I 

117TH CONGRESS 

1ST SESSION H. R. 6149 

To amend the Public Health Service Act to develop and test an expanded 

and advanced role for direct-care workers who provide long-term services 

and supports to older adults and people with disabilities in efforts to 

coordinate care and improve the efficiency of service delivery, and for 

other purposes. 

IN THE HOUSE OF REPRESENTATIVES 

DECEMBER 7, 2021 

Mr. CARTWRIGHT (for himself and Mr. MCKINLEY) introduced the following 

bill; which was referred to the Committee on Energy and Commerce 

A BILL 

To amend the Public Health Service Act to develop and 

test an expanded and advanced role for direct-care workers who provide long-term services and supports to older 

adults and people with disabilities in efforts to coordinate 

care and improve the efficiency of service delivery, and 

for other purposes. 

1 Be it enacted by the Senate and House of Representa2 tives of the United States of America in Congress assembled, 

3 SECTION 1. SHORT TITLE. 

4 This Act may be cited as the ‘‘Improving Care for 

5 Vulnerable Older Citizens and People with Disabilities 

6 through Workforce Advancement Act of 2021’’. 


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1 SEC. 2. FINDINGS. 

2 Congress finds the following: 

3 (1) As of 2019, more than 54,000,000 Ameri4 cans were age 65 or older. By 2030, the Census Bu5 reau projects that one in five Americans will be 65 

6 or older. More than 80 percent of older Americans 

7 suffer from chronic conditions which require person8 centered, coordinated care that helps them to live in 

9 a home- or community-based setting. In 2012, the 

10 Government Accountability Office (GAO) found that 

11 34 percent of Americans who are age 60 or older re12 ported needing assistance performing activities of 

13 daily living. According to a 2015 GAO report, be14 tween 67 and 78 percent of older adults who likely 

15 need home-based care receive limited or no help with 

16 their difficulties. 

17 (2) Direct-care workers (referred to in this sec18 tion as ‘‘DCWs’’) provide an estimated 70 to 80 per19 cent of the paid hands-on long-term care and per20 sonal assistance received by elders and people with 

21 disabilities or other chronic conditions in the United 

22 States. These workers help their clients bathe, dress, 

23 and negotiate a range of other daily tasks. They are 

24 a lifeline for those they serve, as well as for families 

25 and friends struggling to provide high-quality care. 


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1 (3) Eldercare and disability services positions 

2 account for nearly one-third of the 18,000,000 

3 health care jobs in the United States. The direct4 care workforce alone accounts for nearly 4,600,000 

5 jobs and is expected to add nearly 1,300,000 new 

6 positions within the next decade. 

7 (4) The majority of DCWs are now employed in 

8 home- and community-based settings, and not in in9 stitutional settings such as nursing care facilities or 

10 hospitals. In 2019, DCWs providing home-based 

11 care already outnumbered DCWs in nursing homes 

12 by more than 4 to 1. 

13 (5) A 2008 Institute of Medicine report, enti14 tled ‘‘Re-tooling for an Aging America: Building the 

15 Health Care Workforce’’, called for new models of 

16 care delivery and coordination, and dedicated a 

17 chapter to the central importance of the direct-care 

18 workforce in a ‘‘re-tooled’’ eldercare delivery system. 

19 (6) An Institute of Medicine report on the fu20 ture of nursing, released in 2016, recommended 

21 nurses should practice to the full extent of their edu22 cation and training. The report also states that all 

23 health care professionals should work collaboratively 

24 in team-based models, and that the goal should be 

25 to encourage care models that use every member of 


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1 the team to the full capacity of his or her training 

2 and skills. 

3 (7) The Patient Protection and Affordable Care 

4 Act (Public Law 111–148) emphasizes the need for 

5 improving care and lowering costs by better coordi6 nation of care and integration of services, particu7 larly for consumers with multiple chronic conditions. 

8 This has required developing new models of care for 

9 those receiving long-term services and supports. 

10 SEC. 3. DEMONSTRATION PROGRAM ON CARE COORDINA11 TION AND SERVICE DELIVERY. 

12 Title III of the Public Health Service Act is amended 

13 by inserting after section 330N of such Act (42 U.S.C. 

14 254c–20) the following: 

15 ‘‘SEC. 330O. DEMONSTRATION PROGRAM ON CARE COORDI16 NATION AND SERVICE DELIVERY. 

17 ‘‘(a) ESTABLISHMENT OF DEMONSTRATION PRO18 GRAM.— 

19 ‘‘(1) IN GENERAL.—The Secretary, acting 

20 through the Administrator of the Health Resources 

21 and Services Administration, shall carry out a dem22 onstration program in accordance with this section. 

23 Under such program, the Secretary shall award 

24 grants to eligible entities to carry out demonstration 

25 projects that focus on care coordination and service 


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1 delivery redesign for older adults and people with 

2 disabilities who have chronic illness or are at risk of 

3 institutional placement by— 

4 ‘‘(A) designing and testing new models of 

5 care coordination and service delivery that 

6 thoughtfully and effectively deploy direct-care 

7 workers in advanced roles to improve efficiency 

8 and quality of care for older adults and people 

9 with disabilities; and 

10 ‘‘(B) giving direct-care workers opportuni11 ties for career advancement through additional 

12 training, an expanded role, and increased com13 pensation. 

14 ‘‘(2) DIRECT-CARE WORKER.—In this section, 

15 the term ‘direct-care worker’ has the meaning given 

16 that term in the 2010 Standard Occupational Classi17 fications of the Department of Labor for Home 

18 Health Aides [31–1011], Psychiatric Aides [31– 

19 1013], Nursing Assistants [31–1014], and Personal 

20 Care Aides [39–9021]. 

21 ‘‘(b) DEMONSTRATION PROJECTS.—The demonstra22 tion program under this section shall be composed of 4 

23 demonstration projects, as follows: 

24 ‘‘(1) Two demonstration projects shall focus on 

25 using the abilities of direct-care workers to promote 


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1 smooth transitions in care and help to prevent un2 necessary hospital readmissions. Under these 

3 projects, direct-care workers shall be incorporated as 

4 essential members of interdisciplinary care coordina5 tion teams. 

6 ‘‘(2) Two demonstration projects shall focus on 

7 maintaining the health and improving the health sta8 tus of those with multiple chronic conditions and 

9 long-term care needs or on training direct-care work10 ers to take on greater responsibilities related to spe11 cific diseases, including Alzheimer’s disease and de12 mentia, congestive heart failure, and diabetes. Under 

13 these projects, direct-care workers shall assist in 

14 monitoring health status, ensuring compliance with 

15 prescribed care, and educating and coaching the 

16 older adults and people with disabilities involved, as 

17 well as any family caregivers and other members of 

18 the care team. 

19 ‘‘(c) ELIGIBLE ENTITY.—In this section, the term 

20 ‘eligible entity’ means a consortium that consists of— 

21 ‘‘(1) at least 1— 

22 ‘‘(A) skilled nursing facility or other resi23 dential long-term care provider; or 

24 ‘‘(B) home health and personal care service 

25 provider; and 


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1 ‘‘(2) at least 1— 

2 ‘‘(A) hospital or health system; 

3 ‘‘(B) labor organization or labor-manage4 ment partnership; 

5 ‘‘(C) community-based aging and disability 

6 services provider; 

7 ‘‘(D) patient-centered medical home; 

8 ‘‘(E) federally qualified health center; 

9 ‘‘(F) managed care entity, including a 

10 managed health and long-term care program; 

11 ‘‘(G) entity that provides health services 

12 training; 

13 ‘‘(H) State-based public entity engaged in 

14 building new roles and related curricula for di15 rect-care workers; or 

16 ‘‘(I) any other entity that the Secretary 

17 deems eligible based on integrated care criteria. 

18 ‘‘(d) APPLICATION.—To be eligible to receive a grant 

19 under this section, an eligible entity shall submit to the 

20 Secretary an application at such time, in such manner, 

21 and containing such information as the Secretary may re22 quire, which shall include— 

23 ‘‘(1) a description of the care coordination and 

24 service delivery models of the entity, detailed on a 

25 general, organizational, and staff level; 


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1 ‘‘(2) a description of how the demonstration 

2 project carried out by the entity will improve care 

3 quality, including specific objectives and anticipated 

4 outcomes that will be used to measure success; and 

5 ‘‘(3) a description of how the coordinated care 

6 team approach with an enhanced role for the direct7 care worker under the demonstration project will in8 crease efficiency and cost effectiveness compared to 

9 past practice. 

10 ‘‘(e) PLANNING AWARDS UNDER DEMONSTRATION

11 PROGRAM.— 

12 ‘‘(1) IN GENERAL.—Each eligible entity that re13 ceives a grant under this section shall receive a 

14 grant for planning activities related to the dem15 onstration project to be carried out by the entity, in16 cluding— 

17 ‘‘(A) designing the implementation of the 

18 project; 

19 ‘‘(B) identifying competencies and devel20 oping curricula for the training of participating 

21 direct-care workers; 

22 ‘‘(C) developing training materials and 

23 processes for other members of the interdiscipli24 nary care team; 


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1 ‘‘(D) articulating a plan for identifying 

2 and tracking cost savings gained from imple3 mentation of the project and for achieving long4 term financial sustainability; and 

5 ‘‘(E) articulating a plan for evaluating the 

6 project, encompassing workforce outcomes, care 

7 outcomes, and cost outcomes. 

8 ‘‘(2) AMOUNT AND TERM.— 

9 ‘‘(A) TOTAL AMOUNT.—The amount 

10 awarded under paragraph (1) for all grants 

11 shall not exceed $600,000. 

12 ‘‘(B) TERM.—Activities carried out under 

13 a grant awarded under paragraph (1) shall be 

14 completed not later than 1 year after the grant 

15 is awarded. 

16 ‘‘(f) IMPLEMENTATION AWARDS UNDER DEM17 ONSTRATION PROGRAM.— 

18 ‘‘(1) IN GENERAL.—Each eligible entity may re19 ceive a grant for implementation activities related to 

20 the demonstration project to be carried out by the 

21 entity, if the Secretary determines the entity— 

22 ‘‘(A) has successfully carried out the ac23 tivities under the grant awarded under sub24 section (e); 


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1 ‘‘(B) offers a feasible plan for long-term fi2 nancial sustainability; 

3 ‘‘(C) has constructed a meaningful model 

4 of advancement for direct-care workers; and 

5 ‘‘(D) aims to provide training to a sizeable 

6 number of direct-care workers and to serve a 

7 sizeable number of older adults and people with 

8 disabilities. 

9 ‘‘(2) USE OF FUNDS.—The implementation ac10 tivities described under paragraph (1) shall in11 clude— 

12 ‘‘(A) training of all care team members in 

13 accordance with the design of the demonstra14 tion project; and 

15 ‘‘(B) evaluating the competency of all staff 

16 based on project design. 

17 ‘‘(3) EVALUATION AND REPORT.— 

18 ‘‘(A) EVALUATION.—Each recipient of a 

19 grant under paragraph (1), in consultation with 

20 an independent evaluation contractor, shall 

21 evaluate— 

22 ‘‘(i) the impact of training and de23 ployment of direct-care workers in ad24 vanced roles, as described in this section, 

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1 comes, such as direct-care worker job satis2 faction and turnover, beneficiary and fam3 ily caregiver satisfaction with services, rate 

4 of hospitalization of beneficiaries, and ad5 ditional measures determined by the Sec6 retary; 

7 ‘‘(ii) the impact of such training and 

8 deployment on the long-term services and 

9 supports delivery system and resources; 

10 ‘‘(iii) statement of the potential of the 

11 use of direct-care workers in advanced 

12 roles to lower cost and improve quality of 

13 care; and 

14 ‘‘(iv) long-term financial sustainability 

15 of the model used under the grant and the 

16 impact of such model on quality of care. 

17 ‘‘(B) REPORTS.—Not later than 180 days 

18 after completion of the demonstration program 

19 under this section, each recipient of a grant 

20 under paragraph (1) shall submit to the Sec21 retary a report on the implementation of activi22 ties conducted under the demonstration project, 

23 including— 


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1 ‘‘(i) the outcomes, performance bench2 marks, and lessons learned from the 

3 project; 

4 ‘‘(ii) a statement of cost savings 

5 gained from implementation of the project 

6 and how the cost savings have been rein7 vested to improve direct-care job quality 

8 and quality of care; and 

9 ‘‘(iii) results of the evaluation con10 ducted under subparagraph (A) with re11 spect to such activities, together with such 

12 recommendations for legislation or admin13 istrative action for expansion of the dem14 onstration program under this section on a 

15 broader scale as the Secretary determines 

16 appropriate. 

17 ‘‘(4) AMOUNT AND TERM.— 

18 ‘‘(A) TOTAL AMOUNT.—The amount 

19 awarded under paragraph (1) for all grants 

20 shall not exceed $2,900,000. 

21 ‘‘(B) TERM.—Activities carried out under 

22 a grant awarded under paragraph (1) shall be 

23 completed not later than 3 years after the grant 

24 is awarded.’’. 

Æ 


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