Beyond Shortages: Creating a New Narrative for the Direct Care Workforce

Buttoning a shirt, filling a bathtub, brushing our teeth: All everyday activities we likely take for granted — until we cannot perform them without help, a situation becoming increasingly prevalent as the population ages.

While the loss of independence is personal, the public impact is acute and escalating. It is driving increased demand for care outside of traditional institutions, particularly toward models that support “aging in place,” with direct care workers serving clients in their homes. But a worsening direct care labor shortage is threatening service delivery, safety, and, ultimately, organizational viability for companies serving this sector.

In an employment era where companies no longer choose people, people choose companies, how should direct care companies be responding? First, it is important to understand the full context.

An aging population meets a shorthanded workforce

The U.S. population is getting older and requiring more care. As the Baby Boomer generation ages and medical advances increase longevity, the share of the U.S. population ages 65 and older has grown 5.6 percent over the past two decades. These older adults are increasing demand for healthcare services. According to a recent study from the Centers for Disease Control and Prevention (CDC), 93 percent of older adults reported at least one chronic condition; nearly 80 percent reported having two or more. These conditions can affect functional capacity, compromising their ability to remain independent at home, or “age in place,” without assistance.

Home- and community-based service (HCBS) companies provide that help, supporting older adults with both health and personal care services, ranging from blood pressure checks and wound care to grooming and dressing. The crux: rising consumer preference for aging in place is happening in a sector long strained with workforce shortages.

Known by a variety of titles, including home health and personal care aides, projections estimate 8.9 million direct care jobs will require staffing to care for older adults by 2032. But when the growth of the older population eclipses that of working-age adults by nearly 12 percent, supply cannot satisfy demand. A nearly 80 percent industry-wide turnover rate further exacerbates the issue.

For companies trying to recruit and retain direct care workers, the issue transcends population demographics: the qualities of the job itself reveal additional underlying causes for the shortage. These are low-wage, physically and emotionally demanding roles with few career advancement and training opportunities that often leave direct care workers feeling undervalued for the care they provide.

An estimated 37 percent of the direct care workforce lives in or near poverty, with a median wage of $16.78. With unpredictable work schedules and full-time hours not always guaranteed, total compensation can oscillate throughout the year. When coffee shops offer larger paychecks, being a barista can look more appealing than assisting a chronically ill adult to the bathroom. Lack of health insurance and other benefits is common: approximately 29 percent of direct care workers are enrolled in Medicaid.

Further, direct care workers account for some of the highest occupational injury rates in the country. Threats loom in unsafe home conditions (poor air quality, tripping hazards), in physical tasks (lifting and transferring clients), and in client or family member aggression. Further, a recent study found home health and personal care aides are “vulnerable to stress, isolation and depressive symptoms, which impact their own health as well as their patients’ desire to age in place.”

Lack of common standards and the inadequate training that can result make it harder to progress to higher-paying roles, leading to workforce churn. It can also harm client outcomes.

Viewed as unskilled employees, direct care workers report being excluded from client -focused discussions with the larger care team, discounting their distinct perspectives and insights while creating critical information gaps that can compromise quality, safety, and continuity of care.

Implications for healthcare leaders

The implications for companies in the $107 billion U.S. homecare services market — and the U.S. healthcare system at large — are significant, posing risks to quality, safety, and cost of care as well as financial sustainability. For healthcare leaders, this is more than an HR concern. It’s a market positioning and strategic growth issue.

Gaps in staffing from high turnover rates and unfilled positions can compromise safety and continuity of care, worsening outcomes while eroding trust and client satisfaction. For a sector dependent upon referrals from healthcare systems and payers, establishing a reputation as a reliable and high-quality provider is paramount for sustainable market positioning.

Medicaid and other payers are increasingly focused on quality and outcomes, and home care providers who cannot meet these standards risk losing contracts. As key referral pipelines, building relationships with healthcare systems becomes more difficult when companies cannot staff to meet the perennial need for post-acute care that leaves patients stranded in hospitals and healthcare systems shouldering the financial burden. The cycle continues as companies that cannot meet demand must turn away clients or lengthen waitlists, making for missed revenue and growth opportunities.

Moreover, these scenarios exist in a shifting policy landscape. When federal Medicaid cuts in the One Big Beautiful Bill Act take effect, states may be forced to reduce HCBS services with federal long-term care requirements. State Medicaid programs are only mandated to cover long-term care services and support in nursing homes; HCBS coverage is optional. As the primary funding source for HCBS, those who rely on Medicaid for in-home care may find themselves transitioning to more costly institutional care, straining the bed capacity and finances of long-term care facilities and leaving home care companies bereft of critical funding mechanisms.

Creating a new narrative for the direct care workforce

Federal and state legislative efforts to ease the shortage have been underway for years. The resulting uncertainty around government funding can leave healthcare leaders searching for levers they can control to remain competitive both as an employer and as a service provider.
A solution: Create a fresh, value-driven narrative around the direct care workforce to reframe it as a respected, socially critical profession and address the needs and aspirations of those drawn to the work.

If an Employee Value Proposition (EVP) tells current and prospective employees why they should choose your company over another, a role-specific value proposition can go deeper into showing them why they should choose the career — and choose you. A role-specific value proposition offers a direct message to the prospective employee as a skilled care provider, not as just another employee.

A compelling role-specific EVP will:

1. 1. Illustrate the value of direct care work. Employees want to know their work matters. Describe the critical role direct care workers play in their clients’ lives as trusted partners for retaining independence and quality of life. Describe the job duties as responsibilities requiring skills and expertise, not simple tasks. Bathing a client is a job duty, but understanding the physical and emotional gravity of such intimate tasks is another. Protecting the client’s dignity while ensuring safety is a balancing act; acknowledge it. Emphasize the role as a profession, a vocation, even a calling.

1. 1. Prioritize safety and well-being. Demonstrate a commitment to both employee and client safety to differentiate your company as an employer of choice. Rather than whitewashing the work, cultivate trust by both acknowledging the physical and emotional tolls these roles entail and defining the antidotes you offer. Emphasize the safety training and mental health resources you provide, from safe lifting practices to peer support groups. Show prospective employees that you understand the imperative: to ensure safety for those we serve, we must equip our own team members with the skills and resources they need to be safe themselves.

1. 1. Promote professional growth. Affirm your support for continuous learning and career advancement opportunities. Companies that offer these benefits show prospective employees they value their personal and professional growth. Through offerings like specialized training opportunities, mentorship programs, or even financial aid for certifications, companies not only demonstrate their commitment but give credence to their narrative that direct care work is a profession, not just a job. Further, linking professional development with a company’s broader mission of excellence in care signals that employee growth translates to better client outcomes.

1. Incorporate real voices. Despite the extensive studies by federal agencies, think tanks, and academic institutions on long-term care labor shortages, home health aides have rarely been asked for their own recommendations on potential solutions to the mental health impacts of their work. Whether through focus groups, surveys, or interviews, add richness and authenticity to your messages by asking your current employees about their experiences: What attracted them to direct care work? What makes them stay? This internal research doesn’t just surface issues and identify solutions; it also provides testimonies that can humanize the role-specific value proposition to enhance its resonance with prospective employees. Further, embrace the Gemba mindset by observing their processes firsthand. Accompanying a personal care assistant to a client’s home can reveal further opportunities for improvement and support that may not arise in employee surveys. This multimethod approach to gaining insights helps ensure credibility in your messaging.

Reframing the role of a direct care worker alone cannot solve the labor shortage, but it’s a critical and feasible initiative leaders can use to stabilize their own workforce. Companies that create a new narrative for direct care, one that emphasizes its value and affirms the dignity of the work, can set themselves apart not just as employers of choice, but as providers of choice: With the right people doing the work, quality follows.

Bridget Haeg
U.S Corporate Affairs Director, Healthcare