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Four Pillars of Equitable Direct Care Workforce Development

1. Condition Funding on Measurable Equity, Job Quality and Worker Voice Outcomes


Condition public funding for workforce development on creating high-quality jobs that guarantee all direct care workers family-sustaining compensation and a robust set of labor protections and benefits. Federal and state government agencies should collaborate with workers, unions and other impacted stakeholders to create sectoral job quality and equity standards across direct care with requirements for transparent disaggregated data collection and reporting on worker outcomes.

  • Governments and impacted stakeholders should work together to create job quality and equity standards organized around key categories to address workplace challenges endemic to the home care and nursing facility industries.

  • The Center for Equity created “Good Jobs Measures,” a set of worker-informed job quality metrics tailored to the workplace challenges endemic to home care and nursing homes, which impact the majority BIPOC and immigrant women caregiving workforce. These measures were informed by the Black Women Best framework Center for Equity’s participatory qualitative research conducted in January 2022 with caregivers active in SEIU Local 2015 who identify as Black women. From our learnings, we recommend developing standards around the following seven categories:



Refer to our “Good Jobs Measures” for job quality metrics H-CAP’s Center for Equity developed using our participatory caregiver research results with direct care workers and the “Black Women Best” framework.


For too long, public workforce development in healthcare, particularly in the direct care sector, has effectively subsidized low-wage employment through training grants and investments focused on job attainment by filling “in-demand” jobs without requiring the job placements to be high quality with better long-term outcomes for workers. Critically, today’s low-quality direct care jobs are primarily financed by public dollars—in 2020, over 72 percent of long-term services and supports for older adults and people with disabilities were paid for by a mix of federal and state government funds.  

To address the care crisis, state and federal government agencies—especially since Medicaid is the primary payer of direct care workers’ wages—should create a system that works with workers and communities to ensure caregiving jobs are good jobs. 

  Colello, K. (2022, June). Who Pays for Long-Term Services and Supports? Congressional Research Service: IF10343, Version 9.,42.1%25%20 of%20all%20LTSS%20expenditures.



Pillar 1

2. Prioritize Direct Care Career Education and Training Programs Led by Labor-Management Partnerships that Advance Job Quality and Career Pathways within Direct Care


Center impacted stakeholders, including workers and service recipients, in workforce development strategies by prioritizing holistic direct care career education and training programs led by labor-management partnerships. These partnerships are uniquely situated to address the workforce crisis by advancing job quality and creating career pathways within direct care.

  • Intentionally center equity and confront exclusions and access issues in healthcare education opportunities for Black, indigenous, and people of color (BIPOC) learners and women. 

  • Offer accessible, diverse training that includes career ladders (not only options to advance “out” of direct care roles but also to advance within the direct care field into advanced roles). 

  • Employ an “earn-and-learn” training approach, ensuring program costs are covered and compensating workers for attendance and completion of training; workers should receive a wage increase consistent with their newly increased skillset upon training completion.

  • Promote labor-management training partnership (LMTP) approaches. LMTP organizations convene employers and union members to design worker-centered, industry-responsive training, programming, and employee benefits. Featured LMTP interventions include peer mentorship, advanced roles, career ladder programs, complex care and other advanced skills certifications.

  • Equip direct care workers with wraparound supports and services that help increase job satisfaction and improve quality of life. Caregivers who participated in our 2023 qualitative research study had many insights about supports and services that would help them stay on the job in the direct care field and enjoy a better quality of life with their families, most often, access to affordable, reliable transportation and child/dependent care. 


All direct care jobs, regardless of education or patient interaction level, should be good jobs with career ladders within each worker’s essential role, not just “up and out” of lower-paying direct care jobs into more specialized positions. Historically, the workforce development system has not focused on creating good jobs for all workers; instead, efforts have focused on job attainment regardless of quality or retention outcomes. 

Focusing on job attainment without assuring job quality rewards “low road” employers that exacerbate workforce shortages by placing direct workers–disproportionately Black, brown and immigrant workers and women–in poor-quality jobs with little opportunity for advancement, family-sustaining pay or benefits. Persistent occupational segregation in poor-quality direct care jobs is also intrinsically linked to historical and present exclusionary policy choices that racialized and feminized care work, devaluing the importance of essential workers. 

Pillar 2

3. Utilize Worker-Centered Participatory Research Methods When Designing and Evaluating Workforce Development Programs


Ensure workforce development programming is worker-centered by applying a participatory research, design, and evaluation process that centers workers as experts by experience. 

  • Participatory research and worker-centered research, program and policy design, and evaluation processes are vital tools for creating effective workforce development interventions in the direct care sector. Start with listening directly to the most impacted workers and centering their experiences as experts in what policy and workforce development interventions will be most impactful.

  • Center workforce equity in all phases of program and policy development. This can include implementing equity frameworks such as Black Women Best at each step and ensuring whole-person supports are targeted to different populations of workers’ unique needs.

  • Participatory research and evaluation do not have to be conducted by costly, professional research and evaluation firms to be effective at centering worker voice in policy and programs. Smaller-scale worker-centered methods are also impactful and can include conducting worker surveys with program participants, talking to workers at worksites and in informal settings about what would improve their job and life quality, holding “town hall” style sessions at worksites and training programs to get a sense of workers’ needs and goals, performing a quick intake session with new program participants on what supports would be helpful, or creating systems to call or follow up with workers after they graduate from training programs to track successes and understand any needed improvements. 



Our report, “Recruiting and Retaining Caregivers: Top 5 Solutions from Care Workers,” contains additional context and maps out innovative workforce development solutions directly informed by participatory caregiver research and the Black Women Best framework. 


Advancing job quality for all direct care workers requires workforce development leaders to confront and rectify the historical and present policy choices that lead to Black and brown women’s disproportionate employment in healthcare’s most demanding, lowest-paying jobs. This process starts with listening directly to the most impacted workers and centering their experiences as experts in what policy and workforce development interventions will be most impactful. 

Worker voice is critical to the Center for Equity’s operational and theoretical framework. We have applied a participatory research, policy and program design process that centers workers as the experts to inform any policy and program recommendations from our initiative, avoiding relying on preconceived notions of successful workforce development. 

Pillar 3

4. Anchor Efforts in Equity-Focused Organizational Processes, Including Internal Data Collection and Evaluation


Workforce development stakeholders should anchor their work in anti-racist and worker-centered organizational processes, methods and operational structures, with accountability benchmarks and internal equity assessments. Use equity-focused data collection, analysis and evaluation to understand current challenges and to build the case for effective workforce development interventions.

  • Ensure workers are meaningfully represented at tables where decisions that impact the workforce are being made. Listen and learn from new perspectives and include processes to re-work decisions and return to the drawing board if required to implement workers’ insights. 

  • Utilize a rapid cycle feedback model to elicit feedback from workers and other impacted stakeholders on decisions and other work elements, revise, and repeat until the work product accurately reflects worker input.

  • Query implicit biases on both an individual and organizational level regularly when doing direct care workforce development work. H-CAP’s Center for Equity developed a user-friendly worksheet to help you practice applying racial equity “Lasik” on an ongoing basis to create anti-racist policies, programs, practices, and organizational decisions. 

  • Collect data disaggregated by race, ethnicity, gender, sexuality, age, immigration, disability, and any other relevant categories to the targeted workforce population before, during, and after designing and implementing a workforce development intervention or program. Disaggregated workforce data helps stakeholders interpret outcomes across different worker populations to understand and address inequities. 



For applied practices on equity-oriented program design and evaluation from labor-management partnership organizations, refer to our practitioners’ brief, “Strategies to Support Caregivers’ Role in a Changing Climate.” Our founding policy brief, “The Racial Equity and Job Quality Crisis in Long-Term Care,” describes organizational processes and frameworks to implement when designing worker-centered workforce development programs and policies.


Equity must be a foundational pillar and operating principle for all our workforce development programmatic efforts. The reality is that even the best workforce programs can fall prey to exacerbating inequity because of existing systemic racism, sexism, xenophobia, and other oppressive structures inherent in the ecosystems within which these programs and policies operate. Workforce development leaders must intentionally cultivate internal and team processes to apply anti-racist, worker-centered, and equity lenses to programmatic and policy development work. 

At H-CAP’s Center for Equity specifically, we believe that to genuinely confront the links between systemic racism, sexism, ableism, and poor job quality in long-term care, it is essential to integrate racial equity into internal work processes. We call this applying racial equity “Lasik,” as in the permanent corrective eye surgery, imbuing that centering racial equity is how we strive to see and navigate the world all the time–rather than a single step or “box to check,” a “lens” to take on or off, or one of many factors to consider after the rest of the work is complete. 

Pillar 4

About This Platform

H-CAP’s organizational mission is to promote job quality and equity for the healthcare workforce across sectors through “high-road” training partnerships and workforce development strategies focusing on the intersection of equity, job quality and educational attainment. A particular set of challenges faces direct care workers, who provide vital services to older adults and people with disabilities in home- and community-based services as well as nursing facilities. Most of these essential workers are trapped in “dead end,” poor quality jobs with low pay, little to no benefits and few opportunities for career advancement. This is no accident–the majority of caregivers are Black and brown women and immigrants who, as a result of a series of intentional policy choices, are overrepresented in low-wage caregiving occupations. Caregiving jobs are some of the fastest-growing professions in the United States. Yet, these jobs are growing without proper attention to the systemic racial and gender inequities inextricably tied to poor job quality. Solutions that address the poor job quality and racial equity at the root of the caregiving workforce crisis are long overdue. At H-CAP, we believe creating the equitable caregiving system our nation needs depends on designing and delivering innovative workforce development programs and policies intentionally centered on Black, Indigenous and people of color, women and immigrant caregivers. In service of this important goal, the W.K. Kellogg Foundation awarded H-CAP a three-year grant to create our Center for Equity, a national hub focused on developing a direct care workforce policy platform that centers job quality and equity and promotes narrative change. Over the past three years, a dynamic Advisory Board has guided our work. We strategically convened a table that includes workers, caregiver unions, employers and health plans, labor/management training funds, care consumer groups representing older adults and people with disabilities, national worker advocacy groups, and racial justice and policy thought leaders. By collaborating across industry siloes to advance equity and meaningfully change the lives of care workers, we have created a body of work anchored in worker-centered principles and practices. Our portfolio includes participatory research studies with caregivers, policy briefs and reports, user-friendly toolkits, job quality metrics, and technical assistance applying worker-centered equity principles in on-the-ground programming. The four pillars of equitable healthcare workforce development distilled into this platform represent the summary of our intentional efforts to create tools, policies and best practices stakeholders can apply in their day-to-day caregiving workforce development efforts. We offer our learnings to support your work in building a more equitable future for caregivers, service recipients and our communities.

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