Happy young latin nurse with stethoscope holding a binder clip. She is outdoors at day light around hospital or medical clinic
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Supportive environments to increase retention, domestic and immigration policy reform, and solid data-gathering measures are among the recommendations coming out of a new report addressing the direct care workforce shortage.

The Bipartisan Policy Center’s Health Program released “Addressing the Direct Care Workforce Shortage: A Bipartisan Call to Action” on Thursday to highlight the need for broadly supported federal policy reforms.

A panel discussion laid out the background on the crisis and delved into the paper’s recommendations.

Challenges facing direct care workers

The COVID-19 pandemic, combined with the exponential growth of the aging population, exacerbated workforce shortages that have been in place for the past two decades, according to Bipartisan Policy Center Senior Vice President G. William Hoagland, who introduced the panel. 

Although the number of direct care workers more than doubled from 2.2 million in 2000 to 5.1 million in 2022, the supply of workers will fall short of the expected demand associated with 8.9 million projected job openings between 2022 and 2032. 

Through research, interviews with stakeholders and federal policy experts, and roundtable discussions, the Bipartisan Policy Center identified key challenges to expanding the direct care workforce and federal policy reforms to address those challenges.

The three major challenges to recruiting and retaining direct care workers were identified as:

  • Unsupportive work environments that contributed to feeling undervalued due to inadequate and stagnant wages and benefits, limited access to training, and a lack of career lattices for professional advancement.
  • Domestic workforce programs that target more medicalized or credentialed professions, and an immigration system  that does not ensure adequate visa and green card pathways for foreign-born workers.
  • A lack of standardized data collection and publicly available data on the direct care workforce.

The field of long-term services and supports is in “chronic crisis mode” with regard to the direct care workforce, according to panelist Kezia Scales, PHI vice president of research and evaluation. And a lack of data creates a barrier to identifying and resolving issues within a LTSS field that is “complex, fragmented and dispersed.” 

“The bottom line is in order to be able to design, justify, implement and evaluate policy interventions, we need more systematically collected data on this workforce and on long-term care services,” Scales said. “We also need periodic surveys and other targeted research efforts to better understand particular issues and trends.”

Part of the problem, according to Henry Claypool, Brandeis University community living policy director, is that the competition for the direct care workforce is “fierce.” Direct care worker wages are below the hourly wage paid in entry level jobs in all 50 states, and jobs in fast food pay comparable wages without the same physical and emotional demands placed on workers delivering LTSS.

“Institutional employers compete with community-based providers for the same limited pool of direct care workers,” Claypool said. “Long-term services and supports providers are competing with other sectors of the economy for this labor force.”

The recommendations

The report includes legislative and administrative federal policy solutions to promote retention of direct care workers through reforms that encourage supportive work environments. These solutions include domestic and immigration policy reforms, and standardized data collection on the workforce to measure the effects of these efforts and inform evidence-based policymaking.

Among the recommendations highlighted in the report:

  • Ensure supportive environments to increase workers retention — This includes increasing transparency and oversight of state Medicaid provider payment rates direct care worker compensation. 
  • Grow the number of new workers via domestic and targeted immigration reforms — This means strengthening registered apprenticeship programs, reauthorizing federal workforce development programs, creating a grant program to reduce barriers to recruiting direct care workers, recapturing unused permanent employment-based visas, classifying direct care professions as Schedule A shortage occupations, increasing cultural exchange category to permit immigrants to work in caregiving professions for older adults, and creating a nonimmigrant employment-based visa classification for low-skill healthcare workers.
  • Improve data on workforce characteristics to measure progress on enlarging the workforce — The paper recommends creating a standardized set of data measures for the direct care workforce based on the recommended State MInimum Dataset on Workforce for Long-term Care Systems Change previously developed by the Center for Medicare & Medicaid Services’ Direct Service Workforce Resource Center. The dataset should capture the volume, stability, compensation and profile of the direct care workforce.

Challenges within the immigration system are numerous, said Theresa Cardinal Brown, BPC immigration senior advisor. 

“Challenges with recruiting immigrants come because the immigration system doesn’t allow employers to recruit from abroad for most of these jobs directly,” she said. “The employment-based immigration system is heavily skewed toward higher-skilled occupations.”