JANUARY 2023 Issue Brief Lauren Hunt, PhD, RN, FNP, Jarmin Yeh, PhD, MPH, MSSW, and Margaret Fix, MPH, University of California, San Francisco California's Direct Care Workforce: Who They Are, the Work They Do, and Why It Matters B y 2030, one in four Californians will be age 60 Direct Care Worker Job Categories or older.1 The aging population in California and Responsibilities will require increasing support from direct care The US Bureau of Labor Statistics 2018 Standard workers to care for their essential needs, yet experts Occupational Classification (SOC) System codifies predict a shortage of between 600,000 and 3.2 million direct care workers into three categories: (1) personal direct care workers by 2030.2 Fixing the historically care aides (PCAs), (2) home health aides (HHAs), and fragmented and under-resourced infrastructure sup- (3) nursing assistants, which California calls certified porting this workforce presents urgent challenges nurse assistants (CNAs) (Table 1).5 These occupational that diverse stakeholders must collectively address.3 categories are not necessarily discrete. Similar job Bolstering the direct care workforce is a win-win prop- descriptions and overlapping responsibilities blur the osition. Not only will investments in this workforce boundaries between categories. For instance, direct improve the quality of life for older Californians, but support professionals (DSPs) and In-Home Supportive they should also improve working conditions for an Services (IHSS) providers are generally considered sub- essential workforce that has been historically margin- types of PCAs, but some of these direct care workers alized and underpaid. may also have some responsibilities similar to those of HHAs. Moreover, multiple job titles for the same job create confusion. For example, PCAs are also known Who Are California's Direct as personal care attendants, personal assistants, or Care Workers? home care aides. Direct care workers are paid to provide essential, hands-on, daily, and long-term assistance to older Direct care workers can be responsible for custodial adults and people with disabilities. They work in a care, skilled care, or both. range of settings (from private homes to community A Custodial care involves assisting clients with non- to congregate settings), assisting their clients to maxi- mize their quality of life and supporting their clients' medical, personal care supports for activities of daily ability to remain in their own homes or communities living (ADL) (e.g., eating, dressing, bathing, toilet- when possible. Many of California's direct care work- ing) or instrumental activities of daily living (IADL) ers come from historically marginalized backgrounds: (e.g., housekeeping, chores, meal preparation). 80% are women, almost half (47%) are immigrants, and A Skilled care involves managing medical condi- over three-quarters are people of color (38% Latino/x; tions, monitoring health status, or assisting with 24% Asian, Native Hawaiian, and Pacific Islander; 12% health-related tasks (e.g., changing bandages, tak- Black; 3% other).4 ing blood pressure, assisting with range-of-motion exercises). These services can be provided in the person's residence (e.g., their home, an assisted liv- ing facility, or a nursing home). The care provided varies across direct care worker occupational categories. In general, PCAs provide custodial care, while HHAs and CNAs provide both custodial and limited skilled care. Some PCAs (i.e., IHSS providers) can be delegated to provide paramedical services, which are services ordered by a licensed health care professional who is lawfully authorized to do so, which a person could provide for themselves if they did not have functional limitations (e.g., medication administration, skin and wound care, injections). Table 1. Direct Care Workers by Occupational Category OCCUPATIONAL CATEGORY PERSONAL CARE AIDES (PCAs) HOME HEALTH AIDES (HHAs) CERTIFIED NURSE ASSISTANTS (CNAs) SOC Code: 31-1122 SOC Code: 31-1121 SOC Code: 31-1131 CARE PROVIDED $ Custodial care $ Custodial care $ Custodial care $ Limited skilled care $ Limited skilled care WORK SETTING $ Home $ Home $ Community* $ Community* $ Community* $ Residential care facilities† $ Residential care facilities† $ Residential care facilities† $ Skilled nursing facilities $ Hospitals SUBTYPES WITH SIMILAR RESPONSIBILITIES $ Direct support professionals (DSPs) N/A N/A $ In-Home Supportive Services (IHSS) providers‡ Notes: N/A is not applicable; SOC is Standard Occupational Classification. * Includes a client's place of work or leisure (e.g., adult day programs). † Includes assisted living, board and care, and other residential care facilities. ‡ IHSS workers may be allowed to provide paramedical services in some cases. Paramedical services are services ordered by a licensed health care professional, which a person could provide for themselves, but for their functional limitations. See Paramedical Services (PDF), California Department of Social Services, accessed August 29, 2022. Sources: "2018 Standard Occupational Classification System," US Bureau of Labor Statistics, last modified April 17, 2020; "CDA's Direct Care Workforce Initiative" (webinar) California Department of Aging, June 14, 2022; and Direct Care Workers in the United States: Key Facts, PHI, September 6, 2022. California Health Care Foundation www.chcf.org 2 $ Direct support professionals (DSPs) specifically Number of Direct Care Workers in California support people with intellectual or developmen- Getting an accurate count of California's direct care tal disabilities (I/DD) to live independently and workforce is challenging. According to the US Bureau remain integrated in their communities. Some of Labor Statistics (BLS), California had 811,670 direct advocates for DSPs aim to establish a specific care workers in 2021, including 717,220 PCAs and code from the US Bureau of Labor Statistics for HHAs (who were counted as a single category) and this job category.6 94,450 CNAs.10 The California Department of Social Services estimated over 550,000 IHSS providers in $ In-Home Supportive Services (IHSS) provid- 2021.11 These numbers may be incomplete and inac- ers are part of a statewide Medi-Cal benefit that curate for several reasons.12 First, BLS estimates of provides long-term services and supports (LTSS) PCAs and HHAs include those employed by home to older adults and people with disabilities who health agencies, agencies providing elder care ser- cannot live at home safely without support.7 vices (e.g., senior centers), and some but likely not � IHSS providers may provide personal care all IHSS agencies/employers; these counts may services and/or paramedical services as autho- miss PCAs and HHAs who are independent provid- rized by the IHSS program.8 ers, including some IHSS providers.13 Second, direct care workers may have multiple jobs in different job � IHSS clients self-direct their care, which allows categories, which could lead to double-counting. them to choose and hire their own provider, For example, a worker might have a full-time job including friends and family. at a nursing home as a CNA and pick up shifts as a � About 70% of IHSS providers are related to PCA at a second job. Finally, a hidden gray market their client.9 for direct care workers occurs when consumers hire their own workers outside of a regulated program,14 making accurate counts of direct care workers even Community Health Workers/Promotores more complicated. Generally, community health workers/promo- tores (CHW/Ps) are considered a different type of worker than direct care workers. While the What Do California's Direct boundaries of these job definitions can blur or Care Workers Do? overlap at times, generally CHW/Ps provide care The three direct care worker occupational categories navigation to help people get the services they (PCA, HHA, and CNA) share many - but not all - need, while direct care workers provide hands-on care to assist patients with day-to-day activities. job responsibilities. Each faces distinct supervision For more information on CHW/Ps, see Advancing and training requirements and is overseen by different California's Community Health Worker & Pro- regulatory entities. See Table 2 for a comparison of motor Workforce in Medi-Cal, California Health direct care worker jobs by category. Care Foundation, October 2021. California's Direct Care Workforce: Who They Are, the Work They Do, and Why It Matters 3 Table 2. Comparison of Direct Care Worker Jobs by Occupational Category OCCUPATIONAL CATEGORY PERSONAL CARE AIDES (PCAs) HOME HEALTH AIDES (HHAs) CERTIFIED NURSE ASSISTANTS (CNAs) DUTIES $ Provide custodial care to clients, $ May monitor and address client's $ May monitor and address clients' such as bathing and dressing, and health-related needs in addition to health-related needs in addition to cooking and laundry if care is providing custodial care. providing custodial care. received at home. $ Keep records on clients and report $ Provide care that is coordinated with changes to supervisor. a client's health care team.* $ Are often the principal caregiver to clients in a nursing or residential care facility. SUPERVISION $ When the worker is hired directly $ Supervised by medical practitioners $ Supervised by on-site medical practi- by clients or their family, the client (commonly nurses), with periodic tioners (commonly a registered nurse or family assumes responsibility for check-ins/visits. or licensed practical nurse). deciding what the worker needs to $ May work with therapists, social know and providing training for workers, case managers, and other those tasks, most often through medical staff. direct supervision. $ The California Health and Safety $ Periodic check-ins/visits by supervisor Code states that HHA services do not (e.g., client's family, case managers). include services provided under the IHSS program. TRAINING $ 0–8 hours, varying by type of worker, $ 120 hours minimum (4 hours of intro- $ 160 hours (60 classroom hours agency, or program (e.g., registered/ duction + 20 hours of clinical training + 100 clinical hours). unregistered worker, direct employ- + 70 hours of personal care services $ Includes facility-based and online ment by client). + 16 hours of nutrition + 10 hours of training programs. $ Direct support professionals (DSPs) cleaning and care tasks in the home). must complete 70 hours of training $ CNAs can complete an additional (two segments of 35 hours completed 40 hours to also become certified as in successive years) and must pass a HHAs (2 hours of introduction challenge test for each 35-hour train- + 5 hours of medical and social needs ing program. + 20 hours of personal care services $ In-Home Supportive Services (IHSS) + 5 hours of cleaning and care tasks providers must attend an orientation + 8 hours of nutrition). that reviews program rules given by the county IHSS Office or county IHSS Public Authority. RESPONSIBLE DEPARTMENT(S) $ California Department of Social California Department of Public Health CDPH Services (CDSS) (CDPH) $ California Department of Health Care Services (DHCS) $ California Department of Developmental Services (DDS) * CNAs are often considered part of a client's health care team of providers, along with physician, nurse, social worker, etc., especially if they work in an institutional setting. Sources: "Occupational Outlook Handbook," US Bureau of Labor Statistics, last modified September 8, 2022; Joanne Spetz, Home Health Aides and Personal Care Assistants: Scope of Practice Regulations and Their Impact on Care (PDF), Healthforce Center at UCSF, July 2019; "Training Program Review Unit," California Department of Public Health, last updated April 25, 2022; "CDA's Direct Care Workforce Initiative" (webinar), California Department of Aging, June 14, 2022; "Application Submission Requirements (120 hour) Home Health Aide Training Program (HHP)," California Department of Public Health, last updated April 14, 2022; "Nurse Assistant Training Program Applicants: Educational Institution & Agency Application Requirements," California Department of Public Health, last updated April 14, 2022; California Department of Public Health, last updated August 23, 2022; "Home Care Services," California Department of Social Services, accessed July 31, 2022; "1915(c) Home and Community-Based Services Waivers," California Department of Health Care Services, last modified July 18, 2022; "Home Health Aide," California Department of Public Health, last updated January 14, 2022; "Direct Support Professional Training," California Department of Developmental Services, last modified April 8, 2021; and "IHSS Provider Orientation," California Department of Social Services, accessed July 31, 2022. California Health Care Foundation www.chcf.org 4 Why Do California's Direct Hawaiian, or Pacific Islander; American Indian or Alaska Native; or multiracial, necessitating Care Workers Matter? more culturally competent and linguistically Over the next decade, demand for direct care work- appropriate services and providers.23 ers will outpace supply in California, with an estimated � Over one million older adults in California shortage of 600,000 to 3.2 million direct care work- are projected to have self-care limitations by ers by 2030.15 Job openings for PCAs are expected to 2030, which includes a variety of needs like have the largest growth of any occupation in California, transportation and cleaning services and help with 1.1 million openings between 2018 and 2028 with basic tasks such as bathing or eating. and a total workforce growth of over 30%.16 Growing demand is driven by an aging and increasingly diverse $ Fewer working-aged adults and family population, fewer working-aged adults and family caregivers: caregivers to support this aging population, a grow- � In coming decades, the ratio of working-age ing desire to remain in home and community-based adults (ages 18–64) to older adults age 65+ settings, and an increased need for complex care pro- will shrink significantly: from 4 to 1 in 2020 vided in facility-based long-term care settings. to 2.4 to 1 in 2040. This will put a strain on the tax base to fund support programs and Several factors constrain the supply of direct care will drastically shift the balance between the workers. Direct care work is physically and emotionally population providing care and the population demanding, yet wages for direct care workers remain needing care.25 low, and many direct care workers live in poverty. This contributes to high rates of burnout, turnover, � While society has historically relied on women and fewer people willing to perform these jobs.17 to provide unpaid caregiving support, women Moreover, direct care workers have been on the front are increasingly entering the paid labor force, line during the COVID-19 pandemic. Yet they were so they are often no longer available or ame- often rendered invisible despite their essential role, nable to serve in the role of unpaid caregiver. receiving little support, supplies, or resources from $ Increasingneed for home and community- their employers.18 based care: Factors Contributing to an Increased � Older adults and people with disabilities and Demand for Direct Care Workers their families increasingly prefer and/or rely on $ Aging and diverse population:19 home care as an alternative to nursing homes or hospitals. � Allbaby boomers (those born between 1946 and 1964) will be age 65+ by 2030.20 � A recent California survey found that among older adults and people with disabilities who � One in four Californians will be age 60+ by need support at home, almost 40% have an 2030, representing 10.8 million people.21 unmet need for this type of help. Of those � White, non-Hispanic Californians age 60+ with an unmet need, almost 20% went without will no longer represent the majority of older groceries because of difficulty shopping.26 adults by 2030.22 � By 2030, the majority of Californians age 60+ will identify as Black; Latino/x; Asian, Native California's Direct Care Workforce: Who They Are, the Work They Do, and Why It Matters 5 $ Growing need for facility-based $ Low wages contribute to impoverishment long-term care: of workers: � Older adults with chronic, complex, or progres- � California's direct care workers earn median sive diseases (e.g., heart disease, dementia, wages between $14.00 and $18.00 per hour and diabetes) may prefer, or rely on, living in a (see Table 3).30 congregate setting, such as a long-term care � California's minimum wage of $14.00/hour or assisted living facility. These facilities rely on for employers with 25 or less employees and direct care workers to provide day-to-day care $15.00/hour for employers with 26 or more for these residents. employees is well below the living wage of $21.82/hour for a single adult with no children Factors Contributing to a Constrained in California.31 Supply of Direct Care Workers $ Providing care is physically and emotionally � Nearly half (47%) of California's direct care demanding work:27 workers receive benefits from public assis- tance programs.32 � CNAs have among the highest rates of injuries and illnesses of all occupations.28 � Direct care workers who do not have work authorization or documentation are ineligible � Direct care workers face risk of injury when for certain public assistance programs, putting helping clients move (such as into or out of additional financial strain on them and their bed, or with standing or walking), especially if families. proper lifting techniques are not used. $ High turnover: � Directcare workers can face difficult or violent behaviors from clients with cognitive impair- � Low and stagnant wages, burnout, lack of ment or mental health issues, and hazards advancement opportunities, insufficient from infections and exposures to communi- training, job-related injuries, concerns about cable diseases. COVID-19 and other infectious diseases, and � During the COVID-19 pandemic, direct care workers were forced to make impossible Table 3. Wages of California Direct Care Workers by choices, such as taking care of a client who Occupational Category (May 2021) had become infected with the virus, which OCCUPATIONAL CATEGORY posed risks to themselves and their families, PERSONAL CARE HOME HEALTH CERTIFIED NURSE or staying home and seeing their financial situ- AIDES AIDES ASSISTANTS ation worsen.29 (PCAs) (HHAs) (CNAs) � Many direct care workers experience burnout MEDIAN HOURLY WAGE and exhaustion from working multiple part- $14.27 $18.00 time jobs or working full-time or more, such as MEAN HOURLY WAGE by taking shifts at night, on weekends, or over $15.26 $19.12 holidays so clients always have a care worker. MEAN ANNUAL WAGE $31,740 $39,760 Source: "May 2021 State Occupational Employment and Wage Estimates: California," US Bureau of Labor Statistics, last modified March 31, 2022. California Health Care Foundation www.chcf.org 6 lack of family leave policies are all factors con- $ Initiative111: Convene a Direct Care Workforce tributing to high turnover and job vacancies. Solutions Table to address workforce supply challenges and opportunities in skilled nurs- � The estimated cost of turnover per direct care ing facilities (SNFs). (Lead agencies: California worker is, at minimum, $2,500 in direct cost Health and Human Services Agency [CalHHS], (use of temporary staff, training, etc.), plus an California Labor & Workforce Development indirect cost (loss of productivity, lost clients, Agency [LWDA].) etc.) that is harder to measure but could dou- ble the estimate.33 $ Initiative112: Consider expanding online train- ing platforms for direct care workers, including � California'sIHSS providers have an estimated opportunities for dementia training for IHSS 33% annual turnover rate, leaving as many as family caregivers seeking a career ladder 180,000 clients searching for a new provider and more. (Lead agencies: CalHHS, LWDA, to hire and train each year.34 community colleges.) How Do Various Investments $ Initiative113: Diversify the pipeline for direct care workers in home and community settings Impact California's Direct by testing and scaling emerging models. (Lead Care Workforce? agencies: CalHHS, LWDA, community colleges.) Solving the direct care workforce shortage requires a multipronged approach.35 Providing a living wage Investments in the Direct Care Workforce is essential to supporting the direct care workforce. California is making several investments in the direct Workers also need career ladders for advancement care workforce through state and federal funds.38 In and career lattices for movement across the continuum fiscal year 2021–2022, California invested $964.4 mil- of occupational categories that operate in different lion in direct care workers. These included investments settings. Training programs are critical but must pro- in specific direct care worker occupational categories vide wraparound services to be accessible, including (PCAs, CNAs, HHAs) and investments in specific set- supports like stipends, child care, and transportation.36 tings (e.g., home and community-based programs and Direct care workers, employers, and clients need cul- residential care settings). Initiatives include the follow- turally and linguistically appropriate systems that are ing: (1) IHSS Career Pathways Program, (2) California easier to navigate. The California Master Plan for GROWs: Growing a Resilient, Outstanding Workforce Aging begins to address these needs with a goal of in the Home and Community, (3) Direct Support creating one million high-quality caregiving jobs by Professional Workforce Training and Development, 2030 and several direct care workforce investments (4) Home and Community-Based Services Clinical are already underway. Workforce Program, and (5) Certified Nurse Assistant Workforce Program. Details of these investments are California Master Plan for Aging: provided in Table 4. Direct Care Workforce Goals for 2030 California's Master Plan for Aging, released in 2021, describes five bold goals. Of those related to the direct care workforce, goal #4 specifies the need to create one million high-quality caregiving jobs by 2030.37 Three sub-initiatives outline solutions for the direct care workforce: California's Direct Care Workforce: Who They Are, the Work They Do, and Why It Matters 7 Table 4. Comparison of Direct Care Workforce Programs and Initiatives in California OCCUPATIONAL CATEGORY PERSONAL CARE AIDES (PCAs) CERTIFIED NURSE ASSISTANTS (CNAs) HOME HEALTH AIDES (HHAs) PROGRAM IHSS Career California GROWs Direct Support HCBS Clinical Certified Nurse Assistant Workforce Pathways Program39 Professional Workforce Program Program Workforce Training and Development RESPONSIBLE DEPARTMENT CDSS $ CDA DDS HCAI HCAI LWDA $ DHCS PURPOSE To enhance IHSS To improve job To foster a more To increase the To establish new $ To expand the worker skills with satisfaction, reten- substantial DSP home and commu- and expand current CNA apprentice- compensation tion, and career workforce through nity-based clinical training opportuni- ship program. for courses. advancement training and devel- workforce. ties for CNAs. $ To develop a through training opment. new CNA-to-LVN and stipends. apprenticeship pathway. TARGET POPULATION IHSS providers Non-IHSS provid- DSPs HHAs and CNAs; CNAs at skilled CNAs at SNFs ers with HCBS LVNs and RNs with nursing facilities programs HCBS programs (SNFs) TOTAL $ INVESTMENT $ $295.1M $ $150M $ $7.9M (FY21–22) $75M $45M $14.5M $ $137M for $ $12.5M for $ $23.4M stipends* stipends† (FY22–23) $ $85M ongoing TIME PERIOD Through December Through December Ongoing (once 2 years 6 years 4 years 2023 2023 implemented) COMPENSATION Hourly wage paid Mirrors IHSS Career $ Wage differ- Under develop- Scholarships, $ Wraparound for training, plus Pathways Program entials tied to ment stipends, and grant services‡ incentives compensation three-tiered amounts to be $ "Earn and training/certifica- determined Learn"** tion $ Wage increases $ Bilingual pay after passing differential state exam Notes: CDA is California Department of Aging; CDSS is California Department of Social Services; DDS is Department of Developmental Services; DHCS is Department of Health Care Services; DSP is direct support professional; FY is fiscal year; GROWs is Growing a Resilient and Outstanding Workforce; HCAI is Department of Health Care Access and Information; HCBS is home and community-based services; IHSS is In-Home Supportive Services; LVN is licensed vocational nurse; LWDA is Labor & Workforce Development Agency; M is million; RN is registered nurse. * Funding from the IHSS HCBS Care Economy Payments. † Funding from the Non-IHSS Care Economy Payments. ‡ Providing participants with help covering the costs of childcare, groceries, and transportation. **Participating facilities will be reimbursed for the wages of the participants in CNA training and thus CNAs will continue to earn while they are training. Sources: "Direct Care Workforce Current Investments" (webinar), California Department of Aging, February 1, 2022; and "CDA's Direct Care Workforce Initiative" (webinar), California Department of Aging, June 14, 2022. California Health Care Foundation www.chcf.org 8 Conclusion Endnotes 1. "Master Plan for Aging," California Department of Aging, The need for direct care workers has never been accessed July 20, 2022. greater. Yet supports and resources for this essen- 2. "Direct Care Workforce Current Investments" (webinar), tial workforce have historically been sorely lacking. California Department of Aging, February 1, 2022; and Jeannee Parker Martin and Cheryl Wilson, "The Need to Solve Investing in the direct care workforce is a win-win for California's Caregiver Shortage," CalMatters, September 27, improving the quality of life of direct care workers and 2021. the people for whom they provide care. California is 3. "CDA's Direct Care Workforce Initiative" (webinar), California making strides in investing in the direct care workforce, Department of Aging, June 14, 2022. but continued attention, resources, and cross-sector 4. "Workforce Data Center," PHI, last modified September 22, collaboration are needed to ensure we have a fairly 2022. compensated and well-trained direct care workforce 5. "2018 Standard Occupational Classification System," US Bureau of Labor Statistics, last modified April 17, 2020. that can meet the needs of Californians, today and into the future. 6. Joseph M. Macbeth, "Standard Occupational Classifications: Why Are They So Important?," Frontline Initiative: Making Direct Support a Career 16, no. 2 (2020); and "Who Are Direct About the Authors Support Professionals?," National Alliance for Direct Support This issue brief was written by researchers at the Professionals (NADSP), accessed August 25, 2022. University of California, San Francisco. Lauren Hunt, 7. Joanne Spetz, Home Health Aides and Personal Care Assistants: Scope of Practice Regulations and Their Impact PhD, RN, FNP, is an assistant professor at the School on Care (PDF), Healthforce Center at UCSF, July 2019. of Nursing; Jarmin Yeh, PhD, MPH, MSSW, is an assis- 8. Spetz, Home Health Aides and Personal Care Assistants; and tant professor at the Institute for Health & Aging and Paramedical Services (PDF), California Department of Social the Department of Social & Behavioral Sciences at Services, accessed August 29, 2022. the School of Nursing; and Margaret Fix, MPH, is a 9. "IHSS Program Data," California Department of Social research associate at the Philip R. Lee Institute for Services, accessed August 25, 2022. Click the link for June 2022 to download the relevant Excel file, then select the Health Policy Studies. "Provider Details" tab. 10. "May 2021 State Occupational Employment and Wage About the Foundation Estimates: California," US Bureau of Labor Statistics, last The California Health Care Foundation is dedicated modified March 31, 2022. Click the link for "Healthcare Support Occupations" (31-0000). to advancing meaningful, measurable improvements in the way the health care delivery system provides care 11. "IHSS Program Data." to the people of California, particularly those with low 12. Sarah Leberstein, Irene Tung, and Caitlin Connolly, Upholding Labor Standards in Home Care: How to Build Employer incomes and those whose needs are not well served Accountability into America's Fastest-Growing Jobs, by the status quo. We work to ensure that people have National Employment Law Project, December 2015. access to the care they need, when they need it, at a 13. Direct Care Workers in the United States: Key Facts, price they can afford. CHCF informs policymakers and PHI, September 6, 2022; and personal communication, PHI, October 2, 2022. industry leaders, invests in ideas and innovations, and connects with changemakers to create a more respon- 14. Regina A. Shih et al., "Prevalence and Correlates of Gray Market Use for Aging and Dementia Long-Term Care in the sive, patient-centered health care system. U.S.," Journal of Applied Gerontology 41, no. 4 (Apr. 2022): 1030–34. California's Direct Care Workforce: Who They Are, the Work They Do, and Why It Matters 9 15. Workforce Blueprint for Action (PDF), LeadingAge California, 32. "Workforce Data Center." 2021; "Direct Care Workforce Current Investments"; and 33. Dorie Seavey, The Cost of Frontline Turnover in Long-Term Martin and Wilson, "The Need to Solve California's Caregiver Care (PDF), Better Jobs Better Care, Institute for the Future of Shortage." Aging Services, American Association of Homes and Services 16. "California Occupational Guides," California Employment for the Aging, October 2004. Development Department, accessed August 25, 2022. To 34. Sarah Thomason and Annette Bernhardt, California's access pertinent data, (1) click on "Launch the California Homecare Crisis: Raising Wages Is Key to the Solution Occupational Guide"; (2) select the "Search for Occupations" (PDF), UC Berkeley Center for Labor Research and Education, tab; (3) under Step 3, select "Personal Care Aides"; then (4) November 2017. select the "Job Market Data" tab. 35. "CDA's Direct Care Workforce Initiative." 17. "The Direct-Care Workforce," in Retooling for an Aging America: Building the Health Care Workforce (Washington, DC: 36. Meeting the Demand for Health: Final Report of the National Academies Press, 2008), 199–240. California Future Health Workforce Commission (PDF), California Future Health Workforce Commission, February 18. Robert Espinoza, "The Impact of COVID-19 on Direct Care 2019; and Patricia E. Powers, Progress Since the California Workers," Generations, April 27, 2022. Future Health Workforce Commission: State Policy and 19. "Projections," California Department of Finance, accessed July Budget Actions on Priority Recommendations (PDF), 20, 2022; and "Facts About California's Elderly," California California Health Care Foundation, January 2022. Department of Aging, accessed August 24, 2022. 37. "Goal Four: Caregiving That Works," California Department 20. "2020 Census Will Help Policymakers Prepare for the of Aging, accessed July 31, 2022; and "Master Plan for Aging." Incoming Wave of Aging Boomers," US Census Bureau, 38. "Direct Care Workforce Current Investments"; and "CDA's December 10, 2019. Direct Care Workforce Initiative." 21. "Master Plan for Aging." 39. "IHSS Career Pathways Program," California Department of 22. Master Plan for Aging: Five Bold Goals for 2030 (PDF), Social Services, accessed July 31, 2022. California Department of Aging, September 2021; and "Master Plan for Aging." 23. Master Plan for Aging: Five Bold Goals for 2030; "CDA's Direct Care Workforce Initiative"; and "Master Plan for Aging." 24. Hans Johnson and Laurel Beck, Planning for California's Growing Senior Population, Public Policy Institute of California, August 2015. 25. "Projections." 26. Kathryn G. Kietzman and Lei Chen, Unmet Needs for Help at Home: How Older Adults and Adults with Disabilities Are Faring in California (PDF), UCLA Center for Health Policy Research, August 2022. 27. "Occupational Outlook Handbook: Home Health and Personal Care Aides," US Bureau of Labor Statistics, last modified September 8, 2022 (to view relevant data, select the "Work Environment" tab); and "Occupational Outlook Handbook: Nursing Assistants and Orderlies," US Bureau of Labor Statistics, last modified September 8, 2022 (to view relevant data, select the "Work Environment" tab). 28. "Occupational Outlook Handbook: Nursing Assistants and Orderlies." 29. Espinoza, "The Impact of COVID-19 on Direct Care Workers." 30. "May 2021 State Occupational Employment and Wage Estimates." 31. "Minimum Wage," California Department of Industrial Relations, updated December 2021; and "Living Wage Calculation for California," Living Wage Calculator, accessed October 4, 2022. California Health Care Foundation www.chcf.org 10