Assessing Extended Family Exemptions for Individual Providers

The departments of Health and Social and Health Services each administer a segment of Washington’s long-term care workforce known as home care aides. Certain people may be paid to provide care as aides without taking all the training specified in law or attaining certification. For example, they might already hold another qualification or be the parent of the person needing care. A subset of care workers, called “individual providers,” care for Medicaid-eligible people in their clients’ own homes. The audit looked at how expanding the degree of family relationships that are exempt from certification might affect the availability of these workers. In addition, it outlined some of the risks and benefits of broadening these exemptions.

Read the two-page summary (pdf).

Report Number 1023358 Report Credits

Key Results

Neither state officials nor others researching the topic can quantify the unmet need for individual providers. However, demographic trends point to a significant and growing shortage of caregivers. Expanding exemptions for individual providers could help fill that gap, but we could not quantify by how much.  Also, expanding exemptions poses both benefits and risks. This audit did not make recommendations. Instead, it sets out the considerations for a legislative policy change to expand exemptions.


A 2008 voter-approved Initiative required long-term care workers to be certified by the Washington State Department of Health as “home care aides” after completing specific training and passing an examination. Initiative 1163, passed in 2012, advanced the date by which the state had to put the requirements into effect. It also mandated annual performance audits on in-home long-term care.

There are four earlier audits in this series:

Unmet need for care

Washington does not have enough data to calculate the extent of Washington’s unmet need for individual providers, and long-term care workers overall. Only a very small proportion of care workers —those that contract with the state and those that are certified as home care aides — are known with any certainty. However, national studies point to a significant and growing shortage of long-term care workers, as growth in the aging population is outpacing growth in the labor force. In addition, as policy and preferences shift, older people increasingly prefer to age in their homes rather than in institutions, such as nursing homes.

Expanding current exemptions

One option for increasing the number of people who serve as caregivers is to broaden the family-based exemption from full training requirements for extended family members. Exempted family members must complete some training, but less than non-exempt home care aides, and are not required to become certified. At present, these types of long-term care workers are exempt from full requirements:

  • Parent or adult child IP caring for elderly or functionally disabled child or adult
  • Parent IP caring for developmentally disabled child
  • IP providing respite care for developmentally disabled person, working 300 hours or less annually

Examples of the degree of family relationship that might be eligible for exemption includes siblings, grandchildren and cousins. In addition, legislators would need to consider the number of hours of training that newly exempt family members should have before being considered individual providers.


As the number of older people grows, the state may benefit if expanded exemptions increase the total amount of long-term care for in-home clients. This increase will also help to reduce the likely shortage. Two groups of people may be enticed to participate in these circumstances:

  • Family members who are currently providing unpaid care might provide more care if they are paid
  • Family members not currently providing any care might provide at least some care

These workers would need to take some training, although less than people without exemptions. However, the amount of any increase in care is unknown.


The importance of trained workers is well documented, and family members who become paid caregivers without previous experience may benefit most from the full training. With expanded training exemptions, program costs could rise as more paid caregivers provide in-home care, though the amount is unknown. In addition, exempt extended family would fall outside DOH’s licensing and regulatory umbrella.


This audit did not make any recommendations.