker wages and/or other compensation by a specified dollar amount. This indicator only includes wage pass-throughs that were current in 2022, not historical wage pass-through policies (100=yes, 0=no).

Source: PHI review of wage pass-through resources (please email us at info@PHInational.org for more details); compiled 2022

Percentage Wage-Pass Through Policy (Current)

A percentage wage pass-through is a state policy that requires Medicaid-funded employers to spend a specified proportion of their Medicaid reimbursements on direct care worker wages and/or other compensation. This indicator only includes wage pass-throughs that were current in 2022, not historical wage pass-through policies (50=yes, 0=no).

Source: PHI review of wage pass-through resources (please email us at info@PHInational.org for more details); compiled 2022

State-Funded Matching Service Registry

Matching service registries are online platforms that facilitate matching between self-directing home care consumers (and other employers, in some cases) and direct care workers. For this indicator, states were scored on whether they have a statewide, state-funded registry in place (1=yes, 0=no).

Source: https://www.phinational.org/advocacy/matching-service-registries/; updated 2019

Universal Labor Policies

Universal Labor Policies are defined as state policies that support all workers’ abilities to access health insurance, take paid time off, collectively bargain, achieve greater economic stability, and access and maintain employment without discrimination. Each of these policy indicators is equally weighted in the sub-index based on standardized scores (as shown in brackets for each indicator below).

Minimum Wage Exceeds Federal Minimum Wage

The federal minimum hourly wage in 2022 is $7.25. For this indicator, states were scored on whether they have set a higher minimum wage at the state level (100=yes, 0=no).

Source: https://www.dol.gov/agencies/whd/mw-consolidated/; published 2022

Medicaid Expansion

Under the Affordable Care Act, states have the option to access additional federal funding to expand Medicaid eligibility for all adults to 138 percent of the federal poverty level. For this indicator, states were scored on whether they have opted to expand Medicaid (100=yes, 0=no).

Source: https://www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/; published 2022

Paid Sick Leave

Paid sick leave policies allow workers to accrue a specified number of paid hours off to address their own or a family members’ health needs (and for certain other reasons, in some cases). For this indicator, states were scored on whether they have a paid sick leave law in place (100=yes, 0=no).

Source: https://www.phinational.org/resource/essential-support-state-hazard-pay-and-sick-leave-policies-for-direct-care-workers-during-covid-19/; published 2022

Paid Family and Medical Leave

Paid family and medical leave laws allow workers who meet certain requirements to take extended paid time off for their own medical needs, to bond with a new child, to care for a family member, or (in some cases) for other covered reasons. For this indicator, states were scored on whether they have a paid family and medical leave law in place (100=yes, 0=no).

Source: https://bipartisanpolicy.org/explainer/state-paid-family-leave-laws-across-the-u-s/ and PHI review of administrative and legislative resources (email us at info@PHInational.org for more details); compiled 2022

Right to Work Laws

State “Right to Work” laws prohibit employers from requiring workers to join a labor union as a condition of employment. In practice, these laws hinder efforts to organize workers and collectively bargain on their behalf. For this indicator, states were scored on whether they have a “Right to Work” law in place (100=no, 0=yes).

Source: https://www.ncsl.org/research/labor-and-employment/right-to-work-laws-and-bills.aspx/; accessed 2022

Refundable State Earned Income Tax Credits

State Earned Income Tax Credit (EITC) programs reduce the tax burden for low- to middle- income taxpayers. When the EITC is refundable, taxpayers may receive a refund if their credit exceeds their state income tax bill (i.e., the amount of tax owed). For this indicator, states were scored on whether they have a refundable EITC program in place (100=yes, 0=no).

Source: https://www.urban.org/policy-centers/cross-center-initiatives/state-and-local-finance-initiative/state-and-local-backgrounders/state-earned-income-tax-credits#eitc/; published 2022

Non-Refundable State Earned Income Tax Credits

State Earned Income Tax Credit (EITC) programs reduce the tax burden for low- to middle- income taxpayers. When the EITC is non-refundable, the credit cannot exceed the taxpayer’s state income tax bill (i.e., the amount of tax owed). For this indicator, states were scored on whether they have a non-refundable EITC program in place (50=yes, 0=no).

Source: https://www.urban.org/policy-centers/cross-center-initiatives/state-and-local-finance-initiative/state-and-local-backgrounders/state-earned-income-tax-credits#eitc/; published 2022

Protections for LGBTQ+ Workers

State-level protections for LGBTQ+ workers prohibit employment discrimination based on workers’ sexual orientation and/or gender identity. For this indicator, states were scored on whether they have enacted protections against employment discrimination based on sexual orientation, gender identity, or both (100=yes, 0=no).

Source: https://www.hrc.org/resources/state-equality-index/; published 2021

DIRECT CARE WORKFORCE ECONOMIC INDEX

For the Direct Care Workforce Economic Index, states are ranked according to a composite score reflecting several indicators of direct care workers’ compensation and economic stability. The total score for each state is an average of the standardized scores for the component indicators, which are all equally weighted. Indicators with missing values are not counted in the total.

Median Wage

The median wage for direct care workers in each state is calculated as a weighted average of the median wages for personal care aides, home health aides, and nursing assistants, then standardized to 100.

Source: https://www.phinational.org/policy-research/workforce-data-center/; 2021 data point

Wage Competitiveness

The values for the wage competitiveness indicator reflect the difference between direct care worker median wages and median wages for occupations with similar or lower entry-level requirements, standardized to 100. These comparative occupations fall into Job Zone 1 (“Little or No Preparation Needed”) and Job Zone 2 (“Some Preparation Needed”) as defined by the Occupational Information Network (O*NET), which is maintained by the North Carolina Department of Commerce with funding from the U.S. Department of Labor.

Source: PHI analysis of data from the U.S. Bureau of Labor Statistics’ State Occupational Employment and Wage Estimates and the O*NET 27.0 Database (please email us at info@PHInational.org for more details); 2021 data point

Median Personal Earnings

Median annual personal earnings for direct care workers are calculated as a weighted average of median annual personal earnings for personal care aides, home health aides, and nursing assistants, then standardized to 100.

Source: https://www.phinational.org/policy-research/workforce-data-center/; 2020 data point

Low-Income Household

For this indicator, states were scored according to the percentage of direct care workers in the state living in households below 200 percent of the federal poverty level.

Source: https://www.phinational.org/policy-research/workforce-data-center/; 2020 data point

Lacks Affordable Housing

For this indicator, states were scored according to the percentage of direct care workers in the state who lack affordable housing or are housing cost-burdened, meaning their housing costs—including rent or mortgage payments and utility bills—exceed 30 percent of their household’s total income.

Source: https://www.phinational.org/policy-research/workforce-data-center/; 2020 data point

Uninsured

For this indicator, states were scored according to the percentage of direct care workers in the state who do not hold any form of health insurance, including through their own or a family member’s employer or union; through Medicare, Medicaid, or another public program; or through the health insurance marketplace.

Source: https://www.phinational.org/policy-research/workforce-data-center/; 2020 data point   

For additional information on the methodology, please email us at info@PHInational.org.