High Performance Revisited: Examining the Direct Care Workforce Supporting Older Adults and Individuals With Physical Disabilities

Young woman with prosthetic and crutches in park
Published August 17, 2023

AARP Public Policy Institute (PPI) published the inaugural Long-Term Services and Supports (LTSS) State Scorecard (the Scorecard) in 2011. This first-of-its-kind project measured state LTSS system performance and ranked states in comparison with one another. Building on the work of previous similar projects focused on health care (e.g., the Commonwealth Fund’s State Scorecard on Health System Performance), this Scorecard sought to raise the profile of LTSS and drive action both federally and within states. Since then, the Scorecard has helped both to propel and spotlight change in state LTSS systems as well as to improve services and supports that older adults, people with physical disabilities, and family caregivers receive.

The 2023 Scorecard, set for release in September, will be the first since the COVID-19 pandemic began. In light of the impact of COVID-19, the Scorecard team has spent time taking stock of the current LTSS landscape and what has changed. With input from a wide range of advisors and stakeholders, we have revised the framework and it will include more of a focus on two issues that have always been important but that emerged as urgent priorities during the COVID-19 pandemic: 1) direct care workforce shortage and stability and 2) equity in terms of access and quality to LTSS across different racial and ethnic groups. This paper lays the groundwork for our approach to addressing state performance in ensuring an adequate direct care workforce. Although direct care workers are typically employed privately by provider agencies, individuals, or families, many of the services these workers provide are paid for through state Medicaid or other public LTSS programs. State agencies have an obligation in their capacity as administrators of these public programs to ensure there are enough workers, competent and prepared, to serve all program enrollees.

Direct service worker is a broad category that encompasses many job titles held by people who provide hands-on services and supports across LTSS systems for all populations. Within this larger group of workers, the term direct care worker describes the individuals, with job titles like home care aide and personal care aide, who provide LTSS for older adults and individuals with physical disabilities. They work in multiple settings. With more than 80 percent of adults reporting they would like to live in their homes and communities as they age, rather than in a nursing facility, direct care workers play an important role in helping individuals live where they choose. A high-quality and competent workforce ensures the independence, well-being, and safety of these individuals. Despite their critical role, direct care workers face multiple challenges including low wages, few employee benefits, and minimal training opportunities. The current workforce supply is not nearly enough to meet an increased demand for supports as individuals live longer and turnover rates are high. Investments in data collection can support quality measurement about the direct care workforce. In turn, quality measurement can inform strategies for enhancing the strength and stability of the workforce, which is essential for the well-being of the individuals who rely on its services.


High Performance Revisited: Examining the Direct Care Workforce Supporting Older Adults and Individuals With Physical Disabilities

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Suggested Citation

Alexci, Lisa, Erika Robbins, and Carrie Blakeway Amero. High Performance Revisited: Examining the Direct Care Workforce Supporting Older Adults and Individuals With Physical Disabilities. Washington, DC: AARP Public Policy Institute August 17, 2023.


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