Direct Care Workforce Research Articles

Health Insurance Matters: Insurance Coverage and Health Service Use Among Direct Care Workers in the United States

ObjectivesDirect care workers (DCWs) play a central role in supporting individuals' health and well-being across care settings, yet may face barriers to accessing health care themselves, particularly because of high rates of uninsurance. DesignAn observational study using pooled National Health Interview Survey (NHIS) data from 2014 to 2018. Setting and ParticipantsThe sample included survey respondents employed as direct care workers (DCWs), including hospital aides, home care workers, and nursing and residential care aides. MethodsWe used bivariate analyses to compare differences in health insurance coverage and health service use, defined in terms of access, utilization, and affordability, among DCWs by care setting. We then used stepwise multivariable logistic regression analyses to explore the associations between insurance coverage and health service use. ResultsThe sample included 1499 DCWs. Compared with hospital aides, home care workers and nursing and residential care aides had lower insurance coverage rates, were more likely to rely on Medicaid, and reported lower health care utilization and higher cost barriers. Health insurance through Medicaid was associated with the highest odds of health care access and utilization and the lowest odds of cost barriers for DCWs. Conclusions and ImplicationsGiven the projected 9.3 million total job openings in the direct care workforce from 2021 to 2031, policy and practice interventions designed to support DCWs' health are essential for ensuring continuous and quality care for older adults and people with disabilities and serious illness.

Understanding Multilevel Factors Related to Retention Among the Direct Care Workforce: Incorporating Lessons Learned in Considering Innovative Interventions.

This article explores how broad, contextual factors may be influential in the retention of direct care workers (DCWs; i.e., entry-level caregivers) who provide vital support to patients in healthcare settings. We reflect on lessons learned from an evaluation of a multisite intervention to improve retention among DCWs employed primarily in hospital settings at three health systems. We evaluated a multitiered program for entry-level caregivers that included a risk assessment, a 4-day curriculum, and follow-up sessions, as well as workforce coaching at the three health systems. As part of our evaluation, we collected data on roughly 3,000 DCWs from the three health systems; the information included hiring date, any transfer date, and any termination date for each new DCW, as well as demographic information, position characteristics, and termination status and reasons for any termination. In addition, we collected information about organizational characteristics, including staffing and number of employees. We also conducted interviews with 56 DCWs and 21 staff members who implemented a retention program across each of the three health systems and remotely conducted virtual observations of the curriculum sessions at each system. Although the program we evaluated focused on individual-level factors that may affect retention, our findings revealed other broader, contextual challenges faced by DCWs that they said would have an impact on their willingness to stay in their positions. These challenges included (1) job-related factors including limited compensation, aspects of the job itself, and the inability to advance in one's position; (2) health system challenges including the mission, policies, staffing, and organizational culture; and (3) external factors including federal policies and the ongoing COVID-19 pandemic. As the direct care workforce continues to grow, interventions to improve retention should consider the interconnectedness of these multilevel factors rather than solely individual-level factors. In addition, further research is needed to rigorously evaluate any potential intervention and consider how such an approach can target DCWs in hospital-based settings who are most affected by the multilevel challenges identified. Finally, any intervention to improve retention must be also aligned to ensure equity, especially in this population of low-wage DCWs, many of whom are marginalized women and individuals of color.

WHO CARES? RETENTION STRATEGIES FOR DIRECT CARE WORKERS

Abstract More than 30 years ago the Gerontological Society sponsored a congressional briefing about a growing problem; concerns about the adequacy and quality of the direct care workforce in long-term care. In 2002 the Robert Wood Johnson Foundation sponsored the Better Jobs, Better Care demonstration, in response to this continued challenge. Today recruiting and retaining high quality workers in the long-term services system has moved beyond a challenge to an all-out crisis. The initial paper of the symposium presents recent retention and work culture data highlighting todays’ hurdles, collected from more than 80% of long-term care facilities across Ohio. The second presentation provides a comprehensive review of state-level initiatives and innovations aimed at improving recruitment and retention for direct care workers (DCWs) in both facility-based long-term care and home and community-based long-term services across the country. A third paper focuses on retention-promoting factors from the perspective of providers and DCWs working in high-performing long-term care facilities in Ohio. In-depth interviews with 37 providers and DCWs revealed an overarching theme of the importance of work culture, highlighting the modifiable, intangible aspects for promoting DCW retention. The final paper introduces a tip sheet with practical strategies for providers who are seeking to retain direct care workers. Symposium findings will include both practical implications for long-term care providers and ideas for future studies. The direct care workforce crisis is the result of an array of challenges, which means that there will not be one solution, but rather many ideas will be needed.

STATE-LEVEL INITIATIVES FOR DIRECT CARE WORKERS

Abstract As problems surrounding recruitment and retention of direct care workers continue to worsen, changes have been made at both the state and national level to accommodate for these challenges. This paper provides a literature review of various state-level initiatives and innovations aimed at improving recruitment and retention strategies for direct care workers in both facility-based long-term care and home and community-based long-term services across the country. Research revealed three themes, 1) strategies to improve wages and benefits, 2) education and training, and 3) community support. To improve wages and benefits, many states increased compensation and benefits for DCWs with the implementation of wage pass-throughs, minimum wage increases, and earmarked funds. Education and training efforts were identified as another way to enhance recruitment and retention efforts for the direct care workforce, such as through credential and certification opportunities for workers, as well as standardizing current training requirements. Lastly, increasing community support was identified through advocacy and research efforts specifically aimed at understanding and supporting DCWs. This study seeks to inform policymakers and providers of current initiatives that can be used to address the ongoing workforce crisis.

WORKFORCE CHALLENGES DURING COVID-19

Abstract As of October, 2022 nearly 1.1 million individuals in the United States died of COVID-19 with approximately 790,000 being individuals ages 65 and older. This age group accounts for 16% of the total US population but 75% of all COVID deaths to date. Covid-19 has taxed the United States public health system resulting in clinician burnout and a lack of trust in the public health system. The demands of the pandemic physically, psychologically, and logistically overwhelmed many clinicians resulting insomnia, anxiety, depression, and increased risk for substance use and misuse. Burnout at the institutional level is associated with increased medical errors, lower quality of care, and hospital-acquired infections. Compounding the issue of burnout was the lack of public trust that subsequently developed. Facts about COVID-19 competed with misinformation of the disease, false medical cures, contradictory health messages, an overwhelmed health care system in many areas, and conspiracy theories. One solution to these concerns is to increase the use of Community Health Workers (CHC). CHCs are trusted members of the communities they serve and play an essential role in assisting in care, providing factual information, and dispelling misinformation related to health topics such as COVID-19 infection, symptoms, and vaccination. Augmenting this workforce may help the system prepare for future emergencies. This presentation will discuss the recommendations of the Federal Advisory Committee on Interdisciplinary, Community-Based Linkages’ latest report “Building Trust, Addressing Burning, and Expanding the Direct Care Workforce”.

WHAT MATTERS MOST? REACTIONS TO THE RAISE ADVISORY COUNCIL’S NATIONAL STRATEGY TO SUPPORT FAMILY CAREGIVERS

Abstract This presentation reports on feedback from advocates and researchers, those working in organizations serving family caregivers, and family caregivers themselves regarding the 2022 National Strategy to Support Family Caregivers. The Strategy was issued by the RAISE Family Caregiving Advisory Council, created under the Recognize, Assist, Include, Support, and Engage (RAISE) Family Caregivers Act (2018). A Request for Information (RFI) published in the Federal Register garnered nearly 600 responses from a wide range of individuals and organizations, providing feedback about top priorities for action, topics or populations that were not adequately addressed, and recommendations for actions that could help meet stated objectives; these comments will prove critical in implementing the National Strategy, as well as in updating and revising it. This presentation sets the progress of the National Strategy in context, reports on the RFI analysis, and describes next steps, highlighting key areas of focus for the federal government, states, and other entities. Priorities included expanding the direct care workforce and increasing access to caregiver training and supports, particularly respite. Other top comments pertained to financial and workplace security for family caregivers - encouraging caregiver-friendly workplaces, paying family members to provide care, and strengthening the Family and Medical Leave Act. Respondents broadly endorsed the Strategy and noted the need for campaigns promoting greater awareness of family caregiving. The findings suggest that there is strong consensus among caregiver advocates regarding the most critical areas for action and the most favored strategies to achieve caregivers’ priority goals.

USING THE LTSS STATE SCORECARD TO MEASURE PROGRESS ON THE 2022 NATIONAL STRATEGY TO SUPPORT FAMILY CAREGIVERS

Abstract Through the Recognize, Assist, Include, Support, & Engage (RAISE) Family Caregivers Act of 2018, the RAISE Family Caregiver Advisory Council was created. Since 2019, the Council has directed in-depth information-gathering and research efforts to develop recommendations and an implementation plan for addressing our critical family caregiving crisis. The Council recently released the 2022 National Strategy to Support Family Caregivers, which highlights nearly 350 actions the federal government will take to support family caregivers in the coming year and more than 150 actions that can be adopted at other levels of government and across the private sector to build a system to support family caregivers. Integrating measures of improvement with regard to family caregiver support, across the domains identified in the National Strategy into the LTSS State Scorecard will provide a tool by which progress toward the RAISE goals can be measured. Currently, the Scorecard focuses on indicators specific to Supporting Working Family Caregivers. While these are critical, our research team has identified at least 10 additional indicators that could be included and that would address other caregiver support domains such as adequacy of direct care workforce, integration of family caregivers into care plans, direct pay to family caregivers, and more. In this session we will identify the indicators, explain how they relate to RAISE goals and discuss methods for including them in the Scorecard.

FOSTERING CONSISTENT AND ENGAGING CARE FOR PEOPLE WITH DEMENTIA IN LONG-TERM CARE

Abstract Maintaining a stable and qualified direct care workforce in long-term care organizations has become increasingly difficult as shortages intensify, turnover increases, and the use of agency staff remains at high levels. Efforts to improve this situation need to include high quality training that is incorporated into onboarding, ongoing continuing education, and infused into the culture of the organization. Using data from our ongoing NIA-funded study, “Meaningful Engagement and Quality of Life among Assisted Living Residents with Dementia,” we describe the competencies used by direct care workers (DCWs) with exceptional capacity, or ability and resources to engage people with dementia, and the factors that promote or limit the development and use of these competencies. Focal residents with dementia (N=66) were followed at eight diverse assisted living communities for one year and 53 DCW were interviewed across three waves of data collection. Interview transcripts and fieldnotes from more than 2000 hours of observation were analyzed using a grounded theory approach. Organized by four engagement approaches: knowing the person, connecting with and meeting people where they are, being in the moment, and viewing all encounters as opportunities, we identified competencies and the multiple intersecting factors which impact meaningful engagement and competency development including community staffing, consistent assignment, scheduling, DCW training, DCW tenure, and community resources. Implications for practice, which emphasize the elaboration of specific competencies, have the potential to inform the development of DCW training, the promotion of supportive work environments, and social policy that support person-centered dementia care.

Innovation in direct care worker training: preparing a workforce to provide in‐home care to older adults living with Alzheimer’s disease and related dementias

AbstractDirect care workers who provide in‐home care – such as caregivers hired by consumers of California’s Medicaid‐funded In‐Home Supportive Services (IHSS) program – are well positioned to observe changes in their consumer’s cognition, health, or behaviors to report to family members and healthcare partners, thereby helping to reduce risk of emergency department visits, avoidable hospitalizations, and other adverse outcomes that are disproportionately high among people living with Alzheimer’s disease and related dementias (ADRD) (Alzheimer’s Association, 2023). Despite their vital role in supporting people living with ADRD, direct care workers receive low wages and minimal training or supportive supervision. Strengthening the dementia care workforce is a public health priority; failure to do so will add health, social, and economic burdens to individuals, families, and society (American Public Health Association, 2020). An innovative initiative to bolster the direct care workforce is the IHSS+ADRD Training Project, which provides a 10‐week, instructor‐led, competency‐based, online training in English, Spanish, and Cantonese. The goal is to train 600 IHSS caregivers in Alameda County, California between 2020‐2024. We use a quasi‐experimental, longitudinal design to evaluate outcomes. Pre‐training, post‐training, and 3‐month follow‐up surveys are used to compare changes in IHSS caregivers’ dementia knowledge and self‐efficacy. Administrative records pulled one‐year before and after training are used to compare healthcare utilization patterns of IHSS consumers whose caregiver completed the training. This poster presents updated preliminary results from an analytic sample of 165 IHSS caregivers and consumers for whom we have complete follow‐up data to‐date. Dementia knowledge and self‐efficacy significantly increased at post‐training (p≤ 0.05), with trends suggesting retention at follow‐up. Most IHSS caregivers were very satisfied with the training (83%). Healthcare utilization data followed expected trends given COVID‐19 pandemic protocols in Alameda County. These results reveal promising signs that direct care workers do value training opportunities to better support consumers at home; however, the results need to be further understood in the context of COVID‐19 and the ADRD illness trajectory. Implications include replicating this training to other counties and beyond California to help meet the estimated 1.2 million additional direct care workers needed in the U.S. by 2030 (PHI, 2022).

Building a Stronger Direct Care Workforce: The Moving Forward Nursing Home Quality Coalition Is Taking Action Now

Building a Stronger Direct Care Workforce: The Moving Forward Nursing Home Quality Coalition Is Taking Action Now

Recruiting a Person-Centered Direct Care Workforce Through Situational Judgement Tests: A Pilot Study in the Community Support of Older People in England.

Studies have found that older people value care workers' character traits and interpersonal judgment even more highly than their technical skills. Yet identifying these traits at recruitment is challenging. This study aimed to evaluate the first situational judgement tests (STJs) for direct care workers. Online tests were conducted with 251 care workers and members of the public in England. Participants evaluated the appropriateness of 61 potential behavioral responses to 11 "critical incidents," each depicting challenging care work scenarios. Data collection included a measure of personality traits. A subsample of 72 participants completed a second "test-retest" assessment. A majority of test-takers (53%) found the test easy/very easy to complete, and most (55%) participants who worked in care reported the scenarios were highly realistic. Psychometric tests were positive. Test scores were unidimensional under a Confirmatory Factor Analysis (RMSEA = 0.038), and items broadly fit Rasch assumptions. Test-retest reliability (rho = 0.77) was acceptable, and for the general public sample, a modest increase in perceptions of the social standing of care work was observed. Test scores were positively correlated with 2 personality traits: agreeableness (r = 0.250, p < 0.001) and openness to experience (r = 0.179, p = .005). Test scores were not related to age, gender, or education level. The findings indicate support for the use of SJTs in direct care work. Its psychometric properties appear satisfactory, and collectively give confidence in the use of SJTs for assessing the suitability of candidates during recruitment. Further research should corroborate these findings in a new sample, and examine the relationship between test scores and job performance.

A Profile of the Direct Care Workforce in Home- and Community-Based Services.

We used data from the 2020 American Community Survey to compare direct care workers (DCWs) in home and community-based services (HCBS) with workers in other long-term supportive services (LTSS), such as skilled nursing facilities (SNFs) and assisted living facilities (ALFs). Compared to DCWs in SNFs and ALFs, a higher proportion of DCWs in HCBS were over age 65, Latino/a, and single. A lower proportion of DCWs in HCBS worked for a for-profit company, worked year-round and full-time, and had employer-based health insurance.

Stabilizing the Direct Care Workforce: Challenges and Progress

The pandemic intensified a 25-year direct care worker (DCW) crisis in the United States. COVID-19 along with preexisting recruitment and retention challenges have pushed many workers to leave their positions caring for some of the most vulnerable of our society when economic challenges, illness, fear, and family responsibilities became too much to handle (Johnson et al., 2021). Projections predict an additional 1.2 million new positions are needed by 2030, predominately in home- and community-based services (HCBS), leading some experts to recast this situation from workforce crisis to systemic failure (Johnson et al., 2021; Paraprofessional Healthcare Institute, 2022). However, collaborative work among researchers, advocates, and politicians at the state and federal level in a variety of states has led to actionable plans poised to make meaningful progress toward righting the complex and cumbersome ship that is the long-term services and supports (LTSS) system here in the United States and the workforce that is its “backbone” (Bogenschutz et al., 2014).

Who Will Care for Rural Older Adults? Measuring the Direct Care Workforce in Rural Areas.

Using the 2021 Occupational Employment and Wage Statistics (OEWS) dataset, we calculate the ratio of direct care workers relative to the population of older adults (ages 65+) across rural and urban areas in the US. We find that there are, on average, 32.9 home health aides per 1000 older adults (age 65+) in rural areas and 50.4 home health aides per 1000 older adults in urban areas. There are, on average, 20.9 nursing assistants per 1000 older adults in rural areas and 25.3 nursing assistants per 1000 older adults in urban areas. There is substantial regional variation. Greater investment needs to be made in improving wages and job quality for direct care workers to attract workers to these critical occupations, especially in rural areas where the need for direct care is greater.

Insights and Innovation: How a Local Public-Private Partnership is Building Home Care.

Recent national reports asserted an urgent imperative for transforming working conditions for the direct care workforce in the US. These clarion reports identified key influencers in reform as federal and state governments, workers' unions and coalitions, individual and organizational employers. Equally essential and well-positioned local actors have been overlooked in the conversation-namely, municipalities, area agencies on aging, higher education, philanthropic entities, and community. Although deemed "essential," direct care workers have been disproportionately affected by the COVID-19 pandemic. This paper examines an early public-private partnership initiative designed to recruit and train PCAs in Virginia.

Recruiting a Person-Centred Direct Care Workforce through Situational Judgement Tests: A Pilot Study in the Community Support of Older People in England

Recruiting a Person-Centred Direct Care Workforce through Situational Judgement Tests: A Pilot Study in the Community Support of Older People in England

DIRECT CARE WORKFORCE IN THE US BEFORE AND DURING COVID-19

Abstract Purpose This study describes the changes in the direct care workforce between 2019 and 2020. Design and Methods Data were from the 1% Public Use Microdata Sample (PUMS) of the 2019 and 2020 American Community Survey (ACS). Logistic regression was used to compare demographic and employment characteristics of direct care workers (DCWs) in 2019 and 2020. Results While the total number of DCWs increased by 0.08% and the number employed in home care increased by 3.45%, the number of DCWs employed in hospitals decreased by 3.73% and the number employed in residential care facilities decreased by 4.01% from 2019 to 2020. Compared to 2019, DCWs in 2020 were more likely to be nonmedical aides, under 25, over 65, non-white, to purchase health insurance directly, and to receive health insurance from Medicaid. DCWs in 2020 were less likely to be widowed, to be recently married, to be non-English speaking, to work year-round and full-time, to have moved in the last year, and to be below poverty than they were in the previous year. Implications: By the end of 2020, the early effects of the COVID-19 pandemic on the direct care workforce could be seen. While the total number of DCWs increased slightly, this was due to the accelerated growth of DCWs in home care, as the decline in the number of DCWs in hospitals and residential care facilities also accelerated. The direct care workforce in 2020 was more nonmedical, part-time, entry-level or exit-level and non-white than in the previous year.

CARING FOR CAREGIVERS: HEALTH AND HEALTHCARE EXPERIENCES OF DIRECT CARE WORKERS

Abstract Direct care workers play a significant role in supporting the health of older adults and people with disabilities across long-term care settings—but as a primarily low-income, women of color workforce, they likely face significant health risks themselves. To build understanding on the health of this essential workforce, this paper examines direct care workers’ health status, health insurance coverage, and experiences utilizing, accessing, and paying for healthcare services using pooled 2014 to 2018 data from the National Health Interview Survey. We find direct care workers have worse health, lower rates of insurance coverage, poorer access and utilization, and greater cost barriers compared to other healthcare workers. We also observe disparities within the direct care workforce according to industry, gender, and race/ethnicity. This study helps inform efforts to support the health of direct care workers and stabilize the critical services they provide.

FORMAL CAREGIVER BURDEN IN NURSING ASSISTANTS IN NURSING HOMES: A FEASIBILITY STUDY

Abstract Formal caregivers are the direct care workforce that aid residents in nursing homes. Providing care to residents is hazardous and physically demanding. Formal caregiver burden encompasses five attributes – perceived stress, caring for another, dependency of the older adult, responsibility, and competence. Exploring the five attributes of formal caregiver burden using a mixed-methods approach will determine if the attributes are present and how the nursing home setting contributes to formal caregiver burden. The purpose of this feasibility study is to describe formal caregiver burden of nursing assistants who provide direct care to residents in a nursing home setting in the Midwest United States. Study site one was only able to enroll three participants; therefore, results were limited. However, study site two was able to recruit and enroll the desired sample size (N=9). Interviews and self-report measures (Background/COVID-19 Questionnaire, Perceived Stress Scale, Caring Behaviors Inventory, and Nursing Home Staff Competency Assessment) were completed, and the PI compared integrated mixed methods results. Results suggest all the attributes of formal caregiver burden were present, and no additional attributes were identified. The feasibility of virtual recruitment, enrollment, and data collection procedures were confirmed. Multiple challenges played a role in the unsuccessful recruitment of this feasibility study at site one; however, virtual recruitment was successful at site two. Further exploration will inform identification and measurement of formal caregiver burden to ensure support for nursing assistants, continue the vitality of the nursing assistant workforce in nursing homes/long-term care, and improve the lives of nursing assistants.

ORGANIZATIONAL SUPPORTS ASSOCIATED WITH NURSING ASSISTANTS’ JOB SATISFACTION DURING COVID-19

Abstract The COVID-19 pandemic has disproportionately affected nursing home residents and staff, including the nursing assistants who provide critical supports for older adults and people with disabilities. The pandemic has added significant strain to an already vulnerable nursing home workforce, which has historically experienced high levels of turnover, chronic staffing shortages, and high burnout. At the same time, it has generated awareness of the value of the direct care workforce to provide care in places for those most at risk from the disease. Job satisfaction of nursing assistants is as major driver of turnover and intent to leave the job. Research has demonstrated organizational supports and job stresses that are associated with job satisfaction and turnover. However, limited research has investigated the factors associated with job satisfaction in nursing homes during the COVID-19 pandemic. Using data from an employee engagement and management system, we examined organizational supports (e.g., supervision, appreciation, safety) and work-related stresses associated with job satisfaction among nursing assistants in nursing homes (n=402). Higher quality of supervision, feeling appreciated for the job, and feeling safe and comfortable at work were associated with higher levels of job satisfaction. Work-related job stressors –increased workload demands and understaffing – were associated with lower job satisfaction. Our findings provide insights into the importance of employer supports and reducing work-related stressors in nursing assistants’ job satisfaction and practical implications for nursing home leadership regarding how to support workers