Direct Services Workforce Shortages during COVID-19

Direct Services Providers (DSP) are an essential workforce for a range of supports and services. Direct services include non-clinical help with activities of daily living (ADLs) and instrumental activities of daily living (IADLs), such as personal care assistance, homemaker assistance, and assisted transportation. Direct services may also include home health services involving clinically based care that may encompass skilled nursing care, rehabilitation (physical and occupational therapy), home health aide services, and some medical supplies, equipment, and appliances. COVID-19 has highlighted the critical role the direct services workforce plays in supporting the health, well-being and resilience of their clients—and the broader health system.

Problem: Workforce Shortages Exacerbated during the COVID-19 pandemic may limit access to Direct Services

During the COVID-19 pandemic, gaps in availability of direct services, direct care, supportive services, and home health (generalized as “direct services” hereafter) has been a significant and increasing problem. These workforce shortages were previously an issue, but this issue has been exacerbated significantly since the pandemic.

Client Implications: Greater Vulnerability to Adverse Health Outcomes

Individuals who rely on direct services are often more vulnerable to health complications related to COVID-19 (e.g., older adults, people with disabilities and chronic health conditions, and children with special healthcare needs requiring specialized care). Additionally, individuals who received treatment due to a COVID-19 illness often require direct services following discharge to support their recovery.

Health System Implications during COVID-19 and Response

Due to shortages in direct services, care may be compromised and clients may unnecessarily experience decline in health status
Unnecessary hospitalizations due to compromised care can add pressure to hospitals, emergency department visits during COVID-19
Due to lack of direct services, clients may increase the use of emergency services

Background

Terms: Many individuals rely on direct services at home to maintain their health and well-being. There are many job titles used to describe this essential workforce: direct service providers, direct care workers, direct support professionals, supportive services providers, personal care assistants, personal assistance services, home health aide, certified nursing assistant, and home care aide.

Funding: Direct services may be funded through programs by the HHS Administration for Community Living and the Centers for Medicare and Medicaid Services (CMS) (Older Americans Act, Medicaid and Medicare, respectively), through private insurance, or out of pocket. Medicare Home Health and Medicaid Home and Community-Based Services (personal care) provide the majority of the funding in this space.

Workforce & Client Estimates


Direct Service Workforce 4.3 million¹	Family caregiver 53 million²	Home Health Workforce 1.5 million³	Home Health Clients 4.5 million^3,4

Implications

Causes of Direct Services Workforce Shortages:

Prior to COVID-19, there was a critical shortage of DSP for a variety of reasons, including significant challenges in recruiting and retaining this workforce, low wages, high turnover, lack of access to benefits, and lack of economic security. As a result of poor job quality and limited career advancement opportunities, workers often leave their jobs for other industries.
During the COVID-19 pandemic, workforce shortages have been exacerbated due to lack of sufficient personal protective equipment (PPE), fear of exposure to COVID-19 infection, lack of COVID-19 testing, required long hours of work, reliance on public transportation, lack of accessible childcare, competing family obligations and potential infection risk to family members.
Additionally, DSP are recognized as “essential workforce” by local law enforcement and typically do not carry credentials designating their critical role in emergency response or to be prioritized for vaccination.

Possible Unmet Client Needs during COVID-19:

Clients refusing or not receiving services.
Clients experiencing social isolation and/or loneliness.
Clients missing scheduled medical appointments.
Clients unable to get assistance to get re-fills of essential prescription(s).
Children with special health care needs may be unable to attend virtual school without support(s) in place.
Family and other caregivers unable to get respite and other services.

Just-In-Time Solutions/Workaround Opportunities during COVID-19

Amplify Volunteer Roles within the Community

Reassigning Volunteers or Staff from congregate programs can provide support for home-based services including assisting school systems, local community food banks, Meals on Wheels programs, senior centers, and local area agencies and departments with packaging and food delivery and distribution. Shift existing adult daycare workforce to congregate services to deliver in-home services.
Due to COVID-19, the preferred option is to receive direct services at home, rather than in a congregate setting.
Medical Reserve Corps (MRC) units, many of which are sponsored by local health departments, are important public health preparedness and response assets and can help bolster their local community’s emergency response infrastructure by providing supplemental personnel when needed. More than 400 MRC units across the country have responded to the COVID-19 pandemic, supporting their communities in a wide array of response roles. Units are assisting with community screening and testing operations; medical surge support at long term care facilities, health care facilities, and alternate care sites; patient case and contact investigations; call center operations; community education and outreach; logistics support; and more. See FEMA guidance: Delivering Personal Assistance Services in Congregate and Non-congregate Sheltering.
National Corporation for Community Services (AmeriCorps, FEMA Corps, and Senior Corps) engages Americans through service. During disasters, deploy members and volunteers to tackle the nation’s most pressing challenges. National Volunteer Care Corps through a cooperative agreements, local grantees advance innovate models to support volunteer programs to provide non-medical care and assist caregivers, older adults, and/or persons with disabilities.
National Volunteer Organizations Active in Disaster (NVOAD) is an association of organizations that mitigate and alleviate the impact of disasters, provide a forum promoting cooperation, communication, coordination and collaboration; and foster more effective delivery of services to communities affected by disasters.

Supplemental Workforce Option

National Guard units have provided both administrative support and direct support to nursing home facilities in assisting with relocating long term care clients during the COVID-19 pandemic.
Public health staff are making well-check calls and visits to older community members and those on special needs registries to provide wellness checks and assess needs; providing in-home flu vaccines and COVID-19 testing to homebound seniors and at-risk populations; making cloth masks for community members; healthcare plans conducting wellness checks of members.
Community health workers support DSP by providing care for individuals with Alzheimer’s disease or other dementias.
Transportation services assist with grocery and prescription medication pick-up and delivery.
Advancing States through the ConnectToCareJobs.com program which facilitates job matches between healthcare and long-term services and supports providers and people who have the appropriate skills and are available to work. This resource provides facilities with an easy-to-use portal to manage their workforce needs for individuals looking for jobs and volunteer opportunities in healthcare and long-term care a one-stop shop to connect with employers in whatever area of the country they are willing to serve. See

Leverage COVID-19 Policy Flexibilities to Reduce Pressure on DSP Providers, While Expanding Provider Pipeline

Use of telehealth services to mitigate some DSP activities (e.g., avoid transportation services for clinical assessments that can be conducted remotely) and for assessments, care coordination, and delivery of behavioral health (CMS Telehealth Waivers)
CMS 1915(c) Waiver Appendix K during COVID-19 providing flexibility for family members to be paid to render direct services, provide hazard pay for workers, retainer payments if the client is hospitalized, and payment increases.
Incentivize DSP training by increase rate of pay (10%) for DSP
Temporarily relaxing cogent (national) background check requirements, act on any findings in the background check, recommend complete in-depth background check while they work under provisional authorization.
Expand contracts or new contracts for additional DSP. See FEMA guidance: Delivering Personal Assistance Services in Congregate and Non-congregate Sheltering.

Expand the Pipeline for DSP

Increase internship opportunities at earlier stages of curricula for those studying to become DSPs of various types in trade schools or higher educational institutions. This is a short-term solution under exigent circumstances, but it could make a difference as a surge response. Consider a strict supervision plan.
Partner with high schools, training senior students to conduct virtual visits with home-bound older adults; training high school students in competencies for home delivered meal services.

¹ Estimate based combining personal care aides, home health aides, and nursing assistants from American Community Survey (2019)
² Estimate from AARP/National Alliance for Caregivers see Caregiving in the United States 2020 (May 14, 2020); https://www.aarp.org/ppi/info-2020/caregiving-in-the-united-states.html
³https://www.cdc.gov/nchs/fastats/home-health-care.htm
⁴http://ahhqi.org/images/uploads/AHHQI_2019_Home_Health_Chartbook_Final_Updated_10.3.2019.pdf

Addressing the Access and Functional Needs of At-Risk Individuals