Direct Care Workers and Quality Jobs/Quality Care

October 4, 2016
By DC Coalition on Long-Term Care

This month, the Consumer Health Foundation (CHF) will post a series of blogs on the direct care workforce in partnership with the DC Coalition on Long-term Care, a nonprofit organization which was formed to improve the quality of long term care programs and ensure that low-income District residents with disabilities or chronic care needs can continue to live in their communities safely and with dignity. We would like to thank the Coalition for interviewing stakeholders from the nonprofit, business, and local government sectors on their views about this important workforce. We would also like to thank the Coalition for facilitating CHF’s interview with a direct care worker from the Washington, DC region.


The Paraprofessional Healthcare Institute (PHI) described the direct care workforce as composed of home health aides, nursing assistants, psychiatric aides, and personal care aides. The direct care workers provide 70-80% of caregiving for older adults and people with disabilities. It is projected that by 2020, there will be more than 5 million direct care workers, which will make it one of the largest employment sectors in the country. Nationally, direct care workers are 88% female; 20% are foreign born; the average age is 42 and growing older; and 55% have a high school diploma or less.

Direct care workers have the lowest wages in the health care sector. In the Washington, DC region, direct care workers’ yearly wages range from $19,000 to $22,500. However, an individual with no children needs to earn at least $31,656 and higher to meet basic needs. Approximately 30% are uninsured and 47% are enrolled in public benefit programs. Other challenges include the lack of training and high worker turnover. The Affordable Care Act also requires expansion of roles, higher skills and performance from the health workforce, including direct care workers, to deliver care. At the same time, it is an opportunity to improve both patient care and provide career pathways and better employment for direct care workers.

CHF views the direct care workforce as an example of the intersection between the health reform and economic justice fields. According to PolicyLink, increasing wages for direct care workers has a significant impact. For example, California saved more than $5 billion each year after the hourly wage was increased to $14 for direct care workers because they did not need to avail of public benefits. In San Francisco, workers’ turnover fell by 57 percent.

The following interviews reflect many of the above issues nationally and within our region.



Daniel Wilson, Paraprofessional Healthcare Institute

PHI is a national organization that works to improve the lives of people who need home or residential care by improving the lives of the workers who provide that care.

What are some of the biggest challenges of direct care workers?

(One major challenge is) how direct care workers (DCW) are valued in the home care workforce. We at PHI believe that (their wages) should start at $15. It goes back to the value of the job. We see direct care workers as an integral part of America’s aging and disabled population.

I think many people are unaware of how extensive the home care industry is. Can you give me an idea of the scope of the direct care workforce?

There is some statistic that says 8 out of every 10 hours of service that was delivered to an elder person was not given by a doctor or nurse, but by a direct care worker. 7 out of 10 employees within the elder care/disability services are direct care workers. Their footprint is huge.

Are there any state or federal policies that have been enacted that support direct care workers and consumers?

The Affordable Care Act had a provision that gave states demonstration grants for the Personal and Home Care Aide State Training (PHCAST) Program, which provided a standard for training for personal home care aides. We really saw that as a baseline step for our direct care workers. We are hopeful that Congress will pick up where PHCAST left off.

What motivates you personally to seek better quality jobs and better quality care?

For me, it really is personal. When I was a sophomore in college, my mother was diagnosed with stage 4 breast cancer. My mother was an educator for 40 years in the Chicago Public Schools. Education was first and foremost for her. My aunt lived in the same building as us. But she had to manage the family business so we had to hire a direct care worker. The only way I could go to school was if we had a quality home health care aide. For me it really is personal because I see how critical the value of this job is.

Can you tell me a little bit about the work that PHI does to strengthen the direct-care workforce?

We train direct care workers and improve the quality of the job by advocating for fair wages. We also advocate around continuing education, which leads into a career ladder. Many of (the agencies have) low retention rates because there is no upward job mobility. So we looked into the positions for senior aides, registered nurses, and certified nursing assistants so direct care workers can transition to higher positions.

What are some of your short-term and long-term goals for the direct care workforce?

Our question is what are the unique challenges that face direct care workers? The disability community, more than anyone else, values self-directed care. We have to look at what that means for training for DCWs, how we are able to meet an individual with a disability where they are and have a competently trained DCW to support them. (Another goal is to) ensure that DCWs are seen as vital. What people do not realize is that the only interaction that an individual may have during the day is with DCWs. (Clients) depend on the DCWs to be their eyes and ears. They are the voices of the individual that they care for.

What do you want funders to know about programs that improve the quality of direct care jobs?

We as a country have not yet grasped the enormity of the situation as it relates to the number of baby boomers that will come into the health care system in the next few years – the number of people that will need care that may be complex; they may want to stay at home; and age in place in an environment where they feel loved and supported and that is familiar to them. Unless we have the number of (direct care workers) to fill those needs, we are going to be in a health care crisis. I don’t know what the country will do to respond to this. Until Congress and the federal government see this as an issue, we will continue to advocate for better quality jobs.

What are your thoughts on a cooperative for direct care workers and how could a co-op model contribute to quality jobs and quality care?

I am certainly in favor of cooperatives. If formed and managed and maintained properly it gives workers a true sense of value. Our partnership with Cooperative Home Care Associates (CHCA) in Bronx, NY is one example. The cooperative is constantly on the cutting edge of innovative training for the workers. The workers have an opportunity to expand their skills and be promoted within the organization. Several of the managers started as direct care workers and are now in management roles. The cooperative model is a great way to promote quality care through quality jobs by investing in the worker.

Read Marla Lahat, Home Care Partners’ Executive Director, interview here.

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