Robert Espinoza, Executive Vice President of Policy at PHI: The Direct Care Crisis Hits Home

Van Ton-Quinlivan: Welcome to WorkforceRx with Futuro Health, where future-focused leaders in education, workforce development and healthcare explore new innovations and approaches. I’m your host, Van Ton-Quinlivan, CEO of Futuro Health.

Every day, nearly 4.7 million direct care workers support older adults and people with disabilities across the United States. The critical need for this workforce is only increasing as the proportion of people over sixty-five continues to grow dramatically. Today, we’re going to explore who these workers are, how their role is changing and the workforce development implications created by shortages.

With me is Robert Espinoza, a nationally recognized expert in aging, caregiving and long-term care workforce issues. For more than twenty years he has spearheaded advocacy campaigns and written seminal reports on aging and long-term care, LGBTQ rights, social justice and immigration, amongst other topics.

He’s currently executive vice president of policy at PHI, formerly the Paraprofessional Healthcare Institute, where he oversees its national advocacy and public education division on the direct care workforce. Thanks so much for joining us today, Robert.

Robert Espinoza: Thank you, Van. I’m looking forward to this conversation.

Van: Absolutely. Let’s start by having you give us a quick overview of PHI and its mission.

Robert: Sure. PHI is a national organization that’s focused on strengthening the direct care workforce which is made up of about 4.7 million home care workers, residential care aides and nursing assistants who support older adults and people with disabilities in various settings. They work in private homes. They work in nursing homes. They work in residential care settings like assisted living facilities, for example.

PHI has been around for more than thirty years. We do a few things. One is, we advocate for policies at the federal, state and local level that improve these jobs and optimize their role in care delivery. We also design a range of workforce interventions such as training programs, advancement approaches and so much more. We study and analyze this workforce, so we produce regular data and analyses on these workers and on the policies that are shaping their lives. So, in many ways, we are offering a 360-degree perspective on this workforce.

Van: Wonderful. Thank you for doing the work that you do.

Robert: Absolutely. Thank you.

Van: Tell me about the typical home care worker in this country today.

Robert: The typical home care worker in the U.S. is a woman in her mid-to-late forties. She is most often a woman of color and in many cases, an immigrant. She is low-income because direct care jobs are low-wage jobs, in many ways. The typical home care worker is someone who struggles with poverty even though she’s working jobs that, while rewarding, are actually quite difficult physically and emotionally. The typical home care worker also doesn’t last in these jobs. Turnover rates tend to be high in home care. Many workers often leave within the first ninety days because either wages are too low, or because of their supervisors. Those are the two top reasons that tend to show up.

I will say also, the typical home care worker is becoming increasingly older as well. Our research does show that one in four direct care workers is aged fifty-five and older. So, as this country has aged, so as its workforce.

Van: You mentioned a number of troubling trends there. But let’s for a moment stay on this issue of wages being too low. Home care workers and nursing assistants are essential to millions of people and their families, and yet these jobs don’t often pay enough, and as you mentioned, workers leave this field fairly quickly. Why is that, and is there anything we can do about that?

Robert: Absolutely. I think that what we’ve seen in the last few years because of the COVID-19 pandemic is a growing recognition that direct care workers are essential to older adults, to people with disabilities, to family caregivers, and to the entire healthcare sector in our U.S. economy and yet these jobs are grossly neglected and undervalued.

The median wage for direct care workers at this point is about $15 an hour. But it’s not a wage that has increased much over the last ten years when adjusted for inflation, and that pushes about 40% of workers into near poverty. Now, these jobs have remained low in pay for a variety of reasons. Oftentimes, this work is seen as women’s work or the work of people of color. We know that we live in a country where those sexist and racist ideas devalue a range of occupations, and direct care is an example of that.

Another reason is that direct care is primarily paid for by Medicaid, a system that is often strained at the federal and state level and it’s increasingly under attack. So, when Medicaid is improperly financed, so are these jobs.

What can we do about it? I think primarily we can really elevate the role of direct care workers in healthcare and long-term care delivery. We can value them as essential members of people’s care teams; as essential members of the long-term care system — nursing homes, private homes and residential care settings; and as a valuable part of our economy.

When we improve direct care jobs — either by improving wages, strengthening training programs, creating more advancement opportunities and so much more — we ultimately don’t just improve their economic security and the care that they offer older adults and people with disabilities, we also actually reduce expensive costs like hospitalizations and achieve other cost savings. So, it’s a win-win for everyone when we transform these jobs.

Van: Are there strategies that help improve the quality of the job to make them more attractive?

Robert: I think there are a variety of strategies that could improve these jobs. The first is that we could strengthen a variety of measurements or indicators of job quality in this workforce. We could create not just a living wage, but a competitive wage for workers that allows employers to compete with comparable employers in this country. Like, right now, a lot of long-term care employers are competing with fast food and retail, as two examples, and yet the wages they offer aren’t competitive with those sectors.

I think the role of sector partnerships and state policies, in particular, are really critical because we need to figure out ways to pull resources at the sector level and at the state level to create things like better training programs and more advancement opportunities. We also really need to think about the regional supports that are offered within a state, because every state is different. And, I think, the more we think about that localized state approach, the more successful that will be.

Van: Let me ask you, Robert, what is the ideal training path to become a direct care worker, and are there education paths to go to the next level and perhaps pursue a better wage?

Robert: What we see in this sector is that both training and advancement varies by state, it varies by occupation and it varies by employers. So, it’s a very scattered and fractured training system that we see for direct care workers. In the ideal, there would be entry-level training for workers that would be based on standardized core competencies that we can agree on… the right skills and knowledge bases that all direct care workers should have. The training would be affordable. It would be accessible to workers.

Then, there would be some way of certifying these workers and making those records available to employers in the state. There would also be advancement opportunities both within direct care — so that we don’t lose workers to other sectors and people can see that there are advancement opportunities — but for workers who do want to advance beyond direct care either into administrative or management positions, or into other healthcare careers like an LPN, for example, there would be those opportunities as well.

Unfortunately, that is not the reality. Right now, training requirements are limited. They tend to focus more on home health aides and nursing assistants than they do on personal care aides who don’t perform the same clinical tasks that their peers do. Those training requirements vary by state. So, in many states, personal care aides undergo maybe ten to twenty hours of training before they start this work. There isn’t enough specialized training to address the more common chronic conditions that we’re seeing, like dementia care, or advanced training to make sure that workers can advance in their careers.

That’s a problem, right? If we were to strengthen the overarching training and advancement infrastructure of this workforce, we would address recruitment and retention, and that would support both workers and the people they support.

Van: Well, I have to scratch my head a little bit and maybe the listeners will have some ideas. Do we have any analogs to a marketplace where it’s this fragmented and this low-paying and where the workforce has been able to evolve its way out? Maybe we can borrow some best practices there.

Robert, let me go to the next question. Why does the average American household struggle so much to find long-term care in this country?

Robert: There are a number of barriers that average Americans struggle with when seeking long-term care. Anyone who’s gone through this process can attest to it. I can attest to it personally, and I can attest to it as a professional. The first is the confusion of the sector. Let’s say your father is diagnosed with dementia and you realize that you need a home care worker for a set number of hours per week. What you will struggle with immediately is you may not know where exactly to turn to. This isn’t necessarily information that’s often centralized and if it is, it’s not readily available to many people, or they don’t know where to start searching for it. I think several of my peers would say they have websites, for example, and yet I think it’s actually quite a confusing first entry point for many people who need this care.

The other reality is that it’s unaffordable in many instances. Medicaid right now is the primary payer in long-term care. Medicaid is a program that’s for poor and low-income families and individuals. For middle-income people or higher-income people, they typically need to exhaust their income and their assets in order to qualify for Medicaid, and that’s not fair. We see the story of family caregivers who are cutting work hours and spending down their savings to be able to care for a loved one, and that’s because we live in a country where long-term care is not affordable.

The third barrier is that let’s say you do know where to go and you can afford it, but then the challenge is workers. You may find a home care agency and you may find that you’re eligible for a certain number of hours. What we’re seeing more and more is that home care agencies, nursing homes and assisted living settings simply can’t find workers to fill jobs. That means that they can’t deliver the hours of care that many people need. what we’ve seen is that many states are picking up and leading the way. We’re seeing states develop wage pass-through laws that help increase wages for direct care workers and make sure that the money goes directly into their paychecks. Or we’re seeing states develop certification programs and stronger training requirements so that workers are equipped with the right skills and knowledge, and so much more. I think there’s a lot of opportunity for state-level innovation.

Van: Boy, we seem to be heading for a disastrous future of care as you lay out all those trends with the shortage, with the costs, and with the confusion. Is this situation solvable, Robert?

Robert: I think it is solvable. I think part of what motivates me every day is knowing that part of solving this crisis in long-term care — especially the workforce side, which is the side that I focus on — is trying to think about all those pieces in the puzzle. Tackling each piece bit by bit to make sure that we’re tackling the key concerns that are driving this crisis. I mentioned a few of them.

One is, of course, the compensation for workers and the financing of this system, which makes it unaffordable for many people to pay for long-term care. The second is that workers simply aren’t trained enough and the sector doesn’t offer the kind of advancement opportunities or support those workers deserve.

The third that I would offer is that when you think about this workforce, I don’t think that they are top-of-mind for everyday people. What we saw in the early stages of the COVID-19 pandemic was a number of telethons, for example, that were honoring all the essential workers that were getting us through those catastrophic few months. It’s still a catastrophe, but especially in the beginning. We would see these much-deserved images of grocery store workers and nurses and doctors flying from one state to another. I never saw a home care worker in those telethons. I never saw nursing assistants even though, at the time, half of the deaths were in nursing homes. And that’s a tragedy.

It tells me that we live in a country that still devalues older adults and people with disabilities, especially when you’re low-income. It devalues workers, especially when you’re a woman of color and an immigrant. If we can think about turning that bias on its head and think about how do we more value the reality that all of us — if we’re not there already — will need professional care as we age. But also, that all of us — regardless of our race, our gender or immigration status — deserve a good job. I think we would see more of those pieces of that puzzle that I just described.

Van: Have you seen any models, Robert, either within the U.S. or outside of the U.S. where you would point to it and say, “Hey, there’s something good happening there that we should study or emulate.”

Robert: Within the U.S., we see a few models that are worth replicating. The first model is what you might call a universal worker model. This is a model where you think about designing an occupation that’s quote-unquote, universal. So, a worker is trained across the standard set of core competencies. They’re able to move from one setting to another and, ideally, from one state to another so that when a pandemic emerges or when the next health crisis emerges, those workers can work from one state to the next. I think that’s an important model.

Another model is bolstering the consumer-directed model. This is a model that you see where if you’re a family member and you’re supporting someone you love, your state has a consumer-direction model that can pay you for being a caregiver. We call them independent providers as part of the workforce. Many states like California, for example, and Washington State have really robust consumer-directed models where they are training and supporting their consumer-directed workers and helping ease the strain on the caregiving crisis that we’re seeing.

In terms of other countries, I will say that we have heard from a variety of countries, mostly in Europe, that are struggling with the same questions that we are struggling with, which is a growing shortage of people who are taking these jobs, and a growing number of older adults and people with disabilities who need this level of care and the need to find solutions.

One promising practice that we’re seeing in Europe, and I hope that we can emulate in the U.S., is a more humane and sound approach to immigration. I think immigrants deserve good jobs in general, but I think they can also be a solution to the staffing crisis that we’re seeing in direct care. We don’t need to necessarily start by recruiting foreign workers into this country because there are millions of undocumented immigrants already in the U.S. that we can draw from to fill these jobs. It does mean being more humane and sound in our immigration policy, and we do live in a country that is still quite hostile to immigrants.

Van: Are there any other aspects of tapping into the immigrant population that you’d like us to think about?

Robert: What we know is that immigrants are a big part of the direct care workforce. Our research shows that about one in four direct care workers is an immigrant and I believe it’s one in three in home care. And really, immigrants are essential to the entire long-term care sector and healthcare sector. Without them, those two systems would collapse across other occupations.

What we know in terms of immigration is that there are a few solutions that would help address the crisis that we’re seeing in the direct care workforce. The first is making sure that we offer a pathway to citizenship for undocumented immigrants in this country, and perhaps provide a pathway into caregiving and into direct care for many of those immigrants. I think that would be a big support. We can imagine that a number of immigrants who are already in the U.S. probably have some level of background in healthcare. I think we see that in other research.

Certainly, we could think about a temporary visa that would recruit workers from abroad maybe into the caregiving profession and help address the crisis that we’re seeing there. Of course, we would need to make sure that there are strong worker protections in those temporary visas…that workers are offered an opportunity to become permanent residents so that we avoid the exploitation that we’ve seen with previous temporary visa programs.

The third is that there are many programs in the U.S. that are already offering support to immigrants to become home care workers. For example, in New Mexico, there’s an organization called Encuentro. What they do is train immigrants, typically from Mexico and Latin and South America, to become home care workers. They help place them with agencies around the state. As part of their training, they also help them navigate the kind of barriers that many immigrants in this country face related to navigating the immigration system, dealing with limited English proficiency, and so much more. I think those three prongs are a big part of the solution for this workforce.

Van: I’m glad you were a speaker at the National Skills Coalition’s recent “Skills in the States Forum.” We both were there in New Orleans, and I hope you were able to share some of those policy ideas with the folks there.

Robert: I was. It was a terrific gathering there. My plenary was focused on state solutions and the role of sector partnerships. What we’re seeing around the country is that states are really leading the way on the direct care workforce. We, unfortunately, saw the biggest federal proposal on caregiving — Build Back Better — fall apart in the last year, and that was devastating. I think many people thought that would really transform both the home and community-based services sector, and also the direct care workforce.

In the absence of that federal reform, what we’ve seen is that many states are picking up and leading the way. We’re seeing states develop wage pass-through laws that help increase wages for direct care workers and make sure that the money goes directly into their paychecks. Or we’re seeing states develop certification programs and stronger training requirements so that workers are equipped with the right skills and knowledge, and so much more. I think there’s a lot of opportunity for state-level innovation.

Van: Explain the wage pass-through law. Is that because the agency takes such a big cut?

Robert: I think what we see is that it’s unclear how much of the money that’s often dedicated from Medicaid, for example, goes toward operating costs versus wages. Many employers will say that the reimbursement rates under Medicaid already are insufficient to deliver services and so it’s even harder to increase wages. We know regardless of that, too many direct care workers are in poverty.

A wage pass-through law is a way to ensure that if a state increases its Medicaid reimbursement rates, or its Medicaid funding in general, a certain percentage of that money will go directly to workers themselves. That helps address their financial insecurity. It will make it easier for them to make ends meet and it will keep them in this sector.

Van: You mentioned the disappointment at the federal level and that the states are doing the heavy lifting. What would it take to convince policymakers to take this issue much more seriously because right now, as you mentioned, this is relatively invisible to policymakers?

Robert: There are at least two current reasons that I see policymakers taking up these issues. The first is that policymakers are seeing a crisis in their elected areas — their states, their localities and their regions. What they’re seeing is that older people and people with disabilities, and sometimes people they know directly, are not able to access the care that they need and deserve. It’s because there’s a staffing crisis in direct care. That crisis has a financial cost and it has an emotional cost on people. I think more and more people elected to office or appointed to office are recognizing that reality.

The other reason is that by far when a policy maker or a journalist or an industry leader or someone of influence contacts me and they’re interested in learning more about how to support this workforce, the vast majority of cases are people who have suddenly become personally invested in this issue because they know somebody who needs care and they’ve realized how underfunded and dysfunctional the system is and how often it’s a workforce crisis that’s at the core of that problem.

So, they’ve seen their father be diagnosed with dementia, or they’ve seen a loved one try to access home care for some reason and they can’t access it. They can understand it, and they can afford it, and they know that there aren’t workers available. The more that people will begin to recognize and see the personal impact of this crisis in their daily lives, I think we’ll see more policy change and more industry action.

Van: As part of contributing to the solution, PHI and Futuro Health are partnering with Homebridge, a San Francisco-based caregiving organization, under a new state grant to help train in-home care providers. Talk more about what excites you about this grant.

Robert: Well, it’s an exciting grant. We’re super grateful to Homebridge and Futuro Health for partnering with us on this initiative. It’s an exciting grant because what it is offering is a more comprehensive training advancement and support approach to consumer-directed workers in the state. It’s offering an opportunity for family caregivers or individuals who are paid by the state as in-home supportive services workers to be better trained and to be better supported as caregivers.

I think what’s important about this model is that in order to address the staffing crisis that is existing in every single state and that’s worsening by the year, we’re going to need to think about other ways of supporting caregivers. I do think the consumer-directed model is one of those solutions. I’m hopeful that together with Futuro Health and with Homebridge, we’re going to really innovate in this area and inspire states all over the country.

Van: Well, we’re looking forward to that. I know we’re going to be contributing some work around the mental health and behavioral health curriculum as that’s more and more on everyone’s mind these days as an aftermath of the pandemic.

Robert: Absolutely. We saw the mental health issues really amplified in the last few years, both among workers and among the people they support. The challenge with mental health among the direct care workforce is that it’s a job that is very emotionally taxing, and yet it’s a sector that doesn’t often offer workers grief support or bereavement leave or the kind of mental health resources that they deserve. If we can innovate in that regard, I think we’ll fill a major gap.

Van: You developed a hybrid in-person and virtual approach to training home health aides during COVID. What part will online training play in the future, do you think?

Robert: Online training is a big part of training the direct care workforce in the future. The main reason is that what COVID-19 illustrated is that a pandemic or a health crisis can emerge and the in-person training that has been the norm in our sector for decades doesn’t quite work because people, of course, aren’t safe enough to meet in person. We need to figure out more cost-efficient ways to train more and more workers especially as the sector expands.

And yet, what we also know is that the best methods for training workers — and specifically training direct care workers — is in person, and it’s a mix of in-person and virtual methods. So, we took our learning from the COVID-19 pandemic and our long experience developing in-person training over the decades and merge them to create a hybrid training program in New York that mixes both the virtual learnings of what it takes to train workers online and through e-learning with some instructor-led content. That instructor can really guide workers through the kinds of exercises and lessons that typically a worker needs to know to care for somebody in the home.

I think it’s the future of this sector. I think more and more people are recognizing that there are many, many workers that need training and we need to be able to train people quickly and efficiently. We need to evaluate those trainings to make sure that when a worker finishes the training — whether it’s one month or three months or six months afterward — that they’ve retained the right skills and the right knowledge. I think workers deserve it and the people they support deserve it.

Van: Well done. Well done. As we head towards wrapping up here, I just wanted to give you a chance to mention any other exciting developments in this field that make you optimistic.

Robert: I think one development that’s exciting me in this field is a growing focus on the relationship between family caregivers and direct care workers. Our research shows that family caregivers and direct care workers, together, are the front line of support for older adults and people with disabilities in this country. Yet, in many cases, they share similar struggles in terms of a need for compensation, a need for recognition, a need for training and for support.  In many cases, they are the same people. Many direct care workers are also caring for family members. Family caregivers, of course, in many states are being paid as consumer-directed workers.

What we haven’t focused on as a country is the dyad relationship between family caregivers and direct care workers. How do we strengthen that relationship so that when they’re supporting their loved one — who is, of course, in charge and they’re the ones who are really shaping the kind of support they want to receive — when those family caregivers and direct care workers work together, how do we optimize that relationship through training, through policy supports and through so much more? I think the more we focus on that dyad relationship, the stronger the sector will be.

Van: Well, let’s benefit from your expertise in one final question, Robert. If our listeners are now faced with caring for a loved one, what advice would you give us?

Robert: I would give the advice to somebody who’s struggling to support a loved one that it’s a common struggle. We are seeing millions of people turn sixty-five every day. We’re seeing more and more people needing support in their private homes or in their residential care setting or in a nursing home.

The advice I would give is that it’s important to take that process step-by-step. It might be confusing at first and scary at first — since it’s often a moment of crisis that compels many people to seek care — but the information does exist. It just requires being able to piece it together. Oftentimes, many people will go to a local area agency on aging if it’s about an older person, and they can be a one-stop shop in somebody’s local region that can help them answer basic questions about caregiving. I think many organizations exist online. Typically, if you Google by ZIP code, you can find local aging organizations or workforce organizations.

I would encourage people also to become advocates for themselves. The more and more that all of us who are impacted by this caregiving crisis begin speaking in public, in the press and to our elected officials about these issues, we’re going to create a stronger system and we’re going to solve it for the next generation, I think.

Van: We learned so much in our session with you today, Robert. Thank you very much for spending time to share your wisdom with our listeners.

Robert: Van, thank you for the conversation. I had a great time and I appreciate this interaction.

Van: Likewise. I’m Van Ton-Quinlivan with Futuro Health. Thanks for checking out this episode of WorkforceRx. I hope you will join us again as we continue to explore how to create a future-focused workforce in America.