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Where is the Diversity in Long-Term Care Leadership?

Aging services providers employ diverse staffs offering hands-on care, but their leadership often looks nothing like their caregivers. Some groups are trying to change that.

By Robrt L. Pela

Serita Jones hasn't given much thought to her career.

"Mostly I'm thinking about my feet," she says. "I don't even know if you'd call what I got a career. What I got is a job. Two jobs, to be honest."

A non-diverse group of leaders during a meeting. Next Avenue, long-term care, diversity
Credit: Getty

Jones is a direct-care worker at a long-term care (LTC) facility in Glendale, Ariz. After a day spent delivering lunch trays and supervising singalongs, she drives a half-hour to a big-box store where she has a job as a cashier. Neither of her employers has ever mentioned career advancement.

"They're not that kind of jobs," says Jones, a 37-year-old Black woman. "Anyhow, you have to have a college diploma or something to be a manager at the facility. I only finished high school."

Natasha Bryant has heard stories like this before. "They're the result of a disconnect in the LTC industry," says the managing director and senior research associate at LeadingAge, an association of nonprofit aging-services providers. "We have diverse frontline staff, but our leaders are predominately white."

Where Are the LTC Leaders of Color?

A just-published report from PHI, an authority on the direct-care workforce, backs that up. It found that workers in the industry are well represented by people of color, but only about 12% of long-term care leaders are people of color.

"Frontline staff were largely people of color who often had to work two or three jobs to make a living wage. We found few opportunities for advancement."

Marvell Adams found similar biases with a more casual investigation.

"My colleagues and I Googled the CEOs of the top 200 LTC service providers in the country," reports Adams, COO of Kendal Corp., a nonprofit elder-care services organization in Pennsylvania. "And then we threw in the top ten percent of the board chairs from those organizations and we came up with nine or ten people of color."

A 2020 report from the U.S. Census Bureau says Americans 65 and older will number more than 77 million by 2035. As the population grows more ethnically diverse, the need for an ethnically diverse elder-care system is a must.


Winds of Change?

It can happen, according to principal players in the LTC industry who claim things are changing on the diversity, equity, and inclusion (DEI) front.

Leaders are gearing up to address issues of compensation for lower-lever caregivers; the need for mentoring and career-laddering; more and better internships and college-incentive programs that will promote leadership-level courses by people of color.

"It's a lot to go after," admits Adams, who's also a LeadingAge board member. "And because a lot of this is new, we're all still in the talking and organizing stages. Nothing will happen overnight. But it's got to happen, because our workforce is increasing."

"When you start out with no diversity in leadership and your CEO retires, your board of directors will usually bring in a search firm to locate candidates. Are both of these groups made up of white men? Probably."

He isn't kidding. The PHI report found that 4.6 million workers were employed in facility and private-care jobs last year, up from 3.1 million just 10 years before. The study projects another 1.3 million direct-care personnel will join that workforce in the next decade, creating more new jobs than any other single occupation.

But will direct-care workers be led by more ethnically diverse leaders?

It's possible, says Adams, who points out that other American industries have mastered workplace diversity. But it won't happen in long-term care, he believes, until the industry cops to its own systemic racism.

"When you start out with no diversity in leadership and your CEO retires, your board of directors will usually bring in a search firm to locate candidates," Adams says. "Are both of these groups made up of white men? Probably. So you can guess who they're going to hire when there's no history of diversity among those doing the hiring. It's this insane cycle."

Adams knows that insanity firsthand. He's been in the long-term care field for 20 years, yet only once has a recruiter who was a person of color reached out to him.

Another time, a white recruiter confided the worst. "She told me I wasn't being considered for a position because I'm Black," Adams recalls. "The employer used words like 'wouldn't be a good fit' which, when you're Black, usually means 'He's not white.' And this was a recruiter whose recruitment package promoted diversity."

A Big Time Blind Spot

Christopher Laxton, executive director of a group known as the American Medical Directors Association (AMDA) and The Society for Post-Acute and Long-Term Care Medicine, acknowledges that long-term care groups fill executive positions with mostly white candidates found through less-than-diverse search firms.

"It's a blind spot," admits Laxton. He found out firsthand when AMDA presented a summit last December on the impact of racism on long-term care.

"We focused on facility residents, frontline staff and leadership," Laxton says, "and found stark disparities. Frontline staff were largely people of color who often had to work two or three jobs to make a living wage. We found few opportunities for advancement."

Solutions to the DEI Leadership Problem

Bryant believes placing term limits on board positions is a good first step in creating diversity. "Also, expanding the number of board members would create more intentionality in the industry," she says, "and prevent a decision-making board from being the same white faces year after year."

Paying LTC workers a living wage wouldn't hurt, either. That PHI report found that direct-care workers continued to struggle in poverty-level jobs across all long-term care settings. Fixing that might be the best place to start, says Janet Coffman, an associate professor at University of California, San Francisco. That's because it could reduce job turnover and make the industry more attractive to people of color, who might then be more likely to stay and advance into leadership positions.

"We've got to start with these difficult, messy conversations with our boards and our leaders."

But neither Coffman nor others interviewed for this story are sure where money for better wages will come from.

"This is an industry largely dependent on Medicaid for funding, and Medicaid is already strung pretty tight," Coffman points out. Bryant has heard of private-pay facilities charging more in order to pay staff a higher wage but says that doesn't address wage issues at Medicaid facilities.

"While we figure out where more money is coming from, we need leaders to invest in staff development by partnering with community colleges," says Coffman, who co-authored a 2018 report on racial and ethnic diversity in the LTC workforce. "Let's clear pathways for people of color to progress educationally and professionally within their LTC workplace."

Incentivizing education for LTC workers is a new frontier, reports Adrienne Ruffin, LeadingAge vice president of Strategic Initiatives. Toward that end, her organization is launching numerous diversity initiatives and programs aimed at inspiring college students to consider LTC work.

"We worked with twenty-nine students over ten weeks at our recent Summer Enrichment Program," Ruffin says. "About half of them were people of color. We gave them a variety of work opportunities and a mentor to ensure their success, and onsite training and networking opportunities. The students saw the lack of diversity in leadership and wanted to work on that."

"This is a change in culture, and it's going to be a long journey that's just getting started."

LeadingAge has a range of further initiatives planned, including learning modules on LGBTQ+ inclusion; how to engage residents in dialogues about racial justice and why unconscious bias shows up in the workplace.

The organization's late-October LTC leadership conference will emphasize ways to bring more people of color into management roles and offer sessions on diversity in aging services through seminars with titles like "How to Start Talking about Diversity, Equity and Inclusion" and "Creating Brave Spaces for Conversations about Diversity."

Ruffin is all for initiatives, sessions and seminars. "But once we get qualified people of color into leadership roles, we have to support them," she cautions. "I talked to a leader of color who felt lonely in her job. Support from her colleagues would have prevented that. White men are accustomed to support at the leadership level, but we've got to learn to offer it to leaders of color, too."

In the meantime, diversity in the LTC workplace is still mostly just being born.

"We've got to start with these difficult, messy conversations with our boards and our leaders," Bryant says. "Because this is not a one-size-fits-all thing, and there's no checklist of what to do. This is a change in culture, and it's going to be a long journey that's just getting started."

It's a journey that Serita Jones can't fathom.

"I'd love to get better paid," she admits with a laugh. "I'd love to wear something other than scrubs and have a nice office and not have to soak my feet in ice when I get home at night."

She shakes her head. "But I don't know. Where will I find time to go to school and learn how to be a manager or whatever? And who's going to pay for that? You know what I'm saying?"

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.

Robrt L. Pela
Robrt L. Pela is a Pulliam Prize-winning writer who has worked at magazines including Psychology Today, The Advocate, Phoenix Home and Garden and Men’s Fitness. For the past 30 years, he has been a columnist at Phoenix New Times and a correspondent with the NPR member station KJZZ. His last book was Filthy, a biography of the film director John Waters. He and his husband live in Phoenix, Ariz., and look forward, post-pandemic, to returning to their homes in Niles, Ohio and Bargemon, France. Read More
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