As worker shortages loom, some states move to train paid caregivers

“Somebody who is a caregiver by nature doesn’t want to do something wrong,” said Hayes, who just recently became a registered nurse. “And you get put in situations where it can be scary if you’re not fully supported or know what you’re doing, and this is someone’s life.”

The world of paid caregiving consists of three main roles: personal care aides, home health aides and certified nursing assistants. Hayes, like many others entering this workforce, began as a personal care aide, one of the most poorly defined roles on the front lines of long-term care for older adults.

The need for caregivers like Hayes is skyrocketing. The field is expected to have nearly 8 million job openings by 2026, fueled by the growing ranks of people over age 65, who by 2050, will number almost 90 million in the United States. Most of those people will want to age at home and will need support from personal care workers who already are in short supply.

Typically, personal care aides assist with things like bathing, cleaning and other activities of daily living. Once an individual needs more clinical support like taking blood pressure readings and administering medication, they require home health aides and certified nursing assistants.

But unlike home health aides and nursing assistants, personal care aides have no national, uniform training standards, which many experts argue devalues the jobs, negatively impacting workers and also employers’ ability to recruit and retain them. They are also paid much less, often little more than minimum wage.

Personal care aides are “as critical to the life and well-being of an older adult and a person with disability as a nurse is or a doctor is in a hospital setting,” said Robert Espinoza, executive vice president of policy at PHI, which works to ensure quality jobs for caregivers. “And yet we don’t value long-term care or the workers who work in those settings at the same level.”

Although Hayes was not measuring vital signs or assisting with medical equipment, he was often thrown into situations that required medical knowledge and an understanding of not only how to administer care, but where to get help.

And with higher rates of dementia, cardiovascular disease and diabetes coupled with the expanding list of clients whose backgrounds and needs vary widely, direct care has become increasingly more complex. When caregivers don’t have proper training, advocates say, they are more likely to feel unsupported and make mistakes that can harm clients.

A few states have established training mandates, which advocates see as a first step in creating a uniform standard that would professionalize the workforce and create a system that could support future demand.

“It is a very complex landscape. There’s so much variety across the country, between states but then also within states,” said Kezia Scales, vice president of research and evaluation at PHI. “Not having a consistent definition of this role, the core competencies involved and the training that’s needed undermines efforts to better recognize, value and compensate these workers and the services they provide.”

$10 an hour

The typical personal care worker makes $10 an hour, works irregular and part-time hours, and relies on public benefits to remain financially secure, according to PHI.

Their work can look deceivingly simple, covering such tasks as toileting, bathing, dressing and housecleaning. But caregivers also can manage a range of emotional and behavioral issues, and navigate these challenges as the only person in the home.

“You have to be very competent in understanding dementia, understanding behavioral health and having emotional intelligence, knowing how to communicate with older adults who may have vision and hearing challenges as well as mobility problems,” said Robyn Stone, senior vice president of research at LeadingAge, a network of nonprofit aging services providers.

“But the variation in the requirements around training is all over the place. And there’s no set standard that says, you know, you must at least do this,” she added.

Ultimately, she said, caregivers need better pay. With standardized training, the industry can build an argument for larger reimbursements from government payers and private insurance.

Medicaid is the largest payer for long-term care services, according to KFF. Even though Medicaid is a state-federal partnership, support for home and community-based services is determined at the state level.

Some industry advocates worry that implementing training requirements will make it more difficult for caregivers, who are disproportionately women of color, to join the workforce — particularly if training require people to drive to locations out of the way and pay for courses out of pocket.

However, Espinoza argues that the consequences right now of not having any training standards or way to pay for training are a bigger problem.

He says that just like other businesses, private-pay agencies should play a role in putting a percentage of their business operations spending into training their workers, while also coupled with government spending.

“What’s challenging is that it’s not financed as a system properly,” Espinoza said. “It would require a higher level of funding, probably first through federal, and then states should also play a role. It is an investment that hopefully saves money as well, if it’s tested.”

He said that before anything can change, lawmakers need to become more educated on the complexities of long-term care in the United States. “To move policy change for this sector requires policymakers to fully understand this system, and the complexity of this system might be one of the reasons why these things are also not improving,” Espinoza said. “I think the better our country understands the system, the closer we get to solutions.”

States step in

Training requirements vary by state and depend on factors such as whether the aide works in assisted living or in private homes, what type of care is being provided and who is paying for that care.

More than a dozen states have some training standards. New York’s and Washington’s are more rigorous, requiring personal care aides to have 40 and 75 hours of training, respectively, and proof of specific competencies to work in any Medicaid program or at an agency.

Meanwhile, Oregon has created a Home Care Commission, which provides training and certification opportunities, as well as a registry of enrolled caregivers that the public can access. The commission sets competitive wages through collective bargaining and offers pathways to higher wages through completion of state certification.

Seven states — Connecticut, Indiana, Nebraska, Kansas, Tennessee, Texas and Vermont — have no training requirements for personal care aides.

Following Oregon’s lead, Wisconsin recently launched its own certification system to train 10,000 caregivers in essential skills. The program aims to recruit and retain workers by creating a ladder to career advancement.

“We’re hoping that once we have people that are in these positions, it also gives the direct care professional leverage,” said Kevin Coughlin, policy initiatives adviser for the Wisconsin Health Services Department. “The one good thing about this crisis is it has shifted the power to the people to become free agents and say, ‘Hey, you know, I’ve got this great training. I’m on the registry. I’ll come and work for you if you’re willing to pay me more.’”

Wisconsin is rolling out the program this year, offering a $500 incentive — $250 for completion of the course and another $250 as a six-month retention bonus. The project builds off the success of a workforce development program that Wisconsin launched last year using $6 million in American Rescue Act funds to address the shortage of certified nursing assistants.

As part of that effort, the Wisconsin Department of Health Services has created a one-stop shop for employers as well as those seeking jobs as nursing assistants and in-home caregivers.

Through a collaboration with the University of Wisconsin at Green Bay, Wisconsin’s caregiver training program curriculum is self-paced and online, focusing on 14 competencies that home and personal care workers need to achieve. From there, DHS is hoping to create a career ladder for building skills to other certifications.

Hayes, the former personal care aide from Madison, built his skills without the benefit of such programs, transitioning from in-home aide to certified nursing assistant to nursing school, where he just graduated in June. But he says Wisconsin’s new program, which is more in-depth than the eight-hour orientation he received, will make caregiving more attractive. “I think for the people that want to be in the field, it’s going to really help.”

Katie Rodriguez is a writer with the Investigative Reporting Program (IRP) at the University of California at Berkeley’s Graduate School of Journalism. The IRP reported on this story through a grant from The SCAN Foundation.