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Given the recent actual —  and potential — federal investment in federal Medicaid programs, a panel of experts has laid out the current landscape and key opportunities for states that are “way beyond crisis” to use that money to strengthen the direct care workforce.

Programs lifting workers out of poverty, improving data to strengthen the workforce, and investing in workforce innovations to encompass elements of job quality unrelated to compensation are key to improving the quality and number of direct workforce employees, according to a panel discussion hosted Tuesday by New York-based data and research firm PHI.

The discussion comes on the heels of a PHI report revealing that COVID-displaced workers have shied away from direct care jobs due to poor job quality and low wages.

The direct care workforce will need to add 1.3 million new jobs by 2029 to meet the rapidly growing population of older adults. But high turnover, an aging workforce and those who leave the workforce altogether equates to 7.4 million job openings by 2029 —  which trails only the rising demand for fast food workers at 8.3 million.

“A holistic approach is needed to address every aspect of job quality,” said Stephen McCall, moderator and a PHI data and policy analyst. 


Panelist Andrea Price-Carter, LeadingAge’s manager of congressional affairs, discussed significant current and future opportunities for states to leverage federal funding to invest in their direct care workforce.

Several initiatives directly affect the direct care workforce in long-term care, Price-Carter said, including the reconciliation package. 

The American Rescue Plan Act of 2021, Price-Carter said, includes a 10% federal medical assistance percentage increase for Medicaid home- and community-based services that states can use for direct care worker recruitment, as well as retention and training initiatives. The ARPA also includes $360 billion in aid to state and local governments to offer premium pay for eligible workers performing essential work.

The proposed $3.5 trillion Build Back Better Act — often referred to as the human infrastructure plan — contains historic funding that increases support to aging services and direct care workers in particular. This includes $190 billion to expand Medicaid HCBS, paid family leave, $4 billion in elder justice funding and subsidized child care for workers.

The act also proposes $1.5 billion for competitive grants to recruit, train and retain direct care workers, and $5 million for a Direct Care Workforce Technical Assistance Center. 

Price-Carter also discussed a variety of grants aimed at supporting the long-term care workforce, including the $425 million Health Profession Opportunity Grants program, which provides five-year competitive grants targeting low-income recipients for high-demand jobs in the healthcare industry. The grants are intended to provide support services (childcare and transportation support) and training for certified nursing assistants, home health aides, licensed practical nurses and registered nurses.

The Older Americans Act also allocates $1.2 billion in funding for the aging services network and infrastructure, including $650 million to support HCBS supportive services. 

On the ground

Patti Klingsworth, assistant commissioner and chief of long-term services and supports for TennCare, Tennessee’s state Medicaid program, described how the state is leveraging enhanced FMAP federal funding to improve direct care jobs.

Klingsworth said the state is projecting spending almost $200 million on workforce development and provider capacity building investments. Another $240 million is targeted for waiting list initiatives and increased access to benefits. 

Tennessee also is proposing to spend about $137.5 million over almost three years to provide provider rate increases passed through as wage increase for frontline direct care workers.

“Overall, by paying a higher wage, we are able to support providers in recruitment and retention efforts, ensuring people have access to the care they need through consistent staffing,” Klingsworth said. 

Jess Maurer, executive director of the Maine Council on Aging, discussed her state’s priorities regarding recent federal investments in its direct care workforce.

“We’re way beyond crisis,” Maurer said, adding that as the oldest state in the country by median age, it has one of the smallest working age populations. “We were looking at crisis a couple of years ago and are starting to see the long-term impacts of not being able to find a sufficient number of workers.”

To address the challenges, Maine Council on Aging forged an alliance with advocates across all settings supporting older adults and individuals with developmental disabilities and behavioral health issues. 

The alliance supports essential workers in homes, community settings and residential care settings by establishing a care reimbursement rate floor. The alliance also is launching a public service campaign to promote direct care jobs and hired career center navigators to help onboard new direct care workers.