One November afternoon, Chris Espedal asked a group of caregivers — all of whom work with people who have cognitive impairments, behavioral health issues, or complex physical needs — to describe what happens when their work becomes too much to bear. The participants, 13 caregivers from all over California, who had gathered in a Zoom room, said they experienced nausea, anxiety, shortness of breath, elevated heart rates, and other telltale signs of stress.

“I want to scream!” one called out. “I feel exhausted,” said another.

Espedal, who has been training caregivers for 18 years, guided the class through a self-soothing exercise: “Breathe in for four counts, hold the breath for four, exhale for four.” She taught them to carve out time for themselves, such as setting the goal of reading a book from beginning to end, and reminded everyone to eat, sleep, and exercise. “Do not be afraid to ask for help,” Espedal said. She added that one of the best ways they can care for their clients — often a loved one — was to care for themselves.

The class is a little touchy-feely. But it’s one of many offerings from the California Department of Social Services that the agency says is necessary for attracting and retaining caregivers in a state-funded assistance program that helps 650,000 low-income people who are older or who have disabilities age in place, usually at home. As part of the $295 million initiative, officials said, thousands of classes, both online and in-person, will begin rolling out in January, focused on dozens of topics, including dementia care, first-aid training, medication management, fall prevention, and self-care. Caregivers will be paid for the time they spend developing skills.

Whether it will help the program’s labor shortage remains to be seen. According to a 2021 state audit of the In-Home Supportive Services program, 32 out of 51 counties that responded to a survey reported a shortage of caregivers. Separately, auditors found that clients waited an average of 72 days to be approved for the program, although the department said most application delays were due to missing information from the applicants.

The in-home assistance program, which has been around for nearly 50 years, is plagued by high turnover. About 1 in 3 caregivers leave the program each year, according to University of California-Davis researcher Heather Young, who worked on a 2019 government report on California’s health care workforce needs.

It doesn’t help that the pay is low. According to the state, the average hourly rate for caregivers in the in-home assistance program is $15.83. Rates vary because the program is administered locally, with each county setting its own.

“Training is very helpful,” said Doug Moore, executive director of the United Domestic Workers of America AFSCME Local 3930, which represents roughly 150,000 caregivers in California. “But when the wages are low — and you can make more at Target or McDonald’s and get a signing bonus — then you’re going to go and do that work versus harder work, which is taking care of someone with a disability or a person that’s aging.”

The training initiative came out of Gov. Gavin Newsom’s Master Plan for Aging to improve the quality of caregiving careers. Theresa Mier, a spokesperson for the Department of Social Services, said the state hopes financial incentives will help attract new workers and keep them caring for people with specialized needs longer. In addition to their hourly pay for taking classes, in-home caregivers will receive incentive payments that start at $500 for 15 hours of training. They can earn up to $3,500 if they go on to work at least 40 hours a month with a qualified client for at least six months. Previously, counties offered some training but did not pay workers for their time.

The state issued grants, including $16 million to Homebridge, a San Francisco-based caregiving organization, to coordinate training. Classes will be offered in Spanish, Cantonese, Mandarin, and Armenian, in addition to English, to reach more workers. And state officials are planning a social media campaign to recruit new caregivers.

But the incentives are committed only through the end of 2023.

Greg Thompson, executive director of the Personal Assistance Services Council, the public authority that manages Los Angeles County’s in-home program, would like to see paid training become permanent. “There needs to be, in my opinion, some kind of accountability, structure, supervision, and ongoing training,” he said.

Many caregivers who attended early courses care for family members with a mix of physical and behavioral needs. In fact, 3 out of 4 caregivers in the in-home assistance program are relatives of clients. But the state needs to prepare for a workforce shift, one that requires people to look outside their families. The number of California seniors is expected to be nearly 8.5 million by 2030, an increase of more than 40% from 2019. Many of them will be single.

The state will need more caregivers like Luz Maria Muñoz, who has worked in the in-home assistance program for six years. The Bakersfield resident has navigated challenging situations on the job. One older client was on 30 medications. Another had bedsores, which can be life-threatening if not properly treated. Muñoz peppered the client’s nurse with questions about dressing the wounds and felt responsible for the client’s well-being.

“Those wounds needed to be cleaned daily,” she said.

Muñoz said she’s interested in the training. The department said it sent notices about classes to all participating caregivers and will follow up with updates. Counties also helped spread the word online, in newsletters, and via posted flyers.

Early sessions have filled up as soon as they’re set up. Leslie Kerns, the in-home assistance registry manager for Connecting Point, the public authority for the program in Nevada, Plumas, and Sierra counties, said some classes were full after three hours.

Angelina Williamson cares for her mother, who has a disability, in San Diego and took a course on mobility and transferring patients. She said she learned how to use her body to break a fall and that if her mother falls, it’s better to bring her a chair than pick her up because her mother has enough upper body strength to pull herself up, with Williamson’s help.

Recent surveys suggest that caregivers are likely to be interested in self-care. In a review of nonprofit caregiver resource centers in California, 35% of caregivers reported that their health had worsened while providing care, and 20% had experienced symptoms of depression. Some caregivers also reported being lonely, which could include lacking companionship, feeling left out, or feeling isolated from others. And a 2020 report by the National Alliance for Caregiving and AARP found that 26% of caregivers had difficulty managing their stress.

Robbie Glenn, a single father in Anaheim, attended Espedal’s self-care class and learned to take time for himself. By day, Glenn cares for his 11-year-old son, Edin, who has birth defects from alcohol exposure and has nonverbal autism. Edin needs help going to the toilet and bathing. He has epilepsy and sometimes walks in his sleep. By night, Glenn freelances, doing post-production work, such as film editing and color grading.

Glenn now uses a timer to remind himself to take a break. “And,” he said, “I’ve been doing those breathing exercises a lot.”

This story was produced by KHN, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.