A Crisis of Short-Term Employment for Long-Term Care

By 2060, the number of people in the United States aged 65 or older is expected to grow by 54%, while those 85 and older is expected to increase by 170%. The nation is already facing a major health workforce shortage, and as the population ages, the need for compassionate, consistent, and dependable care will continue to grow.

Direct Service Workers (DSWs) are health care and health-adjacent providers who provide services to older adults and people living with physical disabilities. DSWs represented more than five million workers in 2023, and are a growing share of the workforce, with nearly a million more jobs expected to be added over the following decade.

Despite increasing need, states are experiencing rapid turnover amongst DSWs. To track state performance and improve services for older adults and people with disabilities, ADvancing States and the Human Services Research Institute, have formed the National Core Indicators® Aging and Disabilities (NCI-AD) report. In April 2025, NCI-AD released its 2023 State of the Workforce Survey Report, which documents the current state of DSWs across six states (Colorado, Illinois, Indiana, Missouri, Oregon, and Wisconsin). NCI-AD reported that in 2023, the six states surveyed faced nearly 50% turnover of their DSW workforces, only compounding the DSW workforce shortages across the country.

Aging Population, Less Experienced Workforce

DSWs play a critical role in helping people maintain their independence by providing supports with activities of daily living, performing basic clinical tasks, providing respite support, and assisting with in-home supports like housekeeping and cooking. They are a first line of care, and continuity in position matters for supporting wellbeing.

NCI-AD found that 43% of the DSW workforce had been in their roles for less than one year, and half of all workers leaving the workforce had also been there less than one year.

Agencies that employ DSWs are serving more people year over year, with one-third reporting more than a 10% increase in their number of members. This increased means a higher case load per DSW, and more urgent pressure to keep staffing levels consistent, if not growing.

Pressures to Leave the Field

Three-quarters of the DSWs who left their roles did so voluntarily. Retaining talent is difficult in all sectors, but when compensation is not adequate, and there is not a clear path for advancement, it becomes hard to keep experienced staff in their roles. While there are many reasons a worker may leave their role, NCI-AD identified a few common motivations:

• Low pay: More than 99% of agencies surveyed offered median wages below the living wages in their state. Similarly, PHI identified that in all 50 states and D.C., DSW median wages were lower than those for all other occupations with similar or lower entry-level requirements.

• Poor benefits: NCI-AD found that 60% of agencies did not offer health insurance benefits to their DSWs, while 62% did not offer any employer-sponsored retirement plan benefits.

• Lack of career progression: States can require Less than a quarter of agencies offered a DSW ladder to retain their workers or offer any clear form of career progression.

Meeting the Need

Agencies, states, and the federal government can help address these workforce challenges which are only getting worse. Federally, the Ensuring Access to Medicaid Services final rule, also known as the Access Rule sets a focus on improving access to home and community-based services. These changes include requiring that by 2030 80% of HCBS provider payments go towards compensating direct service workers who are performing the services.

At the state level:

• Washington created and funded and apprenticeship pathways for DSWs.

• Minnesota requires personal care assistance provider agencies to spend nearly 3/4s of their Medicaid funds on aides’ wages and benefits.

• Indiana implemented a 14% rate increase for DSWs.

Additionally, states should continue engaging directly with the direct service workforce via workgroups and other forums, to hear about their challenges and successes. While the problems DSWs face are common, the specifics vary and are worth investigating within each state.

Aurrera Health Blog Series on Home and Community-Based Services

This year, Aurrera Health is publishing a series of blog posts highlighting the latest information on state and federal investments in home and community-based services (HCBS). We look forward to helping states and other stakeholders understand and implement strategies to support serving people who use long-term services and supports through HCBS. If you would like to discuss how we can help you, please reach out to Kristal Vardaman.

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Authors

Erik Hirschman [Policy Consultant]

Kristal Vardaman [Managing Principal]