The Struggle and Advocacy of Direct Care Workers: A Call for Change
By Grace Vitaglione
Diondre Clarke, 60, discovered her calling as a direct care worker in 2013 after caring for her parents and grandmother during their illnesses.“I found a passion to help people,” she said. But her journey has been far from easy.
When the COVID-19 pandemic hit, Clarke transitioned to working in assisted living facilities and skilled nursing facilities, commonly known as nursing homes. despite earning $20 an hour, she still needed a second job to make ends meet. “It was tiring. It was a lot of work. I was stressed out,” she recalled. “I was scared that I was going to get COVID and take it home.”
today, Clarke is an advocate for workers like herself with the National Domestic Workers Alliance, an association fighting for the rights of millions of nannies, housecleaners, and home care workers. She emphasizes the need for higher wages, health insurance, and more training and support for direct care workers.
But advocating for these changes starts with a fundamental question: Who exactly is a direct care worker? Is it someone who works in home health care, or also in facilities like nursing homes? Does it include those who assist with activities of daily living, such as bathing and feeding? And what about registered nurses—do they fall under this category, or are they distinct due to their licensure and status?
These questions were at the heart of a workshop hosted on January 15 by the NC Center on the Workforce for Health, in collaboration with the N.C. Department of Health and Human Services, the North Carolina Institute of Medicine, the North Carolina Coalition on Aging, and other organizations.
The workshop marked the first in a series aimed at addressing recommendations from a 2024 report by the Caregiving Workforce Strategic Leadership Council. The goal? To strengthen North Carolina’s direct care workforce.
Leaders of these organizations recognize that defining the direct care workforce is the first step in tackling a critical issue: there simply aren’t enough workers to meet the growing demand.
Key Challenges Facing Direct Care workers
Table of Contents
- North Carolina’s Direct Care Workforce: Challenges and Opportunities
- The Direct Care Workforce: Defining an Emerging Collective Identity
| Challenge | Impact |
|—————————–|—————————————————————————|
| Low Wages | Many workers, like Clarke, need second jobs to make ends meet. |
| Lack of Benefits | Health insurance and other benefits are often unavailable. |
| Insufficient Training | Workers need more support to handle complex care needs. |
| Workforce Shortages | The aging population is increasing demand,but supply remains limited. |
the direct care workforce is essential to the well-being of older adults and people with disabilities. Without adequate support, families and caregivers face increased pressure to step in, often providing care that falls short of meeting complex health needs.
As Clarke and others continue to advocate for change, the first step is clear: defining and valuing the direct care workforce is crucial to building a sustainable future for caregiving in North Carolina and beyond.
For more insights into the challenges and solutions for the direct care workforce, explore the resources provided by the National Domestic Workers Alliance and the NC Center on the Workforce for Health.
North Carolina’s Direct Care Workforce: Challenges and Opportunities
North Carolina’s direct care workforce is at a crossroads. With nearly 120,000 workers, this essential sector is predominantly composed of women (92 percent) and people of color (61 percent), according to PHI-sponsored research. Though, the state faces a looming crisis: over the next decade, north Carolina will need to fill more than 186,000 openings in direct care, including nearly 21,000 new jobs to meet rising demand and 165,500 vacancies due to workers leaving or retiring.
The Direct Care Workforce: A Complex Ecosystem
At a recent event on january 15, attendees emphasized the need for a clear framework to categorize and track direct care workers. Clarke, a participant, likened the workforce to a tree: “The many branches make up all the different roles that could fall under the label of ‘direct care worker,’ and they’re all connected by the trunk: providing care for a human being.”
The personal care aides, home health aides, and nursing assistants. While all three assist with activities of daily living, such as eating and dressing, each role has distinct responsibilities:
- Personal care aides may also help with housekeeping, medication management, and community engagement.
- Home health aides perform clinical tasks like wound care and blood pressure readings, often under remote or intermittent supervision by a licensed professional.
- Nursing assistants handle certain clinical tasks under on-site supervision.
However, some attendees noted that critical roles, such as those in behavioral health and care for individuals with intellectual or developmental disabilities, are not included in this classification.
Challenges Facing the Workforce
Despite their vital role, direct care workers in North Carolina face significant challenges. Before pandemic-era salary increases, wages had decreased over the past decade when adjusted for inflation, according to PHI. Other barriers include lack of professional advancement, inadequate training, and insufficient respect for the profession.
The aging population further exacerbates the demand for these workers. as Andy MacCracken, director of the NC Center on the Workforce for Health, noted, addressing these challenges will require collaboration from all stakeholders.
Recommendations for Growth
To tackle these issues, the leadership council has proposed several recommendations:
- Increase wages and benefits to attract and retain workers.
- Provide extensive training and opportunities for professional progress.
- enhance public recognition and respect for direct care workers.
| Key Statistics | Details |
|———————|————-|
| Total Direct Care Workers in NC | 120,000 |
| Women in Workforce | 92% |
| People of Color in Workforce | 61% |
| Projected Job Openings (2018-2028) | 186,000 |
| New Jobs Needed | 21,000 |
| Vacancies Due to Turnover/Retirement | 165,500 |
A Call to Action
the direct care workforce is the backbone of North Carolina’s healthcare system. As the state prepares to meet growing demand, it’s crucial to invest in these workers through better pay, training, and recognition. As Clarke aptly put it, “The many branches of this workforce are all connected by the trunk: providing care for a human being.”
By addressing these challenges head-on, North Carolina can ensure a robust and sustainable direct care workforce for years to come.
The Direct Care Workforce: Defining an Emerging Collective Identity
The direct care workforce is a critical yet often overlooked pillar of the healthcare system, providing essential support to individuals with disabilities, older adults, and those in need of long-term care. However, defining this workforce remains a challenge, as it encompasses a diverse range of roles and settings.Trish Farnham, program coordinator with the N.C. coalition on Aging, emphasized this during a recent workshop, highlighting the need for a unified definition to foster “an emerging collective identity” while recognizing the distinct groups within it.
The Complexity of Defining Direct Care Workers
The direct care workforce includes peer support specialists, who assist individuals with mental health challenges, and supported employment specialists, who help disabled adults find and maintain jobs. Though, federal codes frequently enough exclude autonomous providers, such as direct care workers employed through Medicaid consumer-directed programs, where individuals can choose their own caregivers.Additionally, the “gray market” — workers hired privately by households — is not accounted for in official definitions.
PHI, a leading authority on the direct care workforce, categorizes these workers based on their settings: home care workers in private residences, residential care aides in group homes and assisted living communities, and nursing assistants in nursing homes. This segmentation underscores the diversity of roles within the workforce but also complicates efforts to create a cohesive definition.
Why a Unified Definition Matters
A clear definition is essential for creating a workforce inventory, as outlined in the Caregiving Workforce Strategic Leadership Council report. Such an inventory would enable better data collection and analysis, addressing critical issues like turnover, job satisfaction, and pay disparities. Currently, the state “lacks reliable and actionable data” about this workforce, making it arduous to implement effective solutions.
Though, defining the workforce also means drawing boundaries. “It’s about who is in and who is out,” farnham noted. This distinction is crucial for ensuring that direct care workers are included in conversations about their roles and rights. Titles, as Farnham explained, considerably impact how workers perceive themselves and how others view their abilities.
Challenges in Valuing Care Work
One of the most pressing issues facing the direct care workforce is the lack of respect and recognition. A 2021 study by the FrameWorks Institute revealed that many Americans view care work outside hospital settings as “less skilled and less important.” This perception contributes to the undervaluation of direct care workers, who frequently enough face low wages and limited career advancement opportunities.
To address these challenges, the report recommends that the N.C. Department of Health and Human Services (NCDHHS) partner with public and private employers to standardize
This Health is dedicated to ensuring that various stakeholders remain committed to the long-term goals, even as external circumstances change.
“We’re not going to solve all these problems within a two-year legislative term. So our ability to create a space that is designed for that coordinated persistence over time is really important,” MacCracken said.
The collaborative approach has been well-received by stakeholders, from educators to employers, who all recognize the urgency of the crisis. Bringing everyone together is seen as a more efficient way to address the challenges collectively.
“for a long time, what we’ve been doing hasn’t been working collectively. So it’s actually not a hard sell for folks to come together and say, ‘Hey, we need to figure out a different way to approach this,’” MacCracken added.
as North Carolina continues to navigate this workforce crisis, the emphasis on coordinated persistence and actionable solutions offers a hopeful path forward.
North Carolina Tackles Caregiving Workforce Crisis with Coordinated Persistence
North Carolina is taking bold steps to address its growing caregiving workforce crisis, a challenge that is not unique to the state but is being met with innovative and collaborative solutions. the Caregiving Workforce Strategic Leadership Council has laid out a comprehensive roadmap to tackle the issue, focusing on actionable strategies and long-term persistence.
The crisis at Hand
The workforce crisis in the caregiving sector has been described as “insurmountable” by experts. Though, the spirit of collaboration among stakeholders is fostering hope. Traditionally, groups in the direct care space have competed for limited funding and resources. but the severity of the shortage is now unifying these groups, creating a shared sense of urgency.
Four Key Recommendations
The Caregiving Workforce Strategic Leadership Council has identified four critical areas to address the crisis:
- Define the Workforce: Creating a clear definition of the caregiving workforce to develop targeted strategies.
- Advance the Data Landscape: Improving data collection and analysis to better understand the needs and gaps in the sector.
- Create a Living Wage: Ensuring caregivers are paid a living wage to attract and retain talent.
- Expand apprenticeship programs: Developing more apprenticeship opportunities to bring new people into the field.
Each of these recommendations will be the focus of dedicated workshops later this year,with the N.C. Institute of Medicine synthesizing the information to make it actionable for state agencies and other entities.
Advocacy and Accountability
One of the significant steps being taken is advocating for higher Medicaid reimbursement rates for direct service providers. This will likely require substantial effort and coordination with state lawmakers at the NC General Assembly.
Accountability is also a major focus. The Center on the Workforce for Health is dedicated to ensuring that various stakeholders remain committed to the long-term goals,even as external circumstances change.
“We’re not going to solve all these problems within a two-year legislative term. So our ability to create a space that is designed for that coordinated persistence over time is really important,” said MacCracken of the NC Center on the workforce for Health.
A Collaborative Approach
The collaborative approach has been well-received by stakeholders, from educators to employers, who all recognize the urgency of the crisis. Bringing everyone together is seen as a more efficient way to address the challenges collectively.
“For a long time, what we’ve been doing hasn’t been working collectively. So it’s actually not a hard sell for folks to come together and say, ‘Hey, we need to figure out a different way to approach this,’” MacCracken added.
Summary of Key recommendations
| Recommendation | Description |
|———————————-|———————————————————————————|
| Define the Workforce | Create a clear definition to develop targeted strategies. |
| Advance the Data Landscape | improve data collection to understand needs and gaps. |
| Create a Living Wage | Ensure caregivers are paid a living wage to attract and retain talent. |
| Expand Apprenticeship Programs | Develop more apprenticeship opportunities to bring new people into the field. |
Moving Forward
As North Carolina continues to navigate this workforce crisis, the emphasis on coordinated persistence and actionable solutions offers a hopeful path forward. The state’s proactive approach,combined with the collaborative efforts of various stakeholders,sets a precedent for addressing similar challenges nationwide.
For more information on the Caregiving Workforce Strategic Leadership Council and their initiatives, visit their official website.
Workforce Inventory Challenges and Opportunities
Addressing the challenges in valuing care work and defining the direct care workforce requires a comprehensive approach that includes data collection, policy changes, and cultural shifts. Here are some opportunities and challenges related to creating a workforce inventory:
Challenges:
- Overlapping and Fragmented Data: Different organizations and agencies may collect data on the direct care workforce, but these datasets frequently enough overlap or are fragmented, making it difficult to achieve a comprehensive view of the workforce.
- Limited Resources and Funding: Addressing data limitations requires resources, including funding for data collection, analysis, and maintenance efforts. Securing and maintaining sustained funding can be challenging.
- Data Silos: Different sectors and settings within the direct care workforce (e.g., home care, nursing homes, residential care) may have disjointed data systems, hindering the development of an integrated workforce inventory.
- Privacy and Confidentiality Concerns: Collecting detailed workforce data raises privacy and confidentiality concerns. Ensuring the protection of sensitive data is crucial to gain workers’ trust and cooperation.
Opportunities:
- Interagency Cooperation: Different state agencies can collaborate to compare and consolidate existing data, reducing overlaps and filling gaps. Examples include the N.C. Department of Health and Human Services (NCDHHS), the Division of Workforce Solutions, and the Department of Commerce.
- Federal Data Resources: Utilizing federal data resources,such as the Bureau of Labor Statistics’ National Occupational Employment and Wage Estimates or the U.S. Census Bureau’s American Community Survey, can provide additional insights into the direct care workforce.
- Stakeholder Engagement: Engaging relevant stakeholders, such as workforce boards, educational institutions, and employer associations, can facilitate data collection and ensure that the workforce inventory addresses their needs and priorities.
- Data Visualization and Storytelling: Develop user-friendly data visualization tools and stories to effectively communicate the findings from the workforce inventory to policymakers, the public, and other stakeholders. This can definitely help build support for data-driven policies and investments in the direct care workforce.
- Periodic Updates and Refreshening: Regularly updating and refreshing the workforce inventory ensures that it remains relevant and useful. this can be achieved by incorporating new data sources, revisiting and refining research methods, and engaging with stakeholders to address emerging needs and challenges.
