Inside The Senior Alliance: Direct Care Workers (Ep. 1.12)

In episode 12 of “Inside the Senior Alliance,” Jason Maciejewski talks to Dr. Clare Luz, a gerontologist from Michigan State University and Director of Impart Alliance, to discuss the work of direct care workers and what is needed to help them do their jobs well, especially in the midst of the changes the field is experiencing because of COVID-19.


Jason Maciejewski (00:00):

Welcome to Episode 12 of “Inside the Senior Alliance,” a podcast exploring resources in the field of aging. I’m Jason Maciejewski, Chief Operating Officer and Deputy Director of the Senior Alliance, the area agency on aging, serving Western and Southern Wayne County. Today, I’m joined by Dr. Clare Luz, a gerontologist from Michigan State University with four decades of experience in the field of aging and a focus on direct care workforce issues. Clare, welcome to “Inside the Senior Alliance.”

Dr. Clare Luz (00:26):

Thanks, Jason. I appreciate this opportunity.

Jason Maciejewski (00:29):

Today, we’re talking about the state of the direct care workforce, specifically, those working with older adults. Clare, what exactly is a direct care worker, and what types of settings do they work in?

Dr. Clare Luz (00:39):

Well, direct care workers are people who assist older adults and persons with disabilities with what are referred to as activities of daily living, such as bathing, dressing, transferring, and also instrumental activities of daily living, like cooking, and cleaning, and transportation, and they may also provide companion services, job coaching, other critical supports. They go by many, many names, some are called personal care assistance or direct support professionals or home health aides. These are just a few of the titles that they have been given. And they work in all long-term supports and services settings, including individuals, private homes, assisted living facilities, group homes, hospice, nursing homes, and they work across aging and behavioral health programs with all different kinds of populations, including those with mental illness and intellectual and developmental disabilities. But, regardless of the title or the program or the population that they work with, they do share some common functions and experiences, and they all play a very critical role in assisting individuals live independently, as independently as they can, with as much quality of life as possible. And this is because they usually spend more time with an individual than most if not all other members of the support team.

Jason Maciejewski (02:00):

They play a critical role in our healthcare system, especially for older adults. The impact of a direct care worker helps not only the person receiving care but the person’s regular caregivers as well, correct?

Dr. Clare Luz (02:11):

Yes, absolutely. The vast majority of care in the U.S. has always been, and it still is, provided by family caregivers, but there are fewer family caregivers now for many reasons, and the care provided is now much more complex. Also, for many reasons, people are living longer, which is good, but the number of those with long-term multiple chronic conditions and dementia has risen dramatically as the population ages. So, family is very stretched thin. They need help, especially family members who are also employed or who are aging and have health concerns themselves. So, they really need help, and the paid direct care workers provide critical support. That helps, as you said, not just the person receiving support, but the whole family system,

Jason Maciejewski (02:58):

Those respite services are critical for so many people. There is an incredible need for direct care workers right now. How many people are needed in that workforce to meet the demand?

Dr. Clare Luz (02:59):

Well, the statistic that really grabs people’s attention – it’s estimated that in Michigan alone, we need about 34-36,000 more direct care workers than we currently have. And we don’t need just warm bodies. We want people who know what they’re doing, who are kind, and who care about the people that they are supporting. And that is why it is critical that we address the root causes of the shortage and build a high-quality direct care workforce that is qualified and not only wants to stay in their job, but they’re able to stay in their job because they have the necessary supports.

And as you may know, it’s not just about the number of workers. We need more workers, but we need to stabilize this workforce. The turnover rate within this workforce is currently at about 80% and higher, and it keeps the whole system churned up. It destroys continuity of care, and it’s very, very expensive. Every turnover costs the employer somewhere around $3,000, if not more.

Jason Maciejewski (04:11):

Traditionally, what education is required, and what type of training do direct care workers typically receive?

Dr. Clare Luz (04:18):

Certified nursing assistants, or CNAs, and certified home health aides, they are required by federal law to have 75 hours of training. And the states can require more than this, and many states do, but Michigan still requires just 75. For most other types of direct care workers, such as the personal care aides that I mentioned, there are absolutely no federal competency or training requirements. None. And direct care work at the state level, direct care workers employed through CMH, for example, funded programs have some fairly robust requirements and there’s some minimal training required by some of the Medicaid funded programs. Otherwise, it is mostly up to the individual employers. And as you can imagine, there is a huge range in terms of the number of hours, the content, and the quality of the training that is given. And there’s little if any oversight. This is something we’re working on at the state level is to begin to establish some quality standards, some competency guidelines, and training guidelines. It’s critical to professionalize this workforce, which will help stabilize it and grow it.

Jason Maciejewski (05:31):

The lack of training, the significant need in the community – you’re working with Impart Alliance on these issues. Tell me about your work with the Impart Alliance and what you’re trying to do to improve the delivery of direct care for older adults.

Dr. Clare Luz (05:43):

Yes, of course. Jason, thank you for this opportunity. I’m the director of Impart Alliance. Impart was formally established in 2016 with funds from the Michigan Health Endowment Fund. We’re housed in the Michigan State University College of Osteopathic Medicine, and our sole purpose is really to help Michigan build an infrastructure that can grow this workforce and support a sufficient qualified direct care workforce. Michigan doesn’t have an infrastructure currently to do this. Impart grew out of years of collaborating with the state, with community partners, with the triple A’s to develop comprehensive, evidence-based direct care worker training programs. With federal funds, back in 2010, we’ve developed such a program referred to as Building Training-Building Quality, or B2B Q, for short. And that was an in-person 77-hour person-centered training program specifically for direct care workers. And we were getting ready to scale this up when COVID hit. And we have spent the last year and a half converting all of the content over to a new virtual program with 60-to-90-minute modules delivered live via Zoom. And I’m happy to provide more information about our training programs. People can contact us

But we also, in addition to training, we also engage in a great deal of advocacy on behalf of direct care workers for higher wages, for better job conditions, for more respect. As you said, Jason, we have to address all of these issues to make this a career that people want to get into. I am honored right now to co-chair the statewide MDHHS Direct Care Workforce Advisory Committee, as well as the fairly new statewide Impart Alliance Direct Care Worker Coalition, which is established through a partnership with PHI. PHI is a national group that advocates for better care through better jobs for direct care workers. So, both of these statewide groups are trying to build partnerships with the triple A’s, with Michigan Works, with all kinds of community partners and stakeholders to work together for a stronger direct care workforce. And I hope listeners will consider joining this coalition and these efforts. It really takes all of us to move this forward. And these statewide groups are working on all different angles to professionalize this workgroup and get it the wages, the respect, the training, the hours that it deserves and that we all need.

Jason Maciejewski (08:21):

When the Senior Alliance has been in Lansing advocating for older adults, we have focused on direct care worker issues. It’s really been something we’ve put a lot of effort into. We’ve stood shoulder-to-shoulder with a variety of organizations advocating for better education training and wages for direct care workers. And I know that during the COVID-19 pandemic, direct care workers have been on the front lines, working with people in the community. They received a wage increase from various COVID-19 relief funding bills. What is the typical compensation for a direct care worker right now? And how does that compare to others?

Dr. Clare Luz (08:53):

So, first of all, let me say thanks to you, Jason, and to the Senior Alliance for doing such great work over the years and working with all of us together. Now, you know, just getting the word out about things like wages is important, raising public awareness and podcasts like this are critical.

In terms of wages, it’s variable depending on the level of training and the setting and the program that the direct care worker works in. Without counting the premium pay of $2 that they were able to get during the pandemic and are still getting at the moment, which by the way is not yet permanent, the range is from minimum wage to 16 to $17 per hour, with the median range being approximately $12 per hour. Most of the direct care workers that I work with are not certified, they’re not served by nursing assistants, and there they’re making somewhere around $10 an hour.

If you are a CNA in a nursing home, you may make more than this. But again, if you’re an uncertified direct care worker, such as the personal care aides working in a home setting, it could be far less. Then, a couple of important points I would like to say about wages, it’s not just about the pay rate itself, it’s also about the number of hours worked. So, you know, just theoretically somebody could be making $20 an hour, but if they don’t have enough hours during the week to make ends meet, that’s a problem. They may have a higher wage, but fewer hours, and the hours, especially in-home care, are generally not guaranteed. People who have one or two clients, if something happens to those clients, they enter the nursing home, or they pass away, then there’s no longer an income.

And a comment just about the premium pay. Even if you add $2 to these wage rates, it doesn’t bring the average or median wage up to a living wage. It certainly doesn’t bring it up to a level that’s competitive with the wages that are now being offered in the private sector. It’s almost impossible to compete with Target, for example, who’s now offering higher wages, plus, you know, covering college tuition for people. So, it’s really difficult to be competitive with the private sector when a lot of the direct care workers are paid through a Medicaid program and there’s a limit on the Medicaid reimbursement rate for the employers. So that all of these things, it’s very complex, all of these things need to be addressed.

Jason Maciejewski (11:22):

It is certainly a complex situation in terms of compensation for such a critical workforce. Is there anything you would like to add about the direct care workforce that we haven’t covered?

Dr. Clare Luz (11:30):

Oh gosh, there’s so much I could talk about. I’m obviously passionate about this subject, and there’s a lot of work to be done. I guess what I’d like to say is that this work requires skill. For the listeners, I hope you get the message that this is not non-skilled or low-skilled work. It is anything but that. Many of the direct care workers that I have interviewed over the years have said that they are often referred to as a “professional butt wiper” or “the maid,” and people don’t understand the extreme skills that go into this, especially when direct care workers are often in a pivotal position and they’re making decisions that can make a situation turn out okay or go terribly south. They’re even making decisions that might make the difference between life and death. If they’re trained, they can avert some very life-altering events, like falls, and nursing home placements, and emergency room visits. Especially in-home care when you have a direct care worker who’s out there on their own, they don’t have a big staff backing them up, and they’re having to make decisions on the spot. So, and as you pointed out, the direct care worker doesn’t support just the client, they support the whole family unit. This shortage affects all of us. It’s not just a problem for long-term supports and services. It’s a workforce issue. It’s an economic development issue that affects so much more than just long-term supports and services. And of course, it’s all been exacerbated by COVID, by the recent auto insurance reforms, and so forth. So, we have to wake up and pull together and address this head-on together. So, I’m deeply grateful for opportunities like this, to try to bring this message home.

Jason Maciejewski (13:15):

Clare, thanks for joining me today and bringing us so much great information on direct care workforce. Thank you for joining us on “Inside the senior Alliance.”

Dr. Clare Luz (13:23):

You’re welcome. And thanks for all you do. And for this platform.

Jason Maciejewski (13:25):

If anyone has questions about services or programs the Senior Alliance offers, you can call us at 1-800-815-1112 or email us at Information about our agency or the programs and services we offer can be found on our website at On Facebook, we can be located by searching for the Senior Alliance. Finally, our Twitter handle is @AAA1C. I’m Jason Maciejewski. Thank you for listening to this episode of “Inside the senior Alliance.”

Jason Maciejewski (13:57):

“Inside the Senior Alliance” is a production of the Senior Alliance and Blazing Kiss Media.


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