Impact Feature Issue on Direct Support Workforce Development

In their 2003 Joint U.S. House/Senate Direct Support Professional Recognition Resolution (S. Con. Res. 21/H. Con. Res. 94), Congress noted that “private [service] providers and the individuals for whom they provide support and services are in jeopardy as a result of the growing crisis in recruiting and retaining a direct support workforce” and that “it is the sense of the Congress that the Federal Government and the States should make it a priority to promote a stable, quality direct support workforce for individuals with mental retardation and other developmental disabilities that advances our nation’s commitment to community integration.” In pursuit of greater specification of actions that would promote a “stable, quality direct support workforce,” in 2004 Congress requested that the Department of Health and Human Services (DHHS) conduct a study on the shortage of Direct Support Professionals (DSPs) supporting persons with intellectual and other developmental disabilities (ID/DD). This study was to include analysis of “the root causes associated with high vacancy and turnover rates and an examination of the impact this shortage may be having on services for people with ID/DD.”

That requested report was transmitted to Congress in 2006 (U.S. Department of Health and Human Services, 2006). It confirmed the crisis in direct support, reporting back to the Congress that in the 15 years between 2005 and 2020 the number of DSPs needed to provide long-term supports for individuals with ID/DD would increase by about 323,000 or about 37% because of population growth, increased life expectancy among persons with ID/DD, aging of family caregivers, and expansion of home and community-based services. The report further observed that “meeting the future demand for DSPs will be extremely difficult to achieve through enhanced recruitment,” and that “it will be critically important to improve the retention of existing DSPs along with efforts to attract new ones” (U.S. Department of Health and Human Services, 2006, p. vi). To highlight the importance of retention the report summarized 26 studies yielding an average turnover rate of 50% among DSPs supporting persons with ID/DD. To demonstrate the significance of retention to the challenge of maintaining a sufficient DSP workforce up to 2020 the report provided the graph above (see Figure 1) to show the dramatic effects of very modest decreases in DSP turnover on the total number of new DSPs that would need to be recruited each year to meet the projected growth in service need. It shows the number of DSPs who will be needed each year between 2005 and 2020 if (as shown in the dark line) DSP turnover remains at 50% each year as opposed to an alternative scenario (shown in the light line) in which DSP turnover were reduced by 2% each year for 10 years and then remained at 30% between 2015 and 2020 (i.e., 48% in 2006, 46% in 2007, etc.). As shown, the net effect of the second scenario would be a need to recruit 289,000 fewer DSPs to meet the needs of persons with ID/DD in 2015 than if turnover were to stay at current levels, and a need to recruit 346,000 fewer new DSPs in 2020.

There are many factors that have been identified over the past 30 years to have constant association with DSP turnover. But without question the most consistent and consistently strong predictors of DSP turnover are factors related to compensation (e.g., amount of pay, value of wages and benefits, satisfaction with pay, pay relative to local cost of living). Concerns about the low pay of community DSPs, its effects on staff recruitment and retention, and ultimately the links between these and the viability of the nation’s commitments to community lives for people with disabilities have led to Congressional activity.

In March 2007, Representatives Capps (D-CA) and Terry (R-NE) introduced the Direct Support Professionals Fairness and Security Act of 2007 (H.R. 1279). Its operational purpose is to provide federal funding to States to allow them to respond to the crisis in recruiting and retaining DSPs in private community service settings. The legislation specifically targets private agency DSPs because, as the DHHS report to Congress notes, DSPs in private agencies earn on average 26% less in wages and substantially less in fringe benefit contributions than public agency DSPs. To address the crisis in wages for private agency DSPs, H.R. 1279 focuses on the discrepancy between public and private employee wages and authorizes states to develop a “Direct Support Professional Wage Enhancement Plan” by which the State would utilize federal funding augmentations over a five-year period to equalize average wages (and fringe benefits up to 20% of wages) for private and public agency DSPs. In addition to its primary provision, H.R. 1279 would authorize State planning grants and require Inspector General and Government Accountability Office audits of the implementation and outcomes of the program.

The proposed legislation has a steadily growing number of co-sponsors, more than 100 at this writing. Its critics view the proper environment for such policies to be with States, which control Medicaid expenditures and are free to implement policies to increase DSP wages, but are also responsible for paying the State’s share of those increases (25-50% depending on the state’s per capita income). The critics in Congress should, however, be held accountable for their own characterization of the current situation as a crisis and their associated responsibility to act accordingly. Alternatives to H.R. 1279 are certainly possible, but doing nothing in the face of the recognized crisis will only contribute to the vulnerability of already vulnerable people.