Direct Care Workforce Challenges: Improving the Recruitment and Retention of Workers Who Provide Direct Support to Persons with Disabilities
by Stuart Bratesman, Policy Analyst, Edmund S. Muskie School of Public Service
December 28, 2000

Find out about direct care workforce shortages and some ideas on how to fix it.

• Overview of the problem
• Wages and benefits
• Promotion and advancement
• Recognition and respect
• Cross-training and cross-certification
• Allowing some consumers to hire their own workers
• Recruiting and training
• A partial list of Maine initiatives

Overview of the Problem: Scope and Causes
States, provider agencies, and non-profit organizations, in Maine and across the country, are searching for new answers to the growing challenge of hiring and keeping enough workers to provide direct care services in the community for persons with disabilities. While the need for these workers grows, low wages, lack of benefits, difficult working conditions, limited opportunities for career advancement, and competition from other fields of work make it difficult now, and will make it more difficult in the future, to hire and keep enough qualified persons to meet the need.

Direct care workers are employed under many job titles: nurses aides, home health aides, home care aides, personal care aides, homemakers, behavioral specialists, mental health rehabilitation technicians, qualified mental health professionals, educational technicians, and others provide basic and essential services and supports across the full range of disabilities including mental illness, developmental disabilities, physical disabilities, dementia, and the need for assistance with basic activities of daily living. These are the paid caregivers, who, along with unpaid relatives and friends, make it possible for many persons with disabilities to live at home or in other community settings, instead of in an institution.  Direct care staff are a fundamental key to the basic quality of life for the consumers they serve.  The shortage or availability of direct care staff is a key variable in the quality of care.

Direct care work is a fast-growing field.  Agencies and programs need to keep creating more direct care jobs to keep up with the growing need for services.  A recent survey of Medicaid agencies and State Units on Aging found that 42 of the 50 states already consider hiring and keeping direct care aides to be a "major issue." (Harmuth 1999)  The U.S. Department of Labor has found that "personal care and home health aides" is the seventh-fastest growing occupation in the nation. (Braddock 1999)  They predict the number of new direct care jobs will increase by an average of 5% every year between now and 2008.

However, the need to fill new jobs is not even half the problem.  Most newly hired direct care aides leave their jobs within the first year.  Annual turnover rates for all direct care aides vary from 40% to over 100%.  That means that for every newly created direct care job that programs need to fill, these same programs need to hire 8 to 20 or more persons to replace the workers who left.  That means higher job advertising and hiring costs, higher training costs for agencies, and more stress and extra work for the direct care workers who stay on the job.  It also means lower quality of care for consumers who are cared for by a string of inexperienced strangers who don't stay long enough to learn the consumer's preferences and needs.  New aides who are unfamiliar with a consumer’s disability, personality, and normal day-to-day condition may fail to recognize changes that would otherwise signal a need for serious attention. There is no single cause to the high turnover problem, and no single answer.  Below some possible solutions are discussed.

Wages and Benefits
Direct care jobs typically pay low wages for what is often a part-time job that offers few or no benefits.  In Maine, even an average direct care aide who works full-time still earns less than 2/3rds of the average annual salary in this state. (U.S. Dept. of Labor)  That same worker also earns less than the federal poverty level for a family of four.  Direct care workers can often find entry-level jobs in other fields with less challenging work and with better pay and benefits.

To address this problem, Maine and at least fourteen other states have tried a new idea called "wage pass-throughs." (Harmuth 2000)  A wage pass-through is a state requirement that provider agencies use all or a specified portion of a reimbursement rate increase to improve direct care wages and benefits.  The Maine legislature recently funded a 50-cent-per-hour wage increase for home care workers in long term care (excluding nurses).  The 50-cent raise meant about a 7% increase in the average hourly wage.  While wage pass-throughs do improve benefits and wages, they also raise the cost of bookkeeping and paperwork.  The situation gets complicated when direct care employees spend some of their hours serving the types of consumers covered by the wage pass-through, and the rest of their time serving consumers with disabilities who are not covered.

Promotion and Advancement
Many direct care aides also leave their jobs because they find there is no room for promotion and advancement beyond the original entry-level position within their agency.  A few states, including Maine, have responded with plans or initiatives to create multi-level career ladders to allow promotions, greater responsibility and wage increases for direct care aides as they advance in training and experience.  Most of these plans, including one proposed by the Maine State Labor Task Force, combine existing level jobs with new lower-level entry positions and new higher-level team leader positions to allow more experienced aides opportunities for increased responsibility.

Recognition and Respect
Another widely cited cause of high turnover among direct care workers, in both institutional and community settings, is a widespread lack of respect and recognition for the important work they do.  Some innovative agencies have improved morale and retention by showing more appreciation for workers and allowing them a greater role in decision-making.

Based upon surveys with CNAs across the state, the Wisconsin Association of Homes and Services for the Aging (WAHSA) published a detailed and lengthy list of methods to show appreciation including verbal feedback, flowers, awards dinners, thank you notes, employee newsletters, plaques, and more direct interaction between high-level administrators and front-line workers. (WAHSA)

Another way to increase respect and recognition for direct care aides is to improve the professional status of their positions. Maine’s Department of Behavioral and Developmental Services (BDS) created training and certification requirements for direct care providers in the mental health and children’s services fields and is discussing potential plans to do likewise in the mental retardation area.

Cross-Training and Cross-Certification
Until recently in Maine, Educational Technicians, persons certified to provide support in a school setting for children with learning disorders, or emotional or behavioral problems could not continue to provide support in a home or other non-school setting.  However, new training programs to cross-certify Educational Technicians as Behavioral Specialists can lead to better continuity of care, both in and out of school and greater opportunities for children and their families to find behavioral care assistance in the home or other community setting. 

Persons who are dually diagnosed with mental health and substance abuse problems are often treated for one condition, but not the other, or receive treatment from different staff fragmented across agency boundaries.  BDS is building a program to cross-train mental health and substance abuse staff to treat consumers who have both conditions. 

Allowing Some Consumers to Hire their Own Workers
Many states, including Maine, have already found that the traditional pool of direct care aides can be expanded by allowing consumers with disabilities to recruit and hire their own staff through the increasingly popular consumer-directed care option.   Programs like the state-funded home-based care voucher option at Maine’s Bureau of Elder and Adult Services, the consumer-directed Medicaid waiver program for adults with a physical disability, or the Cash and Counseling programs in Arkansas, New Jersey and Florida give consumers a monthly voucher or cash payment that they can use to pay for the services of their own choosing. These consumer often expand the size of the direct care workforce, by hiring relatives, neighbors, or friends who would otherwise not participate in the field.

Recruiting and Training

Recruiting
Inadequate hiring, training, and orientation practices also contribute to high numbers of direct care aides who quit their jobs very early.  A study of support aides in small Minnesota group homes for persons with developmental disabilities found a 46% annual turnover rate.  Over two-thirds of those who left quit within their first year of being hired, and nearly one-half left within the first six months. (Larson & Lakin 1999)  A 1997 survey of Maine nursing homes and boarding homes found that 79% of new Certified Nursing Assistants (CNAs) left within the first year.  (Maine Labor Task Force 1999)  Many newly hired aides leave before their training and orientation are completed.

Some people leave agencies shortly after being hired because the work is not what they expected, or because they have the wrong work habits, abilities or attitudes for the job.  Agencies that address these problems by putting more thought and effort into the hiring process can achieve reduced turnover rates, reduced overall training costs, and better quality of care and support.  These agencies employ a number of methods to attract and select the right kinds of future employees:

• build relationships with job agencies and other organizations that help connect persons to opportunities for employment;
• invest the time to help the people in those organizations understand the true nature of direct care work, and the ideal characteristics of persons you want to hire;
• host group informational meetings where prospective applicants can gain a better understanding of the true nature of the job before they actually apply;
• employ a job counselor who can help applicants overcome transportation, child care, disabilities or other barriers to employment;
• screen out applicants who cannot arrive on time for job interviews or who fail criminal background checks; and
• train agency staff in good interviewing techniques so they are better equipped to select applicants with the abilities, maturity, and caring attitude likely to help them succeed as long-time employees.

Some Maine agencies have already begun to adopt some of these approaches.   For example, Home Resources of Maine has been building closer relationships with the Bureau of Family Independence, senior organizations and others to improve their prospects for finding more workers.  (Note:  The Paraprofessional Healthcare Institute describes these and other approaches in their guide, "Recruiting Quality Health Care Professionals," available in Adobe Acrobat 4.0 format on the web at: http://www.paraprofessional.org/publications/PHIRecruitOvrvw.pdf, or by sending $8.00 to Paraprofessional Healthcare Institute, 349 E. 149th St., Suite 401, New York, NY 10451  To read the document, you may need to download the newest free version of Adobe Acrobat Reader software.)

Using selective hiring practices in times of low unemployment may sound counter-productive, but reducing the constant turnover cycle reduces the number of new hires that need to be recruited.

Training and Orientation
Better training and orientation are also key to reducing high turnover rates. Programs that supplement lectures, reading and videos with training by example and real life experience give new employees a better grasp of job skills, and reduce the surprise factor that confronts many new workers whose training has been limited to the classroom.

An orientation period that allows new aides to ease into a full caseload over two-to-three weeks instead of all on day one reduces stress, mistakes, and a sense of overwhelming that can lead to early resignations. A team approach to orientation that pairs new aides with more experienced staff offers rewards to both. The new aides benefit from lessons of experience and their mentors gain satisfaction from increased responsibility. Continuing training opportunities for established staff not only helps them acquire new skills and improve chances for promotion, it also demonstrates the agency’s dedication and respect for the direct care aides.

Partial List of Maine Initiatives

Sources

• Harmuth, Susan, "Comparing State Efforts to Address the Recruitment and Retention of Nurse Aide and Other Paraprofessional Aide Workers, North Carolina Division of Facility Services, (Raleigh: September 1999) (Available in Adobe Acrobat® 4.0 format at: http://facility-services.state.nc.us/recruit.pdf. Go to Adobe to download their free Acrobat Reader software.)

• Braddock, Douglas, "Occupational Employment Projections to 2008," Monthly Labor Review, (U.S. Dept. of Labor), November 1999, pp. 51-77, http://www.bls.gov/opub/mlr/1999/11/art5full.pdf

• "1998 State Occupational Employment and Wage Estimates: Maine", Bureau of Labor Statistics, U.S. Dept. of Labor, http://bls.gov/oes/1998/oes_me.htm

• Harmuth, Susan, "Results of a Follow-Up Survey to States on Wage Supplements," North Carolina Division of Facility Services, (Raleigh: November 4, 2000).

• "Enhancing Employment in Long Term Care: A Guide to Retention," Wisconsin Association of Homes and Services for the Aging, Madison, Wisconsin, undated, http://www.wahsa.org/empovr.htm

• Larson, S.A. and Lakin, K.C., "Longitudinal Study of Recruitment and Retention in Small Community Homes Supporting Persons with Developmental Disabilities, Mental Retardation, (Vol. 37, No. 4, August 1999)

• "The Shortage of CNAs and PCAs in Maine: Short and Long Term Solutions," Maine Labor Task Force, Augusta, Maine, February 1999.

• The Paraprofessional Healthcare Institute describes these and other approaches in their guide, "Recruiting Quality Health Care Professionals," available in  Adobe Acrobat format on the web at: http://www.paraprofessional.org/publications/PHIRecruitOvrvw.pdf, or by sending $8.00 to Paraprofessional Healthcare Institute, 349 E. 149th St., Suite 401, New York, NY 10451

• Interviews
  The following people quite generously contributed their time, knowledge and ideas in one or more telephone or face-to-face interviews: John Baillargeon, Maine Bureau of Elder and Adult Services; Jane Gallivan, Maine Department of Mental Health Mental Retardation and Substance Abuse Services; Brenda Harvey, Maine Department of Mental Health Mental Retardation and Substance Abuse Services; Sandra Leak, Duke Long Term Care Resources Program; Joanne Ogden, Maine Department of Mental Health Mental Retardation and Substance Abuse Services; Deb Parker Wolfenden, Consultant to the Maine Department of Education; Vicki Purgavie, Home Care Alliance of Maine Susan Rovillard, Home Resources of Maine; John Shattuck, Maine Department of Labor; Ned Vitalis, Maine Department of Mental Health Mental Retardation and Substance Abuse Services; and Jay Yoe, Maine Department of Mental Health Mental Retardation and Substance Abuse Services.