Every conversation I have with operators of senior living facilities and home care agencies quickly pivots to one issue: A desperate shortage of care workers.

The problem isn’t new. Low pay, low status, and physically and emotionally demanding work has plagued the long-term care industry’s ability to hire for years. Highly restrictive Trump-era immigration policies further shrunk the supply of foreign-born workers, who account for about one-quarter of all direct care workers.

The covid-19 pandemic only amplified these problems. More than 160,000 people, including nearly 2,000 staff, died from covid-19 over the past 16 months. Aides, overwhelmingly women, were unable to find care for their children while schools stopped in-person learning and had to leave their jobs. Only about half of facility-based staff have been willing to get vaccinated, putting their jobs at risk. Now, with hospitality and other industries scrambling to find willing workers, care workers suddenly have many work choices, many in less difficult and better paying occupations.

Recruit and retain

As the pandemic eases, new residents gradually are moving into senior living again. But given those staff shortages, this slow recovery may be all these facilities can handle.

Home care agencies are in a different situation. Demand for their services has been growing rapidly—in part because consumers want to avoid facility care, especially for post-acute rehab. But those agencies also are facing severe shortages of experienced staff.

What can senior service providers do to recruit and retain staff post-pandemic?

To start, pay them more. Low-wage service workers are demanding, and getting, raises. Home care workers can go elsewhere to beat the average of less than $11 an hour they got before the pandemic. While many providers gave staff covid-related bonuses last year, they’ll likely have to at least make those raises permanent.

I know, providers that rely heavily on Medicaid reimbursement say the program does not pay enough to support raises. They may be right. But it doesn’t matter. If they want sufficient staff, they are going to have to find the dollars to pay them more.

More than raises

But raising hourly wages is not nearly enough. The Gerontologist, the journal of the Gerontological Society of America(GSA) has just published an entire issue focused on direct care workers. And many of the articles reinforce the idea that simply raising wages will not be sufficient to hire and retain quality workers.

Several of the studies found the best ways to retain direct care workers is by giving them more autonomy, improving management support and training, and creating opportunities to advance.

This shouldn’t be a surprise, since these factors boost morale of almost any workers in any field. But somehow, they rarely have taken hold in the often-hierarchical world of aging services.

That is not to say that pay does not matter. Taiwan recently restructured compensation for home care workers, providing both a minimum monthly wage and tying compensation to their volume of work and the complexity of the care their clients require rather than merely the number of hours they put in.

While Taiwan obviously is not the US, the new payment model has significantly increased the supply of care workers. There may be lessons for the US in this new model.

The gray market

Separately, we are beginning to learn more about the gray market for home care workers. These are independent contractors, often hired by word of mouth or through online marketplaces such as craigslist. Some work off-the-books, some pay no taxes (and are ineligible for benefits such as Social Security), and have no insurance. Many are unlicensed and not formally trained. There is little data on the quality of care they provide.

In many ways, however, these aides have more of the characteristics of job satisfaction than aides who work for agencies. For example, because they are self-employed, they often have autonomy and flexibility to provide care most appropriate for their clients. The absence of a license raises important safety issues for their clients. On the other hand, it allows aides to avoid often-onerous and counterproductive rules about the kind of care they are allowed to provide.

A new study by Regina Shih and colleagues from the RAND corporation estimates that one-third of families who hire aides to care for relatives living with dementia use the gray market.

No choice

Despite the explosion in demand for care and growing shortages of workers, efforts to improve working conditions and increase skills of direct care workers progress have been painfully slow. In 2008, the Institute of Medicine recommended 13 separate reforms to enhance the geriatric workforce. After more than a decade, just one, involving training of medical professionals, has been adopted.

The rapidly changing market for post-pandemic care is leaving families and providers no choice. Without big changes, there simply will not be enough staff to care for frail older adults.