Sign Up to Receive PHI Alerts

State Language Access Initiatives Are Helping to Serve an Increasingly Diverse Workforce and Aging Population

By Jake McDonald (he/him) | May 9, 2024

Immigrants have long been critical to the direct care workforce and to ensure older adults and people with disabilities receive quality care; in fact, at least 27 percent of our country’s direct care workers are immigrants (up from 21 percent in 2011). The importance of immigrant direct care workers to meeting our country’s long-term care needs and ensuring the quality of that care will only grow as the long-term care sector struggles to fill an estimated 9.3 million direct care job openings in the next decade and an increasingly diverse population of older adults requires culturally competent and language-appropriate care.  

Most immigrant direct care workers are fluent or native English speakers: 56 percent report speaking English “well” or “very well,” and 19 percent report speaking only English. However, many have limited English proficiency and may struggle with English-only training and exams: 25 percent report that speaking English is “not well” or “not at all.”  In addition, many direct care workers serve populations that primarily speak non-English languages themselves—something that will likely become more common as our nation’s aging population becomes more diverse.  

As a result, some potential direct care workers are left out of the workforce because they cannot access training or certification in their preferred language. This can be true even in cases where workers already have substantial healthcare work experience in their home country. Language barriers to training and certification not only deprive states of essential workers amid a nationwide crisis but also mean fewer older adults and people with disabilities receive the culturally and linguistically appropriate care they need.  

Recognizing the situation, several states have moved to expand language access to direct care workers, reducing language barriers to joining the workforce for people who might struggle with English-only training and certification, including many immigrants. A few examples: 

New York created innovative training programs for linguistically diverse home care workers

In 2017, PHI received funds from The New York Alliance for Careers in Healthcare—a public-private industry partnership formed to address system-level challenges facing the local healthcare economy—to create the English as a Second Language (ESL) Bridge to Home Health Aide Training and Employment Program. In collaboration with the Queens Public Library, the Literacy Assistance Center, and several employers, the project targeted intermediate-level English language learners with a program integrating PHI’s home health aide courses with established ESL practices. The overall goal was to increase access for unemployed or underemployed English language learners in New York City to training and employment as home health aides. At the same time, the pilot aimed to develop the capacity of ESL education providers to offer ESL contextualized for home care work. 

Likewise, a union of healthcare workers in New York has experimented with a few ways to prioritize language access for its members and prospective members. In and around New York City—the world’s most linguistically diverse metropolitan area—1199SEIU created a special training program to help build the English skills of people specifically to help them through the state’s home health aide training and certification programs. For example, the 1199SEIU Home Care Education Fund has provided advanced ESL courses custom-tailored around terms needed for employment as a home health aide. The idea is that people with intermediate-level English proficiency can take language courses that will adequately prepare them to complete their home health aide training and certification in English. The union also offers ESL classes for those who are already home care workers to help them pursue other educational and professional opportunities.  

Additionally, New York’s Department of Health has collaborated with community-based organizations and language service providers to expand training and support for direct care workers from a few different linguistic backgrounds. While access is limited, the state has approved training programs for home health aides in Korean and home health aides and personal care aides in Chinese, Russian, and Spanish. 

Wisconsin is translating its free online homecare training

In March, the Wisconsin Department of Health Services unveiled a Spanish version of their online training and exam for certified direct care professionals (CDCPs), called WisCaregiver Careers. We have covered WisCaregiver Careers before because of its innovative structure and incentive programs that are helping to attract more people to the direct care workforce. The expansion of the program with a new Spanish-language training and certification exam is an important step in ensuring the state meets its workforce needs while also providing inclusive, empathetic care for Spanish and English speakers. It also empowers Spanish-speaking workers to start their career in direct care work as a CDCP, opening the door to working in other settings or a career path into nursing. The state is now looking to translate the program into additional languages. 

Washington is leading the country in language access for home care exams

For years, Washington has been the gold standard for providing language access to direct care training and certification. For example, the examination for home care aides is offered in 15 languages with applicants having the option to take the test in written or oral form. If someone wants to become a home care aide but does not speak one of those 15 languages, the state’s Department of Health will provide an interpreter who will read the exam in the applicant’s preferred language after they request a test accommodation. The state also offers provisional certification that provides long-term care workers with limited English proficiency additional time to meet the home care aide certification requirements.  

Massachusetts is translating CNA certification exams

This year, Massachusetts will begin the process of offering CNA certification exams in Spanish and Chinese to, in part, help fill the more than 3,000 CNA vacancies in the state. Legislation being considered would go further: adding Portuguese and Haitian Creole translations and requiring the state Department of Public Health to determine additional languages the exam should be offered in. New Jersey is considering similar legislation that would translate CNA and home health aide certifications into multiple languages.  

California is connecting consumer-directed providers with translated resources

In California, home to one of the most diverse populations in the United States and over 200 spoken languages, the Department of Social Services is expanding language assistance resources for home care aides in the state’s consumer-directed program, ensuring they have access to training materials and ongoing support in multiple languages. For example, several pieces of legislation have required the state and counties to translate materials for In-Home Supportive Services (IHSS) providers into Spanish, Chinese, and Armenian, the three “threshold” languages with substantial populations across the state. PHI’s partner, Homebridge, is assisting with the translation effort, including expanding language access to the training modules PHI developed. Advocates are now looking at creating legislation that would require the state to translate its CNA certification exam into Spanish. 

Challenges ahead

While these state-level initiatives represent significant progress in addressing language access barriers, there are challenges ahead. Lack of knowledge around language access issues, limited resources, and varying language needs across regions pose ongoing challenges. However, as seen from these examples, states are using innovative approaches, including translating materials and exams (and, providing interpreters where needed), expanding language proficiency programs specially created for direct care workers, and strengthening partnerships with immigrant communities to better understand and address their unique language access needs. 

Ensuring language access for direct care workers’ training and certification is paramount to expanding the pool of workers while enhancing quality of care. By creating linguistically inclusive policies, states can create an environment where direct care workers with limited English proficiency (or who otherwise struggle with English-only training and certification) are equipped with the tools and resources they need to excel in their roles. Ultimately, investing in language access is strategically necessary for states struggling to recruit and retain direct care workers as well as meeting the needs of individuals and communities needing linguistically diverse care. 

Jake McDonald (he/him)
About The Author

Jake McDonald (he/him)

Senior State Policy Advocacy Specialist
As the Senior State Policy Advocacy Specialist, Jake McDonald improves job quality for direct care workers by deepening and expanding PHI’s state-based advocacy approach.

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.