'Turning Long-Term Care Into a Long-Term Career' Transcript

October 20, 2022

Note: This transcript has been created with a combination of machine ears and human eyes. There may be small differences between this document and the audio version, which is one of many reasons we encourage you to listen to the episode!

Dan Gorenstein: The pandemic took a big chunk out of the health care workforce, especially among people who care for older adults.

About 10% of long-term care workers have left the field since COVID hit.

Nursing homes are turning people away.

Clip: Nursing homes in Florida are closing wings and refusing patients…
Clip: Seven other nursing homes in Montana have been forced to close this year.

DG: Family caregivers are struggling as they wait months for home health aides.

And the remaining workers are stretched thin, their patients at risk.

Clip: I have had 32 patients on the floor at a time. That’s inhumane. There’s no way I can get to all those patients in a timely manner. 

DG: Pay for this often grueling work is low, with little room for growth.

That has some in long-term care suggesting nursing assistants and home health aides might stick around longer if they had a chance to advance in the sector.

Today, the push to make long-term care a long-term career.

From the studio at the Leonard Davis Institute at the University of Pennsylvania, I’m Dan Gorenstein. This is Tradeoffs.


DG: Serena Maria warmly remembers the first older person she took care of.

Serena Maria: Her name was Liberty Bell, and she was born on 4th of July and she was the sweetest thing.

DG: Serena had been in her early 20s living in Southern California.

A single mom with three kids under 5, finding a job that fit her schedule was tough.

SM: There was a 90-some year old lady who needed care, and she had enough Social Security to pay out of her own pocket.

DG: Serena helped Liberty Bell get dressed, take a shower, eat her meals. 

Initially, Serena took care of Liberty Bell three days a week. Then five. Then on weekends too.

She loved the work.

SM: That feeling at the end of the day that I helped someone and that, you know, just that one on one.

DG: After a year, Serena found a job with benefits, ended up moving to San Francisco. 

She worked as a medical assistant for San Francisco General Hospital.

She found the job boring and repetitive.

SM: It wasn’t what I thought it would be.

DG: Serena missed the close connection and sense of accomplishment she had with Liberty Bell.

As she neared her 40th birthday, Serena rejoined the ranks of frontline home health aides and certified nursing assistants, also known as CNAs.

85 percent of these direct care workers are women. 60 percent are people of color.

Serena hooked on with Homebridge, a local long-term care nonprofit serving older adults in San Francisco, excited to rekindle the kind of thing she’d had with Liberty Bell.

SM: That feeling at the end of the day that I helped someone.

DG: Serena knew the drill: help people bathe, dress, clean their house, make appointments.

Hard work made harder when she cared for clients who struggled with severe mental health and substance use issues. 

They cursed at her, called her names, defecated and urinated all over their apartments,  leaving Serena to clean it up.

SM: They weren’t all little gentle old ladies, you know?

DG: Then there were the gentle old ladies with dementia.

The endurance she summoned to press flowers, page through magazines, laugh at the same stories day after day. 

SM: Those are the toughest, in my opinion, because at the end of the day, it’s like, whoa, it is mentally draining.

DG: For all this physical and mental labor, Homebridge paid Serena just $13 an hour, good for about $27,000 a year.

That’s around $4,000 more than the average home care worker in the U.S. was making at the time.

But significantly less than Serena had made at the hospital.

SM: It was a good maybe $10,000 less a year. I had to cut back on so many things.

DG: She cut back on trips to see her kids in Alabama. 

She went without a car.

She canceled her credit cards.

SM: But it didn’t matter because I was happy with what I was doing. I just knew this is what I want to do and this is what I’m going to do.

DG: As Serena was settling in, many of her coworkers were jumping ship.

Mark Burns: We lost about a third of our workers in just over a six month period. It was a dramatic decline for us.

DG: Homebridge Executive Director Mark Burns said the company started hemorrhaging jobs after the city raised the minimum wage, increasing competition for low-wage workers.

Immediately, Homebridge was forced to pick who needed their care and who would have to fend for themselves.

Waitlisted patients sat stuck often in expensive nursing homes or hospital beds. 

Mark and his team had to stop the bleeding somehow.

One of their first moves was to interview their remaining staff.

MB: What we really learned was a lot more about how people felt about their jobs and how they felt about how we treated them as an employer.

DG: Workers told Mark that they wanted to be treated and compensated like professionals.

Back then in 2017, everyone at Homebridge went through the same initial training and got the same pay — whether they’d been there 3 months or 30 years.

MB: I don’t think we treated our workers poorly necessarily, but we certainly didn’t treat them well and we certainly didn’t value them.

DG: The staff dove into workforce research, and thanks to about $1.5 million in seed money from the city and private philanthropy, Mark started to make a few changes.

Homebridge handed out branded scrubs instead of people going to work in their own clothes.

The company hiked up the starting wage to $16 an hour, about half of a living wage in San Francisco.

And they built a formal path for employees to grow with the organization.

MB: What was really clear to us is that they wanted to have career advancement potential. They wanted to have wage improvement opportunities. They want to be treated like professionals.

DG: They called it the STEPS Program.

Everyone started at Tier 1 learning basic home care skills.

Six months later, if folks showed up and performed well, they leveled up to Tier 2 where staff learned to better treat substance use and mental health problems.

Tier 3 added on medical skills like checking someone’s blood sugar and inserting an enema.

At each step workers got a new title, more responsibility and a 50 cent an hour raise.

MB: It showed employees more respect. It recognized the value that they gained by the time they spent with us. So all of those things were really sort of simple on some levels, but they were major differences in the way we had been running our business before.

DG: Mark hoped career advancement through the STEPS Program would improve recruitment and retention.

These kinds of programs are often called career ladders or lattices, and there’s lots of variation.

Typically, they put workers on a path to becoming a nurse, or maybe a social worker or administrator.

Then there are programs like STEPS that give workers new skills in their current jobs.

Whatever size or shape, they all feature additional training and wage increases.

Serena Maria was one of the first people to go through STEPS.

SM: I was excited because I would learn a little bit more knowledge and it’ll make my job a little easier. And the promotion as well. You know, the $0.50 extra, it would help, definitely. 

DG: Once she was in the program, Serena did well. 

She was quickly promoted to help new or struggling aides.

By May of 2019, she became a supervisor overseeing a whole team of aides.

SM: I was able to advocate for the clients and share my own experiences with the home care providers that I supervise and share helpful tips and tricks that got me through it if they were struggling.

DG: Today, Serena is a Manager of Care Teams making $65,000 a year.

She is responsible for the care of hundreds of people.

But without the job growth and pay bumps, Serena would’ve had to ask herself some tough questions.

SM: Is this what I want to do? Do I want to be tired all the time without getting any rewards? If I was just kind of stagnant in pay, I probably would have left and said, “You know, I got to go. This is not working out for me.”

DG: There’s been no rigorous, independent analysis of the STEPS Program, but Mark Burns says their internal numbers show turnover stabilized shortly after the program started and is running lower than the industry average.

He says once people start STEPS, they’re much more likely to stick around.

Only around 30% of people who make it to Tier 2 leave, and that drops to about 20% after Tier 3.

MB: Those numbers may not sound like a lot, but it’s pretty dramatic when you’re losing 50% of your population to suddenly only be losing a third of your population or a fifth of your population.

DG: Mark says their success, as it were, has been hard fought.

Initially, many workers were reluctant to sign up, skeptical of management and worried about losing their clients.

And Mark is still short 50-75 workers.

But these results, he says, sure beat the old days.

Homebridge is so bullish on career ladders, the company is launching ones for nursing and social work because, Mark says, he’s seen what they’ve done for people like Serena.

SM: It’s not a job. It’s not something that I need to have or need to do. It’s something that I want to do. I feel like this is my career now.

DG: When we come back, we dig into the research on career advancement programs and what’s slowing down their spread.


DG: Welcome back.

Natasha Bryant has studied the long-term care workforce for 20 years.

She knows how much the sector struggles to attract staff given the low wages and hard work. 

And she’s tried to identify solutions.

Natasha Bryant: It’s not just addressing the issue when you’re facing a shortage, but really changing the culture so people want to work and stay at the job.

DG: Natasha is the senior director of workforce research and development for LeadingAge, a group representing more than 5,000 nonprofit long-term care organizations.

Natasha says the current shortage — exacerbated by the pandemic — is as bad as she’s ever seen.

NB: 99% of skilled nursing homes are facing staff shortages. And we’re also seeing closures of some of the nursing homes over the last two years.

DG: And, Natasha says, it looks like it’s about to get worse.

The U.S. Census Bureau estimates the 65 and over crowd will grow 30% by 2030 to 73 million people.

But the number of people under 65 — the ones needed to care for all those older Americans — is barely expected to budge.

NB: So this really increases the demand for this workforce. Sometimes that direct care worker may be the only person seeing that resident or client. And so you don’t want residents or clients who are maybe not getting the care they need because they don’t have the staff.

DG: Natasha says there could be nearly 8 million job openings in long-term care between now and the end of the decade, according to an estimate by the advocacy group PHI.

8 million job openings for CNAs and new home health aides in a field hemorrhaging these workers.

Some would look at this natural-disaster sized problem and walk away. 

Not Natasha.

She sees solutions: higher wages, better working conditions and career pathways like the one Serena Maria went through in San Francisco.

But evidence on career pathways is limited, like no one knows how many are even up and running.

NB: We don’t have any data on the percentage or number of aging services providers that are implementing these type of programs.

DG: Most of the programs Natasha knows of are one-off pilots.

Massachusetts set up one of the biggest back in 2000.

It was called ECCLI or the Extended Care Career Ladder Initiative.

More than 140 nursing homes and home health agencies signed up with about $20 million from the state.

A small evaluation of 11 of those employers found the program reduced turnover, eased recruitment and increased the respect management had for frontline staff.

A more recent pilot of a program in New York showed a drop in patients’ emergency room visits.

NB: I think from these pilot programs, we are seeing there’s a benefit to the worker as well, it seems to be, benefits to the client or care recipient.

DG: Natasha understands the sector needs rigorous, independent evaluations of these efforts to prove to employers and policymakers that they can actually improve recruitment, retention, patient care and potentially reduce spending.

But she’s also seen the things that get in the way of building successful programs: a shortage of workers to cover for people getting trained, professional licensing laws that limit what aides and CNAs can do.

But the biggest challenge comes as no surprise. 

NB: Funding, you know, how do you, if people have new skill sets, if they have a new job description, then how are you going to increase their wages? And that may not be easy for all aging services providers.

DG: What’s clear is that CNAs and home health aides have been taken for granted for decades.

And the chronic workforce shortage is proof.

The researchers and providers we spoke with for this story agree a significant investment must be made, but who’s going to do it?

NB: How do we have that funding to create these opportunities?

DG: Employers could invest in this, and some like Mark Burns at Homebridge are.

But it seems like lots of long-term care companies are watching employees walk out the door, threatening patient care, rather than opening their wallets.

The government is another obvious choice but no sure bet. 

That ambitious pilot program in Massachusetts that showed promise? State lawmakers axed it when money got tight during the Great Recession.

Medicaid — the joint state and federal health insurance program for low-income and disabled Americans — covers more than 40% of all long-term care costs in the U.S.

But nursing homes, in particular, say the rates Medicaid pays them to care for older Americans are too low.

Jon Gruber: It is hard to get the government to pony up money for lots of social causes.

DG: That’s why MIT health economist Jon Gruber is trying a different approach.

Jon is perhaps best known as one of the architects of the Affordable Care Act.

But during the pandemic, all the terrible stories coming out of nursing homes got him thinking about the long-term care workforce.

JG: The problem pre-COVID was bad. Post-COVID it’s horrific, which is that there’s a massive shortage of staff in nursing homes.

DG: To him, the problem felt too big to sit on the sidelines.

His wife, who serves as a volunteer nursing home watchdog for the state of Massachusetts, inspired his search for a solution in one sentence. 

JG: She was saying, look, everyone in America should have to change elders’ beds pans for a couple of years, but no one should do it for more than a couple of years.

DG: To be clear, some people want to be home health aides or CNAs for their entire careers. 

But when Jon conducted a small survey of CNAs in Massachusetts, 80% said they wanted to further their careers in the field. They just couldn’t afford it.

When Jon talked to employers, they worried about paying to train a worker who could up and leave taking their brand new skills with them.

So Jon found his way to a possible solution, and it starts with a pot of money.

JG: That initial sum of money pays for people to go to school and get time off from work.

DG: Jon estimates it costs around $25,000 to cover training, time off and childcare for a CNA looking to become a licensed practical nurse or LPN.

Instead of the employer fronting the money, initial funding would come from the government or philanthropy.

JG: To get that money, people sign a contract saying, I will pay this back. As they pay it back, that creates new funds to send more people to school, and it becomes a self-sustaining program. 

DG: To recap, some third-party — maybe government, maybe philanthropy — would pony up the initial dough to pay for folks’ training and time off.

And then the employee would be responsible for paying back some portion of the costs, which would then fund future trainees.

Jon says that’s what skeptical lawmakers may like: no permanent funding from the state would be needed.

Jon was inspired by the nonprofit Social Finance, which has successfully run several similar, but small programs in other industries, like advancing careers for nearly 900 diesel technicians.

JG: The idea is you have someone doing the financing that’s not the employer. So the employer doesn’t bear the burden if the employees leave.

DG: We asked several long-term care researchers, advocates and providers about Jon’s idea.

Most of them found it intriguing.

But many worried about letting the employer off the hook and saddling workers with debt. 

Several people suggested companies should pay for additional training, as long as employees agree to stick around for a few years. 

Jon, for his part, is flexible. 

JG: I think employers certainly should have some skin in the game, I think it’s probably good to have employees, as an economist, to have employees have some skin in the game, so they take it seriously.

DG: Jon is working with nursing homes in Massachusetts and Social Finance to develop the idea.

They’ve asked state lawmakers to put up $25 million to kickstart the program.

JG: My hope is eventually this can be a model that can be really a way that we can move towards sort of the world my wife envisions, which is a world where sort of many, many people who otherwise might not be attracted to the sector for the low wages say, hey, here’s a good entry level job I can have that can lead in fairly short order to a good living.

DG: A handful of other states, including Kansas, Colorado and New Hampshire, have committed to putting money toward exploring career advancement programs.

Career ladders and lattices alone though, regardless of who pays for them, will not be enough to fill the up to 8 million jobs needed to care for our aging population in the years to come.

Higher wages, more Medicaid funding and a cultural change in how we value this work will also likely need to be part of the equation.

But people in the field all say career ladders would help.

And for individual workers, it can be huge.

Homebridge’s Mark Burns thinks about the home health aide who was able to buy her first car.

And another aide who took her grandkids to Disneyland.

MB: It’s really an amazing honor to get to do this work. It’s about giving people respect. It’s about giving people dignity. It’s about showing them that they can aspire to new things.

SM: It has meant a total, complete change in my life. 

DG: Serena Maria says climbing the career ladder has given her confidence, pride, a sense of satisfaction.

That spills out when she talks to her adult daughters.

SM: I just tell them, like, just say yes, look at where I’m at. Look at where I’m at now. If you asked me when I was a home care provider five years ago, where do you see yourself in five years? I never would have thought that I would be where I’m at today. 

DG: If you ask Serena where she’ll be in another 5 years, she doesn’t hesitate.

She’ll be working in long-term care.

I’m Dan Gorenstein. This is Tradeoffs.

Tradeoffs coverage of issues facing older Americans is supported in part by The SCAN Foundation — advancing a coordinated and easily navigated system of high-quality services for older adults that preserve dignity and independence.

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Episode Resources

Selected Reporting and Research on Long-Term Care Workforce and Career Pathways:

How tight nursing home capacity is bottlenecking hospital operations (Rebecca Pifer, Healthcare Dive, 10/4/2022)

Seniors are stuck home alone as health aides flee for higher-paying jobs (Christopher Rowland, Washington Post, 9/25/2022)

Direct Care Workers in the United States: Key Facts (PHI, 9/6/2022)

What impact has the coronavirus pandemic had on health employment? (Emma Wagner, Imani Telesford, Paul Hughes-Cromwick, Krutika Amin and Cynthia Cox; Peterson-KFF Health System Tracker; 8/24/2022)

Nursing homes can’t retain caregivers. Could career ladder programs be a solution? (Jon Harris, Buffalo News, 6/10/2022)

A shortage of health aides is forcing out those who wish to get care at home (Natalie Krebs, Side Effects Public Media, 5/5/2022)

Direct Care Workforce Policy and Action Guide (Courtney Roman, Clare Luz, Carrie Graham, Nida Joseph and Kate McEvoy; Milbank Memorial Fund; 5/2022)

State Efforts to Address Medicaid Home- and Community-Based Services Workforce Shortages (MACPAC, 3/2022)

Placing a Higher Value on Direct Care Workers (Martha Hostetter and Sarah Klein, Commonwealth Fund, 7/1/2021)

Extended Care Career Ladder Initiative (ECCLI) Qualitative Evaluation Project (Michelle Washko, Alison Gottlieb, Kathy Wilson, Janice Heineman, Robyn Stone and Frank Caro; Institute for the Future of Aging Services; 6/2007)

Episode Credits


Serena Maria, Manager of Care Teams, Homebridge

Mark Burns, Executive Director, Homebridge

Natasha Bryant, Senior Director of Workforce Research and Strategy, LeadingAge LTSS Center @UMass Boston 

Jonathan Gruber, PhD, Ford Professor of Economics, MIT

The Tradeoffs theme song was composed by Ty Citerman, with additional music this episode by Epidemic Sound.

This episode was reported by Ryan Levi and mixed by Andrew Parrella. Editing assistance from Cate Cahan.

Additional thanks to: Latifa Beato, Julia Burgdorf, Emily Dieppa, Robert Espinoza, Chanee Fabius, Wendy Fox-Grage, Bianca Frogner, Matthew Giroux, David Grabowski, Tara Gregorio, Michael Grossman, Vicki Hoak, Andrew Jopson, Kristen Knapp, Colleen Knudsen, Chris Larue, Bryn Lloyd-Bollard, Colin Laughlin, Clare Luz, Kate McEvoy, Mark Montigny, Debbie Morales, Christine Morris, Audra Riding, Lisa Sanders, Tina Sandri, Kevin Smith, Kristin Sousa, Joanne Spetz, Robyn Stone, Damon Terzaghi, Jasmine Travers, Courtney Van Houtven, Sandi Vito, Rachel Werner, Heather Young, the Tradeoffs Advisory Board and our stellar staff!