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A Missed Opportunity for the Direct Care Workforce

Pandemic upheaval across the U.S. workforce hasn’t brought badly-needed paid caregivers into the field

By Kevyn Burger

Since the arrival of the coronavirus, the load that veteran home health aide Zulma Torres carried grew heavier.

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Zulma Torres is a direct care worker in New York City. Throughout the pandemic, she kept up a full and hectic schedule, providing care when families could not visit. She says there has been no bonus or hazard pay.  |  Credit: Kristen Blush

"This job got more intense. A lot of people who do what I do stopped coming in," said Torres, 49, who works overnights in The Bronx, N.Y. "I stayed healthy and kept going with a full schedule. They say we are heroes, but there's been no bonus pay or hazard pay. We are breaking our backs to take care of our clients."

The COVID-19 pandemic created an unprecedented upheaval in the American economy, with millions of workers finding themselves laid off, furloughed or pushed out of their current positions and careers.

"The surprise was that in this period of massive flux, the number of workers displaced by the pandemic and re-employed in the direct care workforce was statistically zero."

But a new report reveals that staff shortages of direct care workers (paid caregivers) actually worsened during the pandemic. Furthermore, the study found that "an immeasurably small" number of the estimated 13.7 million Americans displaced from jobs with similar entry-level requirements applied to work in the direct care sector, even as the number of open jobs in the field rose.

The direct care workforce is composed of home care workers, residential care aides and nursing assistants who provide crucial services to the aging population and people with disabilities, in their own homes or in residential facilities.

The study, which relied on federal employment statistics, was conducted by PHI, an organization focused on strengthening the direct care workforce, and the Health Workforce Research Center on Long-Term Care at the University of California, San Francisco.

The Pandemic Surprise in the Direct Care Workforce

"There was a huge labor pool that could have been tapped to grow this direct care workforce," said Stephen McCall, data and policy analyst at PHI and a co-author of the report. "The surprise was that in this period of massive flux, the number of workers displaced by the pandemic and re-employed in the direct care workforce was statistically zero."

The report also evaluated how pandemic-displaced workers decided which jobs to pursue.

"Early on, we saw story after story about COVID's tragic impact on older and (medically) compromised individuals. Workers who cared for them literally laid their lives on the line," McCall said. "These are physically demanding, emotionally taxing jobs. That led displaced workers to think twice about moving into open direct care jobs."

"To be perfectly frank, these are not good jobs and the pandemic did not make them better jobs."

McCall said the biggest deterrent to expanding the direct care workforce has long been the wages, which didn't budge higher in many of the open positions.

"A worker seeking a new job looks at how much they can earn if they enter this occupation. In direct care, they see low pay in a challenging environment," McCall said. "They look through job listings and see retail jobs with tuition reimbursement or restaurant work where they can grow into management. That affects the decision on where they end up."

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Making Jobs More Attractive

The direct care sector's job stagnation in the pandemic exacerbates its already troubled outlook.

A previous study by PHI calculated that long-term care employers will need to fill 7.4 million job openings in direct care from 2019 to 2029. That includes 1.3 million new jobs to meet rising demand and another 6.1 million openings to replace workers expected to leave the labor force or transfer to new occupations.

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Despite millions of Americans being displaced from jobs during the pandemic, unemployed workers didn't flock to direct care openings  |  Credit: Kristen Blush

"It feels like the job shift during the pandemic was a missed opportunity to make these jobs more attractive to workers. It was a time when people displaced from retail, fast food, hospitality or office jobs might have seen long-term care work as an option. But those industries increased wages to entice workers to come back," said Joanne Spetz, associate director for research at the Health Workforce Research Center on Long-Term Care at UC San Francisco and another co-author of the report.

"To be perfectly frank, these are not good jobs and the pandemic did not make them better jobs," she said.

The report suggests ways that direct care positions could be strengthened to make them more attractive. That includes tailoring strategies to reach candidates from other occupations, providing better support and training for workers new to the field and creating workforce supports specifically for people of color and workers with family caregiving responsibilities.

"Also, a large number of direct care jobs are held by immigrants. If we want this workforce to grow, we need to be thoughtful and proactive about immigration policy," Spetz said.

Recommendations for Direct Care Recruiting and Retraining

One solution that could make direct care jobs more lucrative is currently before the nation.

Federal money from the American Rescue Plan Act is beginning to flow to states. With a proportion dedicated to strengthening home and community-based care for low-income people, these allocations give individual states wide latitude in determining how their funds will be used.

The role of caregivers in sustaining the economy was heightened during the pandemic and the care agenda is now a higher priority among policy makers. PHI recommends that a portion of the American Rescue Plan funds should go into the pockets of the hands-on workforce in the form of a wage pass-through. Such an action would reward direct care workers who kept coming to their jobs and bolster efforts to attract new workers.

"When no one could come visit and when clients have family in other states, we are their family."

"We see states using these funds for relief payments to providers. No doubt these were challenging times for providers who were hit hard with increased costs for PPE [personal protective equipment] and testing. But it's important that states make sure some of the money reaches the workers directly, in the form of one-time or weekly bonuses," McCall said.

With her background as a labor economist, Spetz agrees that a pay hike is the first step in solving the problem of too few workers available to assist the expanding cohort of aging and disabled Americans. Some 80 million of them have incomes low enough to qualify for Medicaid assistance, which sets the rates for workers providing care.

"We need to think about how direct care workers can support a family on their wages," Spetz said. "Medicaid could, and should, be reimbursing at a higher level."

Spetz maintains that less tangible measures could also make direct care careers more appealing in both recruiting new workers and retaining existing ones, critically important in addressing the high turnover in the field.

"Direct care workers need to see pathways for upward mobility, a ladder for career advancement," she said. "And they need more social respect. These workers may not have formal education so they are described as unskilled. That's not true. This work takes interpersonal and physical skills and knowledge to manage technical tasks. If the workforce is valued more, the jobs will have higher status."

Part Therapist, Part Nurse

Torres' working conditions deteriorated as the pandemic lockdown began.

Her ability to travel to her job was complicated when public health concerns halted the trains and buses she typically used for her commute. She relied on family members for rides and then worried about her risk of infection as public transportation resumed. She and her co-workers braved exposure on the job and even created their own makeshift PPE amid early shortages.

"These workers may not have formal education so they are described as unskilled. That's not true."

"My family wanted me to stop, but my clients need me. I put my personal life in my pocket at work," Torres said. "I'm part therapist, part nurse; we follow their care plan and we deal with their emotions, too. When no one could come visit and when clients have family in other states, we are their family."

When Torres began her direct care career 24 years ago, she earned $6.25 an hour. While she now makes $15 an hour, she has little in the way of a financial safety net to cushion her through emergencies.

She finds satisfaction in the personal bonds she's formed with her clients, but Torres would like her work to be acknowledged for its quality.

"It's a lot, but I put smiles on my clients' faces," she said. "I ask the Lord to give me the understanding to be selfless. I ask myself, 'What kind of loving compassion would I want?' and I try to give that. I'm doing what I love, but I can't live for free."

Editor’s note: This story is part of The Future of Elder Care, a Next Avenue initiative with support from The John A. Hartford Foundation.

Photograph of Kevyn Burger
Kevyn Burger is a freelance feature writer and broadcast producer.  She was named a 2018 Journalist in Aging Fellow and a 2020 Continuing Fellow by the Gerontological Society of America. Based in Minneapolis, Kevyn is the mother of three young adults and one rescue terrier. Read More
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