The pandemic heightened reliance on family caregivers and exacerbated the shortage of direct care workers. State policymakers and national experts met at NASHP’s Conference in Seattle, Washington in September 2022 to share insights and promising practices to address these crises.

Direct Care Workforce

Challenges existed with the direct care workforce prior to COVID-19, and the pandemic exacerbated the shortage of these workers as well as issues with recruitment and retention. Presentations and discussions at the conference on the direct care workforce highlighted the variety of ways in which states can work to fill shortages of direct care workers, stabilize the workforce, and keep direct care workers in the field.

There are about 4.5 million direct care workers in the U.S., who are aides working in personal homes, residential care, nursing homes, and other settings. Even before the COVID-19 pandemic, the number of predicted job openings for direct care jobs by 2028 was estimated to be 8.2 million. Direct care workers are disproportionately women (90%) and of a racial or ethnic minority (63%). Due to low wages, along with long hours and difficult working conditions, the direct care workforce turnover rates and vacancy rates are high.

Conference speaker Amy Hewitt, Ph.D. of the University of Minnesota’s Institute on Community Integration discussed that data shows that wages and benefits are the strongest indicators of turnover rates in the direct care workforce. Many states are using American Rescue Plan Act funding for home and community-based services to increase pay and thus retain direct care workers. Hewitt noted that a temporary bonus or wage increase is not enough to create lasting improvements, however, so states must work to permanently increase pay and improve benefits to keep direct care workers in their jobs.

Hewitt also pointed out that pay and benefits alone are not sufficient to solve the direct care workforce problems. Sufficient training, strong collaboration and partnerships, consideration for the mental health and wellness of these workers, and strong data collection on the direct care workforce are needed.

States at the conference shared the creative ways in which they are addressing the variety of challenges that this workforce faces:

• North Carolina, with support from the Robert Wood Johnson Foundation, developed a special license designation for home care agencies, adult care homes, and nursing facilities that have implemented a set of defined workplace interventions to improve the recruitment and retention, quality, and job satisfaction of direct care staff and the care provided. The provider manual for this voluntary program identifies elements of a supportive work environment for direct care workers.
• North­­­ Dakota implemented a tiered rate structure for providers based on how far they travel to provide care. This initiative simultaneously improved access to care for rural residents of the state and financially incentivized direct care workers to continue their work, by paying a higher Medicaid rate for those providers with longer drives.
• Washington state developed a 75-hour training program that is the core curriculum for direct care workers in many settings including adult family care homes, assisted living facilities, and homes. The state has specialty modules for residential settings that provide care for people with dementia, mental illness, or developmental disabilities; nurse delegation modules; and continuing education curricula. Washington is also working to recruit and retain direct care workers through collaboration and outreach with cross-sectoral partners, including high schools, military and veteran associations, local community career fairs, and online promotion.

Family Caregivers

During the COVID-19 pandemic, many family caregivers have isolated, providing care for their family members alone to prevent the virus’ spread. Family caregivers often are relied upon as an essential, yet typically uncompensated, part of the health care system.

Lisa McGuire, PhD, lead of the Center for Disease Control and Prevention’s Alzheimer’s Disease Team and keynote speaker at the conference, framed the caregiving crisis as a public health problem. An estimated 21 percent of adults are caregivers for a family member or friend, 20 percent are in fair or poor health, and one in eight report subjective cognitive decline. McGuire encouraged state policymakers to use a public health approach to address caregiving issues; she emphasized the importance of implementing population-wide solutions, collecting and utilizing comprehensive data, and developing a public health infrastructure to support and improve caregiving.

States at the conference shared the ways in which they are working to improve and expand supports for family caregivers:

• Delaware conducted focus groups of diverse family caregivers to better understand what state reforms are necessary to better meet their needs. The state also passed the Delaware Healthy Families Act to allow Delaware employees to take leave to care for their families.
• Illinois is expanding the use of an evidence-supported tool to assess family caregivers for their own needs, with Area Agencies on Aging in 12 of the 13 regions of the state utilizing it. The state also added $4 million in new state funding to the Department on Aging for caregiving.
• New York developed and distributed a caregiving guide for businesses. This toolkit educates employers of caregivers on best practices to support employees who are caretakers at home, including the provision of caregiving resources and benefits like paid family leave.

A Roadmap for States

On the heels of the NASHP conference, the U.S. Department of Health and Human Services released the National Strategy to Support Family Caregivers, a groundbreaking strategy with actions for federal and state governments as well as the private sector and community collaborators. This document provides a pathway for coordinated family caregiving policy and action in the coming years. To inform this National Strategy, NASHP created the RAISE Act State Policy Roadmap for Family Caregivers, funded by The John A. Hartford Foundation and the RRF Foundation for Aging and in collaboration with the U.S. Administration for Community Living, to help states interested in expanding support for family caregivers and the direct care workforce by highlighting state policy strategies and promising practices, many of which were highlighted at the NASHP conference.

NASHP also is committed to assisting states with their rapidly aging populations. A recent NASHP blog highlights emerging state aging policy priorities and the future of aging policy in states.

This work is generously supported by The John A. Hartford Foundation, RRF Foundation for Aging, and the Ralph C. Wilson, Jr. Foundation.