Tackling the Direct-Care Worker Shortage

Denise Lugo has worked as a certified nurse aide for more than 30 years. She’s stayed in the field despite the low pay and back-breaking tasks. Despite the lack of paid vacation. Despite the lack of health insurance.

“I just like to help,” says the 64-year-old Fayetteville resident. Lugo went to work in a nursing home in the 1980s and now cares for individuals in their homes.

Her clients and their families “trust me, and they depend on me, and we just get close,” she adds.

With higher pay and better benefits in other sectors, there aren’t enough direct-care workers like Lugo in North Carolina. The state is facing a crisis-level shortage of nursing home and home-care workers that will only get worse as the population of older adults grows.

During this year’s legislative session, AARP North Carolina is working to educate state lawmakers about the importance and urgency of addressing this issue. Recommendations backed by AARP and other groups include boosting the pay of direct-care workers, improving their work environments and creating career-advancement opportunities like apprenticeships.

Nursing assistants, home health aides and other direct-care workers help older adults and people with disabilities handle their daily needs, whether in long-term care facilities or home- and community-based settings. That can involve dressing, bathing and feeding care recipients, as well as managing medications, running errands and doing light housework.

The direct-care worker shortage is a national issue, but it is particularly acute in North Carolina. According to the state’s Department of Health and Human Services, 17 percent of North Carolinians are 65 or over—one of the highest rates in the nation. That age group is projected to surge from 1.9 million people to 2.8 million by 2042.

The state currently has more than 115,000 direct-care workers; they earned a median hourly wage of $15,52 in 2023, according to research from PHI, a nonprofit that works to improve elder care and disability services.

“A lot of them are living in poverty, despite the fact that they are the ones ... taking care of our most vulnerable older North Carolinians,” says Chris Brandenburg, AARP North Carolina’s manager of federal and state advocacy.

With the population shift, North Carolina will need to fill an estimated 21,000 new direct-care openings by 2032, on top of thousands of vacancies created through attrition, according to PHI.

“If staffing shortages aren’t addressed, older North Carolinians will face decreased access to care,” Brandenburg says. The quality of existing care also will suffer, and caregiver burnout will spike, he says.

Direct-care workers can often find higher pay, better benefits and more flexibility in retail jobs and other sectors. That makes it difficult to recruit and retain the staff needed to help the aging population, says Heather Altman, executive director of the North Carolina Serious Illness Coalition.

There’s little argument, Altman says, that “it’s going to take money” to solve the shortage.

Brandenburg says one big ask on AARP’s agenda is for the legislature to increase Medicaid reimbursement rates for long-term care providers—with the requirement that the money be passed along to direct-care workers.

As of 2023, 22 other states had such “wage pass-through policies” in effect, according to PHI data. The laws vary by state, but generally they require providers receiving Medicaid reimbursements to pass through either a certain dollar amount or a percentage of reimbursements to direct-care workers.

A 2024 report from North Carolina’s Health and Commerce Departments also calls for key government agencies to work with academic institutions and the private sector to invest in and expand apprenticeship programs. It notes that in 2023, six other states were using federal funds to offer pay increases to direct-care workers who complete specific trainings and courses.

“It’s about creating an environment where workers feel valued, supported and empowered to stay in the field,” says Yisel Pomier Maren, North Carolina state director for the National Domestic Workers Alliance.

The NC Center on Workforce for Health, founded in 2023 as a collaborative forum for the state’s health care sector, will be helping government agencies and private-sector groups implement current recommendations, while also developing new ones. Its principal assignment from the state for now is to analyze wages and the Medicaid rates paid to organizations that employ direct-care workers. The center’s director, Andy MacCracken, says the work needs to demonstrate the need for this care and the economic benefits of fixing the current system. But the big picture is clear.

“The demand’s going up, the workforce isn’t getting bigger, so something has to change,” he says.

Lugo, the nurse aide, agrees. Direct-care workers like her, she says, “need to know that somebody out there cares about what we do.”

Mary Dieter, a freelance journalist, spent two decades covering Indiana state policy and politics for The Courier-Journal of Louisville, Kentucky.

Also of interest:

• Inside the Staffing "Apocalypse" Devastating U.S. Nursing Homes
• New Federal Report Highlights Pandemic Lessons for Nursing Homes
• How to Communicate With Frontline Staff at Your Loved One's Long-Term Care Facility