The Future of Caregiving and the Caregiver Shortage

Caregivers are the unsung heroes of the healthcare system. They provide the majority of hands-on patient care yet the lack of career options has resulted in a dire shortage of caregivers. Linda Leekley, Founder and CEO of In the Know Caregiver Training, joins me on the podcast to help us understand the future of caregiving – and the issues facing caregivers today. Linda launched her company  after recognizing that a void existed when it came to training options for direct care workers. She blended her nursing experience in both acute and post-acute care with her years as a clinical educator to make In the Know a leader in professionally prepared caregiver training.

In our chat, we discuss:

  • The current caregiver shortage – and why its roots go beyond low pay.
  • How we can change the paradigm around caregiving – and what caregivers really want.
  • Innovative approaches to addressing the caregiver shortage – including new caregiver-centered cooperatives.

This is an episode of the Leading with Health podcast, formerly titled “Healthcare Lead Generation.” In this podcast, healthcare IT disruptors, innovative healthcare providers and health sector company leaders join host Jennifer Michelle to discuss growth strategies and navigating change.

Jennifer Michelle, MPH, EMT is a marketing consultant specializing in the healthcare sector. President of Michelle Marketing Strategies, she has a Master’s in International Health & Epidemiology and currently volunteers as an EMT. Her unique background allows her to bring unexpected insight and depth to every interview.

The Future of Caregiving (Podcast Transcript)

Jennifer: 00:03 Hi, everyone! I’m Jennifer with Michelle Marketing Strategies, where I specialize in helping healthcare IT and provider organizations to get more leads. Today on Healthcare Lead Generation, we are talking with the amazing Linda Leekley of In the Know Caregiver Training. You can find her at Linda is the founder and CEO of In the Know. She recognized there was a void when it came to training options for direct care workers back in 1998 and she decided to blend her nursing experience in acute and post acute care with her years as a clinical educator. Her company, In the Know, was the result. Her passion for caregiver education makes In the Know the leader in professionally prepared caregiver training. Linda, welcome. I’m so delighted to have you on the podcast!

Linda: 00:46 Thanks so much for having me, Jennifer. It’s a real pleasure to speak with you today.

Jennifer: 00:52 Thank you, Linda. What I am really interested in is talking about this world of caregivers. I think that it’s one of those things that most families eventually wind up dealing with – either a member of their family needs to be a caregiver or a member of the family goes into caregiving. But there really isn’t enough information out there. I don’t think most people realize what’s going on in that world or how it works or what the career path is or the training. So I am delighted to have you on the show to help enlighten everyone. So why don’t we start with a background orientation of what is going on in the world of caregiving right now.

Linda: 01:36 Sure. You know, the hottest topic really is that we have a caregiver shortage. The Bureau of Labor Statistics, for example, says that by 2024 we’re going to need a million new caregivers across the country. The Wall Street Journal, they’re even gloomier about it. They say it could be up to 3 million.

Jennifer: 01:56 And this is on top of what is already a chronically understaffed situation now, correct?

Linda: 02:02 That’s right. That’s right. And you know, typically the shortage tends to be blamed on baby boomers like myself. There are roughly 10,000 of us turning 65 every day and most of us would prefer to age at home rather than in a facility. So for many, this means at some point needing to hire a caregiver. So the experts tend to say that there just aren’t enough people available to care for the aging population.

Jennifer: 02:32 Now, to be clear, we’re talking the whole range, aren’t we? People who do caregiving part-time, we’re talking about live-in health. There’s a whole range there, correct?

Linda: 02:42 There is a whole range. That does not include family caregivers, so that, for example, if you were to quit your job to care for an elderly relative that’s not counted in that number. That’s a different scenario. So these are paid caregivers.

Jennifer: 03:00 Understood. So let’s talk about what that world is like. Let’s get a sense of how many – I know you’ve told me that there is lot of competition for the people who go into caregiving and it’s not all for other caregiving positions. So what is the frame of reference here?

Linda: 03:20 Well, you’re right. It’s a career that has a tough time attracting a lot of people. It can be really backbreaking, heartbreaking, spirit-breaking work and these employees, you know, they receive little training. They can get going on the job with a couple of weeks training. In some states for non-medical caregivers, there’s no training requirement at all. And they get little recognition and little appreciation for the work they do. So, it’s not so much a shortage of people available. It’s people wanting to get into the career,

Jennifer: 04:05 So they’re competing with jobs that are not even in caregiving.

Linda: 04:08 That’s right. Hospitality, food service, retail. Amazon, for instance, just recently announced that their minimum wage is going to be $15 for any position, any location, and they also include benefits. So that’s a tough thing to, to compete against.

Jennifer: 04:32 And what is the average pay right now for caregivers?

Linda: 04:34 That’s about $10.50.

Jennifer: 04:38 Yeah. So that is a big difference. So why are people drawn to it? Maybe that’s a very interesting point to consider.

Linda: 04:48 They have done surveys about that and the ones that I’ve seen – consistently, the majority of people, the vast majority of people answering these surveys – 60 to 70 percent say that they get into it because they want to help other people. So I think it tends to be one of those things not dissimilar to nursing really, where they feel a real calling for the work.

Jennifer: 05:16 Do people feel that it’s a preparatory step for going into nursing or is it seen as its own career path?

Linda: 05:22 Both, both. In fact there’s a number of nursing schools across the country now that require students to work as a caregiver for up to a year prior to being accepted into the nursing program.

Jennifer: 05:36 Interesting.

Linda: 05:37 Yeah. And, as a nurse myself, I think that’s really great thing to do. It gives the person a taste of the healthcare world before they commit to a nursing school. And, if they do decide to go through with becoming a nurse, they will forever have respect for the work that their caregiver colleagues do, which is so important.

Jennifer: 06:05 I also think it helps so much to orient you when you see how people live when they’re ill. Because, if you’ve never seen it – and very often people going into nursing are young, they’re starting their careers, not all of them, but many of them, so they might not have seen it if they didn’t have an elderly grandparent or a sick relative and their family. And as an EMT, that’s one of the things that always jumps out at me – the things you didn’t really think about, you see right up close and then you get it. And I think that’s profoundly impactful if you are going into any medical field at any level. So I agree completely.

Linda: 06:45 The pay is a big topic. You ask a lot of people, and they just say, well, let’s pay them more – and I don’t disagree. They’re definitely worth more. However, the organizations that hire them are often handcuffed by a government reimbursement if they deal with Medicare or Medicaid patients. They are only reimbursed X amount from the government and, in order to stay in business, they really can’t pay the caregivers more. So that’s really a shame. And, in fact, it means that more than half of all caregivers in the US live below the poverty line.

Jennifer: 07:27 And I’m guessing that means they juggle multiple jobs, as well as their family, which makes it even harder.

Linda: 07:32 They do. It does make it harder. Caregivers are often hired on as part-time employees. Sometimes that’s to avoid giving them benefits, which is also a shame. So they’re juggling several jobs as well as, as you say, their family.

Jennifer: 07:53 And when you mentioned the Medicaid and Medicare situation, are their lobbyists that are working to promote caregivers’ needs?

Linda: 08:01 Yes, there are. There’s an organization, PHI – They have worked for years to help with the caregiver shortage and getting them the respect and benefits they deserve and higher pay. So that’s a great organization.

Jennifer: 08:30 Well, let’s talk more about making that change to a different paradigm. You talk about it not being reimbursed at a higher rate, not being paid at a higher rate, not necessarily getting benefits. I know that you think that there needs to be a paradigm shift there and thinking about it as a respected career path. So let’s talk about what would go into that. Because I agree with you. We have to start valuing the things that we need. It’s not just the things that we can’t have. I mean, everyone values the rarest diamond in the world. But do we value, you know, the water all around us or the air all around us? That’s the thing that we really need. And I think caregiving falls into the same category.

Linda: 09:10 It totally does. Most people or many people may not know that caregivers provide 90 percent of the hands-on care to patients. So if your loved one is in the hospital, 90 percent of the time the attention paid to them is by a caregiver. Not a nurse, not a doctor, not a therapist, but the caregiver. Yet if you ask the general public their impression of what a caregiver does, many are going to say, well, they deal with bedpans. They give baths to grumpy old people all day and they’re basically glorified maids. And, to me, that sort of thinking should offend all of us because, like I said, they are serving the sick, disabled, elderly in a holistic manner. They deal with their physical needs, emotional, social needs. And 90 percent of the care is given by them. They really deserve respect, appreciation, and admiration for what they do.

Jennifer: 10:06 Absolutely. Especially when you tell me that 60 to 70 percent of them want to do it just to help other people. They absolutely deserve that respect.

Linda: 10:16 That’s right. So, yes, I mean to try to shift that paradigm and help make caregiving a respected career. Ideas such as developing a mentorship program, offering a career ladder, holding regular skills fairs, reimbursing tuition for advanced training at a community college. What all these ideas have in common is training.

Jennifer: 10:42 And that’s what you know. So let’s talk about that. That’s a big, important issue and I suspect it’s something people in this field want. People who care about what they’re doing want to do it very well. And it sounds like these people are very dedicated.

Linda: 10:57 They are and they do want to continue learning. Obviously because I run a training company, this is near and dear to my heart, but there’s a real need out there. And it’s interesting, when I talk to healthcare administrators, the conversation usually goes one of two ways. They either say, Oh gee, you know, people say training is important, but I think it’s a waste of time. It’s a waste of money. When I offer training courses, my caregivers don’t even bother to complete them. Or, I hear, Oh yeah, training is the key to keeping great employees. My caregivers always want to learn something new and our patients reap the benefits.

Jennifer: 11:35 Those are two real different worlds.

Linda: 11:38 It is totally. And it just seems to be either one extreme or the other. And what I often think about is that old adage, the only thing worse than training employees and having them leave is not training and having them stay.

Jennifer: 11:53 Exactly, exactly. That’s true in every field. You can either have a very competent workforce that eventually moves on or you can be stuck with completely incompetent people. That’s your choice as the leader. It’s not the choice of the people you’re hiring.

Linda: 12:08 That’s right. Right. And so I think, you know, administrators’ vision of training and belief about training trickles down. So if they’re negative about it, that’s going to trickle down.

Jennifer: 12:20 And it isn’t just in caregiving that we’re seeing this. In our economy right now, we have seen a huge shift and we’re seeing the problems that it comes to where everybody wants to hire people who are already ready to go, even in the most unique specialized aspects of coding or anything – and it makes no sense. Hire people with the capabilities of doing that and train them to exactly what you need, and let them grow with your company. But that thinking, I think it’s going to resurface in the next five years, but it has gone underground for far too long.

Linda: 12:51 No, definitely. I mean, we tell people that all the time. Hire for character.

Jennifer: 12:56 Absolutely.

Linda: 12:58 Train. Train for skill.

Jennifer: 13:01 So let’s talk about the kinds of training that people are interested in and how you provide that to them. What are the things that they’re looking for?

Linda: 13:13 There’s initial training, which is – just like everything else in this country – that’s state by state, so that can be fairly complex. It’s also dependent on, is it a nonmedical caregiver? Is it a home health aide? Is it a certified nursing assistant? A personal care aide? These all have different regulations. So you have four or five different kinds of caregivers in 50 states, all those bureaucratic regulations.

Jennifer: 13:45 I bet that’s crazy.

Linda: 13:47 Yeah. So the initial training can be tricky but it’s, obviously, crucial. And then there’s ongoing training and those regulations. Also Federal regulations require 12 hours of continuing education per year for any caregiver who works with a government program like Medicare, Medicaid. And then the states vary widely. Some require no continuing education. And just think about it. You’ve got a caregiver who’s had maybe two weeks of training and they are put out in someone’s home to work all by themselves and then never have another continuing education class. It makes no sense.

Jennifer: 14:38 It’s isolating and you can see how it might not make them feel as committed to their work. You know, where are they going to go? They’re not learning the new things.

Linda: 14:47 That’s right.

Jennifer: 14:48 How do they prefer to learn? Is it online? Do they prefer courses? What is the best connection that you found?

Linda: 14:56 We really encourage a blended learning program where you do use online training because let’s face it, that’s what’s going to attract the younger generations that are born with a phone.

Jennifer: 15:12 Absolutely. It’s it’s much more convenient, in general.

Linda: 15:15 It is, it is. I mean, our courses can be completed on a phone or an iPad or any kind of tablet or a computer. So yes, e-learning is definitely – it’s revolutionized caregiver training. But that doesn’t mean the classroom learning is obsolete. I think that getting caregivers together as a group is crucial. Especially for the ones that work in clients’ homes. Like I said, they work alone day after day. They don’t get much chance to hang out with their coworkers. So when an administrator has some group, that’s a perfect opportunity for teaching and recognizing caregivers in front of their peers.

Jennifer: 16:01 Absolutely. What are the training topics that are most requested beyond the initial requirements?

Linda: 16:11 You know, caregivers want to learn. We did a poll actually recently and the most in-demand topics had to do with dementia and memory care, you know. That’s not surprising, really.

Jennifer: 16:27 And it’s such a fascinating area. I don’t know that much about it, but what I’ve read has always made me amazed at how a different approach to it, not different treatment, but a different way of working with patients who are dealing with dementia makes everything better for them – and therefore makes it also easier on the caregiver. So I can see why training on that would be tremendously helpful.

Linda: 16:49 That’s right. And you know, we really encourage organizations to look at the population of their clients, their residents, and pick a couple of key diagnoses and then become the experts in their market by offering their caregivers advanced training in that topic. So for example, you know, ABC Home Care, finds that they serve a lot of diabetic clients. If they train all their caregivers with an advanced training program, which many companies have – we have one – they create diabetes specialists. And then they market that training program to the public and to referral sources and in ads for caregivers.

Jennifer: 17:40 That’s brilliant.

Linda: 17:40 As diabetes specialists. When they have these advanced training programs and they market their organization that way, they become the specialist to the referral sources. So anytime you know a hospital is discharging a diabetic client and they need somebody to go, to a caregiver, they can say, oh yeah, I’m going to go with ABC Home Care.

Jennifer: 18:07 Oh, that’s brilliant. That’s brilliant. I love that. You know I’m in marketing and I love that. I love a niche. I can see why that would just be a brilliant approach. Let’s talk more about some of the other support services to caregivers. I know that you had mentioned when we were originally arranging this podcast episode, that part of that paradigm shift that you’ve spoken about is trying to make it easy on the caregiver, so there are support services that make doing their work easier. Can you talk about what those would be?

Linda: 18:43 Sure. I think that the caregiver’s needs need to be looked at holistically, just the same way we look at patients, and then strive to meet the needs that keep them from sticking with the profession. For example, many caregivers will quit their jobs because of their own family responsibilities, like taking care of their kids. So how about an organization partnering with a local daycare center? Many childcare operators now offer corporate partnerships. They offer tuition subsidies, preferred pricing, backup childcare. So having a perk like that can really set an organization apart from the rest. And you know, think of the recruiting possibilities if you’re advertising that you assist with childcare.

Jennifer: 19:27 I think that’s so helpful. And you’re right, it totally ties into everything we talk about for patients regarding social determinants of health. But it’s not just patients who need that – anyone who’s working needs that and caregivers, especially, since they’re often not making enough to handle daycare as smoothly as someone who’s in an executive position. So a bus pass for them can make a big difference.

Linda: 19:51 It can. And many organizations aren’t aware that they can subsidize their caregivers’ transportation or their employee transportation by offering vouchers and bus passes. The IRS allows an employer to pay for employees qualified transit up to $255 a month per employee. And that can be vanpooling, bus, rail, ferry services if you’re living on an island, you know, and then there’s Uber for business. They can get some special rates from Uber to provide affordable rides for employees in emergency situations when they need coverage for a case or what have you. I think the thing is just thinking outside the box,

Jennifer: 20:34 And talking with them, asking them what they might need.

Linda: 20:37 Exactly. Ask what they need. And because of the lifting that caregivers do every day, – and not many people know this, they have a higher rate of on-the-job injury than any other profession, more than construction workers, more than police officers, more than anybody. On an average day, a caregiver lifts about 2000 pounds.

Jennifer: 21:01 Wow.

Linda: 21:02 And they are really prone to injury. I’m in Arizona, and there was an organization where the caregivers asked their employer to help pay for group Pilates and yoga classes for the staff so that they could strengthen their core to avoid injuries. And it worked.

Jennifer: 21:20 I love that. I love that idea.

Linda: 21:22 So that’s another way of thinking outside the box. Do your caregivers need food stamps or other social services? If they’re in need of public assistance, help them. In other words, take away the obstacles that are keeping them from being successful on the job and like you say, ask them what they need and then follow through.

Jennifer: 21:44 Absolutely. And I hope we start seeing more of that as a trend in the coming years because it is so important. In fact, let’s talk about that. What is coming down the pike? I know there are different things being discussed to address the caregiver shortage so let’s talk about some of the issues going on there. What are some approaches people are taking?

Linda: 22:06 Just to sort of cast a wide net over the generations, for the first time in history there are five generations in our workforce. There are still people who were born before 1945 who are working as caregivers, seniors caring for seniors. Then there’s the Baby Boomers. There are plenty of them who are still working. The average age of a caregiver is about 45, so I guess that puts them in the Gen Xers, and Millennials and then the kids who were the Generation Z who are just now entering the workforce. So the hiring population, or possibilities rather, are really unlimited. Some organizations are trying to get people who are newly retired and interested in careers involved in caregiving. They certainly tackle high schools and all different ranges and try to get the younger people involved. But to do that, they really have to be open. The organization has to be open to fresh new ideas and to the ever evolving use of technology. And having a career ladder for caregivers, that’s really crucial to attract young people. They don’t want to feel like they’re entering a dead-end job.

Jennifer: 23:39 No, and who would? You can’t blame them for that. Of course they want what they can get; they have their futures to plan, as well. One thing you had mentioned to me previously was that 25 percent, I think you said of caregivers in the US are immigrants. So what does that do for the future, what people are doing to try and get more caregivers?

Linda: 23:59 Well, I guess that’s sort of an interesting topic in our country right now.

Jennifer: 24:05 It certainly is.

Linda: 24:07 Yes. Actually, most of the immigrants that are working as caregivers are actually US citizens, but not all. There was an immigration education center in Albuquerque, New Mexico where they teach all their caregiving classes in Spanish and all of the students are immigrants, mostly from Mexico. And everyone who passes the course becomes a State-certified home health aide. But many of them are there because of the Family Reunification Act, because they have US-born children. So what our changing immigration laws are going to do to that flow of immigrants who are eager to enter the caregiving profession, I don’t know. I mean it may squash the idea of reversing our shortage by hiring immigrants.

Jennifer: 24:53 Right. Well, I guess we’ll find out in the next couple of years how that goes.

Linda: 24:58 I guess we will.

Jennifer: 24:58 Things are certainly a little ominous around this country lately.

Linda: 25:02 Until recently in Canada, they had a live-in caregiver program to apply for and it was a path toward permanent residency for them. And when I first saw that, I thought, you know, that’s really cool. I wonder if we could try something like that in this country. However, I found out recently that it was discontinued. There were definitely some success stories for sure, no question, but they also found that because these caregivers were live-in and so living with their employers, many of the immigrants were made to work long hours without being paid appropriately for it. So they ended up ultimately doing away with the program.

Jennifer: 25:47 That is such an abuse and any live-in situation for immigrants – they don’t know the system, they don’t know the rules. They feel very vulnerable and people abuse that lack of knowledge and lack of protection. That’s too bad. That’s always too bad when that happens and it;s so sad for the people involved. On another tack that is more of a way to administer the kind of caregiver training that caregivers themselves might want. You had once told me about caregiver co-ops, which I think is a fascinating new development. Can you talk to us about that?

Linda: 26:26 Sure. That’s a new trend that’s starting to gain popularity across the US and I just think it’s amazing. These are employee-owned and operated agencies that typically get born out of the frustration that caregivers suffer in traditional settings where they have no power, no voice, no support and no respect. So these co-ops are turning that around. The caregivers gain a strong voice. They have the opportunity to get involved in the daily operations of the business that they’re involved in, in the decision making at the co-op. The co-ops offer better benefits, in-depth training and stability and flexibility. These are all things, of course, that caregivers are craving,

Jennifer: 27:13 Of course. Are they finding that they’re growing and getting a solid group going in comparison with the for-profit or nonprofit associations in their areas.

Linda: 27:23 I think, to date, the most successful ones have had some benefit from outside financial support. For example, the AARP foundation has funded several caregiving co-ops throughout the country. And other co-ops had been given grants by the US Department of Agriculture and the Cooperative Development Foundation. So it’s a little early to predict whether we can really curb the shortage by using caregiver co-ops, but it’s clear that they have the potential to cause caregivers to really stick around, stick with the profession and change it.

Jennifer: 28:00 They’re probably going to become a great motivation towards increased training and increasing respect, which is what they want and what they deserve,

Linda: 28:12 And decreased turnover. You know, the largest co-op is located in the Bronx, Cooperative Home Care Associates and they have 2100 caregivers and they have competitive wages, regular hours and family healthcare insurance. And their turnover rate is 15 percent, which is a far cry from the national average of 67.

Jennifer: 28:35 Wow. Wow. That is huge difference.

Linda: 28:40 It is huge. It really is.

Jennifer: 28:42 Wow. And how long have they been around?

Linda: 28:46 Golly, I don’t know precisely. They were, I think, one of the first. So I, I’m thinking around five years, but I’m not sure.

Jennifer: 28:57 That just goes to show you how self-fulfilling these prophecies can be when people say, we don’t want to invest because people don’t see this as a long-term commitment, and we don’t want to invest in training them. If you actually invest, they will see it as a long-term place to stay. It’s just the nature of the game. So give them a reason to stay. Give them a reason to commit to working with you. So, Linda, thank you so much for sharing your insights with us. This has just been an amazing education for me and I hope for everyone listening. For those who are listening, please visit to learn more about Linda’s work with In the Know Caregiver Training. Linda is the Founder and CEO of In the Know Caregiver Training. She recognized that there was a void about training options for direct care workers. She took her experience in acute and post-acute nursing care, combined it with her clinical educator experience and created In the Know specifically to address that need. Linda’s passion for caregiver education makes In the Know the leader in professionally prepared caregiver training. Linda, thank you so much. I always love talking with you. Thank you for coming on the show. And for everyone listening. I’m Jennifer Michelle with, where I specialize in helping healthcare IT and provider organizations to get more leads and grow their companies. Catch you next time!