Building the Workforce Behind Long-Term Care

This blog is the third and final part of a three-part series—”Long-Term Care Social Insurance Programs and the Home Care Workforce: A Crucial Investment”—exploring how states can strengthen long-term care for older adults, people with disabilities, and family caregivers—by designing sustainable financing models and investing in the workforce that makes care possible. The first installment examines the growing crisis facing America’s long-term care system—and why state action is urgently needed. The second outlines why many states have considered social insurance and underlying premises for the recommendations that are laid out in this article.

States desperately need a better way to pay for long-term services and supports (LTSS), as was outlined in the first installment in this series. However, a new program will only benefit the people who need services if a sufficient, high-quality workforce is available to provide those services.

Drawing on policy research and key informant interviews, we identified four key recommendations to guide investments in the home care workforce that support social insurance programs. Each recommendation includes specific strategies that could achieve that recommendation. This approach is meant to provide a set of options for state legislators, administrators, advocates, and others as they explore building an LTSS financing program. Depending on political considerations, strategies could be incorporated in: (1) legislation or ballot initiatives that establish a social insurance program; (2) regulations for a social insurance program; and/or (3) a parallel bill. The figure includes the underlying premises for these recommendations, as discussed in the second article in this series.

1. Establish workforce standards across programs.

Key informants agreed that setting minimum workforce standards across LTSS programs (e.g., Medicaid, Veterans Affairs, Older Americans Act, private pay, or a proposed new social insurance program, among others) is vital. The many conflicting requirements spur confusion, complicate training, and make the direct care job less appealing. Creating one standard across programs will prevent workers from having to gain multiple, overlapping authorizations to work as a direct care worker and ease the workforce shortage. It will also avoid pulling workers from one payor to another (avoiding shifting workers to clients whose care is paid for most generously, rather than to clients most in need of care). Two options that would help realize this recommendation include: 

• Create a home care workforce standards board that would issue recommendations about wages, benefits, payment rates to providers, training standards, and/or career advancement opportunities, among other topics. These standards would apply across the LTSS industry, no matter the payer. Creating uniform workforce standards for compensation, training, and career advancement would bolster job quality and, ideally, increase recruitment and retention of workers. Further, it would increase job quality across the system, without creating competition for workers between programs. A home care workforce standards board could include home care workers, consumers, family caregivers, home care providers, unions, state agencies, and other key stakeholders, and should also provide opportunities for public engagement.
• Key informants emphasized that there should be a mechanism that compels policymakers to seriously consider the recommendations of a workforce standards board. For example, Washington State’s Consumer Directed Rate Setting Board issues rate recommendations, including wage and administrative components, that the Governor must include in the state’s budget as long as they are financially feasible.¹ The legislature is then required to vote to approve or deny these rates as a whole, or send it back to the Board. As another example, Minnesota’s Nursing Home Workforce Standards Board recommends minimum hourly wages and training standards for nursing home workers across the state.² It offers three model features: (1) its recommendations become law through an expedited rulemaking process; (2) it has the ability to hire dedicated staff; and (3) it allows for expanded rule enforcement opportunities to ensure workers see the benefit of its recommendations. Lastly, multiple key informants also mentioned the possibility of expanding the scope of the home care advisory rate boards required under the new Medicaid “Access Rule”³ to create a broader workforce standards board.⁴
• Ensure home care workers have the freedom to form and join a union. Unions have a vested interest in bolstering job quality for their members. They negotiate with employers to set wages and benefits, offer training, and support workforce safety. For this reason, unionized workers typically receive higher weekly earnings than their non-unionized counterparts, while also increasing wage standards for these non-unionized workers.⁵ By representing home care workers who provide services through multiple programs, unions help set consistent workforce investments and supports (including wages, training, and more). Some states have utilized the public authority model, which creates a designated entity at the state or county level that is responsible for union negotiations and other workforce supports.⁶ For example, Michigan established a public authority in 2024 that can negotiate with the union and support home care worker training and benefits. Additional responsibilities include developing certification standards, operating a statewide registry to connect qualified caregivers with clients, and collecting statewide workforce data.⁷ This model could potentially expand to cover a new LTSS social insurance program, as well as Medicaid.

2. Support home care workforce development.

Workforce development includes strategies and initiatives that enhance workers’ skills and careers through recruitment, training, and credentialing, among other approaches.⁸ Examples include providing workshops, apprenticeships, and professional certification programs. Because additional skilled and supported home care workers will be needed, any new LTSS financing program should set aside funding for workforce development costs. Two options that would help realize this recommendation include:

• Designate funding for workforce recruitment, retention, and training. Key informants agreed that funding should be designated for workforce recruitment, retention, and training. A modest percentage of social insurance program revenue could go into a separate trust fund to cover workforce development expenses. The 1199 SEIU Home Care Industry Education Fund provides an example that could be replicated or modified. It is a trust fund, supported primarily through grants and donations, that provides career advancement programs such as nursing career ladders, community health worker training, and home care worker certifications.⁹ Although this example is administered by a union, this model can operate in other contexts.
• Require a workforce development landscape study. Each state has its own unique workforce development system, though informed by national standards, policies, and norms. One informant emphasized the need for a landscape study of the workforce development system in each state and determine the best ways to tap into that system to support the home care workforce (including working with the workforce development community to address concerns about the limited economic mobility afforded by home care jobs) . It may be more efficient to provide additional funding for an existing training or career advancement program, rather than creating a new one with an additional set of requirements. For example, a direct care workforce study in California outlined the state’s recent direct care workforce development initiatives.¹⁰ A landscape assessment could go a step further in identifying whether new funding should be allocated for any of those initiatives or if building a new initiative is necessary. A landscape assessment should also identify workforce development programs that do not currently invest in the home care workforce (often due to the low pay and limited economic mobility currently offered in these positions) and determine whether there are opportunities to change this.

3. Ensure actuarial studies incorporate workforce investments.

An actuarial study can assess the detailed costs of a social insurance program. It can be used to estimate future costs and ensure the funding source (such as a payroll tax) is sufficient to cover those costs in the long term. To ensure workforce needs are being met, actuarial studies should incorporate workforce investments that support quality jobs, rather than perpetuating the harms of the status quo. They should not be based solely on historic costs, which have perpetuated under-investment in home care wages and benefits. Two options that would help realize this recommendation include:

• Build a worker registry – While some states already have some form of worker registry,¹¹ most states would benefit from creating one that is up-to-date and that operates across programs. A worker registry, also referred to as a matching service registry, is an online platform that connects workers with people who need home care. This registry would provide older adults and people with disabilities who want to directly hire their workers (rather than go through an agency) with a source of vetted workers to consider. Additionally, as one key informant highlighted, it could be used for back-up when a consumer’s regular aide is unavailable. From the worker perspective, a registry facilitates connections with individual employers who meet their geographic, scheduling, and other needs – making it easier to find compatible work.
• Incorporate sufficient wages and workforce development strategies into estimated costs. Actuarial firms conducting these studies should ensure that the estimated rates they are projecting include a living and competitive wage for workers, supportive benefits (like health insurance and paid time off), and, at a minimum, adjustments based on cost of living and inflation. They should also include workforce development costs, such as investments in skills training and career pathways, as outlined in recommendation two. Specifically, if a specific percentage of revenue is designated for workforce development, the study should factor those elements into cost calculations. 

4. Explore additional workforce strategies.

The establishment of a new LTSS social insurance program could prompt a state to examine other aspects of its LTSS system. Strategies that support the home care workforce, even those not directly implemented through a social insurance program, would help recruit and retain the quality workers people need to support older adults and people with disabilities. Three options that would help realize this recommendation include: 

• Incentivize quality jobs and quality care by using cross-payer payment mechanisms. For example, Tennessee’s Medicaid QuILTSS Initiative financially rewards nursing homes for providing high-quality care, which requires investments in the workforce.¹² An initiative like this could be implemented in the home care sector. Additionally, there may be opportunities to identify preferred home care providers that invest more than the minimum in their workforce. For example, New York’s Medicaid program rewards home care providers that meet certain workforce standards (e.g., wages, health insurance, and others) through grants – a model that could easily be expanded in other states.¹³ By implementing these types of initiatives across payers, it minimizes the burden on home care providers (for example, avoiding creating separate programs with different requirements) while boosting both job quality and quality of care. 
• Bolster Medicaid investment in the workforce. Medicaid underinvests in home care through low reimbursement rates, making it difficult for employers to raise wages and expand benefits. Further, as the largest payer, it sets workforce standards across the system. A social insurance program could be reframed to focus on how it creates “savings” in the long term to the Medicaid program by preventing or delaying individuals from qualifying for Medicaid.¹⁴ These “savings” should be used as an opportunity to remedy Medicaid’s historic under-investment in the workforce. 
• Assess additional training and career advancement opportunities that would better recruit and retain home care workers across programs. Examples raised by key informants include: establishing state compacts that allow certifications to be recognized across states; creating a standard occupational code to more effectively track workforce data; exploring universal worker designations that allow workers to work across LTSS settings; designing advanced certifications that come with a pay increase; and more.

Conclusion

As states consider building their own long-term care social insurance programs, it is vital to include workforce considerations from the outset. This article provides a variety of strategies that states can choose from to invest in and support the home care workforce. Addressing workforce needs will reduce the home care workforce shortage and, ultimately, enable older adults and people with disabilities to live with dignity and independence in the setting they prefer. 

Editor’s Note: The views expressed in this article are those of the author and do not necessarily reflect the views of the National Academy of Social Insurance. The Academy values diverse perspectives to deepen understanding of the potential and promise of social insurance programs.

Acknowledgements & Thanks

We would like to sincerely thank the key informants that participated in this study, including:

• Marc Cohen, LeadingAge LTSS Center @UMass Boston and Community Catalyst
• Eldercare Workforce Alliance
• Madeleine Foutch, WA SEIU 775
• Nicole Jorwic, Caring Across Generations
• Stephen McCall, PHI
• Jake McDonald, PHI
• Robyn Stone, LeadingAge
• Jaimie Worker, Caring Across Generations

We would also like to acknowledge the contributions of the two expert reviewers:

• Robert Espinoza, National Academy of Social Insurance
• Jaimie Worker, Caring Across Generations

Endnotes

1. Aging and Long-Term Support Division. (Accessed June 2, 2025). Consumer Directed Employer Rate Setting Board. https://www.dshs.wa.gov/altsa/stakeholders/consumer-directed-employer-rate-setting-board ↩︎
2. Madland, D, & Shiva, S. (2024, November). Industry Standards Boards Are Delivering Results for Workers, Employers, and Their Communities. Center for American Progress. https://www.americanprogress.org/article/industry-standards-boards-are-delivering-results-for-workers-employers-and-their-communities/ ↩︎
3. The Access Rule requires each state to establish a home care advisory board that would make recommendations on the rates that Medicaid should pay for home care services. This advisory board is comprised of home care workers, Medicaid enrollees, and other representatives. ↩︎
4. Centers for Medicare & Medicaid Services (CMS). (2024, May). Medicaid Program; Ensuring Access to Medicaid Services. Federal Register. http://federalregister.gov/documents/2024/05/10/2024-08363/medicaid-program-ensuring-access-to-medicaid-services ↩︎
5. Bureau of Labor Statistics, U.S. Department of Labor, The Economics Daily. (2020, February). Nonunion workers had weekly earnings 81 percent of union members in 2019. https://www.bls.gov/opub/ted/2020/nonunion-workers-had-weekly-earnings-81-percent-of-union-members-in-2019.htm; Stepick, L, Kim, J, McCall, S, & Scales, K. (2025, June). The Union Effect for Direct Care Workers. PHI. https://www.phinational.org/national-resource-center/resource/the-union-effect-for-direct-care-workers/ ↩︎
6. Smith, P. (2008, May). The Publicization of Home-Based Care Work in State Labor Law. Minnesota Law Review. https://scholarship.law.umn.edu/mlr/601/ ↩︎
7. Home help caregiver council act, Mich. Pub. Act No. 144 (2024). https://www.legislature.mi.gov/documents/2023-2024/publicact/htm/2024-PA-0144.htm#:~:text=AN%20ACT%20to%20create%20the,local%20governmental%20officers%20and%20entities ↩︎
8. Generation You, Employed. (n.d.). What Is Workforce Development? Generation. https://www.generation.org/news/what-is-workforce-development/#:~:text=Workforce%20development%20refers%20to%20a,top%2Dnotch%20service%20to%20clients ↩︎
9. 1199 SEIU. (n.d.). Our Programs. 1199 SEIU Funds. https://www.1199seiuhomecareed.org/our-programs/ ↩︎
10. Hunt, L., Yeh, J., & Fix, M. (2023, January). California’s Direct Care Workforce: Who They Are, the Work They Do, and Why It Matters. California Health Care Foundation. https://www.chcf.org/resource/californias-direct-care-workforce-who-they-are/ ↩︎
11. Paraprofessional Healthcare Institute (PHI). Matching Service Registries. PHI National. https://www.phinational.org/advocacy/matching-service-registries/ ↩︎
12. Stockdale, H., Thayil, J., & Kaye, N. (2024, November). Innovations to Improve Quality and Access in Medicaid Managed Care for Individuals with Long-term Care Needs. NASHP. https://nashp.org/innovations-to-improve-quality-and-access-in-medicaid-managed-care-for-individuals-with-long-term-care-needs ↩︎
13. Paraprofessional Healthcare Institute (PHI). (2017, April). New York’s Home Care Quality Incentive Pool: A State Framework. PHI National. https://www.phinational.org/resource/new-yorks-home-care-quality-incentive-pool-a-state-framework/ ↩︎
14. It can be difficult to quantify or verify how much is “saved” by preventing or delaying someone from needing Medicaid (however, some actuarial studies have attempted to quantify this). These “savings” could ease some of the strain on the Medicaid system – through slowing the growth of the program – but would not likely result in less funding needed for the program compared to current funding levels (due to the growing number of older adults and people with disabilities who require services). ↩︎