Sign Up to Receive PHI Alerts

Expand Navigation

Inadequate Training & Few Opportunities to Advance

Proper training ensures workers can deliver high-quality care, and advanced roles create important career ladders.


Quality training ensures that direct care workers have the skills and knowledge to deliver excellent person-centered care. Unfortunately, training standards are often inadequate, and they vary by occupation and state. For home health aides, fewer than one-third of states require more than the minimum federal standard of 75 hours, and only six states meet the National Academy of Medicine’s (formerly the Institute of Medicine) 2008 recommendation of 120 hours.

For personal care aides, there are no federal training standards, resulting in dramatic differences across states and, in many instances, only minimal requirements. Training standards for nursing assistants in most states also rarely meet the National Academy of Medicine’s recommendation. Further, PHI’s extensive experience in workforce development and curriculum design around the country shows that the existing curricula for direct care workers tends to be outdated, often failing to address the skills, competencies, and learning styles of this workforce.

Federal standards could create opportunities for direct care workers to advance when they improve their knowledge and skills, enabling them to offer an enhanced level of support to older people and people with disabilities. Empowering direct care workers to handle new responsibilities such as assisting with clinical observation and reporting, educating clients on health promotion and medication adherence, and supporting the care team with coordination across disciplines would improve the quality of care and potentially reduce costs. These responsibilities are within direct care workers’ current scope of work and do not require legislative action—and these advanced roles would increase the value of the direct care worker within the health care system.


Recent developments highlight the potential of quality training and advanced roles. A 2016 evaluation report of the federally funded Personal and Home Care Aide State Training (PHCAST) initiative found that this six-state program led to low attrition rates and high levels of satisfaction among direct care aides who participated. [1] In New York City, an 18-month pilot program for advanced training among home health aides found that clients served by aides with advanced training were admitted to the ER at a rate eight percent lower than those admitted in the previous year (when clients weren’t paired with aides with advanced training). [2] Similarly, a multi-year training initiative in New York City led to increased retention and job satisfaction among home health aides who took part in the program.[3] And in June 2016, New York State passed a bill that created an advanced role for home health aides, allowing them to perform tasks such as administering medication and injecting insulin upon completing training and demonstrating competency.[4]


  1. Department of Health and Human Services Health Resources and Services Administration. 2016. Personal and Home Care Aide State Training (PHCAST) Demonstration Program Evaluation. Rockville, MD: HHS.
  2. PHI, 2017.
  3. “New Home Care Aide Training and Employment Initiative Improves Job Satisfaction and Retention, Study Finds.” PHI, February 20, 2015. PHI. 
  4. "New York State Authorizes Advanced Home Health Aides, Enabling More New Yorkers to Live with Dignity in their Homes and Communities," New York State Department of Health, December 2, 2016. NYS DOH. 

Key Takeaways

Training standards should be improved for home care workers, particularly personal care aides.
Advanced roles would empower workers with new responsibilities, improving both client care and compensation.
PHI’s training interventions are showing improved outcomes for both workers and their clients.

By the Numbers: Training & Advanced Roles


Percentage of states without training requirements for personal care aides across all programs. Source: PHI, 2017


Number of states that require at least 40 hours of training for personal care aides in one or more programs. PHI, 2017.


States that have created an advanced home health aide job category. Source: PHI, 2017

Caring for the Future

Our new policy report takes an extensive look at today's direct care workforce—in five installments.

Workforce Data Center

From wages to employment statistics, find the latest data on the direct care workforce.