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 work-
ers 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. 
Be it enacted by the Senate and House of Representa-
tives of the United States of America in Congress assembled, 
SECTION 1. SHORT TITLE. 
This Act may be cited as the ‘‘Improving Care for 
Vulnerable Older Citizens and People with Disabilities 
through Workforce Advancement Act of 2021’’. 
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SEC. 2. FINDINGS. 
Congress finds the following: 
(1) As of 2019, more than 54,000,000 Ameri-
cans were age 65 or older. By 2030, the Census Bu-
reau projects that one in five Americans will be 65 
or older. More than 80 percent of older Americans 
suffer from chronic conditions which require person- 
centered, coordinated care that helps them to live in 
a home- or community-based setting. In 2012, the 
Government Accountability Office (GAO) found that 
34 percent of Americans who are age 60 or older re-
ported needing assistance performing activities of 
daily living. According to a 2015 GAO report, be-
tween 67 and 78 percent of older adults who likely 
need home-based care receive limited or no help with 
their difficulties. 
(2) Direct-care workers (referred to in this sec-
tion as ‘‘DCWs’’) provide an estimated 70 to 80 per-
cent of the paid hands-on long-term care and per-
sonal assistance received by elders and people with 
disabilities or other chronic conditions in the United 
States. These workers help their clients bathe, dress, 
and negotiate a range of other daily tasks. They are 
a lifeline for those they serve, as well as for families 
and friends struggling to provide high-quality care. 
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(3) Eldercare and disability services positions 
account for nearly one-third of the 18,000,000 
health care jobs in the United States. The direct- 
care workforce alone accounts for nearly 4,600,000 
jobs and is expected to add nearly 1,300,000 new 
positions within the next decade. 
(4) The majority of DCWs are now employed in 
home- and community-based settings, and not in in-
stitutional settings such as nursing care facilities or 
hospitals. In 2019, DCWs providing home-based 
care already outnumbered DCWs in nursing homes 
by more than 4 to 1. 
(5) A 2008 Institute of Medicine report, enti-
tled ‘‘Re-tooling for an Aging America: Building the 
Health Care Workforce’’, called for new models of 
care delivery and coordination, and dedicated a 
chapter to the central importance of the direct-care 
workforce in a ‘‘re-tooled’’ eldercare delivery system. 
(6) An Institute of Medicine report on the fu-
ture of nursing, released in 2016, recommended 
nurses should practice to the full extent of their edu-
cation and training. The report also states that all 
health care professionals should work collaboratively 
in team-based models, and that the goal should be 
to encourage care models that use every member of 
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the team to the full capacity of his or her training 
and skills. 
(7) The Patient Protection and Affordable Care 
Act (Public Law 111–148) emphasizes the need for 
improving care and lowering costs by better coordi-
nation of care and integration of services, particu-
larly for consumers with multiple chronic conditions. 
This has required developing new models of care for 
those receiving long-term services and supports. 
SEC. 3. DEMONSTRATION PROGRAM ON CARE COORDINA-
TION AND SERVICE DELIVERY. 
Title III of the Public Health Service Act is amended 
by inserting after section 330N of such Act (42 U.S.C. 
254c–20) the following: 
‘‘SEC. 330O. DEMONSTRATION PROGRAM ON CARE COORDI-
NATION AND SERVICE DELIVERY. 
‘‘(a) ESTABLISHMENT
OF DEMONSTRATION PRO-
GRAM.— 
‘‘(1) IN
GENERAL.—The Secretary, acting 
through the Administrator of the Health Resources 
and Services Administration, shall carry out a dem-
onstration program in accordance with this section. 
Under such program, the Secretary shall award 
grants to eligible entities to carry out demonstration 
projects that focus on care coordination and service 
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delivery redesign for older adults and people with 
disabilities who have chronic illness or are at risk of 
institutional placement by— 
‘‘(A) designing and testing new models of 
care coordination and service delivery that 
thoughtfully and effectively deploy direct-care 
workers in advanced roles to improve efficiency 
and quality of care for older adults and people 
with disabilities; and 
‘‘(B) giving direct-care workers opportuni-
ties for career advancement through additional 
training, an expanded role, and increased com-
pensation. 
‘‘(2) DIRECT-CARE WORKER.—In this section, 
the term ‘direct-care worker’ has the meaning given 
that term in the 2010 Standard Occupational Classi-
fications of the Department of Labor for Home 
Health Aides [31–1011], Psychiatric Aides [31– 
1013], Nursing Assistants [31–1014], and Personal 
Care Aides [39–9021]. 
‘‘(b) DEMONSTRATION PROJECTS.—The demonstra-
tion program under this section shall be composed of 4 
demonstration projects, as follows: 
‘‘(1) Two demonstration projects shall focus on 
using the abilities of direct-care workers to promote 
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smooth transitions in care and help to prevent un-
necessary 
hospital 
readmissions. 
Under 
these 
projects, direct-care workers shall be incorporated as 
essential members of interdisciplinary care coordina-
tion teams. 
‘‘(2) Two demonstration projects shall focus on 
maintaining the health and improving the health sta-
tus of those with multiple chronic conditions and 
long-term care needs or on training direct-care work-
ers to take on greater responsibilities related to spe-
cific diseases, including Alzheimer’s disease and de-
mentia, congestive heart failure, and diabetes. Under 
these projects, direct-care workers shall assist in 
monitoring health status, ensuring compliance with 
prescribed care, and educating and coaching the 
older adults and people with disabilities involved, as 
well as any family caregivers and other members of 
the care team. 
‘‘(c) ELIGIBLE ENTITY.—In this section, the term 
‘eligible entity’ means a consortium that consists of— 
‘‘(1) at least 1— 
‘‘(A) skilled nursing facility or other resi-
dential long-term care provider; or 
‘‘(B) home health and personal care service 
provider; and 
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‘‘(2) at least 1— 
‘‘(A) hospital or health system; 
‘‘(B) labor organization or labor-manage-
ment partnership; 
‘‘(C) community-based aging and disability 
services provider; 
‘‘(D) patient-centered medical home; 
‘‘(E) federally qualified health center; 
‘‘(F) managed care entity, including a 
managed health and long-term care program; 
‘‘(G) entity that provides health services 
training; 
‘‘(H) State-based public entity engaged in 
building new roles and related curricula for di-
rect-care workers; or 
‘‘(I) any other entity that the Secretary 
deems eligible based on integrated care criteria. 
‘‘(d) APPLICATION.—To be eligible to receive a grant 
under this section, an eligible entity shall submit to the 
Secretary an application at such time, in such manner, 
and containing such information as the Secretary may re-
quire, which shall include— 
‘‘(1) a description of the care coordination and 
service delivery models of the entity, detailed on a 
general, organizational, and staff level; 
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‘‘(2) a description of how the demonstration 
project carried out by the entity will improve care 
quality, including specific objectives and anticipated 
outcomes that will be used to measure success; and 
‘‘(3) a description of how the coordinated care 
team approach with an enhanced role for the direct- 
care worker under the demonstration project will in-
crease efficiency and cost effectiveness compared to 
past practice. 
‘‘(e) PLANNING AWARDS UNDER DEMONSTRATION 
PROGRAM.— 
‘‘(1) IN GENERAL.—Each eligible entity that re-
ceives a grant under this section shall receive a 
grant for planning activities related to the dem-
onstration project to be carried out by the entity, in-
cluding— 
‘‘(A) designing the implementation of the 
project; 
‘‘(B) identifying competencies and devel-
oping curricula for the training of participating 
direct-care workers; 
‘‘(C) developing training materials and 
processes for other members of the interdiscipli-
nary care team; 
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‘‘(D) articulating a plan for identifying 
and tracking cost savings gained from imple-
mentation of the project and for achieving long- 
term financial sustainability; and 
‘‘(E) articulating a plan for evaluating the 
project, encompassing workforce outcomes, care 
outcomes, and cost outcomes. 
‘‘(2) AMOUNT AND TERM.— 
‘‘(A) 
TOTAL
AMOUNT.—The 
amount 
awarded under paragraph (1) for all grants 
shall not exceed $600,000. 
‘‘(B) TERM.—Activities carried out under 
a grant awarded under paragraph (1) shall be 
completed not later than 1 year after the grant 
is awarded. 
‘‘(f) IMPLEMENTATION
AWARDS
UNDER
DEM-
ONSTRATION PROGRAM.— 
‘‘(1) IN GENERAL.—Each eligible entity may re-
ceive a grant for implementation activities related to 
the demonstration project to be carried out by the 
entity, if the Secretary determines the entity— 
‘‘(A) has successfully carried out the ac-
tivities under the grant awarded under sub-
section (e); 
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‘‘(B) offers a feasible plan for long-term fi-
nancial sustainability; 
‘‘(C) has constructed a meaningful model 
of advancement for direct-care workers; and 
‘‘(D) aims to provide training to a sizeable 
number of direct-care workers and to serve a 
sizeable number of older adults and people with 
disabilities. 
‘‘(2) USE OF FUNDS.—The implementation ac-
tivities described under paragraph (1) shall in-
clude— 
‘‘(A) training of all care team members in 
accordance with the design of the demonstra-
tion project; and 
‘‘(B) evaluating the competency of all staff 
based on project design. 
‘‘(3) EVALUATION AND REPORT.— 
‘‘(A) EVALUATION.—Each recipient of a 
grant under paragraph (1), in consultation with 
an independent evaluation contractor, shall 
evaluate— 
‘‘(i) the impact of training and de-
ployment of direct-care workers in ad-
vanced roles, as described in this section, 
within each participating entity on out-
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comes, such as direct-care worker job satis-
faction and turnover, beneficiary and fam-
ily caregiver satisfaction with services, rate 
of hospitalization of beneficiaries, and ad-
ditional measures determined by the Sec-
retary; 
‘‘(ii) the impact of such training and 
deployment on the long-term services and 
supports delivery system and resources; 
‘‘(iii) statement of the potential of the 
use of direct-care workers in advanced 
roles to lower cost and improve quality of 
care; and 
‘‘(iv) long-term financial sustainability 
of the model used under the grant and the 
impact of such model on quality of care. 
‘‘(B) REPORTS.—Not later than 180 days 
after completion of the demonstration program 
under this section, each recipient of a grant 
under paragraph (1) shall submit to the Sec-
retary a report on the implementation of activi-
ties conducted under the demonstration project, 
including— 
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‘‘(i) the outcomes, performance bench-
marks, and lessons learned from the 
project; 
‘‘(ii) a statement of cost savings 
gained from implementation of the project 
and how the cost savings have been rein-
vested to improve direct-care job quality 
and quality of care; and 
‘‘(iii) results of the evaluation con-
ducted under subparagraph (A) with re-
spect to such activities, together with such 
recommendations for legislation or admin-
istrative action for expansion of the dem-
onstration program under this section on a 
broader scale as the Secretary determines 
appropriate. 
‘‘(4) AMOUNT AND TERM.— 
‘‘(A) 
TOTAL
AMOUNT.—The 
amount 
awarded under paragraph (1) for all grants 
shall not exceed $2,900,000. 
‘‘(B) TERM.—Activities carried out under 
a grant awarded under paragraph (1) shall be 
completed not later than 3 years after the grant 
is awarded.’’. 
Æ 
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