The direct care workforce includes paid frontline workers who provide critical assistance to older adults and people with disabilities. Representing more than five million workers nationwide, the direct care workforce is essential to helping people receive care and services in nursing homes, assisted living facilities, adult day centers, and in home- and community-based settings. Yet states across the country face significant direct care worker (DCW) shortages. Low wages, limited benefits, inconsistent work hours, and few opportunities for advancement contribute to high turnover and workforce instability. These challenges reduce access to home- and community-based services (HCBS), increase pressure on institutional care settings, and shift caregiving responsibilities to family members, all of which can limit people’s ability to live independently and age in place.

States recognize that addressing DCW shortages and improving care requires large-scale, long-term reforms. At the same time, many states are pursuing practical, incremental strategies to strengthen job quality, satisfaction, and retention in the near term.

Through the national Direct Care Workforce Strategies Center, the Center for Health Care Strategies (CHCS) and other technical assistance partners supported state agency teams in California, Nevada, and Vermont to improve the recruitment, retention, training, and professional development for DCWs. The DCW Strategies Center is led by the National Council on Aging with funding from the Administration for Community Living. As a national partner, CHCS worked to help these state teams develop and implement workforce initiatives tailored to their unique needs and priorities.

Drawing on this work and efforts in other states, the following three strategies offer approaches that states can adapt to strengthen and support DCWs.

1. Expand access to competency-based training.

Providing ongoing training and skill-building opportunities is a core strategy that supports workforce retention and advancement, expands skills necessary to meet patients’ evolving needs, and increases care quality.

States across the country are pursuing a variety of approaches to strengthen training for the direct care workforce.

• California offered incentives and stipends for training, to encourage and reward DCWs for acquiring new knowledge and skills.

• Massachusetts standardized curricula, promoting consistency in knowledge and skills across certain DCW types.

• Michigan developed a competency-based training and credentialing system, offering the state’s DCWs an industry-recognized credential that demonstrates they have key knowledge, skills, and experience to provide safe, high-quality care.

• Tennessee created training programs that promote job portability to support DCWs’ ability to work in different types of roles within the field.

Strategy at Work: California

California’s DCW Strategies Center team developed a specialized training curriculum for direct support professionals (DSPs) — a segment of the workforce that supports people with intellectual/developmental disabilities (I/DD).

After reviewing DSP training curricula across agencies and training platforms, the team identified a major gap: few addressed the unique aging-related needs of people with I/DD. Many people with I/DD experience age-related changes earlier in life compared to the overall population, often in their 40s.

The team convened an advisory panel of clinicians, providers, curriculum developers, people with lived experience, and advocates. A subcommittee of experts focused on linguistic and cultural competency. Together, these groups developed training content to support DSPs in recognizing early signs of aging, through conversation with supported individuals, incorporating real-world scenarios into training to enhance learning. The final curriculum will be available through the Department of Developmental Service’s Employee Development, Growth, and Education (EDGE) online learning system which includes the DSP University (DSP-U), along with public resource for families, social workers, law enforcement, and others who support people with I/DD.

2. Offer non-wage benefits and incentives.

Low wages and limited benefits are the most cited challenge to retaining DCWs. While increasing wages can support recruitment and retention, it is not always a viable policy option. Because Medicaid is the primary payer for HCBS, wage increases are closely tied to Medicaid reimbursement rates and often depend on state budgets, as well as potential legislative action.

In response, states are turning to a range of non-wage benefits and incentives.

• Colorado provides bonuses for hiring, retention, and training completion.

• Minnesota offers eligible unionized DCWs a $1,200 health care stipend after six months of work.

• New Mexico offers childcare assistance.

Strategy at Work: Nevada

Nevada identified Personal Care Aides (PCAs) — non-medical DCWs who help older adults or people with disabilities live independently in their homes — as a segment of the state’s workforce in need of additional supports to promote job satisfaction and bolster retention.

One-time incentives are one way states can help boost morale and demonstrate appreciation for workers. With funding from the American Rescue Plan Act, the Nevada team implemented a short-term incentive program: PCAs who applied verified their employment status and received a one-time payment of up to $500. These funds were targeted to support PCA needs related to social determinants of health, such as housing and food security. The verifications offered updated data for the state and the payments supported a workforce that has been historically underpaid with the goal of bolstering retention efforts.

The Nevada team is now providing a new incentive-based training curriculum for PCAs that would pair skill development with financial support. PCAs and individuals interested in joining the workforce will receive $250 for completing the training, while employers will be eligible for incentive payments based on employee completion rates, until funds are expended.

3. Engage with DCWs to identify and shape state goals.

States cannot build and strengthen the direct care workforce in a silo. Effective workforce initiatives require collaboration among a range of stakeholders, including state departments of aging, labor, developmental services, education, and health, as well as Medicaid agencies and providers.

Just as important, no one understands the realities of direct care work better than the workers themselves. To ensure workforce initiatives reflect on-the-ground needs and priorities, states are actively engaging direct care workers in policy design and implementation.

Strategy at Work: Vermont

The Vermont team prioritized stakeholder engagement, including partnership with direct care workers, to shape their state’s workforce improvement efforts.

The team established a taskforce comprised of DCWs, educational partners, providers, and an interagency team of state employees. Although these entities had not previously worked together, they quickly identified shared goals to strengthen the direct care workforce. Over four in-person meetings, the taskforce identified gaps and inconsistencies across training programs and developed a set of core competencies that reflect Vermont needs while mapping to Medicaid requirements. Vermont is continuing to meet to develop a roadmap for implementing the framework, explore DCW registry options, and refine career progression opportunities.

Looking Ahead

No single policy will solve the diverse challenges facing the direct care workforce. Meaningful progress requires both long-term system change and practical, short-term strategies that improve workers’ day-to-day experiences. States can achieve meaningful improvements by expanding access to training, offering targeted benefits and incentives, and elevating the voices of DCWs in shaping workforce policies. The strategies highlighted here offer practical examples that other states can adapt as they work to build a stronger, more resilient direct care workforce and improve access to high-quality care for the people they serve.