From workforce shortages to immigrant recruitment and artificial intelligence, both countries face difficult choices about the future of long-term care.
As populations throughout the world rapidly age, long-term care has become an ever-more important component of a country’s health and workforce system.
While older adults bring enormous possibilities and strengths to a country’s culture and economy, this massive global aging trend also carries substantial costs to these systems. Most older adults prefer to age in place—living in their homes rather than institutional settings—yet more than 45% of U.S. adults aged 80 and older report difficulty with cognition, mobility, sight, hearing, or self-care, which requires home- and community-based services (HCBS).
In both the U.S. and Germany, families struggle to secure quality services, both because of cost barriers and the inability to find an available worker. Behind this latter challenge are workforce shortages of direct care workers spurred by poor wages and working conditions; few workers are willing or financially able to take these roles. These trends have wide-ranging health and economic implications across countries.
To explore the shared challenges and potential solutions for these issues across two countries, George Mason University’s School of Public Health and the University of Bremen, supported by the German Embassy, hosted a symposium in December 2025 titled “Addressing Workforce Shortages in Long-Term Care: U.S., German, and Global Perspectives.”
This article reports on four key themes discussed at the symposium and urgently relevant to health and workforce leaders in various countries, including Germany and the U.S.: workforce shortages and the role of immigration; education and training approaches; the possibilities and limitations of emerging technologies; and the need for high-quality jobs to stem the exploitation of direct care workers. We argue that improving long-term delivery and job quality in this system requires cross-national learning, dialogue, and workforce approaches, including immigration reforms.
How Workforce Shortages Undermine Health and Care
A high-quality direct care workforce is critical to enabling aging and disabled populations to maintain independence and improve quality of life. Yet direct care workers in the U.S. are some of the most disadvantaged workers in the labor market, experiencing acute financial insecurity and material hardship, rooted in poverty-level wages, insufficient hours, and limited career pathways and labor protections.
Moreover, direct care work is often erroneously perceived as low-skilled, and rarely provides quality training, viable career pathways, or economic mobility. That this workforce is made up predominantly of African American and Latina women whose work has always been undervalued is not an accident. For example, since the New Deal era, U.S. labor law excluded domestic work (predominantly done by African American women) from basic wage and overtime protections for decades. Over time, these exclusions set the foundation for the substandard home care jobs that workers experience today, a primary driver of current workforce shortages.
Poor job quality and high turnover among direct care workers have wider health implications for older adults and people with disabilities, including long waiting lists for HCBS lead to delayed or missed care that leads to higher hospital and premature nursing home institutionalization rates. And for the direct care worker, it means financial insecurity, burnout, and stress-related illness.
While everyone in the long-term care ecosystem feels these challenges, the problems are more acute for low-income households and women of color, which underscores how direct care worker challenges are labor, public health, and equity concerns.
Demographics, Immigration, and the Health Workforce Pipeline
Changing demographics in the United States and Germany affect both the supply of and demand for direct care workers. Between 2024 and 2034, long-term care employers in the U.S. will need to fill 9.7 million direct care job openings, including new jobs and vacancies caused by workers changing jobs or leaving the labor force.
Behind these job opening figures is the fact that the number of U.S. residents aged 65 and older is projected to grow from about 61 million to roughly 95 million by 2060. In comparison, Germany lacks enough working-age adults to take on direct care jobs, and this challenge will worsen in the future as the surge in the older adults outpaces the working population. Workforce shortages ultimately hinder older adults and people with disabilities from receiving the care they need to stay healthy.
Direct care jobs in Germany are characterized by greater structure and higher pay than in the U.S., where efforts to improve job quality for direct care workers have been steady but slow to advance and typically more common in certain states. In this context, both countries stand to benefit from sound immigration policies amid politically charged immigration debates, with more success on moving such proposals in Germany
For example, along with arguing for drastic job improvements for all direct care workers, advocates and industry leaders in the U.S. have proposed a special “caregiver visa” for direct care workers—among other policy solutions. Such a policy would reduce workforce shortages in this job sector and provide immigrants with an opportunity to live permanently in the U.S and strong worker protections to prevent exploitation by employers.
Germany’s Model for Ethical International Health Care Recruitment
Workforce shortages in health and long-term care systems are a global phenomenon, which led the World Health Organization (WHO) to adopt a Global Code of Practice on the International Recruitment of Health Personnel in 2010. This Code of Practice—though voluntary—calls for fairness, transparency, and protection against exploitation, especially in the context of wealthier countries recruiting healthcare workers who might be experiencing their own workforce shortages.
To address severe workforce shortages in long-term care, Germany has strengthened its recruitment of foreign health care workers. Amid intensifying international competition, Germany has created pathways into high-quality health care jobs, making Germany an attractive work option.
Germany promotes fair, ethical, and sustainable international recruitment of health professionals—including certified nurses and nursing assistants—through two core mechanisms: Global Skills Partnerships in Nursing (GSP) and the “Fair Recruitment Healthcare Germany” certification standard. Together, these two mechanisms bring the WHO Global Code of Practice to life by protecting immigrant workers, providing them with viable employment, and reducing workforce shortages in Germany.
Global Skills Partnerships — a model originally developed by Michael Clemens and his colleagues at the Center for Global Development and later promoted by the World Bank — links skills training with managed migration, enabling host countries to co-invest in educating health care workers in their home countries while creating legal pathways that expand training capacity and support both countries’ long-term care systems.
Germany adapted this approach by aligning training curricula, supporting health care trainers and educators, enhancing training where gaps existed—such as in geriatrics, palliative care, and hygiene—and offering parallel German language training and country integration preparation for immigrant workers.
Importantly, GSP allows graduates to choose whether to remain and work in their home countries with improved qualifications. Graduates receive a home-country degree and direct recognition in Germany, avoiding lengthy country certification procedures. This approach aims to create a win-win situation for everyone involved: the health care worker who receives essential training, the home country that supports training its workers, and Germany, which gains new health care workers.
Additionally, “Fair Recruitment Healthcare Germany” offers another approach to strengthen the direct care workforce by operationalizing ethical worker-related principles set by WHO, the International Labour Organization, and the International Organization for Migration. This certificate program raises recruitment quality, protects candidates through transparent contracts and processes, applies the employer-pays principle (i.e. all recruitment costs must be paid by the employer), and extends German labor law protections even before migration.
According to speakers at the George Mason University symposium, pilots are taking place in Mexico, the Philippines, Brazil, India, and Uzbekistan. Evaluation showed that 91 percent of nurses recruited under this system stayed with their employers.
Technology, Training, and Retention: Health System Innovations in Practice
Advances in digital health, mobile tools, and artificial intelligence (AI) are reshaping training and retention strategies. Proponents argue that technology can extend staff capacity by reducing administrative burden, supporting clinical decision-making, and accelerating staff onboarding through digital tools and AI technology. Remote monitoring and caregiver coordination platforms may further enable aging in place.
Yet adoption remains uneven and slow. Many long-term care providers hesitate to adopt new technology, as expenses often go beyond hardware and software and include workflow redesign, cybersecurity, maintenance, and staff training, which are rarely reimbursed under current payment models.
In this context, health and long-term care sectors in the U.S. and Germany have begun examining whether AI and related technologies can serve as a "workforce extender" without inadvertently harming direct care jobs or the people they support.
At the symposium referenced earlier in this article, speakers pointed to early evidence that AI in long-term care can increase employment, reduce turnover, and improve job quality, enabling workers to take on more complex responsibilities. One speaker reported that remote patient monitoring and chronic care platforms helped one nurse safely manage 250–350 complex patients. That said, the use of AI and new technologies, while promising, require on-going user-centered design and rigorous, longitudinal independent evaluations to understand the long-term impact across a range of key workforce and quality of care indicators. .
As demand for long-term care grows worldwide, leaders will need to adopt policies that improve the quality of care and jobs in this field, including immigration and technology solutions. They will also need to examine what other countries are adopting, from Germany to the U.S. and beyond.
We’re facing a global challenge, and we cannot afford to not learn from each other.