Direct Care Worker Demand Continues to Rise, But Progress Stagnates

In recent years, we have all been reminded of the vital role that direct care workers play in our health and long-term care system. Whether supporting individuals living at home, in residential care settings, nursing homes, or other settings, these workers are the backbone of the American care economy. Yet, new data from PHI’s annual research report confirms that despite their essential role, direct care workers continue to face formidable challenges that demand immediate action.

Direct Care Workers in the United States: Key Facts provides an updated annual snapshot of the direct care workforce, including its demographics, roles and responsibilities, job quality challenges, and projected job openings. The report includes detailed overviews of three segments of this workforce: home care workers, residential care aides, and nursing assistants in nursing homes.

Job Growth and Demand

The need for direct care workers is only growing. Our report indicates that from 2021 to 2031, the sector is expected to create over 1 million new jobs—more new jobs than any other single occupation in the country—and will have 9.3 million total job openings, when also including occupational transfers and labor force exits. The figures should be a wake-up call: if direct care work is going to continue to be the bedrock of our long-term care system, we must invest in it now. Yet the demand for direct care workers is rising in parallel with stagnating job conditions.

Over the past 10 years, the direct care workforce has seen incremental wage growth, after adjusting for inflation. This wage growth is due primarily to state and federal investments in Medicaid funding for long-term care and the workforce. Much of this investment occurred in response to the COVID-19 pandemic.

However, this wage growth has slowed dramatically with the reduction of federal pandemic supports. After increasing by $0.68 per hour in 2020, the median hourly wage for direct care workers increased by just $0.07 per hour in 2021 and by $0.02 per hour in 2022, adjusting for inflation.

Inflation-adjusted median hourly wages for home care workers actually declined by $0.72 per hour from 2021 to 2022 as many sources of pandemic-related funding were phased out. These trends mean that direct care wages remain low—the median hourly wage for all direct care workers was $15.43 in 2022, with home care workers in particular earning just $14.50 per hour. As a result, long-term care employers continue to experience acute recruitment and retention challenges in a persistently competitive labor market.

Low wages combined with a high rate of part-time work make it challenging for direct care workers to financially support themselves and their families. Median annual earnings for direct care workers are just $23,688. Thirty-nine percent of direct care workers live in low-income households—defined as subsisting at less than 200 percent of the federal poverty level—and 46 percent rely on public assistance, such as Medicaid, food and nutrition assistance, or cash assistance.

These points highlight the significant challenges direct care workers face, particularly in terms of compensation and financial stability, despite the temporarily increased funding and support during the COVID-19 pandemic.

A Hazardous Profession

Our report underscores the injury and illness rates in the nursing home industry, which are some of the highest in the country.

Data from 2020 (the most recent year of data available) show that nursing assistants in nursing homes were nearly eight times more likely to experience workplace injuries than the typical U.S. worker. This is due to the nature of their work, which often involves physically demanding tasks, and their heightened exposure to COVID-19, which is considered a “workforce injury” in this context. Injury rates among nursing assistants increased by more than 300 percent from 2019 (299 injuries per 10,000 workers) to 2020 (1,014 injuries per 10,000 workers).

Although our report notes that newer occupation-specific injury data (i.e., nursing assistant-specific data) are not available, industry-level data for nursing homes shows a decrease in injuries and illnesses from 2020 to 2021. However, the COVID-19 pandemic continues to disproportionately affect direct care workers and those they support. Our report shows that from January 2020 to July 2023, 164,165 nursing home residents and 3,061 nursing home staff died from COVID-19. In the past year alone—from July 2022 through July 2023—over 11,000 resident deaths and nearly 700 staff deaths were attributed to COVID-19.

A Need for Change

Equity issues remain a central concern for this essential workforce. The majority of direct care workers are women (86 percent and a substantial proportion are people of color (62 percent). Immigrants constitute 28 percent of the direct care workforce, higher than the 17 percent of immigrants in the broader U.S. labor force. A quarter of direct care workers also balance unpaid family caregiving roles and 30 percent have children under 18. While this diversity is a strength, the intersectional and systemic challenges these workers face require a nuanced and multifaceted approach.

A holistic approach to elevating the profession must focus on enhancing job quality. Adequate compensation, along with benefits like employer-provided health insurance with affordable premiums and paid leave, is imperative for enhancing the economic stability of these workers. State and federal governments must transition COVID-related funding increases into long-term financial commitments. It’s also critical to address occupational safety, providing the necessary training, support, and equipment to reduce the risks associated with these jobs.

The way we culturally and socially value direct care work must also change. These are not “low-skilled” positions that anyone can do; they are roles requiring significant skill and knowledge, compassion, and a deep understanding of human dignity, especially as it relates to older adults and people with disabilities. They are roles that will become even more vital as our population ages and the need for long-term care expands.

Our society stands at a critical juncture. We can either continue down the path of negligence, leaving an essential yet vulnerable workforce to struggle in the margins, or we can make a committed, collective investment in transforming the quality, stability, and respect accorded to direct care work. For the health of our nation, the well-being of our most vulnerable populations, and the dignity of the workers who make it all possible, let’s choose the latter.