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Placing a Higher Value on Direct Care Workers

Home health aide helps patient in their home
  • Some 4.6 million Americans work in direct care jobs that, while in high demand, pay low wages and offer little opportunity for advancement

  • Employers and states are experimenting with ways to recognize and reward direct care workers — from offering advanced training to creating pathways for promotion and giving them a greater say in management

  • Some 4.6 million Americans work in direct care jobs that, while in high demand, pay low wages and offer little opportunity for advancement

  • Employers and states are experimenting with ways to recognize and reward direct care workers — from offering advanced training to creating pathways for promotion and giving them a greater say in management

During the pandemic, people began paying attention to the essential work done by Americans who can’t work from home. This includes the 4.6 million direct care workers who provide caregiving services to people with chronic conditions or disabilities, both in homes and residential facilities. This workforce is primarily made up of women, the majority women of color, many of whom are immigrants to the U.S. They go by different names — home health aides, personal care attendants, certified nursing assistants, or caregivers — and they provide services ranging from helping people bathe, dress, and eat to cleaning their homes and preparing meals, managing medication regimens, and providing companionship. Some are drawn to the field because of their experiences caring for family members and by the low barrier to entry; unlike some other entry-level careers in health care, direct care workers may not need training or certifications before finding work.

Still, employers struggle to recruit and retain direct care workers, in large part because median wages are only $12.27 an hour, on par with entry-level positions in retail or other fields that are much less demanding. Also, direct care jobs often don’t provide opportunities for advancement. “You go in as a home care worker earning a certain wage. You develop all that rich experience and knowledge and skills, and you are still a homecare worker earning pretty much the same wage 20 years later,” says Kezia Scales, Ph.D., director of policy research at PHI, a research and consulting nonprofit focused on the direct care workforce.

You go in as a home care worker earning a certain wage. You develop all that rich experience and knowledge and skills, and you are still a home care worker earning pretty much the same wage 20 years later.

Kezia Scales, Ph.D. Director of policy research, PHI

The demand for direct care workers will increase substantially in coming years as the population of older adults and people with disabilities in the U.S. swells. Much of the demand is expected to be for home care, as the pandemic hastens the long-term trend away from skilled nursing and other congregate-living facilities and toward home- and community-based services. Despite the shortage of staff, wages for direct care workers have remained flat. This is in large part because payment for direct care providers is mainly determined by states through their Medicaid long-term services and supports (LTSS) programs, which offer a range of benefits for those with disabilities and other conditions. “The funding comes up against other budgetary and political priorities,” says Scales. “And as the largest payer, Medicaid sets the industry standard for direct care wages.”

In an attempt to improve working conditions for direct care workers, the Department of Labor in 2015 extended the Fair Labor Standards Act to make home care workers eligible for the federal minimum wage and overtime. A 2020 Government Accountability Office found that many state Medicaid programs responded by limiting home care workers’ hours to avoid paying overtime, forcing some to cobble together different jobs to get by. In some places, direct care workers have won certain rights (e.g., health benefits or paid time off) as members of unions, but in some states they are barred from unionizing. An unknown number work for cash in private homes with little supervision or training.

Some employers gave direct care workers bonuses or hazard pay as they continued to show up for work during the pandemic, but there is growing consensus that policymakers and health care payers need to do more to recognize and reward the vital role direct care workers play in the health care continuum. Citing the need to bolster the “care infrastructure,” the Biden administration and Democratic members of Congress have called for a $400 billion investment to expand access to LTSS and increase wages and benefits for direct care workers. This issue of Transforming Care profiles efforts by employers and states to document direct care workers’ contributions and create new career pathways by offering them training and opportunities for advancement.

Innovative Approaches

In this section, we examine innovative approaches taken by four organizations that employ different types of direct care workers: aides who support people with chronic physical and/or behavioral health conditions in their homes, personal care attendants who support people with intellectual and developmental disabilities, and certified nursing assistants who work in skilled nursing facilities.

Homebridge: Creating Pathways to Higher-Paid Careers

Homebridge is a San Francisco–based agency that provides in-home supportive services each year to some 1,000 to 1,200 people with physical or cognitive disabilities that are often exacerbated by behavioral health problems and substance use disorders. Recruiting staff is an ongoing challenge. Some clients live in single-room occupancy hotels where there may be cockroaches, bedbugs, or other pests; others have such severe psychological or behavioral disorders that their functioning can change from day to day. “One day, they will let you in. The next day, the door will be slammed in your face,” says Simon Pitchford, Ph.D., Homebridge’s chief operating officer.

Given the challenging working conditions and the fact that many less-demanding jobs pay San Francisco’s relatively high minimum wage ($16.32 per hour), Homebridge’s leaders have taken an innovative recruitment approach: presenting the job as a gateway to other, more lucrative positions in health care. Homebridge offers a training program for its caregivers to help them become certified nursing assistants (CNAs) and eventually leave for higher-paid careers.

The Skills-Training and Employment Pathways to Success (STEPS) program was launched in 2018 in partnership with the City of San Francisco. The agency offers the free program to people who work for at least four months, have a good attendance record, and receive a supervisor’s recommendation. The curriculum covers topics like infection control, working with mechanical lifts, and self-care. It has four tiers: 1) basic training to work with any client, which starts upon hire; 2) training to support clients with mental health and substance use disorders; 3) training for clients with complex paramedical needs (e.g., for ostomy care); and 4) supplemental training to qualify for the CNA certification (a collaboration with City College of San Francisco).

Homebridge offers its caregivers a free training program to help them increase their skills, earn higher wages, and — if they choose — become certified nursing assistants and find higher-paying careers.

Homebridge offers its caregivers a free training program to help them increase their skills, earn higher wages, and — if they choose — become certified nursing assistants and find higher-paying careers. Source: Homebridge

Homebridge also raised caregivers’ starting wage, which is now $19.25, and increases wages as staff progress through the STEPS program. About 30 percent of those who have gone through the training have become supervisors, earning up to $28 an hour. Participants can also receive coaching to discuss career options, build their resumes, and complete mock interviews. “The whole idea is to change the perception of caregiving from being a single-tier minimum wage job to one where we are going to bring you in, train and upskill you, help you get certified, and then help you find your next step into a health care position,” says Pitchford.

An evaluation of the STEPS program found it changed Homebridge caregivers’ perception of their role. While some said they previously felt like housekeepers, gaining new skills made them feel more like nurses or paramedics. After one year, recruitment levels hadn’t changed much although retention improved somewhat, particularly during caregivers’ first six months when they may feel overwhelmed. The program may also be attracting younger workers: after it launched, new hires were twice as likely to be under age 26, outnumbering older age groups.

Within six months to a year after becoming Homebridge clients, people tend to have more stable lives, as measured by an average 51 percent reduction in hospitalizations and a 44 percent reduction in emergency department visits; clients are also less likely to miss doctors’ appointments (51%) or medication doses (52%). Most of the agency’s funding comes from San Francisco County’s Department of Disability and Aging Services for in-home supportive services. Its 300-plus caregivers are members of the local service workers’ union.

Cooperative Home Care Associates: Empowering Direct Care Workers

Cooperative Home Care Associates (CHCA) of New York City is the nation’s largest worker-owned cooperative, with 1,700 staff. Nearly all of CHCA’s clients — older adults and those with chronic conditions and/or disabilities — are covered by Medicaid or dually covered by Medicaid and Medicare. The company builds its staff pipeline through a free, four-week training program (funded in part through philanthropy) in which 600 people, mostly low-income women of color, earn certificates as personal care aides and home health aides each year, with guaranteed jobs for graduates interested in serving clients in Manhattan, Brooklyn, and the Bronx.

CHCA aides are members of 1199SEIU, the local service workers’ union, and their starting hourly wages are $15; they also receive dental, health, and life insurance benefits and paid time off. Employees can buy into the coop, which gets them voting rights and dividends when the coop is profitable; the latest dividends were $684 (in 2016), $298 (in 2017), and $292 (in 2018).  Workers also receive financial literacy education and can access no-interest emergency loans, providing an alternative to predatory “payday” loans. Many aides advance to work as administrators, peer mentors, or other higher-paid positions within the agency.

In 2019, CHCA partnered with the nonprofit PHI and Independence Care System (ICS) — a nonprofit that offers care coordination services for older adults and people with disabilities in New York City — to create a three-month training program for aides to become care coordinators, envisioned as a bridge between the aides and other health care professionals. Leaders recognized that their aides were often the first to notice changes in clients’ conditions, but they sometimes struggled to know how or when to speak up. “We always believed that a home care worker is an integral part of the health care team,” says Latifa Beato, M.P.A., R.N., vice president of client services at CHCA. “But how do we take that role and bring it into the health care team when they’re working in the patient’s home largely unsupported?” The agency created a triage system so that aides could share their observations with care coordinators. Care coordinators also check on any patient that has had an emergency department visit and provide help in getting needed medications or making medical appointments.

As part of an early pilot of the concept, PHI trained aides from three home health agencies including CHCA to work with 1,400 clients of ICS. A study found the pilot was associated with an 8 percentage point decline in the rate of emergency department visits and reduced family caregiver strain among at least half of those involved.

Q&A: Creating Bridges to Aides Working in Homes and Pathways to Advancement

CHCA partnered with the nonprofit research and consulting nonprofit, PHI, to create a training program for its aides to serve as care coordinators. They received 240 hours of training in chronic disease management and communication skills, as well as observation and reporting skills. The graduates were promoted to salaried positions and now offer coaching and support to home care workers and facilitate transitions in care for clients who have been discharged from the hospital or emergency department. Transforming Care spoke with CHCA’s three care coordinators: Yudelka Gomez, Marisol Rivera, and Rokhaya Sarr. One of them, Gomez, also sits on CHCA’s 14-member governing board, one of eight aides elected to help make decisions about the agency’s budget, executive management, and acquisitions.

Transforming Care: How did you become a home health aide?

Marisol Rivera: I was working as a volunteer in the Alzheimer’s department of a nursing home. One day, there was a work fair and it so happened CHCA had a table. I thought: this is something I enjoy doing, why not get paid for it? I came to the office for an interview and have been here since 1998. I loved the training. A lot of the ladies who were in the training became close friends. We called each other whenever we were confused at the start.

Rokhaya Sarr: I was working in a restaurant and after that I was working in a 99-cent store that my husband opened. One of my friends told me about the program and the benefits. I was very excited about the benefits. That’s why I came in. One of the first things I heard was that you could have a share in the company. Three or four years ago I went to see my mom back home in Senegal and one of my coworkers called me while I was there and said “Guess what? We got a dividend of a thousand dollars.” I was so happy. It helped me a lot.

Transforming Care: Before you became care coordinators, you worked as a home health aide for years. Can you give us a sense of what the job was like?

Rivera: I usually worked close to my home. You don’t realize how many people receive services in your own backyard. It exposes you to different cultures and different people. I remember one client who couldn’t communicate and was in a lot of pain. She frightened away a lot of home health aides and would get very frustrated with me. I would tell her I’m trying to do my best to help you. After she saw that I wasn’t going to leave her, her behavior changed. She came to trust me, and I always looked forward to going to work. Just before she died, she asked me to call people to say goodbye or just reach out. Because I had learned to read her lips, I could tell them what she wanted them to know.

Transforming Care: It sounds like you have to have a lot of patience. Is that part of the training?

Rivera: I think this is something that is me. It just comes naturally. I’ve always wanted to help even when I need help myself. Sometimes I say, “What am I getting myself into?” but I always manage to get through it.

Transforming Care: All three of you now work as care coordinators, fielding calls from home health and personal care aides in the field. Can you give us a sense of what you do day to day?

Sarr: We have to make sure that the member is safe in the community and avoids unnecessary hospitalization. Sometime the follow-up is quick and sometimes it’s not because there’s a lot of phone calls we have to make. If the client is requesting some medication, we have to call the doctor. We schedule transportation. It was smoother before the pandemic. Now you could spend two or three hours just for one client. Sometimes you are on hold for 40 minutes just waiting for someone to take the call.

Gomez: We also help home health aides when a client refuses to take medication or refuses to seek medical attention. When I was a home health aide, I was always trying to explain the good side of taking the medication or going to the doctor. With the pandemic, they were afraid to go outside, especially last year. Now it’s getting a little better. We also advised staff about how to use the PPE [personal protective equipment]. We told them to always wear the mask and all the equipment, especially at the beginning because we didn’t know how serious it was. We always encourage them to use the masks, to wash their hands, to use the gloves and gown when needed, and to report anything, any symptoms they notice in the clients. Now they’re getting vaccinated and they feel a bit more safe.

Transforming Care: What would make it easier for you to do your job or help you be more effective?

Rivera: It would really help if case managers at insurance companies could address things right away. Many of our clients rely on wheelchairs to meet their mobility needs. If their wheelchair isn’t working properly, the aide is not allowed to take the member out in the wheelchair. It takes a lot of time for them to do something about that. If they can’t use the wheelchair because of safety concerns — maybe it doesn’t have a seatbelt or a footrest — the client can’t get to the doctor. Or someone may be waiting for wound care to come. We try to help as much as we can by calling the doctors, getting prescriptions, making sure they received it, and asking supply companies how long it is going to take.

Transforming Care: It sounds like you’re caught between systems that don’t always work well. What do you think makes you successful in your job?

Sarr: You really have to put your heart into it. You have to put yourself in the same shoes as the client to be able to do what you’re supposed to do. The clients are so grateful. I have heard clients say, “If it were not because of you, I would not be able to stay at home safely.” When they say something like that, I am very proud of myself.

Gomez: When you call a person and they are grateful for what you did for them and they tell you you’re helping them — that’s my joy. And the aides too. We call them and let them know, whatever issues you have, we are here for you. I wish we would get more recognition for the type of job we do. Aides out there that deal with this every day, it’s a hard job to do. Getting paid a decent salary would be very helpful.

Trinity Health Senior Communities: Smoothing Care Transitions

CNAs work in skilled nursing facilities, caring for long-term care residents as well as those who come to rehabilitate after a hospitalization. For these rehab patients, the transitions from a hospital to a skilled nursing facility and then home can be stressful at a time when they may feel unwell, may be functionally impaired, and may struggle to understand their treatment regimen. These and other factors make avoidable complications and unplanned hospital readmissions common.

Starting in 2017, Trinity Health Senior Communities, which operates skilled nursing and other facilities for older adults in six states, piloted a program to train and deploy CNAs as “transitions specialists,” shepherding rehab patients from the hospital through their Michigan skilled nursing facilities and then home. Trinity won a $1.5 million grant from Michigan to pilot the program.

Trinity recruited 12 CNAs, both internal candidates and new ones, to work in each of two facilities as transitions specialists. The nonprofit PHI developed a one-week training program to help the CNAs understand and report changes in three common chronic conditions among older adults: heart failure, diabetes, and chronic obstructive pulmonary disease. The training included case studies as well as coaching on effective communication approaches with patients and other members of the care team.

Trinity Health Senior Communities trained CNAs to serve as transitions specialists, helping people navigate their moves from a hospital to skilled nursing facility then home.  Source: Trinity Health Senior Communities.  

Before the admission of a new rehab patient, the transitions specialists work with admissions staff to understand their prognosis and discharge instructions; the specialists then meet patients upon their arrival at the skilled nursing facility. They use a survey to assess patients’ preferences and emotional and mental state and then ensure they get appropriate care, meals, and needed supplies. Importantly, the transitions specialists do not do the regular work of a CNA (e.g., bathing or delivering meals), instead checking in on each of their patients every day, participating in conferences with other members of the care team, and interacting with family members. They work with rehab patients for 30 days after their discharge to their homes, calling them to make sure they are stable and have the support they need.

According to Rakhi Sharma, Ph.D., operation lead, the CNAs initially found the new position hard but grew to love it. “This position gave them so much opportunity and empowered them,” she says. “Now they feel more like an advocate for the patient.” An external evaluation found this approach was associated with lower hospital readmission rates as well as greater satisfaction among rehab patients, who described transitions specialists “as their voice” and “go-to person.” The transitions specialists earned about $3 more per hour than CNAs, adding $5,000 to their annual income.

With the pilot nearly complete, most of the transitions specialists have moved on to better jobs, some within the same skilled nursing facilities, or to higher training (two are pursuing bachelor’s degrees and several are going back to nursing school). Sharma hopes to secure operational funding to expand this approach to more of Trinity’s facilities.

Core Services of Northeast Tennessee: Leveraging Technology and Person-Centered Care

Core Services of Northeast Tennessee, based in Johnson City, employs 110 direct support professionals to care for 44 people with intellectual and developmental disabilities (IDD), most in supported-living homes managed by the agency. Core Services’ work is funded entirely through Tennessee’s Medicaid program.

Prompted by the state’s efforts to improve quality of life and encourage independence among people with IDD, the agency has undergone a transformation in recent years (see more on Tennessee’s Employment and Community First CHOICES Program in our report on models of care for people living with disabilities). In 2016, Core Services’ leaders, direct support professionals, and their supervisors embraced the concept of person-centered care, pursuing training offered by the state and the Council on Quality and Leadership. According to Susan Arwood, M.S., the agency’s executive director, this brought about a cultural shift, leading to changes in the way staff describe the people they serve (e.g., not using possessive words such as “my client”), new supports to help people with IDD find jobs (42 percent now work, up from none in 2015), and accommodating their desire for independence (eight moved into their own apartments).

Direct support professionals at Core Services of Northeast Tennessee help people with intellectual and developmental disabilities find jobs and live as independently as they wish.

Direct support professionals at Core Services of Northeast Tennessee help people with intellectual and developmental disabilities find jobs and live as independently as they wish. Source: Core Services of Northeast Tennessee

Direct support professionals’ jobs also evolved as the agency adopted enabling technology to help people with IDD gain independence. Tablets that allow video communication, smart technology to lock and unlock doors, and automated medication dispensers reduced the need for round-the-clock support and led to total savings of about $10,000 per week. Rather than cutting staff hours or positions, Core Services promoted 10 direct support professionals into supervisory or other positions. Leaders have also used the savings to improve employee benefits: keeping their required contributions to health insurance premiums flat, sponsoring a life insurance program, and starting a retirement savings program with an employer match. (Nationally, only 15.6 percent of direct care workers receive retirement benefits from their employers.)

Leaders also adopted a person-centered approach to managing staff, setting up a worker council that meets each month to discuss problems and share ideas. Managers have acted on suggestions that emerge from these meetings, such as offering bonuses to people working extra overtime and allowing more flexible work schedules. “I think one of the things that’s really impacted our retention is people see us being receptive to their ideas and concerns,” says Arwood. Over the past four years, turnover rates fell by 50 percent. Vacancy rates for staff are well below the national average: 4 percent versus numbers in the teens, according to Nick Filarelli, program director. “We discovered that as the people we support became happier, we had a happier workforce and overtime rates, our turnover rate — everything went down,” Arwood says.

Starting pay for Core Services’ direct staff professionals is about $11 an hour, which is $1 to $1.50 more than other local agencies, according to Filarelli. Staff receive 75 cents per hour raises if they complete training with the National Alliance for Direct Support Professionals (about 15 percent have done so). During the pandemic, leaders used a Paycheck Protection Program loan to give workers three bonuses and retention rates held steady.

State and Local Efforts to Bolster Direct Care Workforce

Given constraints on Medicaid funding, employers face challenges as they experiment with ways to better reward direct care workers and more effectively leverage their skills. Some programs rely on time-limited public or philanthropic funding. Documenting how better training or higher wages for direct care workers can improve people’s health and quality of life could encourage more stable funding for home care services, but getting the data needed to make the case has been a challenge for some employers.

Leaders at New York City’s CHCA, for example, have been working to document the value of their care coordinators and other direct care staff by demonstrating they can help avoid medical complications. But hospitals and other health care providers may not include home care as part of the health care continuum, for example by not sharing medical records. This can make it hard for home care providers to compile a complete picture of clients’ health. There’s also the difficulty of trying to prove a negative (e.g., demonstrating why someone didn’t fall or develop complications) without conducting what can be expensive research trials. And affording the technology platforms to document direct care workers’ efforts is also challenging, according to CHCA’s Beato. Instead of a narrow focus on health care utilization, she would also like to see measurement of how home health aides affect people’s quality of life, such as whether they “honor and respect people’s values and preferences and allow them to direct their own care as much as they can.” she says. “Recipients of long-term care services have the right to age in their communities with dignity, respect, and independence.”

Some states have sought to bolster their direct care workforce by enhancing reimbursement or developing standardized training approaches. For example, Minnesota requires those who employ personal care attendants to care for people with disabilities to spend at least 72.5 percent of their Medicaid reimbursement on aides’ wages and benefits, while New Jersey established a minimum hourly reimbursement rate for personal care services delivered under Medicaid managed care.

Other states, including Washington and Tennessee, have sought to develop training programs for direct care workers that link to advancement opportunities and/or wage increases. In 2018, Wisconsin developed a multifaceted approach to recruiting and retaining more people to work as CNAs in skilled nursing facilities (SNFs), based on evidence that they would soon be unable to meet demand. The state launched a marketing campaign for WisCaregiver Careers, using videos to illustrate the rewards of being a CNA and highlighting the fact it could be a pathway to a health care career. The state then offered free training and testing to certify people to become CNAs; they received 9,000 registrants — far more than anticipated or budgeted to pay for. “It caught us by surprise based on the low unemployment rates at that time,” says Kevin Coughlin, policy initiatives advisor for Wisconsin’s Department of Health Services. Eventually, 3,200 enrolled and most (71%) completed the training program and became CNAs.

The state also offered support to SNFs on best practices for recruitment and retention through webinars and other online resources. Participating SNFs paid $500 bonuses to CNAs who were still working in their facilities after six months. Wisconsin paid for WisCaregiver Careers in part using funds from the Civil Money Penalty program, which are collected from SNFs that are out of compliance with regulations. While other states have expressed interest in this approach, the Centers for Medicare and Medicaid Services has indicated these funds cannot be used to pay for training programs, Coughlin says.

Youtube poster

Wisconsin created marketing videos as part of a campaign to recruit and train more people for careers as certified nursing assistants. Source: Wisconsin Department of Health Services.

Lessons and Policy Implications

There are several ways to build on efforts to better support direct care workers and leverage their experience in supporting older adults and those with disabilities as part of health care teams. 

Increase Medicaid reimbursement in ways that benefit direct care workers.

The Biden administration’s proposal to add $400 billion to spending on Medicaid long-term services and supports has been welcomed by advocates. But they note it matters how and where that money is invested.

Patti Killingsworth, assistant commissioner of Tennessee’s Medicaid and chief of long-term services and supports, says the federal government could provide targeted incentives, such as increasing matching funds for states that offer wage increases or other investments in their direct care workforce. For example, Killingsworth would like to see incentives for providers to use enabling technologies like those adopted by Core Services of Tennessee. “Enabling technologies can support greater independence and safety for people who need LTSS,” she says. “They will never replace the direct support professional workforce, but they have great potential to maximize the efficiency of services and supports, improve quality of life for those receiving LTSS, and allow us to better target resources where needed.”

Anne Tumlinson, M.A., CEO of ATI Advisory and an expert on aging and disability policy, calls for a rethinking of how we as a country finance LTSS — starting with envisioning the types and amounts of in-home and residential services we want. “There’s a planning exercise we need to do,” she says. “We also need to determine the public commitment that has to be made to get the capital and the workforce we need.”

Shine light on direct care workers’ role in improving quality of life and care.

As described above, there have been many discrete efforts to increase recruitment and retention of the direct care workforce and to give them more technical skills and supports to do their jobs. But there are few rigorous evaluations of what seems to work. Since little is known about this workforce, they tend to get left out of health policy debates and their contributions to supporting people’s health and wellbeing go unrecognized.

Killingsworth calls for an accounting of the home- and community-based workforce, similar to how the federal government requires skilled nursing facilities to report on CNA and other staffing levels. “Having this would help us measure the effectiveness of interventions,” she says. Waivers for home- and community-based services would provide a mechanism by which the federal government could require collection of data on direct care workers and their roles. States could also ask health plans to collect such data and report on the metrics they use to measure their impacts, as some states have done with community health workers.

Having a better picture of the direct care workforce would enable employers to make the case to government and private investors for investing in them, says Scales of PHI. Right now, she says, “It’s almost impossible to quantify or monitor conditions of care for people who are receiving direct care services or the working conditions for those providing them.” And the federal Center for Medicare and Medicaid Innovation could play a role in developing and testing new ways to support the direct care workforce, for example ones that hold employers and health plans accountable for worker satisfaction, programs that incentivize training, or pay-for-performance programs involving direct care workers.

Training, supervision, and closer coordination with health care teams are needed.

Advocates note that better pay is only part of the solution; direct care workers also need high-quality training programs and meaningful advancement opportunities. The examples described here suggest it’s possible to build career pathways for direct care workers, but that may mean losing them to other fields.

Henry Claypool, policy director of Brandeis University’s Community Living Policy Center and an advocate for people living with disabilities, notes that training for different roles is highly individualized, which could make it hard to develop standardized programs. Vendors like CareAcademy have emerged to try to thread this needle, creating hundreds of training modules for personal care attendants, home health aides, and other caregivers to complete on their mobile devices. “What we have not seen enough of is workforce training groups collaborating with consumers to develop training modules for people self-directing their own services,” Claypool says. This is important because with greater consumer direction, direct care workers could play new roles — for example helping clients who live in food deserts find healthy food or helping those with physical disabilities find movement classes or mobility training.

Care Heroes Mobile Platform

Care Heroes Mobile Platform Source: Care Heroes

Employers should also offer more supervision and support for direct care workers, particularly those working in private homes. Technology could help here, too. Care Heroes is a mobile platform that creates a communication bridge between home caregivers and the care managers employed by home health agencies or health plans. It also enables caregivers to document the work they do and earn financial rewards for things like reporting safety hazards or helping schedule wellness visits. “Providers and health plans can actually get real-time data coming directly from the home,” says Chiara Bell, J.D., founder and chief executive officer of Care Heroes. “The incentives are an entry point that then can drive all the other pieces you want to touch.”

Ultimately, efforts to recognize and reward direct care workers — who are largely women of color — are part and parcel of dismantling structural racism and sexism in our society and in our health care system. The conversation must consider the high value we put on expensive interventions when people are sick and lesser value we put on services to help people stay well. “I don’t think that as a health care system we really understand the value of caregiving in keeping people well,” Beato of CHCA says.

Publications of Note

Pharmacy Deserts More Common in Black and Hispanic/Latino Neighborhoods

A study examining the availability of pharmacies in 30 of the most populous cities in the U.S. found there were disproportionately more pharmacy deserts in Black and Hispanic/Latino neighborhoods than in white neighborhoods or those where no one group made up a majority. The disparities in access to pharmacies were most pronounced in Chicago, Los Angeles, Baltimore, Philadelphia, Milwaukee, Dallas, Boston, and Albuquerque. The researchers also found that Black and Hispanic/Latino neighborhoods were more likely to experience pharmacy closures than other neighborhoods. The authors suggest various ways of encouraging pharmacies to locate in pharmacy deserts, including using targeted grants and tax incentives or increasing Medicaid and Medicare reimbursement rates for pharmacies most at risk for closure. Jenny S. Guadamuz et al., “Fewer Pharmacies in Black and Hispanic/Latino Neighborhoods Compared With White or Diverse Neighborhoods, 2007–15,” Health Affairs 40, no. 5 (May 2021):802–11.


Recommendations for Accelerating Innovation Through CMMI

In a commentary in the Journal of the American Medical Association, two former directors of the Center for Medicare and Medicaid Innovation (CMMI) — Donald M. Berwick, M.D., and Rick Gilfillan, M.D. — suggest ways the agency could be more successful in promoting health system transformation. Among their recommendations: making some models such as accountable care organizations for clinicians and hospitals participating in Medicare mandatory; sponsoring models that take direct aim at improving health equity; encouraging models focused on delivery system redesign not just payment reform; and changing evaluation methods and cycle times to maximize the speed with which new ideas are tested, evaluated, and scaled. Donald M. Berwick and Rick Gilfillan. “Reinventing the Center for Medicare and Medicaid Innovation,” Journal of the American Medical Association 325, no. 13 (April 2021):1247–8.


Spending on Imaging and Lab Tests Increased with Acquisition of Physician Practices

A study of referral patterns following the acquisition of physician practices by hospitals and health systems found a change in ownership was associated with changes in the site of care and Medicare reimbursement for 10 common diagnostic imaging and laboratory services. After vertical integration, the number of diagnostic imaging tests performed in a hospital setting each month increased by 26.3 per 1,000 attributed Medicare beneficiaries and the number performed in a non-hospital setting decreased by 24.8 per 1,000. At the same time, hospital-based laboratory tests increased by 44.5 per 1,000 and non-hospital-based laboratory tests decreased by 36.0. The researchers also found average Medicare reimbursement rose by $6.38 for imaging tests and $0.57 for laboratory tests, which translates to $40.2 million and $32.9 million in Medicare spending. The study examined all Medicare fee-for-service claims data from 2013 to 2016. Christopher M. Whaley et al., “Higher Medicare Spending on Imaging and Lab Services After Primary Care Physician Group Vertical Integration,” Health Affairs 40, no. 5 (May 2021):702–9.


Hospital Employment of Physicians Associated with Inappropriate Diagnostic Imaging

Using claims data from 2009 to 2016, researchers found the odds of a patient receiving an inappropriate referral for magnetic resonance imaging (MRI) for lower back pain, knee pain, and shoulder pain increased by more than 20 percent after a physician transitioned to hospital employment. Most patients who received an MRI referral by an employed physician obtained the procedure at the hospital where the referring physician was employed. Gary J. Young et al., “Hospital Employment of Physicians in Massachusetts Is Associated with Inappropriate Diagnostic Imaging,” Health Affairs 40, no. 5 (May 2021):710–8.


Hospitals Acquired By Private Equity Firms Tend to be Larger and More Profitable

A study examining the financial and operational differences between short-term acute care hospitals that were acquired by private equity firms between 2003 and 2017 and those that were not found the acquired hospitals were larger and had more discharges and full-time-equivalent staff. Researchers found the acquired hospitals had higher charge-to-cost ratios and higher operating margins, a gap that widened during the study period. The study looked at 42 private equity deals involving 282 hospitals across 36 states. Anaeze C. Offodile et al., “Private Equity Investments in Health Care: An Overview of Hospital and Health System Leveraged Buyouts, 2003–17,” Health Affairs 40, no. 5 (May 2021):719–26.


ED Visits for Patients with Diabetes Decline After Consultation with a Pharmacist

A study that examined whether integrating pharmacists into care teams reduced ED utilization and hospitalization rates for patients with poorly controlled diabetes found in the year following a consultation with a pharmacist, the predicted number of ED visits fell by 21 percent. The researchers found the consultations produced a nonsignificant reduction in hospitalizations of 3.2 percent. Gerado Moreno et al., “Reducing Emergency Department Visits Among Patients with Diabetes by Embedding Clinical Pharmacists in the Primary Care Teams,” Medical Care 59, no. 4 (April 2021):348–53.


Postacute Care Stays May Be Longer Than Necessary

Medicare fee-for-service beneficiaries who were discharged from skilled nursing facilities to home before their cost-sharing obligations kicked in did not experience higher rates of death, hospitalization for fall-related injuries, or all-cause hospitalization within nine days of discharge compared with patients who had supplemental coverage that assumed more of the cost of longer stays, researchers found. For patients without supplemental coverage, the study showed a spike in discharges around day 20, when cost-sharing obligations began. Brian E. McGarry et al., “Nursing Facility Stays Suggest Potential for Improving Postacute Care Efficiency,” Health Affairs 40, no. 5 (May 2021):745–53.


Despite Affordable Care Act, Many Women Receiving Prenatal Care Through Medicaid Lacked Coverage Before and After Birth

A study of women whose prenatal care was covered by Medicaid between 2015 and 2018 found 26.8 percent were uninsured before pregnancy, 21.9 percent became uninsured two to six months postpartum, and 34.5 percent were uninsured in either period. The study, which relied on data from 43 states participating in the Pregnancy Risk Assessment Monitoring System (PRAMS), found higher perinatal uninsurance rates in states that did not expand Medicaid and among Hispanic women who completed the PRAMS survey in Spanish. The researchers say that despite recent coverage gains, further policy changes are needed to help women maintain health insurance coverage before and after pregnancy. Emily M. Johnston et al., “Post-ACA, More Than One-Third of Women with Prenatal Medicaid Remained Uninsured Before or After Pregnancy,” Health Affairs 40, no. 4 (April 2021):571–8.


Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening

Researchers used North Carolina Medicaid claims data to evaluate a model of enhanced primary care for patients with serious mental illnesses. Patients received care through a patient-centered medical home that was located within a behavioral health facility; the medical home offers care coordination, peer support, and self-management programs. Researchers found the patients receiving care through the enhanced model had 1.2 more primary care visits in the 18 months after the initial visit and a decrease of 0.33 non-psychiatric inpatient stays and 3.0 non-psychiatric inpatient days. Enhanced primary care also increased the probability of glucose and HIV screening but had no significant effect on psychiatric service and ED use. It also decreased the probability of lipid screening while having no effect on hemoglobin A1c and colorectal cancer screening. Lexie R. Grove et al., “Effect of Enhanced Primary Care for People with Serious Mental Illness on Service Use and Screening,” Journal of General Internal Medicine 36, no. 4 (April 2021):970–7.


Urgent Care Centers Reduce Some ED Visits But Increase Costs Overall

A study of claims from a national managed care plan between 2008 to 2019 found that the entry of urgent care centers in a given zip code deterred lower-acuity visits to hospital emergency departments (EDs), but the financial impact was small because each reduction in a low-acuity ED visit ($1,646) was offset by the cost of additional urgent care visits ($6,327). The authors recommend that health plans with utilization management programs for ED visits extend them to all unscheduled care settings and consider using nurse triage lines to help patients choose a site of care. Extended hours for primary care offices may also make primary care more convenient to patients. Bill Wang, Ateev Mehrotra, and Ari B. Friedman, “Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending,” Health Affairs 40, no. 4 (April 2021):587–95.


Despite Favorable Tax Treatment, Nonprofits Provide Less Charity Care as a Share of Expenses Than For-Profit Hospitals

Using 2018 Medicare Hospital Cost Reports, researchers compared the charity care provided by government, nonprofit, and for-profit hospitals and found nonprofit hospitals spent $2.30 of every $100 in total expenses on charity care, compared with $4.10 per $100 for government hospitals and $3.80 per $100 for for-profit hospitals. However, in a majority of hospital service areas containing all three types, no hospital ownership type outperformed the others. They also found wide variation in charity care provision within ownership types and no consistent pattern across ownership types. Because many government and nonprofit hospitals receive favorable tax treatment, they suggest policymakers consider initiatives to enhance charity care provision. Ge Bai et al., “Analysis Suggests Government and Nonprofit Hospitals’ Charity Care Is Not Aligned with Their Favorable Tax Treatment,” Health Affairs 40, no. 4 (April 2021):629–36.


Adjusting for Social Risk Factors to Promote Equity in Health Care

David R. Nerenz, Ph.D., director emeritus of the Center for Health Policy and Health Services Research at Henry Ford Health System in Detroit, and coauthors outline the arguments for and against adjusting quality measures for social risk factors so as not to exacerbate inequity in the health care system or unfairly penalize safety-net providers and others serving socially at-risk communities. Before adjusting for social risk, they suggest five questions for measure developers and other stakeholders to consider and offer a set of recommendations on when to adjust for social risk. The questions include: does the effect of a social risk factor reflect quality? Is the risk factor under the control of the entities being measured? Are the necessary data elements available? Does adjustment make a difference? And would adjustment mask poor quality of care? David R. Nerenz et al., “Adjusting Quality Measures for Social Risk Factors Can Promote Equity in Health Care,” Health Affairs 40, no. 4 (April 2021):637–44.

Editorial Advisory Board

Special thanks to Editorial Advisory Board member Kathleen Nolan for her help with this issue.

Jean Accius, Ph.D., senior vice president, AARP

Anne-Marie J. Audet, M.D., M.Sc., senior medical officer, The Quality Institute, United Hospital Fund

Eric Coleman, M.D., M.P.H., director, Care Transitions Program

Marshall Chin, M.D., M.P.H., professor of healthcare ethics, University of Chicago

Timothy Ferris, M.D., M.P.H., CEO of Massachusetts General Physician Organization and professor of medicine at Harvard Medical School

Don Goldmann, M.D., chief medical and scientific officer, Institute for Healthcare Improvement

Laura Gottlieb, M.D., M.P.H., assistant professor of family and community medicine, University of California, San Francisco, School of Medicine

Carole Roan Gresenz, Ph.D., senior economist, RAND Corp.

Allison Hamblin, M.S.P.H., vice president for strategic planning, Center for Health Care Strategies

Thomas Hartman, vice president, IPRO

Clemens Hong, M.D., M.P.H., medical director of community health improvement, Los Angeles County Department of Health Services

Kathleen Nolan, M.P.H., regional vice president, Health Management Associates

J. Nwando Olayiwola, M.D., M.P.H., chief health equity officer and senior vice president, Humana

Harold Pincus, M.D., professor of psychiatry, Columbia University

Chris Queram, M.A., president and CEO, Wisconsin Collaborative for Healthcare Quality

Sara Rosenbaum, J.D., professor of health policy, George Washington University

Michael Rothman, Dr.P.H., executive director, Center for Care Innovations

Mark A. Zezza, Ph.D., director of policy and research, New York State Health Foundation

Publication Details



Martha Hostetter, Consulting Writer and Editor, Pear Tree Communications

[email protected]


Martha Hostetter and Sarah Klein, “Placing a Higher Value on Direct Care Workers,” Transforming Care (newsletter), Commonwealth Fund, July 1, 2021.