Supporting A Trained Direct Care Workforce In Facility Settings During And After The Covid-19 Pandemic

The direct care workforce is a critical component of a well-functioning health system. These occupations are reliable entry points into the health sector, but limited wage potential as well as physical and emotional demands of the jobs contribute to high turnover and shortages.


Executive Summary

The COVID-19 pandemic exacerbated existing challenges in recruiting and retaining direct care workers. The Centers for Medicare & Medicaid Services issued several waivers to address staffing challenges across the continuum of care during the public health emergency, including a waiver to temporarily reduce certain training requirements, and some states have taken complementary action creating new flexibilities to quickly train and deploy a qualified workforce. While responding to urgent direct care staffing needs is a top priority for states in the short-term, it will be critical for states and employers to consider strategies for retaining this workforce when the waiver expires.


The direct care workforce is critical in providing support to individuals with acute and long-term health care needs. Jobs include entry-level opportunities such as certified nurse aides (CNAs) and personal care aides (PCAs). Many of these occupations are regulated at the state level through defined credentialing requirements. In recent years there has been growing concern about high turnover rates and shortages in these fields, and low wages and the intense physical demands of the work contribute to this problem. Individuals frequently leave these jobs for other industries with more competitive pay.

Given the risk factors associated with communal living facilities, individuals in long-term care settings and their caretakers have been particularly susceptible to COVID-19 outbreaks. In addition, it has been hard to credential new staff due to new restrictions on training, testing, and changes to other requirements, while at the same time retaining existing staff as they cope with the ongoing demands, stressors, and trauma the pandemic has wrought. Nursing and residential care facilities have lost 264,000 jobs since February 2020 (representing a 7.8% drop in employment), emphasizing the importance of retaining existing staff, including staff brought into the workforce through waivers, in these critical roles.

Federal Flexibilities for Nurse Aide Training and Certification During the Pandemic

Effective March 1, 2020, CMS used its emergency authority under Section 1135 of the Social Security Act to waive requirements that nurse aides must receive training and certification before working in a nursing facility for longer than four months. This flexibility is available through the duration of the PHE. Long-term care facilities maintain responsibility to ensure competency among nurse aides employed under this waiver who have not met otherwise required training and certification requirements. This flexibility facilitates rapid deployment of nurse aides within nursing facilities.

How States Implemented the CMS Nurse Aide Waiver

In response to staffing shortages during the pandemic, the American Health Care Association (AHCA) created a free temporary nurse aide training that includes an eight hour online training program to provide initial instruction to new temporary nurse aide
(TNA) recruits. After successfully completing the online training, TNAs undergo an onsite skills/competency assessment by the facility prior to beginning work. According to the AHCA website, 25 states currently allow these trainings to satisfy or partially satisfy state requirements. In addition, at least one state, Indiana, temporarily reduced their more stringent certified nurse aide training requirements to align with the federal minimum.

Retaining Direct Care Workers Immediately After the Public Health Emergency

As states and employers respond to the current pandemic, they must also consider strategies to retain this critical workforce when temporary flexibilities end by implementing pathways for currently waivered workers to complete necessary training. Below is a summary of how some states have responded:

INDIANA: Through an emergency order issued by the State Health Commissioner, the State of Indiana set up an expedited pathway for individuals temporarily certified as PCAs or TNAs under emergency flexibilities to become fully certified CNAs. The order authorizes expedited CNA training for those who worked as PCAs or TNAs during the public health emergency. The shortened training provides credit towards certification for up to 45 hours of in-facility work experience as a PCA or TNA. Once the individual successfully completes the additional training, practice hours, and examination, they will be fully certified without needing to repeat didactic training or clinical hours.

PENNSYLVANIA: Governor Tom Wolf of Pennsylvania signed legislation that will allow TNAs to be fully certified in the state, provided during the declared federal emergency they complete at least 80 hours of temporary or regular in-serve nurse aide training and establish they are competent to perform the duties of a nurse aid. Individuals will prove competency by successfully passing the state nurse aide exam, being assessed and certified by a site administrator as part of an approved apprenticeship program, or through an assessment by the hiring entity. Individuals who are eligible for the expedited track will be awarded full certification and placed in the state nurse aide registry.

WISCONSIN: The Wisconsin Department of Health Services (DHS) set up a pathway to allow TNAs to continue to practice after the public health emergency if they participated in an expedited training approved by the state. Health care facilities may create emergency training programs which lead to nurse aide certification and inclusion on the state registry. Wisconsin outlined a minimal competency checklist to guide the expedited curriculum.14 After the expedited program receives approval from DHS, facilities must train students until they demonstrate the competencies defined by the checklist, after which they may submit the student’s information for inclusion on the state nurse aide registry.

The Long-Term Future of the Direct Care Workforce

The direct care workforce is a critical component of a well-functioning health system. These occupations are reliable entry points into the health sector, but limited wage potential as well as physical and emotional demands of the jobs contribute to high turnover and shortages. Federal and state waivers and other programs implemented during the pandemic have successfully brought thousands of new workers into the long-term care workforce, and there are opportunities to act now to retain these workers and help them further advance in direct care roles and careers. Beyond the pandemic, there are significant opportunities for governors to convene academic institutions, employers, insurers, and others to address recruitment and retention as well as to develop pathways that help individuals achieve additional credentials that will lead to higher wages.


The NGA Center would like to thank the Health Resources and Services Administration in the U.S. Department of Health and Human Services for their generous support of the policy academy and this publication under National Forum Cooperative Agreement No. U98OA09028. The contents of this publication are solely the responsibility of the authors and do not necessarily represent the official views of HRSA or the U.S. Department of Health and Human Services.

This publication was developed by Lauren Block and Kelsey Ruane from the National Governors Association Center for Best Practices in partnership with Hannah Maxey and Courtney Medlock at Veritas Health Solutions.