Critical Shortage: Direct Care Workforce Crisis Looms

The direct care workforce—personal care aides, home health aides, and nursing home assistants—is vital to the functioning of our society. Yet, despite its crucial role caring for older adults and people with disabilities, the sector is held up by significant staffing shortages that have been driven by low wages, high turnover, and recruitment challenges.

​Direct care workers provide essential services and support to millions of people in a broad range of settings, including people’s homes, nursing facilities, and other residential settings, said Robert Espinoza, CEO of the National Skills Coalition, a workforce development advocacy organization.

Too often, their jobs are grossly undervalued, lack training and quality, and offer limited recognition and advancement opportunities, he said, speaking at the National Skills Coalition’s 2024 Skills Summit, held May 13-15 in Washington, D.C.

This urgent issue is projected to become a crisis as the U.S. population continues to get older and home-based care becomes more common.

The approximately 5 million direct care workers—predominantly women (especially women of color) and, increasingly, immigrants—will fall short of the demand represented by the nearly 9 million projected job openings in direct care through 2031, including the addition of over 1 million new jobs, more than any other occupation in the U.S.

“The reality is that many workers are leaving for sectors like fast food or retail because care does not pay enough,” Espinoza said. “As a nation, we need to focus on workforce training and career pathways for this group of workers, creating quality jobs that pay good wages.”

Espinoza led a panel discussion on the critical topic at the Skills Summit, which also included Helen Adeosun, CEO and founder of CareAcademy, an online training platform for caregivers; Kevin Coughlin, policy initiatives advisor-executive at the Wisconsin Department of Health Services; Kezia Scales, vice president of research and evaluation at PHI, a nonprofit dedicated to the direct care workforce and long-term care services; and Jason Resendez, president and CEO of the National Alliance for Caregiving, which represents the millions of people caring for family members and other loved ones in the U.S.

“The primary challenge is a fundamental mismatch between the importance of and demand for this work and the way that these jobs are valued,” Scales said. “Everyone either needs care, provides care, or relies on care for loved ones. What is missing are the talent pipelines to bring people into this work, and once they are in, the investment in care services so workers are prepared to thrive in work that is incredibly rich and rewarding but also very physically and emotionally challenging.”

She added that the direct care worker shortage can be resolved by strengthening the quality of these jobs and making them more attractive.

“Compensation needs to be addressed first and foremost,” she said, citing that the $15.50 median hourly wage is less than the wages found in competing industries.

“Another challenge is the inconsistent and inadequate training provided to direct care workers,” Scales said. “There’s a fairly minimal federal standard for home health aides and nursing assistants, but no standard for personal care aides, a large segment of this workforce. “What we end up with is a patchwork of state training requirements and opportunities and a lot of skills gaps. Skills training and opportunities for advancement are part of having a quality job. That means making sure that everyone that comes into this work is adequately prepared to provide the care that is needed and to continue to accrue skills on the job and map out a career in direct care or other related health care roles.”

Coughlin said one successful solution to increase the number of direct care workers in Wisconsin is working with education and public-sector workforce development agencies to create a pathway to becoming certified nursing assistants. His team also partnered with the University of Wisconsin at Green Bay to create a curriculum for direct care workers based on national competencies and undertook translating all curriculum, testing, communications, and marketing materials into Spanish to support new immigrants to the state.

“Instead of thinking about the problem as fundamentally a labor shortage, I think about it as a talent pipelining issue,” Adeosun said. “There is a lack of understanding among employers and potential employees about what makes a good direct care worker. Even when there are standards that exist in some states, you see a lack of understanding of what skills are necessary and a divergence between roles and payer types.”

Adeosun wants to make training more accessible through technology and compile data on the direct care workforce to show the clinical value of their work. “It’s absolutely necessary,” she said. “They do so much important work, and people don’t know what they do. Data on this population will be key to getting resources on behalf of direct care workers.”

The panel agreed that portability of standards across states needs to be addressed.

“If you go from Massachusetts to New Hampshire, there are two different regulatory frameworks,” Adeosun said. “That’s crazy.”

Scales said that interoperability is a major policy goal to improve direct care job quality.

“We want to make it more coherent for people to enter this occupation and move through this occupation,” she said. “We want to make sure that training is applicable across roles, moving toward a universal training model, where all direct care workers receive training in the core competencies across roles and have the opportunity to layer on additional training for particular settings or populations.”

There is bipartisan interest in addressing the direct care workforce shortage. In April, Sens. Bob Casey, D-Pa.; Tim Kaine, D-Va.; and Tammy Baldwin, D-Wis., introduced the Long-Term Care Workforce Support Act.

Even though this particular bill is not bipartisan, there are definitely bipartisan elements within it, “which enshrines many of PHI’s long-standing policy priorities related to compensation, training, employment conditions, evaluation, and more,” Scales said.

The proposal increases funding for long-term care and direct care services; establishes national “competency-based, industry-recognized, and portable” training standards; develops a national direct care compensation strategy; and enhances data collection, research, and evaluation for this critical workforce sector.