PHI’s Direct Care Explainer

Due to the enormous nationwide demand for long-term care services, the direct care workforce in the United States has grown to 4.6 million workers. It is now larger than any other single occupation in the country. These workers act as a lifeline for their clients and residents – providing the daily support that older adults and people with disabilities need to stay safe and healthy.

Despite their essential role, direct care workers struggle with low compensation, insufficient training, and limited career paths that drive many workers out of this occupation. For example, 47% percent of home care workers live in low-income households, and more than half (54%) require some form of public assistance. The COVID-19 pandemic has amplified these challenges, leaving many direct care workers without safe, high-quality jobs – and consumers without the care they deserve.

Unfortunately, the general public in the U.S. lacks a clear understanding of the direct care workforce and the complex realities of how long-term care is financed and delivered. Most published resources on this topic are aimed at policy leaders and industry professionals and are less comprehensible for everyday people who are directly affected by this issue. As a result, there is little grassroots support or momentum around improving direct care job quality in the U.S. In response to these challenges, PHI will foster a deeper understanding of the direct care workforce; build public awareness; and drive collective action and support for these workers.

PHI will create a concise, engaging explainer video on the direct care workforce, drawing from our 360-degree perspective on the long-term care sector and our award-winning communications expertise. The video will describe these workers’ essential roles, the primary challenges they face, and what the United States must do to transform these jobs and improve care for everyone. 

The video will draw from best practices on creating attention-grabbing and effective explainer videos that educate and inspire large numbers of people. PHI will create a video that easily explains complex concepts with data, worker stories, photos, visualizations, video clips, and voice-over narration, among other techniques. While the technology involved is universal – and easily accessible to a general audience – its specific application to advocacy in our sector will be innovative, and directly targeted at solving the problems facing this workforce.

Once the video is published on PHI’s website and YouTube channel, we will promote it widely through our digital and social media platforms that reach millions of people nationwide. We will also integrate the video into our presentations and trainings around the country, reaching an even wider audience.

PHI’s target population is the direct care workforce – formally classified as personal care aides, home health aides, and nursing assistants. These workers provide assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) across various care settings. As noted above, the direct care workforce is currently 4.6 million strong in the U.S. – and demand for these occupations continues to grow, as Americans live longer and present a wider range of long-term care needs. Despite this demand, direct care workers are poorly compensated, and high turnover exacerbates a chronic shortage of employees in this sector.

The direct care workforce is primarily composed of low-income women and people of color, and their essential work has historically been devalued due to the structural racism, sexism, and xenophobia in the United States. Overall, the U.S. direct care workforce is 86% female. Their median age is 41. The majority of direct care workers (59%) are people of color – including 30% who are Black/African American, 18% who are Hispanic/Latinx (of any race), 7% who are Asian or Pacific-Islanders, and 4% who identify as other races or ethnicities. Approximately one in four direct care workers (26%) are immigrants to the U.S.

PHI promotes interventions that fundamentally enhance the quality of direct care jobs, such as improved training, family-sustaining wages, full-time hours, comprehensive benefits, and meaningful career paths. Our proposed Direct Care Explainer video will benefit this population by raising awareness of direct care workforce issues among the general public and policymakers – and building momentum toward improving these jobs on a systemic, nationwide level.

PHI maintains direct connections to the communities we serve, dating back to our founding 30+ years ago. Our organization was created in 1991 as the nonprofit partner of Cooperative Home Care Associates (CHCA), a home care agency serving New York City that is also the largest worker-owned cooperative in the United States. Together, PHI and CHCA co-manage a direct care worker training and employment program; over the past three decades, we have prepared more than 12,000 New Yorkers for jobs in the home care sector. This experience has given us a sophisticated understanding of the workforce, the opportunities and challenges that it faces, and the innovations required to drive job quality in our sector.

Building upon our founding mission in New York City, PHI now operates on a national scale (and across various long-term care settings) to offer providers, payers, and policymakers the tools to transform the long-term care system. Over the past decade, our policy and practice initiatives have been implemented in 29 states. Annually, our services benefit 375,000 direct care workers and clients nationwide.

While expanding the scale of PHI’s work, we have not lost sight of the need to engage direct care workers in our mission and programs. Current and former direct care workers serve on PHI’s Board of Directors and on our staff. PHI engages direct care workers in our advocacy efforts as well, and solicits their feedback on our training and technical assistance programs. We have also developed the Direct Care Worker Story Project, a web-based resource with interviews and photographs of workers that centers their voices. Drawing on this past experience, we will design a Direct Care Explainer video that features direct care workers speaking to their own experiences, their relationships with clients, and the inherent challenges of their jobs.

This close connection to our constituents informs all of PHI’s communications and digital media strategies. We manage a fully integrated communications approach that includes branding strategies, framing and messaging, print and digital media, high engagement across social media, public education and marketing campaigns, and the Direct Care Worker Story Project that highlights the stories and ideas of workers on the ground. We are regularly featured in top-tier media outlets such as The New York Times, the Washington Post, USA Today, and many others. Our public education efforts have received the highest honors from the Academy of Interactive and Visual Arts, which has awarded PHI several Communicator Awards, the largest and most competitive awards program honoring creative excellence for communications professionals.

As noted above, direct care workforce issues are not a mainstream concern in the United States. A significant number of Americans are not even aware of the term “direct care,” which is used by long-term care stakeholders but is not in common parlance. Even those people who are aware of the direct care workforce tend to underestimate its importance. A recent survey by The John A. Hartford Foundation found that, while 66% of people will need direct care services at some point in their lives, most incorrectly assume that they will not.

By applying to this challenge, PHI hopes to bring newfound attention to this workforce and its essential role in the care economy. Because long-term care is chronically underfunded in this country, expensive and/or innovative technology-based solutions are rare in this sector. We can potentially change that by channeling technological expertise from other industries into long-term care. To that end, PHI would appreciate the opportunity to network with other applicants and build partnerships around our mutual concerns and interests.

The innovation in PHI’s proposed solution lies in its simplicity. Long-term care, workforce development, and related policy and practice interventions are all highly complex topics, which can easily alienate a general audience. And yet, our society’s urgent need for eldercare and disability services is almost universally understood and appreciated. Our proposed Direct Care Explainer video will address the universality of these issues – while at the same time boiling down their complexities, making them readily understandable to the public. 

In regard to impact, we expect the video to increase awareness of direct care workforce challenges such as poor compensation and high turnover – and inspire action to address them. We will achieve this by promoting the video to diverse stakeholder audiences, including direct care clients and their families, the workers themselves, and policymakers who have the ability to introduce structural changes to our country’s long-term care system. We will also coordinate a paid advertising campaign on social media to broaden the reach of this video.

The Direct Care Explainer video is one facet of PHI’s broader strategy, based on driving improvements to direct care jobs and services on a national scale. To that end, we recently established the following priority areas for PHI’s work over the next 1-5 years:

1. Grow the evidence base on the direct care workforce – PHI will rigorously evaluate new workforce interventions in direct care that build understanding of job quality in the sector and direct care workers’ contributions to the health care system.

2. Promote diversity, equity, and inclusion in direct care – PHI will build out its newly launched Direct Care Worker Equity Institute to include new offerings related to policy, practice, and research, in an effort to counter the structural racism, sexism, and xenophobia experienced by these workers.

3. Shift the public narrative on direct care workers – PHI will invest in strategic communications, narrative-based partnerships, and capacity-building to re-frame how the public understands direct care. The Explainer Video fits mostly within this priority area.

4. Equip long-term care leaders with job quality tools – Finally, PHI will ensure that long-term care providers and policymakers have practical guidance for improving job quality in this workforce over the next 1-5 years.

To measure progress toward improving direct care jobs, PHI uses a framework we developed called “The 5 Pillars of Direct Care Job Quality.” The framework spans 29 elements across five categories or pillars, including:

- Quality Training, which ensures that all workers acquire the skills, knowledge, and confidence to succeed in their complex roles. A key emphasis of this pillar is designing competency-based, adult learner-centered instruction with hands-on learning.

- Fair Compensation, which enables workers to achieve economic stability, safeguard their health, and plan for the future. This pillar argues for a living wage as a base wage and for access to full-time hours, among other approaches.

- Quality Supervision and Support, which offers workers the support and supervision they need to work safely and effectively. A central element of this pillar is to deliver a clear presentation of job requirements, responsibilities, workflows, and reporting structures.

- Respect and Recognition, which honors the expertise, contributions, and diverse life experience of workers. A key element of this pillar is to position direct care workers in an organization’s mission, values, and business plans.

- Real Opportunity, which invests in workers’ learning, development, and career advancement. This pillar includes the creation of opportunities for promotion to advanced direct care roles with wage and title increases.

PHI’s program outcomes are assessed according to whether they advance one or more of these pillars. For example, recent advocacy efforts by PHI and our allies contributed to a permanent $2.00 per hour raise for direct care workers in Michigan, as well as raises and bonuses for this workforce in North Carolina – in alignment with the second pillar, Fair Compensation.

PHI’s specific approach to systems change is guided by the “power politics” and “messaging and frameworks” theories of change. The power politics theory suggests that policy change is made by working directly with those in power to make decisions or influence decision-making. We couple this with the messaging and frameworks theory, which states that a policy option’s likelihood of being adopted is largely based on the effectiveness of its presentation. The Direct Care Explainer video will contribute to both strategies, as it constitutes an effective example of messaging that can be leveraged to drive policy change.

PHI’s solution is powered by relatively simple and accessible technology. We are proposing to create a digitally recorded video, to be posted on our website and on YouTube. The video will be easily accessible via computers and smartphones, where most people are accessing information. In terms of reach and engagement, videos also perform better on social media than other types of multimedia resources. An engaging video that clarifies for many people the value of this workforce will draw on the widespread use of video platforms, smartphones, and laptops as a method for sharing and receiving information.

PHI is committed to diversity, equity, and inclusion (DEI). We recognize DEI’s centrality to our mission and to direct care work itself – particularly since long-term care, health care, and labor are among the many systems rooted in structural racism. We are also an equal opportunity employer, embracing and encouraging our staff’s differences in race, age, color, national origin, citizenship, religion, gender, gender identity and expression, sexual orientation, transgender status, veteran status, and other characteristics that make our employees unique. 

Internally, PHI has implemented DEI strategies using ProInspire’s “Awake to Woke to Work” framework, a multi-stage process for fostering organizational change. For example, we have integrated new tools into our regular Staff Engagement Surveys, enabling us to track staff feedback on race equity and DEI efforts. We have also formed a Race and Equity Working Group with rotating staff membership. The group examines internal policies, makes recommendations, plans race-conscious activities and related programming, and shares DEI-related communications with staff (such as a race-conscious glossary).

In addition, PHI recently launched a Direct Care Worker Equity Institute that will address the structural inequities and profound disparities facing direct care workers. Through this Institute, PHI will maintain a centralized online hub of equity-focused direct care workforce resources and publications; produce original studies and policy resources; and develop equity-specific advocacy tools, to help state and federal leaders create a strong and equitable workforce.

The structure of PHI’s executive/senior leadership team reflects our commitment to DEI. The executive team is 80% female, 40% people of color, and 60% LGBTQIA+.

PHI’s business model is based on providing innovate policy and practice services to a range of stakeholders in the long-term care sector. The organization maintains a sustainable blend of revenue sources, including private philanthropic grants and earned revenue, both public and private.

We draw on three decades of experience working side-by-side with direct care workers and their clients across the country to offer providers, policymakers, and other stakeholders the tools necessary to ensure quality care and quality jobs. Our overall goal is to create an empowered direct care workforce that is well-trained, properly compensated, and positioned to provide quality care to older adults and people with disabilities.

Specifically, PHI’s Workforce Innovations Team collaborates with dozens of long-term care providers, training entities, and academic partners nationwide to strengthen quality care and quality jobs by addressing entry-level training, upskilling, and advanced roles. We engage in organizational development with these providers, grounded in PHI’s Coaching Approach (R) to building essential communications and problem-solving skills. PHI’s adult learner-centered approach is widely recognized as a best practice for training frontline caregivers.

Meanwhile, PHI’s Policy Team supports policymakers and advocates in crafting evidence-based policies to advance quality care and quality jobs. Our capacity includes policy and labor market research and state, regional, and national policy expertise. This expertise and our related public education campaigns have established PHI as the nation’s primary source of information and analysis on direct care. 

Beyond policy briefs and publications that address issues relevant to the direct care workforce, PHI also produces landscape studies. Drawing on research and informant interviews, we offer in-depth analysis of the care provision landscape at the local and statewide levels – assessing how training, service delivery, regulatory, and payment systems shape our sector. Our reports include detailed recommendations for potential programmatic interventions to strengthen local direct care workforce systems.

PHI is currently financially sustainable, both for the immediate future and in the longer term. Over our 30-year history, we have built up a substantial revenue base consisting of renewable foundation grants, performance-based government contracts, and fee-for-service contracts. Notably, however, we do not currently have a dedicated source of communications funding, and our participation in this challenge would help to fill this particular gap.

PHI’s policy and practice work has garnered support from a wide range of foundations and government entities. Our current funders include the Margaret A. Cargill Philanthropies, the W.K. Kellogg Foundation, Robin Hood Foundation, Tiger Foundation, and the Henry & Marilyn Taub Foundation, among many others. We have not requested support for the Direct Care Explainer video from any other source.