Can Peer Mentors Help Address the Direct Care Workforce Shortage?

For direct care workers, the first few weeks on the job can be challenging—and the most crucial to their retention.

“No matter how much training you do, those first six to eight weeks are where most of the turnover happens,” PHI Senior Advisor Peggy Powell told me. Powell has designed training, recruitment, and retention programs for direct care workers (who include home care workers, residential care aides, and nursing assistants) for more than three decades.

The long-term care field has traditionally offered low-paying, poorly supported jobs for the difficult labor of assisting older adults and people with disabilities in their homes or other care settings, making workforce retention a longstanding challenge. A recent study by Poon et al. confirms that formal peer mentorship programs, a critical component of PHI’s workforce interventions, help both new and incumbent workers navigate the significant learning curve, emotional demands, and marginalization faced in care work.

The study’s findings are timely: the COVID-19 pandemic has left direct care roles even harder to fill over the last two years, with shortages of home care workers and nursing assistants continuing to affect long-term care consumers across the U.S.

INVISIBILITY AND ISOLATION ON THE JOB

Numerous factors influence high turnover rates in direct care, including poverty-level wages, limited access to benefits and workplace protections, and insufficient training. Yet over 10 years of interviewing this workforce, I’ve noticed that the intangible challenges of feeling unseen, disrespected, and misunderstood in this profession are what workers raise more than any other.

“People might think, ‘Gosh, Zulma works in a house. She has it easy.’ No, I don’t have it easy,” said Zulma Torres, a Home Health Aide of 25 years who was interviewed for PHI’s Direct Care Worker Story Project by Manager of Strategic Initiatives Arielle Altman. “We are at the bottom. And sometimes we’re not recognized even though we’re doing a job that’s so important.

Feelings of being undervalued and invisible on the job compound the significant emotional demands of direct care work and can negatively impact workers’ wellbeing, especially in home care settings where workers are isolated from other colleagues. Qualitative studies indicate that this marginalization worsened during the pandemic, when home care workers felt left out of the social recognition afforded to “essential” workers and disconnected from the health care system, despite the fact that they continued to care for people highly vulnerable to COVID-19.

“Even if somebody [in health care] knows of us, they don’t acknowledge what we do,” said Torres. “It’s physical work. And personal: you have to hear the client, like a therapist, and talk to family members. We’re also taking part in health care: we keep clients home and help them avoid going back to the hospital. I have so many emotions when it comes to this. I wish that somebody would acknowledge what we know—that we do know something.”

THE IMPACT OF PEER SUPPORT

Raising wages and benefits for direct care workers is critical to improving their recognition and retention. But interventions that enhance social recognition are also needed, in part because decades of discrimination and stigma have shaped the incorrect notion that direct care work is unskilled or low-skilled. Poon et al.’s research shows that peer mentor programs help home care workers frame what they do as skilled work to contrast this misperception: in their study, peers underscored to one another the level of knowledge and skill needed in their jobs, in particular emphasizing their contributions to client health and COVID-19 safety.

The researchers also likened home care workers’ peer mentor networks to “communities of practice,” a social configuration in which practitioners learn from one another and contribute to professionalization of their occupation by setting norms around their work. Participants in the study did this by sharing best practices for client care, enforcing scope of practice boundaries on the job, and encouraging behavioral standards consistent with being seen as a health care provider.

PIONEERING PEER MENTORSHIP IN HOME CARE

Powell helped launch the first known peer mentor program for direct care workers when she worked at Cooperative Home Care Associates (CHCA) in the Bronx, New York, in the 1980s.

“We knew that workers needed an added level of support to what we were doing as trainers. New people in particular needed someone else they could talk to and who they could trust because that person has done the same job,” said Powell.

Her team trained experienced home care workers in advanced communication, relationship-building, and leadership skills so they could support new hires in navigating the personal and professional challenges of direct care work. As Peer Mentors, these experienced workers received higher pay for time spent calling and visiting new workers on the job. Importantly, the Peer Mentor role was designed as distinct from a supervisor; mentors were trained to coach workers through the lens of their own experience, leveraging a peer connection rather than a hierarchical one.

“The biggest impact on retention came when we integrated the program into CHCA’s strategic interests and structure,” Powell said. With full- and part-time mentors built into the agency’s operations, retention improved both for new workers and for incumbent workers who saw an opportunity for career growth in the peer mentor model.

The program has contributed to CHCA’s field-leading retention outcomes ever since. Today, the agency’s annual turnover rate remains less than 25 percent, well below the industry average.

PHI’S PEER MENTOR PROGRAM

Powell co-founded PHI in 1991, and for more than 30 years, PHI has built on CHCA’s success to bring peer mentor training and workforce models to a wide range of long-term care employers across the country. These programs have contributed to improvements in worker retention among both new workers and those trained to be mentors.

“I felt very honored when I was offered this position, knowing that I was looked upon as a role model and could help coworkers in any way possible,” said Janet Folsom, a Home Health Aide, Certified Nursing Assistant, and Peer Mentor at Knute Nelson, a home and community-based service provider PHI works with in Minnesota. “I help them feel comfortable and confident when they go out into the field on their own, and I get to share some of my experiences with them.”

“If you don’t know something, a Peer Mentor will teach you,” explained Torres, who has spent the majority of her career with CHCA. “If a case is getting difficult and you’re ready to give up, the mentor is going to come in. And they’re going to let you know, ‘Look. It’s okay that you feel this way. We’re going to help you. We’re going to guide you.’

In a word: they’re a picker-upper.”