DIRECT CARE WORKFORCE
DEVELOPMENT PLATFORM

Four Pillars of Equitable Direct Care Workforce Development

1

Condition Public Funding on Measurable Equity, Job Quality and Worker Voice Outcomes

2

Prioritize Direct Care Career Education and Training Programs Led by Labor-Management Partnerships that Advance Job Quality and Career Pathways within Direct Care

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3

Utilize Worker-Centered Participatory Research Methods When Designing and Evaluating Workforce Development Programs

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4

Anchor Efforts in Equity-Focused Organizational Processes, Including Internal Data Collection  and Evaluation

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1. Condition Funding on Measurable Equity, Job Quality and Worker Voice Outcomes

OUR RECOMMENDATIONS

Condition public funding for workforce development on creating high-quality jobs that guarantee all direct care workers family-sustaining compensation and a robust set of labor protections and benefits. Federal and state government agencies should collaborate with workers, unions and other impacted stakeholders to create sectoral job quality and equity standards across direct care with requirements for transparent disaggregated data collection and reporting on worker outcomes.

Governments and impacted stakeholders should work together to create job quality and equity standards organized around key categories to address workplace challenges endemic to the home care and nursing facility industries.
The Center for Equity created “Good Jobs Measures,” a set of worker-informed job quality metrics tailored to the workplace challenges endemic to home care and nursing homes, which impact the majority BIPOC and immigrant women caregiving workforce. These measures were informed by the “Black Women Best” framework Center for Equity’s participatory qualitative research conducted in January 2022 with caregivers active in SEIU Local 2015 who identify as Black women. From our learnings, we recommend developing standards around the following seven categories:

LEARN MORE

Refer to our “Good Jobs Measures” for job quality metrics H-CAP’s Center for Equity developed using our participatory caregiver research results with direct care workers and the “Black Women Best” framework.

Ensure public funds for direct care (from Medicaid payments to WIOA investments) improve worker wages and benefits and advance sectoral job quality standards.
The public workforce system should create a process to independently assess whether funding recipients meet defined job quality metrics for state and federal grants.
Apply the tenets of the “Black Women Best” framework, coined by economist Janelle Jones. Black Women Best asserts that if our government brings Black women from the margins to the center and intentionally creates policies that pull Black women out of economic precarity and into economic prosperity, everyone will benefit. Any metrics for job quality tied to public funding should include equity metrics to evaluate whether funding is successfully supporting quality job opportunities for marginalized workers, particularly Black women, who disproportionately occupy healthcare’s toughest jobs due to intentional exclusionary policy choices and our nation’s legacy of the institution of chattel slavery.

LEARN MORE

Consult our issue brief on the “Better Care, Better Jobs Act” to learn more about integrating pro-organizing and pro-union job quality standards into direct care workforce development policy and public funding packages.

Create a federal standard dataset of direct care workforce data, which sets a “floor” for states to build upon and standardize direct care worker job classifications.
Coordinate the national data collection effort across federal and state agencies.
Appropriate designated federal funds for equitable workforce data collection and system maintenance. Collect robust demographic data in standardized categories and disaggregate the federal standard dataset to facilitate cross-referencing and equity assessments.
Mandate meaningful worker engagement and participatory, community-led data collection, and utilize a Black Women Best model and “data feminism” framework.
Center workers in their own words by designing and implementing the first national worker-centered survey of direct care workers.

LEARN MORE

Explore further about designing equitable public workforce data systems to condition public funding from our policy paper, “Direct Care Workers Count: Why Data Matters to Advance Workforce Equity,” which spells out a data equity framework for moving workforce policy from guesswork to accountability using disaggregated workforce data.

OUR LEARNINGS

For too long, public workforce development in healthcare, particularly in the direct care sector, has effectively subsidized low-wage employment through training grants and investments focused on job attainment by filling “in-demand” jobs without requiring the job placements to be high quality with better long-term outcomes for workers. Critically, today’s low-quality direct care jobs are primarily financed by public dollars—in 2020, over 72 percent of long-term services and supports for older adults and people with disabilities were paid for by a mix of federal and state government funds.

To address the care crisis, state and federal government agencies—especially since Medicaid is the primary payer of direct care workers’ wages—should create a system that works with workers and communities to ensure caregiving jobs are good jobs.

Colello, K. (2022, June). Who Pays for Long-Term Services and Supports? Congressional Research Service: IF10343, Version 9. https://crsreports.congress.gov/product/pdf/IF/IF10343#:~:text=Each%20state%20designs%20and%20administers,42.1%25%20 of%20all%20LTSS%20expenditures.

By setting industry-wide job quality and equity standards based on measurable outcomes for direct care workers and service recipients, the government can maximize the impact of public funding and ensure public dollars are spent on good, family-sustaining jobs and quality care. Instead of funding low-road employers and creating jobs that pay low wages and offer little to no benefits–neglecting to rectify the poor job quality causing workforce shortages and high turnover in direct care jobs–industry-wide accountability standards would help direct public workforce funding to high-road employers and training programs.

Job quality and equity standards should set high-road benchmarks for compensation, training and education, career advancement, worker voice, safety and job security, and mitigating on-the-job risk factors to recruit and retain an empowered healthcare workforce. Workers, unions and worker organizations should be at the table with government leaders to define job quality standards attached to public funding, along with service recipients, consumer advocates and employers.

Public funding streams that impact direct care service delivery and workforce development, such as Medicaid and WIOA, should be attached to jobs meeting or exceeding the “floor” of defined sectoral standards. Requiring transparent data collection and reporting from funding recipients would help ensure public investments are making tangible impacts on targeted outcomes, including increasing job quality in direct care, reducing occupational segregation and addressing worker shortages.

Data equity is a critical tool to advance equitable workforce development. Data reporting requirements would confront a key challenge facing direct care stakeholders and policymakers: accurate, robust, and accessible disaggregated national and regional workforce data (i.e., labor and job quality data broken down by worker demographics) does not exist, further isolating the direct care workforce and obscuring workers’ needs.

We cannot change what we do not measure. With equity-focused data collection on workforce development context and interventions, policymakers and stakeholders would better understand the impacts of programs and policies on workforce challenges. It is crucial for data collection efforts to center intentional engagement with workers, emphasizing consulting workers from a wide range of identities.

Pillar 1

2. Prioritize Direct Care Career Education and Training Programs Led by Labor-Management Partnerships that Advance Job Quality and Career Pathways within Direct Care

OUR RECOMMENDATIONS

Center impacted stakeholders, including workers and service recipients, in workforce development strategies by prioritizing holistic direct care career education and training programs led by labor-management partnerships. These partnerships are uniquely situated to address the workforce crisis by advancing job quality and creating career pathways within direct care.

Intentionally center equity and confront exclusions and access issues in healthcare education opportunities for Black, indigenous, and people of color (BIPOC) learners and women.
Offer accessible, diverse training that includes career ladders (not only options to advance “out” of direct care roles but also to advance within the direct care field into advanced roles).
Employ an “earn-and-learn” training approach, ensuring program costs are covered and compensating workers for attendance and completion of training; workers should receive a wage increase consistent with their newly increased skillset upon training completion.
Promote labor-management training partnership (LMTP) approaches. LMTP organizations convene employers and union members to design worker-centered, industry-responsive training, programming, and employee benefits. Featured LMTP interventions include peer mentorship, advanced roles, career ladder programs, complex care and other advanced skills certifications.
Equip direct care workers with wraparound supports and services that help increase job satisfaction and improve quality of life. Caregivers who participated in our 2023 qualitative research study had many insights about supports and services that would help them stay on the job in the direct care field and enjoy a better quality of life with their families, most often, access to affordable, reliable transportation and child/dependent care.

OUR LEARNINGS

All direct care jobs, regardless of education or patient interaction level, should be good jobs with career ladders within each worker’s essential role, not just “up and out” of lower-paying direct care jobs into more specialized positions. Historically, the workforce development system has not focused on creating good jobs for all workers; instead, efforts have focused on job attainment regardless of quality or retention outcomes.

Focusing on job attainment without assuring job quality rewards “low road” employers that exacerbate workforce shortages by placing direct workers–disproportionately Black, brown and immigrant workers and women–in poor-quality jobs with little opportunity for advancement, family-sustaining pay or benefits. Persistent occupational segregation in poor-quality direct care jobs is also intrinsically linked to historical and present exclusionary policy choices that racialized and feminized care work, devaluing the importance of essential workers.

In addition to systemic challenges, our participatory research with caregivers revealed that many workers are dissatisfied with current training options, particularly workers located in states without high union density. Workers report that training is often rushed, which reduces workplace safety. In contrast, high-quality training increases consumers’ health outcomes and enhances caregivers’ pride in their work and job satisfaction.

Workers are interested in various types of training opportunities, including providing basic care, emergency care, specific condition care, safety, and leadership skills. Barriers to training include lack of availability and awareness of opportunities. Training can feel inaccessible due to a lack of paid compensation, inconvenient time of day, transportation issues, and workplace understaffing prohibiting time off.

To confront these challenges, labor-management partnership models between unions and employers focus on delivering training and education to direct care workers that meet industry needs while improving job quality and creating career pathways in good union jobs. Labor-management training partnerships are uniquely worker-centered and employer-informed, focusing on meeting adult learners where they are and finding non-traditional approaches to training and education to help participants succeed in attaining and retaining direct care jobs.

Labor-management partnerships are distinct among training providers in their worker-centered approach. Unions and employers work together to develop workforce development programming to meet workers’ needs as articulated in their own words through worker surveys, focus groups, and story collection and conversations amongst workers about their life experiences.

Quality jobs and holistic training programs that improve life quality and lead to career advancement enable workers to provide quality care and services to care recipients—better jobs create the conditions for better care. This connection is critical to the shared struggle between direct care workers and recipients, given that Black, brown and low-income older adults and people with disabilities disproportionately suffer from the impacts of poor care quality amplified by ageism, racism, sexism and other interlocking systems of oppression.

Labor-management training partnerships pioneered many innovative approaches to delivering holistic, whole-person-centered training to direct care workers. Equity-oriented best practices include providing “earn-and-learn” entry-level and incumbent worker educational opportunities whenever possible so that participants can get paid to learn hands-on skills on the job (as opposed to in the classroom only) at no cost to the worker and earn higher pay commensurate with skills attainment upon graduation.

Policymakers, government agencies and grantmakers should strengthen and diversify public and private funding streams to promote earn-and-learn training programs because current funding often lacks the stability and sustainability to support compensating workers for their time in training. The system should also provide funding for whole-person supportive services for workforce development program participants, particularly important for women and workers of color to complete education and training programs.

Whole-person program supports include childcare, dependent care, transportation, technology and tech training access, ongoing coaching and peer mentorship, and case management support. With limited funding, labor-management training partnerships successfully implement many of these practices on the ground, including providing training in multiple modalities (such as virtual, hybrid, and in-person learning options) and supporting digital access.

LEARN MORE

For more details about real-world workforce education and supportive services successfully implemented by labor-management partnerships, refer to our report, “Recruiting and Retaining Caregivers: Top 5 Solutions from Care Workers.”

In addition, our labor-management partnership practitioners’ brief, “Strategies to Support Caregivers’ Role in a Changing Climate,” can be used to learn about creating climate resiliency training programs in your state or local area and understanding general labor-management program-building strategies.

Whole-person training and career education programs work best when collecting whole-person workforce data to evaluate needs and design effective, responsive programs that lead to tangible outcomes–refer to our data equity framework paper, “Direct Care Workers Count: Why Data Matters to Advance Workforce Equity,” for details.

Pillar 2

3. Utilize Worker-Centered Participatory Research Methods When Designing and Evaluating Workforce Development Programs

OUR RECOMMENDATIONS

Ensure workforce development programming is worker-centered by applying a participatory research, design, and evaluation process that centers workers as experts by experience.

Participatory research and worker-centered research, program and policy design, and evaluation processes are vital tools for creating effective workforce development interventions in the direct care sector. Start with listening directly to the most impacted workers and centering their experiences as experts in what policy and workforce development interventions will be most impactful.
Center workforce equity in all phases of program and policy development. This can include implementing equity frameworks such as Black Women Best at each step and ensuring whole-person supports are targeted to different populations of workers’ unique needs.
Participatory research and evaluation do not have to be conducted by costly, professional research and evaluation firms to be effective at centering worker voice in policy and programs. Smaller-scale worker-centered methods are also impactful and can include conducting worker surveys with program participants, talking to workers at worksites and in informal settings about what would improve their job and life quality, holding “town hall” style sessions at worksites and training programs to get a sense of workers’ needs and goals, performing a quick intake session with new program participants on what supports would be helpful, or creating systems to call or follow up with workers after they graduate from training programs to track successes and understand any needed improvements.

LEARN MORE

Our report, “Recruiting and Retaining Caregivers: Top 5 Solutions from Care Workers,” contains additional context and maps out innovative workforce development solutions directly informed by participatory caregiver research and the Black Women Best framework.

OUR LEARNINGS

Advancing job quality for all direct care workers requires workforce development leaders to confront and rectify the historical and present policy choices that lead to Black and brown women’s disproportionate employment in healthcare’s most demanding, lowest-paying jobs. This process starts with listening directly to the most impacted workers and centering their experiences as experts in what policy and workforce development interventions will be most impactful.

Worker voice is critical to the Center for Equity’s operational and theoretical framework. We have applied a participatory research, policy and program design process that centers workers as the experts to inform any policy and program recommendations from our initiative, avoiding relying on preconceived notions of successful workforce development.

Integrating the Black Women Best framework into our participatory research and design process is a core aspect of creating equitable research, design, and evaluation processes accountable to our values. The framework states that when Black women thrive, all workers will thrive.

To operationalize Black Women Best, we designed the two qualitative research studies that informed our work to center Black women working as caregivers intentionally, including weighting study demographic composition to include a majority of participants who self-identified as Black women, creating discussion groups within the study in which Black women could directly interact and respond to each other’s insights, and weighting study analysis to uplift the input of Black women participants.

The “Black Women Best”-oriented participatory research we conducted with caregivers in 2022 and 2023 revealed many insights. Both studies focused on caregivers’ experiences in all aspects of life, including on the job, seeking to understand caregivers’ needs, hopes and dreams for advancing job quality and life quality in their own words. The study design prioritized policy questions querying caregivers using accessible, plain language about what interventions would most positively impact their job and life quality, respectively.

Research with Caregivers on Job and Life Quality

In our first participatory research study, "The Voices of Black Women Working as Long-Term Caregivers: Identities, Wellness, Systemic Racism, and Improving Quality of Life," caregivers reported that their quality of life would be most improved by policies such as a living wage floor, guaranteed pensions, paid sick/family leave, and sufficient, guaranteed work hours. Compared with participants in their 60s and older, younger participants especially need policies providing housing assistance, universal healthcare, universal child/elder care, and transportation assistance.

Caregivers also reported frustration in two main areas: concern that their clients cannot receive all the care at the level they need and the lack of appropriate compensation for direct care work. Notably, quality training opportunities were a key priority for home care workers and nursing facility employees: 100 percent of caregivers who participated in the qualitative study believed there should be paid on-the-job training opportunities for all caregivers, regardless of sector.

Caregivers’ Vision for Good Jobs

In designing our second participatory research study, "Working at a Good Job: Caregivers Experiences and Ideas in Their Own Words," we built off prior findings to home in on what changes and reforms are needed to create quality jobs in direct care and what working at a “good job” meant to caregivers in their own words, particularly to Black women working as caregivers. The study explored participants’ experiences and ideas about a) envisioning good jobs, b) evaluating working as a caregiver today, and c) making caregiving a better job in the future.

One of our most frequent findings was that while caregivers’ passion for their work cannot be overstated, low pay, few employment benefits, and little respect deeply affect job quality. Caregivers are overworked, receive insufficient training, and face unstable employment, and caregiving takes a significant physical and emotional toll on workers. Lack of staffing and absenteeism results in service recipients receiving lower quality care and workers experiencing stress and burnout on and off the job. Similarly, lack of sufficient staffing, stress and burnout profoundly undermine workplace safety.

According to the caregivers we engaged in participatory research, “good jobs” must meet core economic and health needs. A “good job” is personally fulfilling, receives appreciation and respect, and complements a worker’s holistic life. Of the many workforce development policies we tested, caregivers named increasing recruitment and retention the most impactful way to improve job quality by enhancing safety, support and satisfaction in the workplace. Workers’ solutions centered around five core categories:

Solution #1: Implement Quality Training Programs that Include Career Ladders within Direct Care
Solution #2: Equip Direct Care Workers with Wraparound Supports and Services that Help Increase JobSatisfaction and Improve Quality of Life
Solution #3: Provide Traditional and Non-Traditional Benefits and Workplace Protections that Strengthen Recruitment and Retention
Solution #4: Improve Recognition for Caregivers on and off the Job
Solution #5: Assist Caregivers with Finding Quality Jobs

Pillar 3

4. Anchor Efforts in Equity-Focused Organizational Processes, Including Internal Data Collection and Evaluation

OUR RECOMMENDATIONS

Workforce development stakeholders should anchor their work in anti-racist and worker-centered organizational processes, methods and operational structures, with accountability benchmarks and internal equity assessments. Use equity-focused data collection, analysis and evaluation to understand current challenges and to build the case for effective workforce development interventions.

Ensure workers are meaningfully represented at tables where decisions that impact the workforce are being made. Listen and learn from new perspectives and include processes to re-work decisions and return to the drawing board if required to implement workers’ insights.
Utilize a rapid cycle feedback model to elicit feedback from workers and other impacted stakeholders on decisions and other work elements, revise, and repeat until the work product accurately reflects worker input.
Query implicit biases on both an individual and organizational level regularly when doing direct care workforce development work. H-CAP’s Center for Equity developed a user-friendly worksheet to help you practice applying racial equity “Lasik” on an ongoing basis to create anti-racist policies, programs, practices, and organizational decisions.
Collect data disaggregated by race, ethnicity, gender, sexuality, age, immigration, disability, and any other relevant categories to the targeted workforce population before, during, and after designing and implementing a workforce development intervention or program. Disaggregated workforce data helps stakeholders interpret outcomes across different worker populations to understand and address inequities.

LEARN MORE

For applied practices on equity-oriented program design and evaluation from labor-management partnership organizations, refer to our practitioners’ brief, “Strategies to Support Caregivers’ Role in a Changing Climate.” Our founding policy brief, “The Racial Equity and Job Quality Crisis in Long-Term Care,” describes organizational processes and frameworks to implement when designing worker-centered workforce development programs and policies.

OUR LEARNINGS

Equity must be a foundational pillar and operating principle for all our workforce development programmatic efforts. The reality is that even the best workforce programs can fall prey to exacerbating inequity because of existing systemic racism, sexism, xenophobia, and other oppressive structures inherent in the ecosystems within which these programs and policies operate. Workforce development leaders must intentionally cultivate internal and team processes to apply anti-racist, worker-centered, and equity lenses to programmatic and policy development work.

At H-CAP’s Center for Equity specifically, we believe that to genuinely confront the links between systemic racism, sexism, ableism, and poor job quality in long-term care, it is essential to integrate racial equity into internal work processes. We call this applying racial equity “Lasik,” as in the permanent corrective eye surgery, imbuing that centering racial equity is how we strive to see and navigate the world all the time–rather than a single step or “box to check,” a “lens” to take on or off, or one of many factors to consider after the rest of the work is complete.

One way to center worker voice in internal policy and program planning processes is to ensure that workers are always at the table, especially at tables where workers are traditionally eschewed in favor of academics, policymakers, executives or other members of the ruling professional class. At the outset of the Center for Equity, we strategically convened a table that includes workers, caregiver unions, employers and health plans, labor/management training funds, care consumer groups representing older adults and people with disabilities, national worker advocacy groups, and racial justice and policy thought leaders. This Advisory Board has guided our work over the past three years, and the worker members of the body have been intentionally centered as true experts in our in-person and virtual convenings with opportunities to lead discussions and drive the group’s work.

It is vital to center the stakeholders and communities most impacted and embed accountability on an ongoing basis into programmatic and policy workforce development. Equity-focused data collection, analysis and evaluation are crucial to undertake both internally and externally to understand organizational challenges and biases and demonstrate successes and areas of improvement in workforce development interventions. A participatory data collection process would include designing and conducting surveys and other data collection methods with workers rather than “about” workers (see previous section).

Anti-racist and worker-centered organizational processes, including equity-focused data collection and evaluation, are essential to success in workforce development efforts. These practices help counteract implicit biases in funding, program design and implementation decisions, data and data collection, partnerships, and other facets of program operations. Resulting learnings and program shifts should be positioned with the broader network, so policymakers and other leaders may continue to advance structural changes to the workforce development system and its policies and practices.

Pillar 4

VIEW MORE RESOURCES AND RESEARCH

About This Platform

H-CAP’s organizational mission is to promote job quality and equity for the healthcare workforce across sectors through “high-road” training partnerships and workforce development strategies focusing on the intersection of equity, job quality and educational attainment. A particular set of challenges faces direct care workers, who provide vital services to older adults and people with disabilities in home- and community-based services as well as nursing facilities. Most of these essential workers are trapped in “dead end,” poor quality jobs with low pay, little to no benefits and few opportunities for career advancement. This is no accident–the majority of caregivers are Black and brown women and immigrants who, as a result of a series of intentional policy choices, are overrepresented in low-wage caregiving occupations. Caregiving jobs are some of the fastest-growing professions in the United States. Yet, these jobs are growing without proper attention to the systemic racial and gender inequities inextricably tied to poor job quality. Solutions that address the poor job quality and racial equity at the root of the caregiving workforce crisis are long overdue. At H-CAP, we believe creating the equitable caregiving system our nation needs depends on designing and delivering innovative workforce development programs and policies intentionally centered on Black, Indigenous and people of color, women and immigrant caregivers. In service of this important goal, the W.K. Kellogg Foundation awarded H-CAP a three-year grant to create our Center for Equity, a national hub focused on developing a direct care workforce policy platform that centers job quality and equity and promotes narrative change. Over the past three years, a dynamic Advisory Board has guided our work. We strategically convened a table that includes workers, caregiver unions, employers and health plans, labor/management training funds, care consumer groups representing older adults and people with disabilities, national worker advocacy groups, and racial justice and policy thought leaders. By collaborating across industry siloes to advance equity and meaningfully change the lives of care workers, we have created a body of work anchored in worker-centered principles and practices. Our portfolio includes participatory research studies with caregivers, policy briefs and reports, user-friendly toolkits, job quality metrics, and technical assistance applying worker-centered equity principles in on-the-ground programming. The four pillars of equitable healthcare workforce development distilled into this platform represent the summary of our intentional efforts to create tools, policies and best practices stakeholders can apply in their day-to-day caregiving workforce development efforts. We offer our learnings to support your work in building a more equitable future for caregivers, service recipients and our communities.

DIRECT CARE WORKFORCE DEVELOPMENT PLATFORM

Four Pillars of Equitable Direct Care Workforce Development

1

2

3

4

1. Condition Funding on Measurable Equity, Job Quality and Worker Voice Outcomes

2. Prioritize Direct Care Career Education and Training Programs Led by Labor-Management Partnerships that Advance Job Quality and Career Pathways within Direct Care

3. Utilize Worker-Centered Participatory Research Methods When Designing and Evaluating Workforce Development Programs

4. Anchor Efforts in Equity-Focused Organizational Processes, Including Internal Data Collection and Evaluation

About This Platform

DIRECT CARE WORKFORCE
DEVELOPMENT PLATFORM