During the pandemic, people began paying attention to the essential workers who can’t work from home. Among them are direct care workers — aides who support older adults and people with chronic 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. Transforming Care spoke to Kezia Scales, Ph.D., senior director of policy research at PHI, a research and consulting nonprofit focused on the direct care workforce, about how health and long-term care organizations can make better use of their talents.
Transforming Care: How have the past few pandemic years affected direct care workers?
Scales: The pandemic has made what were already demanding, difficult jobs even harder and more stressful. In the early stages, direct care workers were often the last to be considered for PPE [personal protective equipment] distribution, information, and training on how best to provide care. As time went on, they continued to risk their health and lives without, in most cases, additional support like hazard pay or even paid sick leave. We are now facing an unprecedented workforce crisis. Providers are struggling to find and retain enough direct care workers to deliver necessary services.
Transforming Care: Is that putting upward pressure on wages?
Scales: We’ve seen a noticeable, if modest, increase in the median wage for direct care workers, up to $14.27 per hour in 2021, but that’s still not a competitive and livable wage — and we certainly haven’t seen a migration of workers to the industry. A real challenge in this field is the limited number of career pathways. You go in as a home care worker earning a certain wage, you develop rich experience and skills, but you may find yourself with the same job title and earning pretty much the same wage 20 years later.
Transforming Care: Why is that the case?
Scales: There are several reasons direct care workers are undervalued, including the fact that these jobs are traditionally performed by women, predominantly women of color who because of racism and sexism have not been recognized as providing skilled, valuable labor. Another reason is that Medicaid is the main financer of long-term services and support, and Medicaid funds are always in competition with other state budget items like education.
Transforming Care: The American Rescue Plan Act included a 10 percentage-point increase in the federal matching rate for home- and community-based services provided through Medicaid. How are states using these funds to shore up their direct care workforce?
Scales: We are seeing exciting investments in job quality and workforce infrastructure across states. Colorado implemented a minimum wage of $15 an hour for home care workers. Several other states, including Wisconsin, are strengthening training programs and creating career ladders for direct care workers. North Carolina is funding research on workers’ experiences to inform policy changes. And the federal government is creating a technical assistance center to promote best practices and support states and providers in recruitment and retention efforts.
Transforming Care: Many direct care workers struggle to get the attention of their patients’ clinicians. How can we include direct care workers as part of care teams?
Scales: Aside from family members, no one else spends as much time with care recipients as direct care workers. They know their patients’ needs and can recognize changes in status. We need to enable them to fulfill their role as observers and reporters as effectively as possible. But it’s just as important to make sure that other members of the care team hear and make use of their input. That may mean training around active listening and cultural competence. It also may mean assessing communication pathways: are direct care workers able to join interdisciplinary team meetings, for example? Are there other ways for them to share their observations? We also need a feedback loop to keep workers updated.
Transforming Care: How can clinicians better leverage direct care workers?
Scales: There’s so much opportunity. Some providers have created advanced roles where experienced direct care workers coach and support other direct care workers. Direct care workers also can improve care for particular conditions, including dementia. Up to 50 percent of people in nursing homes are living with dementia. Direct care workers know their patients’ preferences and routines, can identify the triggers of distress, and can spot symptoms that may lead to ED [emergency department] visits and hospitalizations. By boosting dementia care skills across this workforce and creating specialist roles, we could improve care quality and outcomes for people living with dementia, strengthen career opportunities for direct care workers, and reduce costs.
Transforming Care: How do you see the direct care crisis relating to broader workforce problems, including high rates of turnover and burnout among nurses?
Scales: The direct care workforce crisis and the nursing crisis are mutually reinforcing. If there isn't a direct care worker available to fulfill a certain task, it falls to a nurse who’s likely already too busy. Likewise, turnover among nurses can leave direct care workers without adequate supervision and support.
The health and long-term care industry are competing with other industries for entry-level staff. This is a workforce crisis that no single provider can solve. We really have to think about how the industry can come together, with policymakers and others, to improve these jobs and truly value the crucial work that direct care workers do every day.