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Investing in the Direct Care Workforce of the Future

In the fifth in the Caregiving NOW series, Carol Raphael called for a radical reimagining of the direct care workforce–the nursing assistants, home health aides, and personal care assistants that provide direct care to our loved ones at home and in residential facilities.
DECEMBER 12, 2022

By Michael ‘Misho’ Stawnychy, PhD, CRNP

In the fifth webinar in the Caregiving NOW series, Carol Raphael called for a radical reimagining of the direct care workforce–the nursing assistants, home health aides, and personal care assistants that provide direct care to our loved ones at home and in residential facilities. Ms. Raphael, past president and CEO of the Visiting Nurse Service of New York and senior advisor for Manatt Health Solutions, grounds her research and policy in the voices and experiences of direct care workers (DCWs). To meet the growing demand for direct care, she stressed, we need to create a career path for DCWs that provides training, opportunities, and a livable wage.

Ms. Raphael painted a dire picture of the job duties and challenges that DCWs face. They have physically and emotionally demanding jobs that often pay just $12-$15 per hour. They serve a diverse set of clients with varied needs and goals of care. Today, a home health aide may have a client who is young and paralyzed due to injury, and tomorrow see an older client with dementia. DCWs are not trained for the complexity of their clients. One DCW told Ms. Raphael that, “I was given 19 minutes of training at Burger King before I was allowed to prepare French fries, but in my state it only took 7 minutes for me to obtain a personal care aide certificate.”

More training at Burger King to make french fries than it takes to get a personal aide certificate.

Beyond the lack of training, DCWs also lack proper mentorship and guidance about the clients they care for. Their supervisors have too many employees to be able to respond to queries about clients in any timely manner. “I was stopped in my tracks when several workers told me that their supervisors had 90 to 100 direct care workers reporting into them,” Ms. Raphael said. The pandemic made their jobs even harder, as COVID posed particular risks for DCWs and their families. Many DCWs have their own health challenges and care for children or older parents who were vulnerable to the virus. DCWs took personal risks to care for clients, yet they were not regarded as essential workers. This meant that they did not have access to proper protective equipment, and had to improvise or buy themselves masks, gloves, and gowns.

Demand for Direct Care Workers Growing

Given these working conditions, it should come as no surprise that the supply of DCWs is decreasing even as the demand for DCWs grows. Our aging population prefers their care at home rather than in an institution. Financial incentives encourage the shift from institutional to home care. As demand for DCWs increases, DCW agencies face high turnover rates and are having trouble filling available jobs. It is estimated that 30-40% of people needing services are currently on waiting lists. To fulfill society’s long-term care needs, we will need more than one million DCWs by 2028. Direct care work is the working-class job of the future (far surpassing the steel and automobile industries).

DCWs need a living wage to support family and have some economic security. So why haven’t DCW wages increased in the face of increased demand and a limited supply of workers? Ms. Raphael noted that market dynamics do not work well in direct care work because it is not a traditional marketplace. Instead, DCW wages are dependent on state Medicaid reimbursements, which take up a large share of state budgets. Long term care services are about a third of the Medicaid budget and are expected to grow at three times the rate of other line items. States looking to balance their budgets may be hesitant to increase provider payments, but present levels of reimbursements do not represent the kind of workforce investment needed to have a living wage.

Efforts to Address Workforce Deficit

So what can be done to encourage people to enter and stay in direct care work as a career? Ms. Raphael offered an optimistic vision of how to create more value in the system and examples of promising efforts at state levels. Michigan has recognized the situation and instituted an advisory council on the direct care workforce. Tennessee reimagined training with a 1-year on the job apprenticeship, more pay, and college credits. Arizona moved to a competency-based training program with modules on specific populations to address client complexity.

She urged states to take a more holistic look at what they are paying in the present system, beyond provider payments for direct care. “I think that states need to step back and bring a fresh lens to that issue, because states are paying a lot to these workers but they’re paying it in different channels. For example, almost 50% of direct care workers are on public assistance.

They get Medicaid, they get SNAP. So a lot of money is going out to support these workers; if you look at total government expenditures, it’s there.”

Further, she noted that the system has other costs that all payers should consider. High turnover leads to high administrative costs. Emergency department visits are costly and some may be preventable with a more highly trained direct care workforce. In her reimagining of direct care as a career, agencies could move away from hourly wages to a salary-based system with a predicted income stream. Training and support for DCWs and their supervisors should be ongoing and reflect hybrid training models that use pedagogy for an adult population. Agencies could leverage technology to improve client scheduling, create peer networks, equip DCWs with devices for real-time communication with health care team members, and integrate DCWs into the broader health care team.

Turning a cost into an investment

Ms. Raphael has been talking to states about the investments needed to cover wage gaps. Through savings in administrative costs and increased productivity, models that elevate and value DCWs by professionalizing their roles are viable. Gaining competency and experience with different client situations (e.g., end of life, dementia, rehabilitation) should be rewarded. To start, she suggests that we set federal standards for training that are competency-based and include communication and mental health skills, such as how to tackle depression. States can expand and broaden the pipeline for DCWs by making the work flexible enough for people that can work only a few hours per week (high school students, people who are semi-retired).

Ms. Raphael stressed that DCW experiences need to be shared widely to help us connect with these important, yet overlooked, care providers. The people who provide direct care to our parents, siblings, and neighbors want us to know that they care about their work. Ms. Raphael recounted one poignant vignette:

“I’ll never forget a story where a person who was a patient died and at the funeral there was only one person, and it was the direct care worker who had been at this person’s side for several years. So I do think these people have to be acknowledged…as heroes.”

Caregiving NOW! with Carol Raphael


The next Caregiving NOW conversation on December 14, 2022, features Alexandra Drane, the CEO and co-founder of Archangels. Many of us may not be fully aware of or acknowledge that we are caregivers, and pay little attention to the mounting stresses. Ms. Drane seeks to empower us by measuring the intensity of this stress and developing coping strategies. Please register and join us for this truly interactive session.