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Direct care workers — nursing assistants, personal care aides and home health aides — provide vital assistance with daily care tasks for many long-term care patients and older adults in the United States, but already pronounced challenges in hiring and retaining these workers are expected to worsen as the population ages.

The direct care workforce is made up of an estimated 4.4 million people — about 86 percent of them women — employed in home, institutional and community-based settings, according to PHI, the Paraprofessional Healthcare Institute, a national nonprofit that works to improve long-term care services and supports for elderly and disabled people.

Monica Macias, right, became a nursing assistant at Cerenity Senior Care — Humboldt in St. Paul, Minn., after learning about the profession through a public high school program at Guadalupe Alternative Programs. Here she assists resident Marcella Marzitelli. Bath-sheba Kemp

The U.S. Census Bureau projects that the number of people age 65 and older will grow from about 48 million in 2015 to 73 million in 2030 to about 84 million in 2050.

That increase in the aging population — with all those in the Baby Boomer generation over the age of 85 in 2050 — will increase demand for direct care workers. People are living longer in the U.S., and the older a person is, the more likely he or she is to require assistance with personal care or homemaking tasks or long-term nursing care. There are currently more than 6 million people in the U.S. 85 and older. That's projected to grow to nearly 9 million in 2030, and nearly 18 million in 2050, based on U.S. Census figures.

Ministry human resources professionals can find it difficult to fill vacancies in their direct care workforces today, and demographers project that the share of population age 18 to 64 — the working ages — will continue to decrease over the next three decades.

Today one in four direct care workers is an immigrant, according to PHI. More than half of the estimated 1 million immigrants working in long-term care are naturalized citizens.

"As the caregiver shortage intensifies, and more and more families struggle to find paid professionals to support their loved ones, immigrants will be a critical solution to filling that gap in available caregivers," said Robert Espinoza, PHI's vice president of policy. Changes in U.S. policy that restrict the number of immigrants entering the country, or that revoke the status of someone already living in the U.S., could worsen projected workforce shortages.

According to PHI, the immigrant direct care workforce is largely made up of people who work part-time or part-year jobs and earn a median annual income of about $19,000.

Job enhancement
Paul Osterman, the Nanyang Technological University Professor of Human Resources and Management at the Massachusetts Institute of Technology's Sloan School of Management, said, "As shortages emerge, many people — ranging from people on Medicaid to people who are wealthier but need help — are going to confront the fact that they can't find help."

He calculates a shortfall of about 151,000 paid direct care workers in 2030, but said that's a significant underestimate because it's also projected that there will be a shortfall of unpaid family and friend caregivers of about 3.8 million people by then.

While ministry members say they are committed to paying a fair, competitive wage to direct care workers, compensation is typically low across the industry in these physically and emotionally demanding, vital jobs. The U.S. Department of Labor says 2016 median pay was $12.78 an hour for nursing assistants and $10.66 an hour for personal care aides and home health aides.

Osterman makes the case in his book Who Will Care for Us? Long-Term Care and the Long-Term Care Workforce that expanding the scope of care delivered by direct care workers would create better jobs at higher wages and improve patient care quality.

Direct care workers could be utilized as health coaches helping people manage chronic conditions, or provide support to patients as they transition between health care settings, such as from a hospital to home, he said.

Building the pipeline
Some ministry members have educational programs for direct care workers, both to introduce students to the field and to create career ladders that offer financial support for nursing assistants pursuing a registered nursing credential.

Monica Macias found her way into a nursing assistant job at Cerenity Senior Care — Humboldt in St. Paul, Minn., through the Guadalupe Alternative Programs, a public high school offering. Five years ago, she followed a vocational education track that included 100 hours of volunteering with Cerenity. Cerenity Senior Care is a faith-based partnership between HealthEast Care System, Clement Manor and Benedictine Health System.

After training at school to become a certified nursing assistant, she passed her state exam, graduated high school and was hired by Cerenity.

"I enjoy doing what I do, going there and connecting with people, the residents," she said.

Over the past five years, about 120 students have volunteered at Cerenity through the program; 37 students went on to become certified in roles like nursing assistants and 13 of them are currently employed by Cerenity in Humboldt, said Denise Rene Hannah, development director for the Cerenity campus.

Career paths
In addition to its partnership with Cerenity, Minnesota-based Benedictine Health System owns and operates senior care communities in Minnesota, Illinois, Missouri, North Dakota and Wisconsin. The system hosts or partners with schools on certified nursing assistant training programs. In many Benedictine markets where CNAs are needed, Benedictine pays the course fees.

Patricia Nott, Benedictine's vice president of people development, said the system lets job applicants know: "We can help them into a career," with CNA or other training.

The CNA certification programs generally require about 75 hours of classroom and clinical time. The system has eight days of in-house training for certified CNAs when they begin their jobs, and has started a mentoring program for these employees during their first year to help them feel supported and connected.

Tewksbury, Mass.-based Covenant Health began its Earn as You Learn program about two years ago at St. Mary's d'Youville Pavilion, a long-term care facility in Lewiston, Maine. CNAs who continue to work for the system 24 hours a week while in nursing school can apply for tuition or loan reimbursement, which they receive when they become registered nurses. Covenant Health varies its incentives for education and new hires by market and market need. It hopes to offer Earn as You Learn incentives at more of its facilities, said Lisa Cramm, the system's manager of talent acquisition.

From systemic reforms to individual incentives, there's no clear solution to the workforce shortage, said PHI's Espinoza. "There's no magic key, a variety of things need to happen related to how as a country we finance and value long-term care."

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