Abby Care just raised $82 million to train family members and pay them as caregivers for their own loved ones. The announcement set off the usual debate. Can family members really be trained to deliver care? Will they take it seriously? Will they do the work?

Pennsylvania can save everyone some time, and Pennsylvania is not an outlier. Nearly every state already pays family caregivers in some form. KFF's survey of Medicaid home care programs found that 43 of the 45 states with waivers for older adults and people with physical disabilities pay family caregivers, and every responding state pays them through at least one program. The rules differ, the waivers differ, but the direction is the same everywhere. The payment question is already settled.

Under Community HealthChoices, Pennsylvania's Medicaid managed long-term care program, a family caregiver is not paid under the table or handed a stipend. They are hired, through a licensed home care agency or a fiscal intermediary, as an employee. There is a paycheck. There is orientation. There is required training, including annual training, and their personnel file has to document that they completed it.

So the model Abby Care is building toward already exists, in Pennsylvania and in most of the country, with the money, the employment structure, and the compliance requirements all in place. Pennsylvania is simply where providers have said the quiet part out loud to me.

What the providers tell me

Here is what the providers running it tell me.

A Pennsylvania provider told me how hard it is to get family caregivers through their training. Not the hiring paperwork. Not showing up for care. The training. Then last week, at a conference in Ohio, another provider said the same thing without being asked. Getting family caregivers to complete their regular training, and especially the annual training, is one of the hardest parts of the program.

Sit with that for a minute. These are not unmotivated people. A family caregiver is caring for her own mother, her own child. Nobody in healthcare wants the care to go well more than she does. Her paycheck depends on completing this training. Her loved one's care depends on her knowing it. Every incentive anyone can design is already pointed in the right direction.

And the training still does not get finished.

When the most motivated learner in the entire system cannot get through your training, the learner is not the problem.

The problem is design

This is the same failure playing out everywhere in home care, just with the volume turned up. Agencies watch clinicians ignore the learning platform and conclude the clinicians are not engaged. Published completion benchmarks for industry learning systems run between 20 and 40 percent, and the standard response is more reminders, more escalation, more pressure on the front line. Pennsylvania shows where that road ends. You can put the caregiver on payroll, tie her income to the training, make the patient her own family member, and pressure still does not fix completion.

Because the problem was never pressure. The problem is design.

The training family caregivers are handed was built for a different worker in a different setting. It is generic content, written to satisfy a requirement, covering every condition except the one in front of them. It arrives in blocks, on a schedule set by an office, for a person whose workday is not a workday. Her shift is the whole day, in the home, with no coverage while she sits through a module. The content does not fit her schedule, it does not fit her work life, and most of it does not speak to the specific person she is caring for. So it waits. Then it expires. Then the agency starts chasing her for it, and everyone calls it an engagement problem.

She is not refusing to learn. She is refusing to complete training that was never designed for her.

What training designed for her looks like

What would training designed for her look like? It would be short enough to live inside a caregiving day instead of competing with it. It would be about her person's conditions, her person's medications, her person's risks, not a catalog. It would come back around over time, because understanding fades and conditions change. And it would check that she actually understood, with teach-back repeated over time, not a signature on an attendance sheet once a year.

None of that is exotic. It is just what happens when the training is built around the learner's actual life instead of the auditor's checklist.

Funding scales a model. It does not fix one.

This is why the Pennsylvania experience matters for the Abby Care announcement. Funding scales a model. It does not fix one. If the industry takes $82 million and builds more of the same training, longer catalogs, generic modules, annual blocks that collide with the care day, Pennsylvania already showed us the result. Providers will hire the caregivers, the caregivers will care for their families, and everyone will spend years chasing training completions and blaming the people who were never the problem.

The caregivers are ready. They have been ready. Build training that fits the life they are actually living, and completion stops being the hardest part of the program.