Kulud Hassan Faisal grew up in Ethiopia. She would help her grandparents with chores such as getting a drink or cooking. When she was young, she knew she wanted to be a nurse.
“I want to help people,” said the 27-year-old St. Paul, MN resident, who will take the certified nursing assistant exam next month and hopes to work with seniors. She will join a direct support workforce that relies heavily on immigrants and refugees to help those in need, such as disabled people and seniors.
A January 2024 Health Affairs study found that the percentage of foreign-born CNAs in the United States increased from 13.6% in the 2000s to 19.1% during the height of the COVID-19 pandemic. This can be attributed to a decrease in American-born employees.
The percentage varied significantly by state, ranging from less than 1% in West Virginia to more than 70% in Hawaii. Furthermore, long-term care facilities in locations with a larger percentage of immigrant CNAs provided superior patient care, more direct care staff hours per resident, and improved overall nursing home quality performance.
It is a workforce that is already struggling to meet a growing need. A 2021 survey found that 4% (168,370) of direct support professionals were laid off from their positions during the first quarter of the pandemic. Of these DSPs, 9% (14,770) had returned to employment by March 2021, albeit not in direct support. As of the conclusion of the first quarter of 2021, the remaining 91% (153,610) had not returned to work.
Even with the COVID-19 pandemic improving, the shortage of DSPs is still severe. According to a report released by ANCOR and United Cerebral Palsy, vacancy rates for both full-time and part-time DSP (direct support professional) positions rose significantly last year, with full-time vacancy rates reaching 16.5% and part-time vacancy rates reaching 20.3%. Meanwhile, turnover remained largely unchanged, decreasing from 43.6% in 2020 to 43.3% in 2021.
President Donald Trump’s crackdown on immigration and refugees has put some caregivers and others who rely on them on high alert. Direct support staff, who help vulnerable people, typically require valid immigration documents to complete background check requirements, according to experts in the field. However, this is not always the case for employees’ family members, who may be deported in large numbers.
They are also concerned about the president’s court-challenged ban on resettlement. Hassan Faisal arrived in the United States last year to join her parents, who are refugees. Unfortunately, she is concerned that Trump’s policies would prevent her sister who is in Ethiopia from joining them.
Many direct support workers in Minnesota and nationwide are immigrants or refugees from African nations such as Liberia, the Democratic Republic of the Congo, Ethiopia, and Somalia, according to industry experts. The future number of workers entering the industry is “extremely threatened” by government measures that would reduce immigration from such countries according to Living Well Disability Services’ president and CEO, Tom Gillespie.
The Mendota Heights MN-based organization supports over 300 disabled people in the Minneapolis/ St.Paul Metro area. Gillespie believes more than half of their frontline employees come from other countries. “Tens of thousands of Minnesotans … literally do not get out of bed, do not leave the house, do not eat a meal, any of that, without a caregiver’s intervention,” Gillespie told The Minnesota Star Tribune. “It takes a caregiver to open up the world for people that we serve, and without those caregivers, the world stays far too small for people with disabilities.”
Personal care assistants help Nikki Villavicencio with her everyday needs, such as eating, showering, laundry, and toileting. She estimates that immigrants have made up approximately 40% of her employees over the years.
Even if the people she works with aren’t directly affected by deportations, their anxieties and the possible consequences for their families can have a knock-on effect, according to Villavicencio, a Maplewood City Council member with arthrogryposis.
Arthrogryposis is a broad term for the development of nonprogressive contractures affecting one or more parts of the body before birth. A contracture is a condition in which a joint becomes permanently stuck in a bent (flexed) or straightened (extended) position. This limits the movement of the affected joint totally or partially.
“It affects the whole system of home care,” she said last year. “When my [personal care assistant’s] life is being threatened or is disrupted … that directly affects my care.”
“Direct care—whether it’s in a group home, a nursing home, or even a hospital in some ways—has always depended on immigrant labor,” said John Estrem, CEO of Hammer & NER, which assists persons with intellectual and other disabilities. Census data shows this is true as well. Almost one-fourth of Minnesota’s nursing, psychiatric, home health, and personal care aides are foreign-born.
For many, it becomes something that they can step into relatively easily and it’s something for many immigrant communities that fits with their values. “Honestly, generally speaking, [in] many other countries the value of caring for people is a lot higher than it is in America.” Estrem’s Wayzata-based nonprofit provides services to approximately 360 people Like other providers, he stated that he would like to hire significantly more people to give direct care, but there aren’t enough workers.
Adolphus Kesseh’s passion for the profession has kept him in the field for nearly three decades. Born prematurely in Liberia, he was expected to have health issues. “It could have been me” who required help, said Kesseh, a program manager at an Inver Grove Heights Living Well Disability group home.
Several of their newest hires, including himself, came to the United States as refugees, he said. He is concerned that Trump’s orders would exacerbate employment issues, and the people they care for may suffer as a result. He has previously worked 16 to 18-hour days to fill staffing vacancies. “I feel that anxiety,” he said. “That there will come a time we won’t be able to find people to cover the shifts here.”
Many people don’t want to work in direct support, and the profession has a high turnover rate. Employers have discovered that immigrants are dependable, eager to learn, and willing to work long hours, according to Joseph Macbeth, president and CEO of the National Alliance for Direct Support Professionals. He says that immigrants make up the majority of direct support professionals who assist disabled people nationwide.
He hasn’t heard of any national raids affecting direct support service providers. However, the alliance keeps a close eye on things and ensures that employers and supervisors know about workers’ rights. In addition, the alliance is helping people understand the protections provided by I-9 forms, which verify an employee’s identity and work authorization.
Direct support is often a very difficult job. People need to be dependable, hardworking, and caring. It is clear that many immigrants and refugees enjoy this field, and they are providing critical care to vulnerable Americans.
Sources:
“2024 Key Findings.” The Case for Inclusion , ANCOR/UCP, 5 Mar. 2024,
caseforinclusion.org/resources/key-findings.
“Arthrogryposis Multiplex Congenita.” NORD (National Organization for Rare Disorders), National Institutes of Health, 19 July 2019, https://rarediseases.org/rare-diseases/arthrogryposis-multiplex-congenita/.
Diament, Michelle. “Amid Shortage of Dsps, Disability Advocates Push for Nationwide Head Count.” Disability Scoop, Disability Scoop, 19 July 2024, http://www.disabilityscoop.com/2024/07/19/amid-shortage-of-dsps-disability-advocates-push-for-nationwide-head-count/30973/.
Hall, Sarah A et al. “Direct Support Professional and Frontline Supervisor Perspectives on Work-Life in a Pandemic.” Inclusion (Washington, D.C.)vol. 10,4 (2022): 314-326. doi:10.1352/2326-6988-10.4.314
Jun, Hankyung, and David C. Grabowski. ‘Nursing Home Staffing: Share Of Immigrant Certified Nursing Assistants Grew As US-Born Staff Numbers Fell, 2010–21’. Health Affairs, vol. 43, no. 1, Health Affairs, Jan. 2024, pp. 108–117, https://doi.org10.1377/hlthaff.2023.00881.
McCall, Stephen., et al. ‘Workforce Displacement and Re-Employment during the COVID-19 Pandemic: Implications for Direct Care Workforce Recruitment and Retention’. UCSF Health Workforce Research Center on Long-Term Care, 2021.
VanBerkel, Jessie. “Minnesota Lacks Caregivers. What Could Trump’s Policies Mean for a Workforce That Relies on Immigrants?” The Star Tribune , Star Tribune Media Company, 15 Feb. 2025, http://www.startribune.com/minnesota-lacks-caregivers-what-could-trumps-policies-mean-for-a-workforce-that-relies-on-immigrants/601223265.