Blog September 28, 2018

The Home Care Workforce: Low-Pay and Lack of Respect for a Highly Skilled Lifeline Makes No Sense

Clare C. Luz, PhD
Assistant Professor
Age Alive, Director; IMPART Alliance, PI
Michigan State University

At the end of September, on the heels of Labor Day, it is fitting to recognize a labor force that rarely gets honored: Personal Care Assistants (PCAs). Despite providing up to 80% of paid in-home care to a rapidly aging population and holding a pivotal position in which they can make or break one’s ability to remain at home, PCA’s are rarely acknowledged for this important work. The PCA workforce is in the home, often daily, building relationships, witnessing even subtle client status changes, and potentially averting costly adverse events. Evidence now exists of an association between comprehensive PCA training and a lower prevalence of client falls and emergency room visits.  Noticing a small red area on the skin and knowing what to do can prevent bone-deep decubiti. It is foolish to give so little attention to the very workforce that can sustain the lowest-cost care with the best outcomes and highest quality of life. When PCAs are asked what would happen to their clients without PCA support and services, the answer is often, “They would go to a nursing home or die.” Moreover, PCAs often sustain entire families in addition to their clients. Respite care affects the job productivity and financial, physical, mental and personal health of family caregivers. The PCA shortage is not just about this single workforce. It has a serious impact on health and long-term care systems, family systems, and the collective marketplace, economy, and society.

There are now signs of a slow awakening to these facts. Advocates such as the Eldercare Workforce Alliance (EWA), Leading Age, PHI, and other champions have been invaluable. EWA is an important national voice on the need for a strong eldercare workforce inclusive of all of its members, physicians and PCAs alike. They have provided support to those of us who focus specifically on PCAs, which has helped to nudge our work into the national scene. A recent two-part PBS NewsHour story highlighted the plight of PCAs in Michigan, one that is happening in every state in the nation, and asked, “Why does one of the most needed jobs pay so poorly?”  (Part I-; Part II-

Dr. Archie Green, who died in 2009, has become another champion for this labor force. He was a prominent scholar of labor-related folklore and passionate about documenting the lives of different labor groups, particularly those who have historically been marginalized. Through a Library of Congress Archie Green Fellowship, we were able to conduct in-depth interviews with over thirty PCAs across Michigan this past year and get a very intimate look at their daily work. It became clear that describing PCA work by simply saying that they go into people’s homes and help with giving a bath is a vast understatement. It doesn’t begin to convey what it is like to help shower a full-grown person who is wet, soapy, incontinent, in a wheelchair, and has dementia when the wheelchair doesn’t fit through the bathroom door, the shower is too small for two people, the floor is slippery, and the stakes are high. The stories are endless and moving. They bring to life not only the technical skills needed to be a PCA but also skills required to effectively deal with dementia, depression, mental and behavioral health issues, family dynamics, abusive behavior from some elders and family members, and environmental issues such as unsafe houses and neighborhoods. PCAs often have very little idea of what they are walking into. They walk into homes alone, without the benefit of an onsite back-up staff. The job requires extraordinary courage, patience, listening skills, compassion, creative problem solving skills and the ability to make potentially life and death decisions on the spot. It is anything but unskilled. Even when the only assigned task is to provide companionship, the value to the client in terms of monitoring for change and reducing loneliness, and the value to the family in terms of respite, is monumental.  All for an average wage of 10.40 per hour, few if any benefits, and most often no guaranteed hours, i.e. income on which to depend.

We can’t afford to continue to marginalize the PCA labor force. The cost to society is too great. There are a number of initiatives that are fueling hope in Michigan. Among them is a new organization, IMPART Alliance, which is supported by the Michigan Health Endowment Fund. IMPART is working to develop an infrastructure in Michigan to build and strengthen the state’s PCA workforce. A major aim is to scale up an evidence-based, comprehensive, person-centered PCA training program, called Building Training…Building Quality (BTBQ) that can serve as a model for the nation. We are also in the process of establishing a statewide coalition of people committed to this same goal, and a PCA Professional Association that will develop professional standards, educational requirements, networking opportunities, and other member benefits. One of the most important solutions to the PCA shortage crisis is to raise wages but it is hard to argue for higher wages when people do not have a deep understanding of the work, and when no mandatory professional standard or training requirements exist. Further, higher wages are not the only solution.  The PCA shortage is the result of multiple factors that require a coordinated, strategic, multi-factorial response. It is our hope that by advocating for higher wages while simultaneously tackling training, public and policy-maker education, professional standards, disrespectful language, and other “real solutions”, the climate will shift and better labor conditions will finally be possible. The message of Labor Day is to honor those who labor and whose work contributes to the strength, prosperity, and well-being of the country, which PCAs certainly do. The bonus is that improving their labor conditions benefits us all.


Dr. Clare Luz is a gerontologist who has nearly 40 years of experience in the aging field and for the majority of the past 20 years, her research has focused on direct care workforce issues. She was the Research PI for the HRSA-funded Building Training…Building Quality™ (BTBQ™) project, a comprehensive PCA training program upon which IMPART is based.  Dr. Luz will oversee all IMPART activities, and facilitate the establishment of a coalition comprised of  employers, PCAs, clients and other stakeholders that can jointly generate innovative, feasible, affordable strategies that are beneficial to all parties.