The Critical Role of Direct-Care Workers

In Part 3 of a four-part series, we discuss the importance of direct-care workers in supporting family caregivers. Check out Part 1 of the series on dementia caregivers and Part 2 about identifying and engaging family caregivers, and Part 4 on the stated needs of family caregivers. 

Family caregivers shoulder an enormous burden in the United States, where more than 50 million caregivers provide care to family members each year. This includes the care of older adults with cognitive or physical disabilities and the care of younger adults and children with physical, intellectual, or developmental disabilities. Many family caregivers provide much of this care on their own, whereas others rely on support from paid direct-care workers (DCWs), such as home care aides and personal care assistants. These workers play an essential, but underappreciated, role in our health care and long-term services and supports (LTSS) systems.

For many years, the Bureau of Labor Statistics has predicted an increasing need for DCWs, as this category of workers is the fastest growing across all industries. However, worker shortages have persisted for many years, and these shortages were exacerbated by the COVID-19 pandemic. Recent news reports highlight the difficulty families have in finding DCWs and the additional burden and stress this places on family caregivers.

The 2022 National Strategy to Support Family Caregivers (NSSFC), which was developed by the RAISE Family Caregiving Advisory Council, recognizes the importance of DCWs in supporting family caregivers. The strategy makes recommendations about steps that federal and state governments could take to improve the jobs of DCWs and increase their supply.

For example, the strategy recommends that Medicaid and other funders pay rates for LTSS that will attract and retain a skilled direct-care workforce. It also recommends improving training for DCWs and establishing career paths, so that DCWs can advance to better job opportunities. Many of the recommendations included in the NSSFC have been circulating for many years with little progress. However, in response to the pandemic, some states have made changes that impacted DCWs.

Research conducted by RTI International for the Office of the Assistant Secretary for Planning and Evaluation found that federal and state governments implemented policies aimed at improving DCW recruitment and retention during the pandemic.

For example, some states used funds from the federal Coronavirus Aid, Relief, and Economic Security (CARES) Act and other state funding to increase Medicaid payment rates for home care services. Some of these states intended for the funds to help home care agencies temporarily provide workers with add-on pay, hazard pay, and retainer payments to help overcome disruptions in care. Our policy scan found that 27 states implemented retainer payments and 19 states used add-on or hazard pay for workers. Some states specified the amount of the wage increase and detailed the types of staff it covered.

To ease entry into the workforce, 32 states temporarily modified policies related to staff training, qualifications, or duties, including delaying some pre-employment requirements. These changes also expanded home care agencies' ability to provide virtual training for staff.  

In addition, the American Rescue Plan Act (ARPA) has temporarily increased the federal medical assistance percentage—the share of Medicaid expenditures paid by the federal government—for certain home and community-based services. One goal of ARPA is to strengthen the direct-care workforce through improved wages and training, and many state plans for ARPA funds include this goal. These plans are just beginning to be rolled out by states, so their effect on DCW recruitment and retention is unknown. Research and evaluation are needed to determine which state plans have the greatest success so that other states can replicate those models. Of course, this assumes that policies and programs implemented using ARPA funds have staying power after funding ends.

The staying power of policies and programs implemented in response to the pandemic will likely depend on the advocacy of such policies. DCWs, through their associations and unions, will undoubtedly advocate for themselves, but they could also use the support of family caregivers who so often rely on them. This support can take many forms, but a good starting place is advocating for better pay, training, and career advancement opportunities. Family caregivers need the support of DCWs, and DCWs should benefit from the support of family caregivers.

Learn more about RTI’s home and community-based services capabilities here.