5   Introduction
 6	About the Direct Care
 8	Why Federal Leaders Should Strengthen
     This Workforce
10   Federal Recommendations
     10   Financing
     13   Compensation
     16   Training
     19   Workforce Interventions
     22   Data Collection
     25	Direct Care Worker Leadership
     28   Equity
     31   Public Narrative
37   Appendix 1: Profile of the U.S.
     Direct Care Workforce
39	Appendix 2: PHI Framework:
     The 5 Pillars of Direct Care Job Quality
40	Appendix 3: Highlights of PHI’s Record of
     Bipartisan Federal Policy Action

ACL    Administration for Community Living
CDC    Centers for Disease Control and Prevention
CMS    Centers for Medicare & Medicaid Services
DOE    U.S. Department of Education
DOL    U.S. Department of Labor
FLSA   Fair Labor Standards Act
GAO    U.S. Government Accountability Office
HCBS Home and community-based services
HHS    U.S. Department of Health and
       Human Services
HRSA U.S. Health Resources and
       Services Administration
LTSS   Long-term services and supports
NIH    National Institutes of Health
OMB    Office of Management and Budget

                                                    Federal Policy Priorities for the Direct Care Workforce 1
“We aren’t hearing as much
        about home health aides in
        the news, but we are dealing
        with our own crises during
        this pandemic. It’s a scary
        time right now for us,
        as well as for our clients
        and their families.”
         ome Health Aide at Cooperative
        Home Care Associates, Bronx, NY

2 Federal Policy Priorities for the Direct Care Workforce

Throughout the country, millions of            economic development, and address long-
direct care workers—home care workers,         standing societal inequities. An investment
residential care aides, and nursing            in this workforce also helps all U.S.
assistants—ensure that older adults            workers. To paraphrase a popular saying in
and people with disabilities have the          our field: direct care workers perform the
support they need across care settings.        work that makes all other work possible.
The COVID-19 crisis has reinforced the
enormous value of these workers, and           This report offers an extensive and detailed
government officials have rightfully deemed    set of federal policy recommendations
them “essential” during this period—one of     aligned with the recommendation areas
the greatest truisms ever publicly affirmed    in our flagship report, Caring for the
about this workforce.                          Future: The Power and Potential of
                                               America’s Direct Care Workforce: financing,
Unfortunately, the quality of direct care      compensation, training, workforce
jobs does not reflect their essential          interventions, direct care worker leadership,
contribution. These jobs are often             equity, and the public narrative.1 It also
characterized by inadequate compensation,      includes recommendations for navigating
limited training and advancement               and learning from the COVID-19 crisis.
opportunities, long-standing inequities, and
a general lack of recognition and support.     PHI has worked successfully on
As a result, employers struggle to recruit     bipartisan policy initiatives for decades
and retain workers during a time when          (see Appendix 3). We trust this collaboration
the rapid aging of this country continually    will continue and welcome conversations
drives up demand for these workers—            on any of these ideas.
with many workers opting for modestly
better jobs in fast food and retail. Without
enough workers willing to take these jobs,
consumers are forced to go without the
services they need, and family caregivers
are left without support and respite.

A new presidential administration provides
hope and possibility. Federal leaders—
the White House, Congress, and key federal
departments and agencies—can institute
a broad range of actions that will
improve economic security for direct
care workers, enhance care for
older adults and people with
disabilities, support long-term
care employers, promote

                                                       Federal Policy Priorities for the Direct Care Workforce 3

   Direct care workers support older adults                         Unfortunately, despite their enormous
   and people with disabilities with daily                          value—as demonstrated most recently
   tasks and activities across settings, from                       during the COVID-19 crisis—this workforce
   private homes to residential care homes                          has struggled with poor job quality for
   (such as assisted living) to skilled nursing                     decades with regards to compensation,
   homes. This workforce comprises three                            training, career advancement, employment
   main occupational groups—personal care                           supports, and more. Direct care work is
   aides, home health aides, and nursing                            often unseen or underestimated, including
   assistants—but are known by a variety of job                     its physical demands, social and emotional
   titles in the field. Direct care workers who                     complexity, and contributions to consumers’
   are employed directly by consumers, either                       health management. Poor job quality affects
   through Medicaid programs or private-pay                         workers, who cannot sustain and succeed in
   arrangements, are often called “independent                      these roles; consumers, who cannot access
   providers.” Workers who support individuals                      high-quality continuous care; and employers,
   with intellectual and developmental                              who struggle to find and keep the workers
   disabilities are known as “direct support                        they need to meet growing demand.
                                                                    More than ever, a significant federal
                                                                    investment in this workforce is
                                                                    desperately needed.


   4.6 million | Number of direct care workers
   87% | Percentage of direct care workers who are women
   59% | Percentage of direct care workers who are people of color
   27% | Percentage of direct care workers who are immigrants
   $12.80 | Median hourly wage for direct care workers
   45% | Percentage of direct care workers living in or near poverty
   36% | Percentage of direct care workers who lack affordable housing
   47% | Percentage of direct care workers accessing some form of public assistance
   (food and nutrition assistance, Medicaid, and/or cash assistance)

   7.4 million | Number of job openings in direct care between 2019 and 2029,
   including 1.3 million new jobs to meet rising demand and 6.9 million openings caused
   by workers who transfer to other occupations or exit the labor force altogether

   Source: PHI. “Workforce Data Center.” Accessed 6/8/2021. https://phinational.org/policy-research/workforce-data-center/.

4 Federal Policy Priorities for the Direct Care Workforce
“It takes courage and
 patience to take good care
 of others. It can be so
 hard dealing with sick
 people, but I have empathy
 for others and really
 enjoy this work.”
Caregiver at Courage LLC and Member
of Pilipino Workers Center
Los Angeles, CA

                                       Federal Policy Priorities for the Direct Care Workforce 5

    Direct care workers struggle to make                     Nearly half of direct care workers live in or
    ends meet in their jobs, which drives                    near poverty, a critical reason why so many
    them into poverty and out of this                        workers leave long-term care for other
    field. Federal leaders should improve                    industries, like retail and fast food. Recent
    economic security for these workers and                  research from PHI showed that in all 50
    help stabilize this job sector.                          states and the District of Columbia, the
                                                             direct care worker median wage is lower
                                                             than the median wage for other occupations
                                                             with similar entry-level requirements, such
                                                             as janitors, retail salespersons, and customer
                                                             service representatives. In many states,
“There’s too much work                                      direct care worker wages cannot even
  to get done and not enough                                 compete with occupations with lower entry-
                                                             level requirements.
  people doing the work.
  And I know that a lot of                                   A growing number of older adults and
                                                             people with disabilities rely on these
  that has to do with pay.”                                  workers to live and thrive, yet poor job
                                                             quality makes it difficult to meet this
                                                             need. Federal leaders should ensure that
 ome Care Specialist                                        more individuals can access workers in the
and Personal Care Worker
                                                             long-term care setting of their choice.
at Community Living
                                                             As the number of older adults surges in the
Alliance, Madison, WI
                                                             decades ahead, from 56.1 million in 2020
                                                             to 94.7 million by 2060, demand for direct
                                                             care workers will also increase significantly
                                                             (see the figure on page 9).2 However, unless
                                                             these jobs are transformed, turnover
                                                             will remain high, job openings will be
                                                             left vacant, and consumers will suffer the
                                                             consequences of this staffing crisis.

 6 Federal Policy Priorities for the Direct Care Workforce
Direct Care Worker Projected Job Openings, 2019 to 2029

  LABOR FORCE EXITS                                                                                          3,330,000

  OCCUPATIONAL TRANSFERS                                                                   2,821,000

  NEW JOBS                               1,276,400

Source: PHI. “Workforce Data Center.” Accessed 6/8/2021. https://phinational.org/policy-research/workforce-data-center/.”

Job growth and a strong economy should                            Like in many other sectors where these
go hand in hand, but substandard jobs                             populations form the majority, these
in sectors like direct care disrupt this                          workers are forced to struggle financially in
equation. Federal leaders should advance                          jobs that are not tenable in the long term.
economic development by transforming                              Promoting equity is one more reason why
these jobs. At 4.6 million workers, the                           federal leaders should prioritize these jobs.
direct care workforce is now larger than
                                                                  The COVID-19 pandemic has reinforced
any other occupation in the country. The
                                                                  and amplified the deep-rooted
quality of direct care jobs should reflect
                                                                  challenges facing the direct care
the size and value of this workforce—but
                                                                  workforce. Federal leaders should help
instead, poor job quality leads to high and
                                                                  us move out of this crisis and remain
costly turnover, increased expenditure on
                                                                  focused on sustainable workforce
public assistance, and reduced consumer
                                                                  solutions. Already, the Biden-Harris
spending. The lack of robust training and
                                                                  administration has acted decisively to help
advancement opportunities for direct
                                                                  this country emerge from the COVID-19
care workers foregoes other economic
                                                                  crisis, from a successful (though unfinished)
benefits as well; research has shown that
                                                                  vaccine roll-out campaign to guiding states
investment in training and advanced roles
                                                                  and employers with dealing in the long
can reduce emergency department visits,
                                                                  term with “temporary nurse aides” hired
hospital admissions, and other expensive
                                                                  during the COVID-19 crisis—and much more.
health outcomes.
                                                                  While federal measures will still be needed
The individuals who make up this                                  to address the immediate challenges of
essential workforce have long dealt                               COVID-19 until this health crisis sunsets, the
with the historical inequities created                            recommendations in this report focus on
by structural racism and gender                                   broader measures to dramatically improve
inequality. Federal leaders should                                jobs for our country’s direct care workers.
right these wrongs once and for all.
Women, people of color, and immigrants
comprise most of the direct care workforce.

                                                                             Federal Policy Priorities for the Direct Care Workforce 7

   Reform Long-Term
   Care Financing
   to Strengthen Direct
   Care Jobs
   A stronger financing approach to long-term care would
   improve job quality for direct care workers, as well as better
   meeting consumers’ needs.

   Poor job quality in direct care has persisted                       to create good direct care jobs. From
   for decades—and it has been primarily                               strengthening Medicaid (including raising
   shaped by inadequate public investment                              Medicaid funding levels and providing
   in long-term care and its primary payer,                            adequate reimbursement rates to providers)
   Medicaid. As this country rapidly ages and                          to designing new social insurance programs
   individuals live longer, demand for direct                          in long-term care at the state and federal
   care workers will surge, further straining                          level, significant policy action is needed to
   Medicaid resources and making it nearly                             bolster financing in this sector and transform
   impossible for policymakers and employers                           direct care jobs.


           52%                                       $54,000-                                        1
    Percentage of long-term
  services and supports (LTSS)
        spending in 2018
                                                            Yearly estimated median
                                                                                                   Number of
                                                                                              state-based social
                                                                                             insurance programs
    attributed to Medicaid.3                                                                   in long-term care
                                                                 costs for LTSS.4            (Washington State).5

8 Federal Policy Priorities for the Direct Care Workforce
• Medicaid Reform. Congress and the            (that include workers) to create and regularly
 Centers for Medicare & Medicaid Services       update an “HCBS workforce plan” that
 (CMS) should protect and reform Medicaid,      details the specific needs and costs of fully
 the primary public payer of long-term          supporting home care workers. These
 care. As a key priority, Congress and CMS      workforce plans should include a strategy to
 should support states in ensuring that         establish a wage floor based on a living wage
 long-term care providers receive adequate      (with guidance on the formula from federal
 reimbursement rates to deliver quality         leaders), higher wages tied to advancement,
 services and improve direct care jobs.6        and a transparent rate-setting process that
                                                covers all care delivery costs, including a
• Alternative Financing Models. Alternative    baseline rate for managed care plans.
 financing models are needed to address
 the increased and unsustainable pressures
 on Medicaid as the primary payer of long-
 term care. (Recent research shows that
 56 percent of people turning 65 between        “You need to work really hard
 2020 and 2024 will require some form             on this job, to work really hard.
 of paid LTSS at some point in their lives.7)     You do a lot of things for your client
 As one key action, Congress should enact
 and fully fund the Well-Being Insurance          and at the same time the pay is very,
 for Seniors to be at Home (WISH) Act.            very low. That is something that
 The WISH Act would create a federal              I don’t like from it. This is
 social insurance program in long-term            the only thing that I don’t like.
 care through a public-private partnership,       The salary is very low.”
 assisting individuals with the high costs
 of these services. To ensure consumers          MARIA MARRERO
 can truly benefit from enhanced access to       Certified Home Health Aide
 long-term care, the Act should also include     at HomeCare Options
 measures to transform and fully finance         Totowa, NJ
 direct care jobs.8

• HCBS Access and Workforce Plans.
 Congress should introduce, enact, and
 fully fund the Home and Community-
 Based Services Access Act, which would
 fund states to develop and strengthen
 their HCBS infrastructure and further
 invest in the home care workforce.
 The Act would abolish Medicaid’s
 historical institutional bias by making
 HCBS mandatory. Federal leaders should
 also ensure that this Act requires states to
 convene multi-stakeholder workgroups

                                                          Federal Policy Priorities for the Direct Care Workforce 9
                                                             In response to the growing interest in
                                                             state-based social insurance programs in
                                                             long-term care, PHI issued a report with
                                                             nine concrete strategies for ensuring
                                                             that eligible consumers can access the
                                                             support they require from a high-quality,
                                                             adequately supported workforce.11
                                                             In addition, as part of PHI’s multi-state
                                                             advocacy initiative in Michigan, New
                                                             Jersey, New Mexico, New York, and North
                                                             Carolina, advocates across these states
                                                             are focusing on improving wages and
                                                             reimbursement rates under Medicaid as
                                                             one of their top three priorities to pursue
                                                             over the next two years.12

     s top priorities for the workforce, the
    A                                                        care plans. CMS should also provide
    Act should also address training, career                  guidance and technical assistance to
    advancement, recruitment, retention,                      states on how to invest in the direct
    and innovation.                                           workforce through value-based payment
                                                              arrangements. Effectively leveraging
 • Public Investment Standards and                           the role of direct care workers in value-
    Value-Based Payment. CMS should                           bayed payment arrangements helps
    incentivize states to build minimum                       improve health care quality while reducing
    standards for direct care jobs into their                 unnecessary costs.10
    contracts with providers and managed

10 Federal Policy Priorities for the Direct Care Workforce
 Compensation for
 Direct Care Workers
  irect care workers deserve better wages and benefits
 to improve their economic security and overall wellbeing.
  Wages for direct care workers are untenably     Unfortunately, policy proposals that
  low and have barely budged over the last        aim to increase wages for low-wage
  10 years. As a result, direct care workers      workers (including direct care workers)
  are often forced into poverty, cannot           are rarely paired with an increase in
  make ends meet or support their families,       public funding that would help long-term
  and end up leaving this field for other         care employers cover these higher wages
  industries, such as fast food and retail.       without cutting service hours for older
  Exacerbating this injustice is the reality      adults and people with disabilities.
  that many direct care workers lack access       The entire long-term care system
  to full-time schedules and critical supports    needs sufficient funding and reform to
  such as health coverage, paid sick days,        improve the economic wellbeing of
  paid family and medical leave, or affordable    these essential workers.
  childcare and long-term care support.


   Growth in the inflation-
                                  Median annual earnings for
                                                                       Percentage of direct care
   adjusted median hourly           direct care workers.              workers without any health
 wage for direct care workers                                                 insurance.
  between 2009 and 2019,
   from $12.61 to $12.80.

                                                           Federal Policy Priorities for the Direct Care Workforce 11
    • American Families Plan. Congress should                   enacted, federal leaders should provide
      enact and fully fund the American Families                  rules and guidance to states on how to
      Plan, which would expand affordable                         implement these new provisions, taking
      childcare, universal preschool, expanded                    into consideration the needs of payers,
      higher education access, individual and                     providers, workers, and consumers
      family tax credits, and comprehensive paid                  across long-term care settings, and
      leave for millions of workers, including                    key considerations such as Medicaid
      direct care workers.14 Once the plan is                     reimbursement formulae, managed care
                                                                  contracts, employment practices, and
                                                                  consumer and worker education, among
                                                                  other needs.

“It’s so unfortunate that in the                              • National Compensation Strategy.
                                                                CMS, ACL, HRSA, DOL, and other
 world we live in, the caregiving                               stakeholders should work together to
 profession receives the lowest                                 develop a national compensation strategy
 category of pay. Yet it requires                               that addresses direct care workforce
 a lot of intelligence. It requires                             concerns. Among its responsibilities,
                                                                this inter-agency group should develop
 a lot of agility to be able                                    specific recommendations on how
 to respond to a need or an                                     states should set their Medicaid rates to
 emergency.”                                                    ensure competitive wages and benefits
                                                                for direct care workers, considering
                                                                both traditional Medicaid and managed
 Caregiver and Worker Leader at Pilipino
                                                                care contexts. The recommendations
 Workers Center, Los Angeles, CA
                                                                should take into account full-time
                                                                scheduling barriers, “benefit cliffs” and
                                                                “benefit plateaus,” and other factors
                                                                and possibilities. The recommendations
                                                                should then be translated into regulations
                                                                for rate-setting and enforcement
                                                                processes at the state level.

                                                               • Financial Support Programs. DOL should
                                                                fund financial literacy and counseling
                                                                programs that help direct care workers
                                                                (among other low-wage workers)
                                                                understand complex job-related benefits
                                                                and supports (including health insurance
                                                                options), navigate financial challenges,
                                                                and plan for their short- and long-term
                                                                financial futures.

  12 Federal Policy Priorities for the Direct Care Workforce
                                                   PHI provided in-depth research and
                                                   policy analysis on extending wage and
                                                   overtime protections to U.S. home care
                                                   workers for nearly a decade before the
                                                   U.S. Department of Labor announced,
                                                   in December 2011, that it would extend
                                                   these protections under the Fair Labor
                                                   Standards Act.17 We also joined forces with
                                                   several national organizations to ensure
                                                   implementation of the ruling, launching
                                                   a “Campaign for Fair Pay” that helped
                                                   solidify this win. At the state level, PHI was
                                                   instrumental in designing and helping to
                                                   pass New York State’s historic 2011 Wage
                                                   Parity Law, which established a consistent
                                                   wage floor with benefits for home health
                                                   aides and personal care aides.18

• Benefit Cliffs and Plateaus. DOL and
 HHS should develop a strategy with
 analysis, rules, regulations, and guidance
 to help states address benefit cliffs and       • State and Regional Public Authorities.
 benefit plateaus among low-wage workers,          DOL should fund the creation of state or
 including direct care workers. (These cliffs      regional public authorities that improve
 and plateaus occur when, as low-wage              job quality (including by setting wage
 workers’ wages and hours increase, their          floors) for independent providers, while
 total compensation drops or remains the           promoting the principles of consumer
 same due to a corresponding decrease in           direction. (Independent providers are
 public benefits.) This strategy should build      direct care workers employed directly
 on existing research and guidance from            by consumers through publicly funded
 the field and explore approaches such             consumer-direction programs.) While this
 as adjusting the design of public benefit         figure is difficult to calculate, PHI estimates
 eligibility limits and requirements and           that at least one million independent
 working with workers to reduce the impact         providers are employed through Medicaid-
 of losing benefits, among other strategies.15     funded consumer-directed programs.16

                                                           Federal Policy Priorities for the Direct Care Workforce 13
Strengthen Training
   Standards and
   Delivery Systems for
   Direct Care Workers
     oday’s direct care workers need a training approach that
    appropriately prepares them for the complex and valuable
    services they deliver.

    The training landscape for direct care                          the workforce overall. Additionally, training
    workers makes it nearly impossible to                           requirements for direct care workers tend
    ensure that they are adequately skilled and                     to focus on the tasks associated with
    prepared to succeed in their roles. Training                    assisting consumers with activities of daily
    requirements for direct care workers are                        living and instrumental activities of daily
    uneven and insufficient throughout the                          living, yet less attention has been given to
    country, with federal mandates applicable                       the physical, social, and emotional demands
    only to some workers and state-level                            of direct care or the extent to which direct
    training regulations varying widely across                      care workers are increasingly supporting
    states, long-term care settings and job titles.                 people with complex health conditions.
    Moreover, disjointed training regulations                       The entire training landscape—its standards,
    make it difficult for workers to translate their                curricula, and general infrastructure—must
    experiences across settings (from home care                     be better developed, standardized, and
    to residential care, for example), limiting                     resourced.
    their career mobility and the versatility of


                32                                           18                               7
        States (plus DC) that                           States (plus DC) that         States with no training
      have expanded training                          have expanded training        requirements for personal
     requirements for nursing                      requirements for home health             care aides.
       assistants beyond the                         aides beyond the 75-hour
    75-hour federal minimum.                             federal minimum.

14 Federal Policy Priorities for the Direct Care Workforce
• National Competency-Based Training              s part of this effort, CMS should set
  Standard. CMS, ACL, DOL, DOE, and               and fund minimum standards for training
  other relevant stakeholders should work         quality, for example in regard to instructor
  together to establish a national standard       qualifications, student-teacher ratios, and
  for direct care competencies that draws         training space and equipment, among other
  on existing core competency sets and            factors.
  is applicable to all direct care workers
  regardless of payment source. CMS should
                                                 • New Research. DOL should commission a
                                                  study on the national training infrastructure
  also require that states adopt these core
                                                  for direct care workers to identify gaps
  competencies with the ability to tailor
                                                  and best practices. As well as summarizing
  them to state-specific requirements and
                                                  the evidence base on direct care training
  regulations. Federal leaders should provide
                                                  interventions, this study should examine in
  guidance to states on how to integrate
                                                  detail the characteristics and geographic
  these competencies into their training
  standards and credentialing programs,
  among other concerns.

• Personal Care Aide Training
  Requirements. CMS should create                 “Working in these advanced roles
  minimum federal training standards                has given me a lot of confidence in
  for personal care aides, ensuring parity
  with home health aides and nursing                what I do. I feel good about being
  assistants. Personal care aides are a             able to help more clients, more
  rapidly growing yet largely unregulated           workers, and more family members
  part of the direct care workforce.                in this way. I continue to learn,
• Training Infrastructure. Federal leaders         which is also good for me.”
  should support states in strengthening           MARISOL RIVERA
  their direct care workforce training             Care Coordinator at
  infrastructures, including by providing           Cooperative Home Care
  funding to develop and enforce                    Associates, Bronx, NY
  competency-based training standards
  and deliver and evaluate training. As
  two avenues, Congress should enact and
  fully fund the Direct Support Worker
  Training Reimbursement Act, which
  would increase federal matching payments
  for training programs focused on the direct
  care workforce, and the Mollie Baldwin
  Upskilling of Personal and Home Care
  Aides Act, which would fund competency-
  based upskilling training models in direct
  care.20 Additionally, CMS should expand
  Medicaid to cover entry-level training costs
  for all direct care occupations.

                                                          Federal Policy Priorities for the Direct Care Workforce 15
                                                             ADVOCACY LEADERSHIP
                                                             For years, PHI has been tracking training
                                                             requirements for personal care aides, home
                                                             health aides, and nursing assistants across the
                                                             50 states and DC, describing the significant
                                                             variance across states and occupations and
                                                             highlighting the urgent need to strengthen
                                                             and standardize these requirements.21 PHI’s
                                                             workforce innovations division has also innovated
                                                             in this area: as one leading example, our
                                                             Homecare Aide Workforce Initiative used a mix of
                                                             training, recruitment strategies, peer mentoring,
                                                             coaching supervision, supportive services, and
                                                             case management to improve job satisfaction
                                                             and retention (among other outcomes) among
                                                             participating home care workers.22

    coverage of existing training programs;
     the extent to which these programs
     measure workforce, care, and cost                       • Job Quality Measures. HHS and DOL
     outcomes; funding needs and mechanisms                    should develop and incorporate a core
     for training; the use and efficacy of                     set of direct care workforce quality
     e-learning and virtual training; and the                  measures into federally funded long-term
     prevalence of complementary training for                  services and supports programs and
     direct care supervisors, among other areas.               demonstrations, informed by the National
     This study should also assess how the                     Quality Forum final report of September
     direct care training landscape addresses                  2016. Grantees leading projects that
     topics such as dementia care; other types of              involve direct care workers should be
     condition-specific care; social isolation and             required to submit progress and final
     loneliness; cultural, linguistic, and lesbian,            reports on how their projects have met
     gay, bisexual, and/or transgender (LGBT)                  these quality standards.
     competence; and much more.

16 Federal Policy Priorities for the Direct Care Workforce
Fund, Implement,
and Evaluate
Direct Care Workforce
 rom advanced roles to care integration to recruitment and
retention, a wide array of workforce interventions will help
stabilize the direct care workforce.
 The growing population of older adults           including interventions that strengthen the
 in this country and the persistence of poor      job pipeline into direct care; approaches
 job quality in direct care will continue         that better integrate these workers into the
 to generate a workforce recruitment              consumer’s interdisciplinary care team; and
 and retention crisis in the foreseeable          advanced role opportunities that provide a
 future. To ensure that the long-term care        career ladder with elevated titles, functions,
 sector can meet the growing demand for           and compensation. These interventions
 direct care workers—and that workers             should be properly funded, implemented,
 can thrive professionally and financially        and evaluated with an eye to their impact
 in these critical roles—a variety of direct      on worker, client, and cost outcomes.
 care workforce interventions are needed,


   Turnover rate for
                                   Turnover rate for
                                                                    The estimated savings per
 nursing home staff.23           home care workers.24         supervisor (among those reporting
                                                                   time efficiencies due to the
                                                                training) in a 2006-2010 PHI-led
                                                                intervention that reached more
                                                               than 2,000 supervisors and led to
                                                                enhanced problem solving and
                                                                      efficiency on the job.25

                                                           Federal Policy Priorities for the Direct Care Workforce 17
   • Workforce Interventions Investment                       loneliness, mental health, vulnerable
      and Inter-Agency Coordination. DOL, in                    people (such as LGBT individuals), and
      coordination with HHS and DOE, should                     others. These interventions should engage
      fund and evaluate a broad range of direct                 workforce development providers,
      care workforce interventions in areas such                educational institutions, direct care
      as: entry-level and specialized training,                 employers, labor organizations, and
      advanced roles, recruitment and retention,                industry associations, among other
                                                                stakeholders, and evaluate their impact on
                                                                employment, care, and cost outcomes.

                                                               • Boosting the Direct Care Field. Congress
                                                                should enact and fully fund the Direct
“As a peer mentor, I train                                     Creation, Advancement, and Retention
  new home health aides                                         of Employment (CARE) Opportunity Act,
                                                                which would invest more than $1 billion
  and make myself available                                     over five years in workforce interventions
  to support a group of five                                    that improve training, recruitment,
  aides. They can come                                          retention, and advancement opportunities
                                                                in the direct care workforce.26 This Act is
  to me with any questions                                      designed to support interventions in high-
  or concerns they have, or to                                  need areas and encourage consultation
  simply talk about their day.”                                 with diverse stakeholders, and it requires
                                                                that interventions be evaluated for their
JANET FOLSOM                                                    impact on workers, consumers, and overall
 ome Health Aide, Certified Nursing Assistant,
H                                                               care costs.
and Peer Mentor at Knute Nelson
Alexandria, MN                                                 • Advanced Role Evidence Base. Congress
                                                                should re-introduce, enact, and fully
                                                                fund the Improving Care for Vulnerable
                                                                Older Citizens and People with Disabilities
                                                                through Workforce Advancement Act,
      supervision, e-learning, technology, and                  which would build the evidence base on
      more. CMS, ACL, HRSA, and other relevant                  advanced role models in direct care, with
      agencies should also support new models                   a specific focus on models that better
      of service delivery across long-term care                 integrate workers into the interdisciplinary
      settings, including universal worker roles,               care team and models where workers
      models that connect workers to other                      can improve support for individuals with
      services (such as housing supports), and                  complex chronic conditions.27 As designed,
      models that maximize the direct care role                 the Act would prioritize advanced
      through upskilling, care integration, and                 role interventions that address vulnerable
      meaningful career ladders. Additionally,                  populations, neglected regions of the
      CMS and DOE should support approaches                     country, and rural and urban needs.
      that strengthen workers’ abilities to support
      individuals with dementia, people at risk
      or dealing with social isolation and

  18 Federal Policy Priorities for the Direct Care Workforce
 For years, PHI’s workforce innovations have
 greatly helped direct care workers and their
 employers. Our Care Connections Project
 created an advanced role for home care
 workers—the “Care Connections Senior
 Aide”—which has helped improve job
 satisfaction, decrease emergency department
 visits, and reduce family caregiver strain.31
 As another example, in 2014 PHI worked
 with local colleges, municipal agencies, and
 private employers to better recruit, train,
 and retain direct care workers through the
 City University of New York (CUNY) system.
 This intervention led to high employment
 and retention rates: 76 percent of trainees
 secured a job and 75 percent of those
 workers retained their jobs three months
 after completing the training.32

• Recruitment and Retention. ACL should         certification records of direct care workers
 commission a study on recruitment and            (with privacy safeguards in place). PHI
 retention challenges in the direct care          has identified only 14 matching service
 workforce, scan the field for best practices     registries in 10 states (as of 2019), and
 in program design on these topics, and           many of them are under-resourced and not
 promote these findings broadly. The agency       maximizing their potential.28
 should also work with experts in the field to
 develop a recruitment and retention guide
                                                 • Dementia Care Competence. HHS
                                                  should create a strategy to build dementia
 for ACL grantees that are leading projects
                                                  care competence among direct care
 that employ direct care workers.
                                                  workers (and other health care workers),
• Matching Service Registries. DOL               building on the recommendations from the
 should commission a feasibility study to         Workforce Development Workgroup that
 assess the strengths, risks, logistics, and      was formed as part of the 2020 National
 total costs of launching and promoting           Research Summit on Care, Services and
 matching service registries in every state.      Supports for Persons with Dementia and
 A matching service registry is an online job     Their Caregivers.29 More than 6 million
 board where consumers and workers find           individuals are currently living with
 each other based on needs, preferences,          Alzheimer’s in the U.S.—by 2050, this
 and availability—and can serve as a useful       number will grow to 13 million.30
 platform for centralizing training and

                                                         Federal Policy Priorities for the Direct Care Workforce 19
Improve Direct
   Care Workforce
   Data Collection and
    L ong-term care leaders need better data on the size, stability,
     credentials, and compensation of the direct care workforce
     and on direct care job quality.

    When it comes to tracking and measuring                          need to make sound decisions that would
    key workforce dimensions such as size,                           improve these workers’ jobs. Additionally,
    stability, credentials, and compensation                         federal industry and occupational codes
    (among other variables), federal and                             need updating, which includes developing
    state data collection systems remain                             a new code for direct support professionals
    inadequate and under-resourced. As a result,                     (among other improvements), and job quality
    policymakers, industry leaders, and other                        metrics need widespread adoption across
    long-term care stakeholders—at the local,                        research, policy, and practice.
    state, and federal levels—lack the data they


                  1                                          23%                             12
        Number of staffing                            Percentage of nursing         Number of years since the
      measures included in                               homes reporting              Centers for Medicare &
        the national 5-Star                         staffing shortages during        Medicaid Services (CMS)
      Quality Rating System                        the peak of the COVID-19        published a report calling for
       for nursing homes.33                                pandemic.34              a minimum data set on the
                                                                                      direct care workforce.35

20 Federal Policy Priorities for the Direct Care Workforce

• Workforce Definitions and Eligibility        • Job Quality Measures. HHS and DOL
  Requirements. DOL, in coordination with         should develop and incorporate a
  CMS and other relevant agencies, should         core set of direct care workforce quality
  work with experts in the field to establish     measures into federally funded long-
  a definition of “direct care worker” that       term services and supports programs
  captures the core competencies of this role     and demonstrations, informed by the
  and specifies the additional competencies       National Quality Forum’s final report
  required for distinct settings (such as HCBS    from September 2016.36 Grantees leading
  versus nursing home care) and population        projects that involve direct care workers
  served (such as older adults or individuals     should be required to submit progress and
  with intellectual and developmental             final reports on how their projects have
  disabilities). This definition could be used    met these quality standards.
  to bring greater consistency to the laws
  and other public policies that govern
  this workforce.

• Data Collection Infrastructure.                “You need a whole lot of
  DOL should fund states to build
  and strengthen their data collection
                                                    patience to do this job.
  infrastructure on the direct care                 You don’t know what kind
  workforce—toward the goal of                      of day your clients are
  systematically collecting employer-
  level data on the direct care workforce
                                                    going to have, or what you
  statewide and centralizing the training           are going to be dealing with.
  and certification records of direct care          All clients are different.”
  workers (with clear privacy safeguards
  in place). This investment in state-level        RICARDO ARAUJO
  data collection infrastructure should            Home Health Aide at
  be informed by an updated, national               Cooperative Home Care
  minimum data set on this workforce                Associates, Bronx, NY
  and paired with guidance and
  requirements for reporting and analysis.

• Minimum Data Set on Direct Care
  Workers. CMS should update its
  minimum data set recommendations on
  the direct care workforce, which were
  developed in 2009 by the National Direct
  Service Workforce Resource Center.
  This set should include workforce volume,
  stability, compensation, and training/
  credentialing rates—and should account for
  workers employed across long-term care
  settings and by all employer types.

                                                         Federal Policy Priorities for the Direct Care Workforce 21
                                                                In 2009, as part of the National Direct
                                                                Service Workforce Resource Center
                                                                created by CMS, PHI developed a first-
                                                                ever, expert-informed minimum data
                                                                set on this workforce, which included
                                                                specific indicators related to workforce
                                                                volume, stability, and compensation and
                                                                a list of additional variables for more
                                                                detailed analysis.39 Additionally, our
                                                                annual research on direct care workers,
                                                                typically released the week of Labor
                                                                Day, provides a detailed and up-to-date
                                                                statistical picture for the field on direct
                                                                care demographics, occupational roles,
                                                                job quality challenges, and projected
                                                                job openings.40

 • Direct Support Professionals
    Classification. The Office of Management
    and Budget (OMB) should work with
    long-term care and workforce experts to                    (conducted in 2007), the first and only
    update the existing federal industry and                    national probability surveys focused on this
    occupational classification codes so that                   workforce.
    they characterize the direct care workforce
    more accurately. Specifically, OMB should                • New Research. HHS and the National
    establish a Direct Support Professional                   Institutes of Health (NIH) should
    Standard Occupational Classification code                 fund original studies on the direct
    to distinguish these workers from nursing                 care workforce, including studies that
    assistants, home health aides, and personal               measure workforce size and composition;
    care aides. Congress could alternatively                  consumers’ experiences with direct care
    enact and fully fund the Recognizing the                  workers; and a variety of other vital,
    Role of Direct Support Professionals Act,                 understudied topics.
    which accomplishes this goal.37 This action              • Lessons Learned Report. HHS should
    would help researchers and other leaders                  commission and release a report on
    measure and describe the workforce                        lessons learned from the COVID-19
    capacity for supporting individuals with                  crisis related to direct care workers,
    intellectual and developmental disabilities.              building on the final report to CMS from
 • National Direct Care Surveys. The                         the Coronavirus Commission for Safety
    National Center for Health Statistics at the              and Quality in Nursing Homes and the
    CDC should re-issue its National Nursing                  upcoming report from the Committee
    Assistant Survey (conducted in 2004)                      on the Quality of Care in Nursing Homes
    and National Home Health Aide Survey                      at the National Academies of Sciences,
                                                              Engineering, and Medicine.38

22 Federal Policy Priorities for the Direct Care Workforce
Center Direct Care
Workers in Leadership
Roles and Public Policy
 irect care workers are experts on their jobs and care delivery,
and they should help define the future of this workforce.

 As the paid frontline of long-term care for      leaders should create workgroups to
 older adults and people with disabilities,       develop action plans to improve these
 direct care workers possess unique insights      jobs—and include workers front and
 on how to improve the quality of their jobs      center in these groups. Divisions of paid
 and the delivery of care. Unfortunately,         care can be instituted at different levels of
 their experiences and wisdom are often           government with the remit of supporting
 left out of the discussions and initiatives      direct care workers, childcare workers, and
 shaping policy and practice in this rapidly      housekeepers to access their rights and
 growing job sector. To address these             benefits, among other offerings. Finally,
 problems, a variety of mechanisms exist to       direct care workers should be tapped for
 center direct care workers in leadership         key advisory roles and leadership positions
 roles and public policy. Federal and state       across the public and private sector.


         16                                1                                     38%
    Number of statewide           Number of divisions of               Turnover rate in worker-owned
   direct care workgroups        paid care that have been                 home care cooperatives,
  that have been convened       created at either the local,           compared to the turnover rate
         since 2003.41            state, or federal level.42           of 65 percent or higher in the
                                                                         broader direct care field.43

                                                               Federal Policy Priorities for the Direct Care Workforce 23

   • National Strategy on the Direct                          his council should include direct care
     Care Job. HHS should develop a national                   workers themselves, and its strategy should
     direct care workforce strategy, convening                 include identifying funding for the council’s
     a stakeholder advisory council to identify                recommendations, producing regular
     actions that government, providers, public-               progress reports, and developing new
     private sector organizations, philanthropy,               recommendations as needed. This council
     and others can take to completely                         could take on some of the challenges
     transform the direct care job.                            described above, including the national
                                                               compensation strategy, competency-based
                                                               training standards, and updated workforce

“If I could make a change, it                                • Paid Care Division. DOL should establish
  would be for this field to show                              a division of paid care to work with
                                                               states and localities in assisting direct
  more appreciation for what we                                care workers, childcare workers, and
  do, because we are the main                                  housekeepers with legal and employment
  backbone of this work. We’re                                 concerns, building on the successful model
  the most hands-on with clients                               in New York City.44 This division would
  and spend more time with                                     also educate and support employers in
                                                               fulfilling their responsibilities, and monitor
  them than anyone else.”                                      trends and new developments across these
MICHELLE GODWIN                                                job sectors. As one example, the division
 ertified Nursing Assistant
C                                                              could continue monitoring compliance
Killearn Lakes, Tallahassee, FL                                with the “Home Care Final Rule” that went
                                                               into effect in 2015, extending wage and
                                                               overtime protections under the Fair Labor
                                                               Standards Act (FLSA) to home care workers

                                                              • Domestic Worker Rights. Congress
                                                               should enact and fully fund the Domestic
                                                               Workers Bill of Rights Act, which would
                                                               provide a number of rights and protections
                                                               for home care workers, childcare
                                                               workers, and housekeepers related to
                                                               compensation, worker protections, sick
                                                               leave, discrimination, privacy, health and
                                                               safety, and more.46

 24 Federal Policy Priorities for the Direct Care Workforce
                                                 In 2020, PHI launched the Direct Care
                                                 Worker Story Project, which works with
                                                 direct care workers nationwide to document
                                                 their stories and share their ideas for
                                                 transforming their jobs.48 This project aims
                                                 to enhance the visibility of this workforce,
                                                 amplify workers’ voices, and draw on
                                                 their unique wisdom to inform policy
                                                 and practice. Our multi-state advocacy
                                                 initiative—Essential Jobs, Essential Care—
                                                 has also ensured that workers are centered
                                                 as experts and advocates in state-level
                                                 advocacy.49 As one example, direct care
                                                 workers led panels during the first statewide
                                                 gatherings for this initiative in early 2021,
                                                 grounding these conversations in their
                                                 frontline experiences.

• Statewide Workgroups. DOL should fund
 states to establish and maintain statewide
 workgroups focused on the direct care           • Leadership Development. DOL should
 workforce.47 These workgroups should              fund leadership development programs for
 bring together diverse stakeholders across        direct care workers to build their leadership
 the state to assess the direct care workforce     and advocacy capacities, while connecting
 landscape and identify an expansive set of        this program to leadership positions in
 policy recommendations to improve these           government and the community.
 jobs. Workgroups could also advocate
                                                 • Policy Events. DOL and HHS should
 together to advance these ideas and
                                                   hold regular convenings, hearings, and
 identify new possibilities as they emerge.
                                                   briefings on various topics related to the
• Stakeholder Advisory Groups. HHS and            direct care workforce, including but not
 DOL should require that grantees leading          limited to staffing challenges, training and
 projects that involve direct care workers         advancement, data collection and research,
 form stakeholder advisory groups that             equity and inclusion, and much more.
 include these workers.                            These events should allow for public input
                                                   and engagement.

                                                           Federal Policy Priorities for the Direct Care Workforce 25
Rectify Structural
   Gender and Racial
   Inequities for
   Direct Care Workers
     Women, people of color, and immigrants in the direct care
     workforce merit more attention and support.

    Systemic racism has long harmed the                              political climate has become increasingly
    lives and jobs of people of color in direct                      hostile to immigrants in recent years,
    care—from the creation of these poor-                            limiting targeted supports for immigrants
    quality jobs, through the decades-long                           who are a critical part of this workforce.
    exclusion of home care workers (and other                        Despite these numerous challenges, policy
    domestic workers) from federal wage and                          and practice interventions aimed at direct
    overtime protections, to the widespread                          care workers do not often account for the
    racial discrimination that people of color                       unique structural barriers and inequalities
    and immigrants continue to face regarding                        they face on the job and in their daily lives,
    employment, housing, education, and                              limiting the evidence base on race and
    health care, among others. Additionally,                         gender-explicit workforce interventions in
    caregiving has historically been defined as                      this sector. When focusing on direct care
    “women’s work” and is still often dismissed                      workforce development, we must center
    as a labor of love that requires only minimal                    and uplift women, people of color, and
    compensation and support, perpetuating                           immigrants—these workers deserve good
    poor job quality in this sector. Finally, the                    jobs rooted in equity and justice.


        $11.13                                               53%                     $37,600
        Median hourly wage                           Percentage of women                Median family income
    for home care workers who                     of color home care workers          for women of color home
    are women of color, versus                     living in or near poverty,        care workers, compared to
       $12.38 for white men.                           compared to 38%                 $47,100 for white men.
                                                         of white men.

26 Federal Policy Priorities for the Direct Care Workforce

• Pathway to Citizenship. Congress should        African-American, Asian, American Indian/
 enact and fully fund the U.S. Citizenship Act    Alaska Native, Middle Eastern/North
 of 2021 to provide a pathway to citizenship      African, and Native Hawaiian or Other
 for approximately 11 million undocumented        Pacific Islander), immigrants, and LGBT
 immigrants, including direct care workers        populations, as key examples.
 (classified as “essential workers”).51
                                                 • Workplace Violence Prevention.
• Immigrant Supports and Building                Congress should enact and fully fund the
 the Pipeline. HHS should fund measures           Workplace Violence Prevention for
 that support immigrant direct care               Health Care and Social Service Workers
 workers, including immigrant-specific            Act, which would require DOL to recognize
 workforce programs in direct care. The U.S.      and address workplace violence in health
 Department of State should create special        care, social service, and other sectors.
 visas for direct care workers that would
 build the pipeline for this workforce;
 these visa programs should include
 strong worker protections and should not         “Ten years ago, I came to America
 tie an immigrant worker’s immigration
 status to their employer.52
                                                    with the hope of pursuing a good
                                                    life and happiness, as I believe
• Research on Immigrants and the                   this is the land of opportunity as
 Gray Market. BLS, the U.S. Census                  long as you work hard for it, using
 Bureau, and other agencies should
 integrate additional questions related to          the knowledge and skills that
 immigrants in relevant federal surveys,            we have achieved through our
 building the knowledge on this critical            education and experiences.”
 segment of the direct care workforce.
 HHS should also fund new studies on               TERESITA SATTAR
 immigrants working on the “gray market”           Caregiver at Courage LLC
                                                   and Worker Leader at
 (where consumers directly hire home
                                                   Pilipino Workers Center,
 care workers using private funds), which          Los Angeles, CA
 would increase understanding on the
 unique challenges and characteristics
 of this nearly invisible segment of the
 direct care workforce. HHS should create
 ethical standards for conducting this
 research without threatening the safety
 and security of respondents.

• Equity-Focused Interventions.
 HHS, DOL, and ACL should invest in
 workforce interventions with explicit
 racial and gender equity lenses, including
 interventions that target different
 communities of color (Latinx, Black/

                                                          Federal Policy Priorities for the Direct Care Workforce 27
In June 2017, PHI released a first-ever research
brief on immigrant direct care workers at a time
when the political rhetoric on immigration had
become increasingly toxic. Our study offered
a new angle on this debate, generating news
coverage in media outlets like The New York
Times, Washington Post, and many others.56
Later that year, PHI launched a four-part research
series examining racial and gender disparities
within the direct care workforce, looking closely
at the distinct realities of Black/African-American,
Hispanic/Latino, and Asian and Pacific Islander
direct care workers and offering ideas for
promoting racial equity for this workforce.57

      his Act would be one step toward
     T                                                       • LGBT Protections. Congress should enact
     protecting direct care workers in                        and fully fund the Equality Act, which
     long-term care, who experience                          would ban discrimination based on sex,
      disproportionately high rates of injury                 sexual orientation, and gender identity
      on the job due to a variety of                          in public accommodations and facilities
      workplace risks.53                                      (among other areas).55 These expanded
                                                              non-discrimination protections would
 • Underserved Communities. Congress                         cover long-term care settings, where many
    should enact and fully fund the Career
                                                              LGBT direct care workers are employed
    Advancement for Direct Support Aid
                                                              and LGBT individuals reside and receive
    Workers Act, which would fund direct
                                                              services. Once enacted, the Office for
    care workforce interventions focused on
                                                              Civil Rights should provide guidance to
    education, training, and advancement,
                                                              direct care workers and their employers
    with an emphasis on communities of color
                                                              (among other stakeholders) about these
    and workers in rural areas (among other
                                                              new rights and protections.
    vulnerable populations).54

28 Federal Policy Priorities for the Direct Care Workforce
Shift the Public
Narrative on
Direct Care Workers
  o challenge unfair representations and change minds
 about direct care workers, we must invest in public education,
 capacity building, and storytelling.

 The realities and challenges facing direct       stakeholders need sufficient resources
 care workers are too often invisible in the      to launch impactful public education
 public and political discourse. Additionally,    campaigns and build their communications
 direct care is often wrongly described as        capacities to advocate for direct care
 low-skilled work, which underplays the           workforce reforms. Moreover, storytelling
 complex competencies that it requires—and        projects are a practical approach that should
 does not reflect the training, compensation,     be better funded to enhance these workers’
 or respect that direct care workers deserve.     visibility, amplify their voices, and draw on
 To positively shift the public narrative on      their wisdom to inform policy and practice
 direct care workers, advocates and other         in this sector.


      1.5 M                                 60                                     23
     Number of timeline                  Number of ideas                   Number of in-depth
     deliveries on Twitter              generated by PHI’s              direct care worker stories
 generated by PHI’s year-long           #60CaregiverIssues               published online in the
     Caring for the Future          campaign to help address              first seven months of
   report series and public           the growing workforce             PHI’s Direct Care Worker
    education campaign.              shortage in home care.                    Story Project.

                                                           Federal Policy Priorities for the Direct Care Workforce 29

   • Framing Strategy. HHS should fund a                     • Strategic Communications Capacity.
     research-based framing strategy—similar to                DOL and HHS should adequately fund
     the “Reframing Aging” initiative—to help                  grantees that are leading interventions
     develop effective, strength-based frames                  related to direct care workers to develop,
     and messages on the value and needs of                    implement, and evaluate strategic
     direct care workers.58                                    communications campaigns that integrate
                                                               framing and messaging strategy, branding
                                                               and graphic design, earned and digital
                                                               media, and more. Evaluating these efforts
                                                               would help build the evidence base on
“I do my best to build                                        how to effectively communicate about this
  relationships, and I start by                                workforce to change attitudes and beliefs
                                                               and build support. Special attention should
  thanking them for allowing me                                be given to communications campaigns
  to come in and help them.                                    that are culturally and linguistically
 I understand everybody moves                                  competent and campaigns that focus on
 differently and everybody hurts                               more invisible communities within the
 differently, and I try to be very                             direct care workforce (e.g., immigrants,
                                                               LGBT workers, etc.).
 compassionate in my care.”
 CRYSTAL PROFFITT                                             • The National Direct Care Workforce
                                                               Resource Center. HHS should
  ertified Nursing Assistant and Certified Hospice
 Palliative Nursing Assistant at Transitions                   permanently fund the National Direct Care
 LifeCare, Raleigh, North Carolina                             Workforce Resource Center, the country’s
                                                               premier online library of information on
                                                               the direct care workforce.59 Updated and
                                                               relaunched in 2020 by PHI, the National
                                                               Direct Care Workforce Resource Center
   • Market Research. HHS should commission                   supports researchers, policymakers,
     and fund a comprehensive, nationally                      practitioners, advocates, and journalists
     representative quantitative market research               in better understanding—and building the
     study on direct care workers, yielding                    knowledge base on—this critical workforce.
     insights on their values, needs, and wants.
     This study would bring visibility to this
     growing yet undervalued workforce and
     inform policy and practice, including
     recruitment and retention strategies in
     different parts of the country. Research
     on consumers’ and family caregivers
     perspectives on the direct care workforce
     would also be valuable.

 30 Federal Policy Priorities for the Direct Care Workforce
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