Summary 

The CareFront initiative is designed to catalyze transformative change in health systems’ cultures, practices, and policies to ensure that direct care worker roles are recognized as high-quality jobs that are valued within health systems. The Institute for Healthcare Improvement (IHI), with support and funding from the Ralph C. Wilson Jr. Foundation, is working with 17 organizations to develop and test changes that improve retention and engagement in direct care roles. The goal of the project is to develop and test a theory of change that would result in a 10–20 percent improvement in retention of staff in direct care roles.  

Together with teams and driven by recommendations from direct care workers, we developed a change package that we continue to test and refine with our newest cohort of teams. Changes fall into five categories:  

• Organization distinguishes itself as an employer of choice 

• The direct care worker role is valued in the organization 

• Recruiting and training is exemplary 

• Understanding and addressing structural barriers to succeed in the direct care workforce role 

• Engagement of direct care workers as part of the care team 

Introduction – The Problem

Retention of direct care workers is a challenge that is impacting health systems across the United States.  According to the American College of Healthcare Executives, personnel shortages ranked #1 along with financial challenges on the list of hospital CEOs’ top concerns in 2025. Patient Care Technicians (PCTs) and Certified Nursing Assistants (CNAs) continue to outpace all other job titles when it comes to turnover within hospital systems. These critical roles, which comprise the backbone of the US healthcare system, continued to record an annual turnover rate of more than 30 percent in 2024. Direct care workforce turnover is also a cost driver with an estimated CNA replacement cost of $18,700 per person. The direct care workforce, the majority of whom are women and people of color, are disproportionately impacted by race and gender inequalities in the workplace. (PHI 2022 report, Direct Care Worker Disparities: Key Trends and Challenges). 

Retention rates are low, cost of hiring is high, burnout among healthcare workers is increasing, and there is a growing disconnect between the desire and need to provide compassionate patient care and the job description and expectations of the direct care role within healthcare systems.  

Approach 

To address opportunities and barriers at different levels of the health system, the theory of change focused on five areas:  

• Organization distinguishes itself as an employer of choice 

• Direct Care Worker role is valued in the organization 

• Recruiting and training is exemplary 

• Understanding and addressing structural barriers to succeed in the direct care role 

• Engagement of direct care worker role as part of the care team 

To test and expand the theory of change and develop a measurement strategy, we have engaged 17 healthcare delivery sites in two phases, including 16 hospitals and one long term care facility, to participate in a Learning and Action Network (LAN) and subsequent support activities.  

Phase 1 

• Phase 1, Cohort 1: included seven sites participating in a 22-month LAN (January 2024 – October 2025) including monthly coaching, All Team Calls, and reporting, as well as virtual and in-person learning sessions and site visits 

Phase 2 

• Phase 2, Cohort 1: all seven sites continue to engage with the initiative for an additional year of technical support and testing of the theory via monthly coaching, quarterly All Team Calls, and monthly reporting 

• Phase 2, Cohort 2: a new 22-month Learning and Action Network (January 2026- October 2027) including ten additional hospital sites, all affiliated with health systems that participated in Phase 1   

Teams identified and prioritized change ideas based on feedback collected from direct care workforce staff and other frontline staff via surveys, individual discussions about what makes a good day and what makes a bad day, and “what matters to you” boards. Teams then used the Plan, Do, Study, Act (PDSA) method and engaged direct care workforces in small tests of change. Improvement teams reported back to staff about which changes were prioritized, tested, and implemented, and why. 

Examples of changes introduced based on direct care workforce feedback include:  

• Creating a Lead Patient Care Technician role to represent, orient, and support PCTs 

• Developing a “float guide” to assist direct care workforces to understand expectations and key components of units they are called to as float staff 

• Creating a hand-off checklist to ensure smooth transition between direct care workforce shifts 

• Implementing staff recognition and engagement games and activities 

• Working with environmental services and facilities to ensure sufficient stock of linens and timely equipment repair 

• Including direct care workers in staff huddles and handovers 

To address recurring challenges, managers also recommended changes, such as: 

• Instituting reasonable accommodations to avoid termination for high-performing staff who have child or eldercare responsibilities or transportation challenges 

• Arranging shadowing opportunities to allow potential new hires to determine if the setting and role are right for them ahead of onboarding and training 

• Providing scrubs and bus passes to new staff ahead of a first paycheck to ensure a smooth transition into the role 

• Engaging staff in direct care workforce roles in the interview process for new hires to include perspectives from people closest to the work 

Results 

Results in the first phase of work were promising and increased our degree of belief in our theory of change. In phase 2, Cohort 1 teams have spread successful changes to new units and, in some cases, to new facilities across their health system. Through partnership with data leads at each Cohort 1 site, we have developed a refined measurement strategy for Cohort 2.  

Key results include:  

• Substantial decrease in direct care workforce turnover among 5 of 7 Cohort 1 pilot units; one site achieved a 60 percent reduction in direct care workforce turnover 

• Improvement in census of direct care workforce staff on the unit (achieving full staffing) in 5 of 6 Cohort 1 pilot units tracking this measure 

• 100 percent of teams engaged a direct care worker on their improvement team 

•  Over 3,132 staff directly impacted by changes brought about as part of the CareFront Initiative, as of July 2025, with only seven Cohort 1 sites 

• 6 of 7 Cohort 1 teams reported “incidental” patient safety improvements they attribute to improved teamwork and staffing including reduction in CLABSI, HAPI, and falls 

Discussion and Implications 

Key to the success of the initiative to-date has been engaging a multidisciplinary team at each site which includes at least one (and typically many more) team member(s) working in the direct care workforce role most impacted by the changes tested.  

By engaging frontline staff in the work and focusing on small tests of change, teams were able to learn in a non-threatening way. Participating in generation and prioritization of change ideas helped to build trust among direct care workforce that their ideas were valuable and acted on.  

All teams calls inspired teams to try changes derived by their peer institutions, as well as changes identified locally.  

We are grateful to the Ralph C. Wilson, Jr. Foundation for supporting this initiative and to our 17 prototyping partners sites for their collaboration with us and each other, and their dedication to this important work. 

Related Information 

Blog: How Teams Are Engaging and Retaining Direct Care Workers 

IHI White Paper: IHI Framework for Improving Joy in Work