{"subscriber":false,"subscribedOffers":{}} Workforce Development For Direct Care Workers Could Help Stabilize The Long-Term Care Industry | Health Affairs

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Workforce Development For Direct Care Workers Could Help Stabilize The Long-Term Care Industry

A caregiver's hands hold a set of elderly persons hands while they hold a cane.

Long-term care facilities have lost more than 400,000 professional caregivers since the pandemic started and are facing the worst job losses among all health care sectors. Consequently, nearly 55 percent of nursing homes are limiting new admissions due to a lack of staff, and more than two-thirds of nursing homes fear workforce challenges might force them to close, with several already closing across the US.

More than four million direct care workers (DCWs)—including home health aides, personal care aides, professional caregivers, certified nursing assistants, and companions—support people experiencing chronic conditions and disabilities with activities of daily living such as bathing and mobility. More than three-quarters of DCWs are female, more than half are people of color, and 26 percent are immigrants. These DCWs are weary of the daily grind; their bodies are subject to physically demanding and emotionally intensive work with only median wages and little to no opportunity for career advancement. Supporting DCWs is a health system imperative; inertia in this area presents a significant risk of workforce shortages with consequences for quality of care and sustainability of our long-term support system.

The Biden administration has called for a $400 billion investment in home and community-based services, which would include developing the direct care workforce through training and opportunities for career advancement; it has also issued a recent executive order to support both family caregivers and direct care workers. Here, we draw upon our ongoing mixed methods study involving a nationwide survey of DCWs and interviews with DCWs and home care executive directors to propose an innovative approach to investing in the professional development of DCWs, through recruitment, retention, and career advancement opportunities that reflect the value of the expertise, skills, and versatility with which DCWs are equipped. We outline specific opportunities for career pathways that could enhance the capacity of the current direct care workforce, attract caregivers to the profession, and support the well-being of DCWs. These incremental steps toward building the direct care workforce would reflect an investment in the workforce that could ultimately exceed the benefits of simply raising wages and would also work to mitigate disparities in health and career advancement faced by people of color.

Recruiting And Retaining DCWs Through Workplace Benefits

The US needs nearly eight million DCWs in the next decade to meet demand for home care and nursing services, but projections indicate a shortfall of more than 150,000 DCWs by 2030 and 355,000 by 2040. Administrators in our study worry that younger caregivers are not entering the caregiving workforce, resulting in older caregivers shouldering a disproportionate amount of physically and mentally demanding caregiving responsibilities. Consequently, the rate of attrition is likely to increase, with risks to the sustainability of long-term care services.

And for every 10 paid caregivers who leave the workforce, one will do so to uphold caregiving responsibilities for family members, as many DCWs themselves are also balancing work obligations with unpaid caregiving responsibilities and demands. Administrators in our ongoing study have shared that their clients have a huge demand for these services, but the supply of DCWs is low—resulting in administrators spending months searching for caregivers to fill open positions. The Boston Consulting Group estimates that the US will lose about $290 billion a year in gross domestic product from 2030 onward due to the impending shortage of DCWs and attrition of non-DCW workers across the economy who leave their employment for unpaid caregiving responsibilities.

DCWs are in high demand, subjected to long and demanding work hours and exhausting conditions with little opportunity for respite or time to foster their own well-being. In an interview for our ongoing study, one administrator shared the story of a client who requested 24-hour care for two weeks, starting the following day—a major stressor on the DCWs working with that client. Furthermore, DCWs frequently experience emotionally draining situations yet receive little support from employers. For example, despite their role in assisting clients at the end of life, bereavement support is rarely offered to DCWs, with almost all skilled nursing staff in one study reporting that they would use additional bereavement support services if offered.

DCWs see little to no opportunity for professional growth. DCWs in our research express being “stuck” without opportunities for career advancement despite having decades of experience providing care to clients and supporting their families. Recruiting and retaining a sustainable direct care workforce requires investing in career development and making available career trajectories, including in administration, education, advocacy, and opportunities to liaise with other professionals—but many DCWs don’t experience this. We see investing in career development for DCWs as a key opportunity for intervention.

Career Advancement For DCWs

Our proposal for funding, supporting, and sustaining career advancement for DCWs involves the establishment of workforce development funds specifically for DCWs. These funds could be designated through the portion of the $400 billion home- and community-based services investment allocated to local organizations (for example, home care agencies, school districts, long-term care facilities). When these organizations receive grants, they can use these funds to train DCWs (for example, students) to provide specialized support to other DCWs and family caregivers in different ways. For instance, one pathway could involve training DCWs as caregiving coaches to support other DCWs within their organization as well as family caregivers in their local or cultural community. These coaches can provide training in listening and relationship-building skills and can offer guidance in transitions to new clients and managing challenges in family dynamics. Another pathway could include training DCWs to become a comfort care family coach (CCFC) who supports family caregivers after a care recipient begins end-of-life care. The CCFC could guide family caregivers through the exhausting and emotionally intensive process of supporting end-of-life care.

A third pathway could be to enhance collaborative opportunities for DCWs through a community caregiving squad (CCS) comprising a caregiving coach, CCFC, and other professionals such as community health workers who support family caregivers through and after a hospital discharge. Finally, DCWs could be trained to become administrators and to even develop their own caregiving organizations or specialize in the administration of services relevant and critical for DCW well-being (for example, mental health services).

With this investment in workforce training and development, new DCWs entering the workforce as well as current DCWs would have multiple options of career trajectories. Their experiences and expertise learned on the job could directly prepare them for supporting other DCWs and family caregivers. With this “train the trainer” model, DCWs would not only contribute to building capacity within the workforce, but they would also form a social support network that does not currently exist within the direct care workforce.

Investing In The Long-Term Service System

Investing in DCW career advancement in the ways we’ve outlined above could also generate revenue for home care agencies and skilled nursing facilities, which could offer these services. For instance, a home care agency could invest in training a DCW to become a caregiving coach, who could then offer ongoing support (for example, bereavement support) to fellow DCWs. This model could contribute to lower turnover and a sustainable direct care workforce. Workforce development funds would offset the cost of additional benefits to employed DCWs and in the longer term could increase capacity of home care agencies and skilled nursing facilities to serve the community through expanded availability of services by agencies that are currently understaffed, and through services to support family caregivers in the community. For example, families might hire caregiving coaches within their communities to support primary family caregivers with stress management strategies, decision-making tools, resources for respite, and system navigation support. Increasing Medicaid reimbursements for home health care could leverage increased wages for DCWs, given that effective services from DCWs may also reduce hospital readmissions and improve health maintenance upon discharge. These reimbursements could be increased through wage increases, supplemental payments to home care agencies or nursing facilities based on quality metrics, or staff retention.

The business of caring is costly—to the system, to clients, and to DCWs who have little to no incentive to stay in their job even though our economy and health care system relies heavily on DCWs. Developing opportunities for growth within the direct care workforce is imperative for promoting the well-being of our professional caregivers, the clients and families they support, and the sustainability of our long-term care service system.

Authors’ Note

Sheryl Strasser received a grant from Georgia State University to conduct the research described in this article. Denise Brown and Minakshi Raj were part of the research team as consultants.

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