The Direct Care Workforce Shortage: Opportunities for States
November 26, 2025
As more older adults express a preference to remain in their homes and communities, the need for direct care workers continues to rise, particularly for home health aides and personal care assistants. These workers provide hands-on support with daily activities, filling critical gaps when family members or other informal caregivers cannot. They work across a variety of settings, from nursing homes to private homes, and are the foundation of the long-term care system.
The U.S. is experiencing a direct care workforce shortage across the country, with the Southeast and Midwest experiencing significant shortages. And these shortages are occurring across the long-term care continuum, which can have serious implications for access to care. From an analysis of data from the U.S. Bureau of Labor Statistics, the Bipartisan Policy Center found in its 2023 report that while the number of direct care workers “more than doubled from 2.2 million in 2000 to 5.1 million in 2022, the supply of direct care workers will fall short of the demand associated with 8.9 million projected job openings from 2022-2032.” With an aging population and a workforce strained by low wages, limited benefits, and high turnover, states are pursuing various solutions to better support and invest in the direct care workforce.
“The direct care workforce crisis also places more strain on families as some are forced to choose between their careers and staying at home to care for a loved one due to a lack of available workers, impacting both their personal financial security and the state’s economy.”
PA LTCC Blueprint for Strengthening Pennsylvania’s Direct Care Workforce (2019)
Additionally, the financial stakes are high for older adults. New York’s Master Plan for Aging highlighted the “shortage of workers in caregiving roles has led to services and supports becoming more expensive and less accessible.” Home health and nursing care already account for some of the largest out-of-pocket health expenses. For older adults age 65 and older, 14.6% of their out-of-pocket spending goes toward home health services and 63.7% is spent on nursing home care.
As workforce shortages drive up costs and limit availability, many older adults will face choosing between the care they need and what they can afford. By supporting and strengthening the direct care workforce, states can help ensure accessible, high-quality affordable care for the growing number of older adults who rely on it.
State Policy Actions to Address the Direct Care Workforce Shortage
States are employing several strategies to stabilize the direct care workforce because without these investments, care shortages will continue to strain families, increase hospital and nursing home admissions, and weaken the broader health care system. The Direct Care Workforce Policy and Action Guide highlights key actions states can pursue to strengthen the direct care workforce, such as increasing wages or benefits, supporting professionalization of the direct care workforce, elevating the social value of DCWs, and improving data collection, monitoring, and evaluation for the direct care workforce.
States have adopted several of these approaches as part of their efforts. For example, Colorado created the Direct Care Workforce Collaborative to “identify and move forward strategies to support the recruitment and retention of Colorado’s direct care workforce.” One of the group’s successes included increasing the average wages from $13/hour to $18.29/hour. The state also passed the Direct Care Workforce Stabilization Board Act, which has charged a group to develop recommendations to the Governor and legislature on strategies to strengthen the direct care workforce. Wisconsin established a Governor’s Taskforce on Caregiving via Executive Order, which developed a set of policy proposals that included creating a tiered system for career advancement and piloting a home care registry. New Jersey created the Office of Care Workforce, which is a cross-agency partnership “to develop sustainable career pathways, improve skills, and increase compensation for care workers.” In 2024, the NJ Task Force on LTC Quality & Safety outlined in its final report a series of recommendations for strengthening the direct care workforce, that ranged from addressing wage parity to developing apprenticeship programs for direct care workers to streamlining the process for obtaining certifications. In Arizona, managed care organizations are required to identify workforce challenges by collecting workforce data (e.g., retention, turnover, number of licensed and unlicensed staff) and develop solutions in partnerships with providers and DCWs.
Additionally, states are considering ways to incorporate these strategies in various planning efforts such as multisector plans for aging (MPAs). For example, one of Pennsylvania’s MPA strategies focuses on strengthening the DCW in their state by creating an implementation plan for their 2019 Blueprint for Strengthening Pennsylvania’s Direct Care Workforce, which included recommendations for enhancing wages, benefits, training, and development of a career ladder. One of the opportunities North Carolina identified was to address recommendations from its Investing in North Carolina’s Caregiving Workforce report, developed in partnership between the NC Department of Health and Human Services and the NC Department of Commerce. This report identified approaches to address the growing demand in the health care workforce, particularly for direct care workers in nursing homes and other home and community-based settings in the state.
Looking Ahead
Addressing the shortage will require bold solutions such as improving wages and benefits, offering clear career pathways, investing in training and supervision, and elevating the status of this vital workforce, which can help mitigate downstream impacts across the health care system. Policymakers, health systems, and communities will need to come together to create a sustainable direct care workforce to meet the needs of our aging population, particularly as ARPA funds and other resources shift.