Program Profile

Impact Feature Issue on Direct Support Workforce Development

State Initiatives to Strengthen the Direct Support Workforce


Steve Edelstein is National Policy Director, Paraprofessional Healthcare Institute, New York, NY.

Carrie Blakeway is Direct Service Workforce Resource Center Manager, The Lewin Group, Falls Church, VA.

As states strive to rebalance their long-term care service systems and improve access to home and community-based services for individuals with disabilities, they have found that access to community services depends on the availability of a well-trained, stable, and sizable direct support workforce. Obstacles to achieving such a workforce include low wages, poor benefits, lack of training and professional development opportunities, lack of respect and appreciation from supervisors, lack of control over their jobs, and limited opportunities for advancement. Recognizing that the quality of the workforce has a direct and immediate impact on the quality of long-term services, states are intensifying their efforts to find innovative solutions to these workforce challenges.

Several national grant programs and initiatives have supported states in implementing significant workforce improvement activities, including:

  • The Centers for Medicare and Medicaid Services (CMS):Real Choice Systems Change, Direct Service Workforce (DSW) Demonstration, and Direct Service Workforce Resource Center Technical Assistance grant projects
  • The Robert Wood Johnson Foundation and Atlantic Philanthropies:Better Jobs, Better Care grants
  • The U.S. Department of Labor:High Growth Job Training Initiatives

States are drawing from a growing set of best practices in pursuing a range of strategies within these programs to improve the recruitment and retention of their direct support workforce, such as:

  • Offering better employee benefits, including health care.
  • Providing enhanced training for Direct Support Professionals (DSPs) and supervisors.
  • Creating opportunities for professional development and advancement.
  • Recognizing and rewarding performance of individual workers and of employer agencies.
  • Implementing more effective recruitment and selection strategies.

Twenty-eight states are participating in at least one of these initiatives and many are participating in several. Four states with particularly innovative initiatives underway are featured here:

  • Kentucky.DSW Demonstration (CMS) and Real Choice Systems Change (CMS)
  • North Carolina.Real Choice Systems Change (CMS), DSW Demonstration (CMS), DSW Resource Center Intensive TA (CMS), and Better Jobs, Better Care (Robert Wood Johnson and Atlantic Philanthropies)
  • Pennsylvania.Better Jobs, Better Care (Robert Wood Johnson and Atlantic Philanthropies), and High Growth Job Training Initiative (U.S. Department of Labor)
  • Washington.DSW Demonstration (CMS)

Details of these efforts are provided in the remainder of this article.


Through a DSW Demonstration grant awarded in 2004, eight provider agencies in the metro-Louisville region established the Support Providing Employees’ Association of Kentucky (SPEAK). SPEAK provides professional development opportunities and bonus payments for DSPs employed by its provider agency members. One of SPEAK’s most successful initiatives is a preservice orientation they provide to prospective job candidates – a Realistic Job Preview (RJP) that occurs before an individual is hired. Once a member agency finds a prospect, the agency does an initial interview. If the agency is still interested in the job candidate after the initial interview, they refer that individual to SPEAK to participate in the RJP. The RJP is delivered in-person by the SPEAK project coordinator, an employee of one of the lead organizations in the project. The session lasts up to five hours and includes three components: an initial visit with the SPEAK coordinator, a site visit, and a family visit. The session is extremely informal and casual by design, to increase the comfort level of the prospective employee. Prospective employees are given a $50 cash payment at the completion of the session. Because of this practice, as well as the other activities of SPEAK, turnover in partnering organizations has dropped from 62% to 27% in three years. All of the SPEAK partners plan to continue using the preservice orientation as a selection tool beyond the grant period.

In 2001, Kentucky was awarded a Real Choice Systems Change grant to develop a Direct Support Work Certificate program offered through the state’s community and technical college system. The certificate prepares people to work in a variety of community programs. The outcomes are currently being evaluated and it is hoped that increased education will result in better wages for direct support workers and lead to lower turnover for employers.

North Carolina

In the past five years, North Carolina has received several grants resulting in a flurry of activity aimed at improving the recruitment and retention of a quality direct support workforce. Through a 2001 Real Choice Systems Change grant, the state created a career ladder for direct support workers by recognizing two advanced practice job categories – medication aide and geriatric nurse aide. The state also created the Direct Care Worker Association of North Carolina to support the professional development of direct support workers and to promote public awareness of the importance of the profession, and trained a cadre of trainers to help providers implement a more supportive, coaching style of supervision.

With a Better Jobs, Better Care grant, the state created the North Carolina New Organizational Vision Award (NC NOVA), a special licensure designation that recognizes long-term care providers who demonstrate their commitment to their direct support workforce through supportive workplace practices and leadership and career development opportunities. With the pilot phase near completion and the full implementation stage getting underway, the state is measuring specific outcomes such as reductions in turnover, decreases in job vacancies, and increases in job satisfaction in order to make the case to state policymakers to tie financial incentives to the special licensure.

In 2004, a group of agencies in the western part of the state received a DSW Demonstration grant to explore the impact of providing health insurance coverage to home care workers on the workers’ decision to stay in direct support. Although the project encountered difficulty finding affordable comprehensive coverage, it did have a positive impact on retention and turnover from the coverage it was able to offer. Based on the study, the grantee hopes to interest other agencies in the state in creating a bigger pool of workers that would improve coverage and lower costs.


In Pennsylvania, the State Workforce Investment Board and the Governor’s Office of Health Care Reform convened a group of over 100 stakeholders representing providers, labor representatives, people with disabilities, and other advocates across all service sectors to address its workforce crisis. Through this unique high-level collaboration between the State’s workforce development and health care systems, the group laid out a comprehensive vision for improving direct support job quality and building adequate workforce capacity to meet future long-term care needs. The group’s key recommendations included a system for training, credentialing, and career advancement for direct support workers; creation of statewide quality standards to encourage supportive workplace practices; exploration of options for affordable health insurance; and an analysis of rate setting and reimbursement practices to ensure that policies are consistent with workforce goals.

The signature achievement of the Pennsylvania Better Jobs, Better Care project was the development of a universal core curriculum to provide initial training to all direct support workers, regardless of setting. Project leaders are seeking to promote the curriculum in connection with the Commonwealth’s efforts to create a competency-based training program for direct support workers. Through a U.S. Department of Labor High Growth Initiative grant to the Paraprofessional Healthcare Institute, Pennsylvania also served as a pilot site for a new apprenticeship for home care workers. The apprenticeship is also using a competency-based training model and creates a structured career ladder for direct support workers in home and community-based settings.


Washington State has a consumer-directed in-home services workforce composed of 23,500 workers, called Individual Providers (IPs). In 2002, this workforce unionized and bargained with the state for wage increases and health insurance benefits. Today, IPs who work at least 86 hours a month and meet other eligibility requirements can enroll in either of two comprehensive health insurance plans.

Washington’s Home Care Quality Authority (HCQA) received a DSW Demonstration grant in 2004. With this grant, HCQA has marketed and promoted the new health benefit to IPs across the state and implemented several other interventions designed to improve staff recruitment and retention. The grantee piloted Home Care Referral and Registry Centers (HCRRs) in four regions of the state, and the number of sites has now expanded to 14. The HCRRs provide worker orientation, training, and peer mentorship. Case managers at the HCRRs help to match workers with people with disabilities needing services in the community. HCQA developed a Web-based worker referral registry that matches worker skills, training, and abilities with consumer needs and preferences.

With so many different strategies and initiatives underway, states are turning their attention to evaluation and outcomes measurement. State policymakers need to know which strategies work and which have the greatest impact. However, many states do not consistently or systematically collect workforce data, such as retention and turnover rates, worker wages, benefits, and training. States will have to invest considerably in evaluation and make an enduring commitment to data collection, so that they can monitor their progress, learn from their experiences, and continue to develop good workforce policy going forward.